University of Oklahoma

College of Dentistry

Clinic Policies Manual

2008- 2009

TABLE OF CONTENTS

Section A: General Information and Clinic Guidelines CLINIC OPERATIONS ......................................................................................A-1 MAIN TELEPHONE/ROOM NUMBERS............................................................A-5 ARRANGEMENT OF CLINICS..........................................................................A-7 Clinic Dispensaries Clinic Laboratories CLINIC HOURS.................................................................................................A-9 CLINIC ATTENDANCE .....................................................................................A-9 DRESS REGULATIONS .................................................................................A-10 General Attire General Appearance Clinical Attire PAIRING OF STUDENTS ...............................................................................A-11 CLINIC SCHEDULES......................................................................................A-12 BLOCK ROTATIONS ......................................................................................A-13 MINIMUM CLINICAL EXPERIENCES.............................................................A-14 Periodontics Operative Dentistry Endodontics Fixed Prosthodontics Removable Prosthodontics TREATMENT PLANNING CLINIC...................................................................A-21

GENERAL CLINIC PROTOCOL......................................................................A-22

STERILIZATION..............................................................................................A-23

DENTAL SUPPORT LABORATORY...............................................................A-25 Policies/Procedures Regarding Gold Requisitioning Artificial Teeth Working Time/Service Schedule

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PATIENT PARKING ........................................................................................A-27

CLINIC GOVERNANCE ..................................................................................A-27 Clinic Policies Committee Health and Safety Committee

Section B: Patient Management Policies

PATIENT SELECTION AND ASSIGNMENT ……………………………............B-1 Selection Assignment DENTAL HYGIENE PATIENT MANAGEMENT……………………………………………………………………..B-4 Patient Assignments Types of DH Patients Scheduling Patients Chart Documentation Releasing Dental Hygiene Patients Emergency Appointments for Dental Hygiene Recall Patients PEDIATRIC/ ORTHODONTIC PATIENT MANAGEMENT……………………...B-7 INITIAL PATIENT CONTACTS………………………………………....................B-9 PATIENT RELEASE……………………………………………………………….B-10 INFORMED CONSENT……………………………………………………………B-12 CLINIC SIGNUP PROCESS………………………………………………………B-13 Patient Cancellation Late Tray Treatment Planning Clinic PATIENT RECONCILIATION…………………………………………….............B-15 Patient Completion Patient Transfer Patient Release Limited Care Treatment TREATMENT ON UNASSIGNED PATIENTS…………………………………..B-22 Treatment on Other Students

PATIENT ABANDONMENT…………………………………..…………………. B-23

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CLINIC INCIDENT REPORTING FORM……………………………………………B-25 OUCOD REFERRAL PROCESS……………………………………………………B-26

Section C: Patient Records Policies CHART SECURITY ……………………………………………………………………...C-1

REQUESTING/FILING CHARTS………………………………………………………C-1

TYPES OF CHARTS AND RECORDS………………………………………………..C-2 CHART ARRANGEMENT………………………………………………………………C-2 MASTER TREATMENT PLAN…………………………………………………………C-3 TREATMENT PROGRESS NOTES…………………………………………………...C-3 CHART AUDITS…………………………………………………………………………C-6 Overview of Chart Audit Process Appointment Time Table Scoring Column Definitions OTHER CHART GUIDELINES…………………………………………………………C-9

Section D: Financial Policies

CLINIC FEE SCHEDULE ..................................................................................D-1 FEE REDUCTIONS/REFUNDS.........................................................................D-2 COLLECTION OF FEES ...................................................................................D-2 MANAGEMENT OF DELINQUENT ACCOUNTS..............................................D-3 ENCOUNTER SLIP FORM ...............................................................................D-4 CLINIC FEE DISCOUNTS…………………………………………………………..D-5

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DENTAL INSURANCE ......................................................................................D-6 OTHER FINANCIAL POLICIES.........................................................................D-7

Section E: Management of Patient/ Visitor Medical Emergencies INITIAL EMERGENCY MANAGEMENT............................................................E-1 PROCEDURES FOR MEDICAL EMERGENCIES ............................................E-2 INGESTION OF A FOREIGN BODY……………………………………………….E-3 EVENING/ WEEKEND EMERGENCIES...........................................................E-3 After Hours Protocol for Emergencies Involving Student Clinic Patients EMERGENCY EQUIPMENT/SUPPLIES...........................................................E-5 HYPERTENSION GUIDELINES………………………………………………........E-7 ENDOCARDITIS POLICY...................................................................................E-8 ANTIBIOTIC REGIMENS....................................................................................E-9

Section F: Guidelines for Use of Ionizing Radiation

POLICY ADMINISTRATION..............................................................................F-2 PHYSICAL FACILITIES.....................................................................................F-3 INSTRUCTIONAL SUPPORT ...........................................................................F-4 CRITERIA FOR RADIOGRAPHIC EXPOSURES………………………………....F-5 OPERATING PROCEDURES……………………………………………………….F-7 INFECTION CONTROL.....................................................................................F-8 RADIATION SAFETY........................................................................................F-9 RECORDS ......................................................................................................F-10

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Section G: Patient Care Guidelines PATIENT MANAGEMENT

Admissions.................................................................................................. G-1 Assignment ................................................................................................. G-1

Treatment.................................................................................................... G-2 Completed Care.......................................................................................... G-2 Limited Care................................................................................................ G-3 Emergency Services ................................................................................... G-3 Patient Release........................................................................................... G-3 Examination Guidelines .............................................................................. G-4 Radiographic Guidelines ............................................................................. G-4 Patient Dental Records ............................................................................... G-5 Management of Medical Emergencies ........................................................ G-5 Infection and Biohazard Control .................................................................. G-6

CLINICAL GUIDELINES

Anesthesia/Sedation.................................................................................... G-7 Dental Hygiene............................................................................................ .G-7

Endodontics........................................................................................... ..... .G-8 Fixed Prosthodontics.................................................................................... G-8

Occlusion/ TMD........................................................................................... .G-9 Operative..................................................................................................... .G-9

Oral and Maxillofacial Surgery....................................................................G-10 Orthodontics................................................................................................G-10

Pediatric Dentistry.......................................................................................G-11 Periodontics................................................................................................G-11

Preventive Dentistry....................................................................................G-12 Removable Prosthodontics.........................................................................G-12

POLICY COMPLIANCE................................................................................. G-13

Health and Safety Manual 2008-2009

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FOREWORD In support of the mission of the University of Oklahoma College of Dentistry, the clinical facilities provide an environment where the knowledge and technical abilities gained in the classroom and laboratory can be applied through the clinical treatment of patients. The College is committed to the philosophy of comprehensive patient care (CPC) -- the provision of all dental services needed by patients accepted for treatment in the pre-doctoral program. While clinical program parameters may restrict the type and complexity of the services the student, will personally render, his/ her training will include appropriate interactions with dental specialties, in-house graduate/residency programs and, on occasion, extramural referrals for dental care that may be beyond the student’s knowledge, skills and expertise. In this way, the commitment to the CPC concept is continually stressed. This commitment is vital to the College's mission of graduating the competent dental practitioner with not only the technical abilities to render general dental care, but also the judgmental maturity to recognize his/ her limitations and to seek the assistance of more qualified colleagues in the interest of addressing the patient's total dental needs. The delivery of dental care requires the interaction and integration of many dental disciplines. It is imperative that the student has a working knowledge of the procedures he/ she will be expected to perform in each discipline. Entry into the clinical phase of dental education implies that the student has mastered the basic procedures of these disciplines and can now apply his/ her skills and knowledge to the actual treatment of patients. Of equal importance is the ability to coordinate and integrate the demands of each clinical discipline into a coherent whole. Becoming familiar with the operations of the clinics initially may seem an overwhelming and bewildering task as the student will encounter multiple clinic policies, protocols, and procedures that define what can and cannot be done in given clinical scenarios. It is therefore imperative that the student’s introduction to the clinical program and the policies that govern its operations be as complete and thorough as possible. The student will be afforded the opportunity to apply his/ her knowledge of the science and art of dentistry to the equally important business and practice of dentistry. These are challenging objectives and success in this phase of the educational process, will in many ways be the most accurate benchmark of success following graduation. This manual is a reference to assist the student’s understanding of what will be expected in the clinics and to facilitate the student’s transition from the classroom and laboratory to the clinical setting. It is primarily devoted to those policies and protocols that will govern general clinical activities; specific departmental objectives and minimum clinical experiences are outlined in manuals and handouts distributed by the individual departments and should be consulted for the most accurate information regarding departmental requirements. The student is expected to be thoroughly familiar with the contents of this manual and to consult it as often as necessary to facilitate his/ her clinical experiences. It will be assumed that the student clearly understands and abide by the policies and procedures contained herein. Failure to adhere to published protocol cannot be blamed on ignorance! Even if a given circumstance or situation is not addressed in this manual, the student will be expected to seek clarification and guidance before he/ she act.

Section A

General Information &

Clinic Guidelines

CLINIC OPERATIONS Management of the pre-doctoral and baccalaureate clinical program is the primary responsibility of the Department of Clinic Operations which monitors or directs the following: clinic appointments and unit assignments; clinic and rotation schedules; patient assignments; clinic finances; equipment and supplies inventory/ requisition; patient questions and information; patient recordkeeping and chart audits; sterilization; infection control protocols; hazard communications training; adverse incident reports; general clinic policies; third-party insurance claims; and patient account management. The primary purpose of the Clinic Operations staff is to help the student through the educational process as smoothly and seamlessly as possible. The student is expected to treat all staff with professionalism, courtesy, and respect at all times; and the student is entitled to the same in return. If you experience a problem with any staff member the student should maintain a professional attitude and make every effort to resolve the problem. Issues that cannot be resolved with the staff member or their immediate supervisor will be addressed by the Assistant Dean for Clinics (Director of Clinics) after completion of a “Professional Conduct Report” by the student and the staff member or their immediate supervisor. The major staff divisions in Clinic Operations are [1] Office of Patient Management, [2] Information, [3] Central Business Office, [4] Central Sterilization, [5] Clinic Dispensaries, and [6] Equipment Service/Maintenance. Specific positions, names of current staff, and a summary of duties in these areas are as follows:

ADMINISTRATIVE

Assistant Dean for Clinics (Director of Clinics): Jeanne C. Panza, D.M.D. Room 240A Responsibilities include the overall management of the pre-doctoral and baccalaureate clinic programs. Assistant Director of Clinics/Patient Advocate: Kathryn F. Miller, R.D.H., M.Ed. Room 240 Assists the Assistant Dean for Clinics in overall management of the pre-doctoral and baccalaureate clinic programs.

OFFICE OF PATIENT MANAGEMENT

Staff Assistant: Ms. Linda Hale Room 239 Responsibilities include the supervision of the Office of Patient Management. Also responsible for developing the clinic schedules, overseeing patient management, patient assignments for limited care, patient transfers, monitoring treatment progress, assisting in chart audits, and patient completions. Assists the Assistant Dean and Assistant Director for Clinics in the overall administration of Clinic Operations. Supervisor: Dr. Jeanne C. Panza, Assistant Dean for Clinics

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Patient Services Representative: Patty Dodson Room 238

Receives and documents incoming patient phone calls, coordinates release of records (duplications), enters patient profiles in Quick Recovery and assists the Patient Advocate. Supervisor: Ms. Linda Hale, Staff Assistant

Dental Hygiene Patient Care Coordinator: Position Vacant (DHI and DH II) Room 238 Responsible for patient assignment in Quick Recovery and Filemaker, monitoring treatment progress, patient release, maintenance of student information packets, assisting in chart audits, student advising on Clinic Operations policies, enters data from appointments into Filemaker, the dental hygiene database. Dental Hygiene Patient Scheduler: Robin Vinson (DH I and DH II) Room 238 Enters appointments in Quick Recovery, enters patient data into the dental hygiene patient database, assists the Dental Hygiene Patient Care Coordinator. Supervisor: Kathryn F. Miller, R.D.H., M.Ed., Assistant Director of Clinics

OFFICE HOURS: 8:00 a.m. – 5:00 p.m. Clinic Attendance and Forms Coordinator: Sandi Powell Room 234 Responsible for coordinating clinic attendance in the pre-doctoral program with printed daily schedules, late tray entries, rotations, and student assisting for an accurate overview of the student’s individual clinic utilization. Also coordinates the management and inventory of forms for the pre-doctoral and baccalaureate programs. Supervisor: Ms. Janet Jones, Senior Administrative Assistant OFFICE HOURS: 8:00 a.m. – 5:00 p.m. Chart Room: (Senior Records Clerk) Rick Stuecken, (Records Clerk) David Railback Responsible for printing all daily Clinic Schedules, Encounter Forms, and preparation of all charts for clinic. Also responsible for maintaining patient charts in student families, assembling new charts, processing charts for late tray requests, and compiling student’s patient family of charts for chart audits. Rick Stuecken will also build and maintain clinic schedule templates. Supervisor: Ms. Linda Hale, Staff Assistant OFFICE HOURS: 7:00 a.m. – 4:30 p.m.

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INFORMATION DESK

Front Desk Receptionist: (Jo Rumley) Room 101 Responsible for greeting all patients and visitors, routes incoming telephone calls, logs and routes troubleshooting calls, coordinates service order requests, manages student telephone message system. Supervisor: Ms. Janet Jones, Senior Administrative Assistant FRONT DESK HOURS: 7:30 a.m. – 4:30 p.m.

OFFICE OF EQUIPMENT SERVICE

Service Equipment Installer II: (Rocky Polk) Room 135 Primarily responsible for the service, maintenance, and replacement of clinic equipment, student hand-piece repair, and general troubleshooting. Supervisor: Ms. Kathryn F. Miller, Assistant Director for Clinics Service Equipment Installer II: (Darryl Vogt) Room 135 Primarily responsible for the service, maintenance, and replacement of pre-clinic laboratory equipment in Rooms 433 and 301. Supervisor: Ms. Kathryn F. Miller, Assistant Director for Clinics Preclinical Laboratory: (Ron Ackerson) Room 433 Responsible for stocking and cleaning the preclinical simulator lab and senior lab. Supervisor: Darryl Vogt, Service Equipment Installer OFFICE HOURS: 7:00 a.m. – 4:00 p.m.

CENTRAL BUSINESS OFFICE

Technical and Billing Administrator: (Tammy Vogt) Room 265 Supervises the Central Business Office and assumes responsibility for a complex, high volume bookkeeping/accounting system for all pre-doctoral dental students, dental hygiene students, and Graduate Periodontics. Supervisor: Dr. Jeanne C. Panza, Assistant Dean for Clinics

Patient Account Representatives: Linda Bahr, Meme Jackson, Tina Miller, Van Bell, Rachel Jackson, Sylvia Alden Responsible for managing patient transactions, arranging finance plans, processing insurance claims and coordinating payments from public service agencies, refunds and collections. Supervisor: Ms. Tammy Vogt, Technical and Billing Administrator OFFICE HOURS: 8:00 a.m. – 5:00 p.m.

A-3

CENTRAL STERILIZATION

This area oversees the sterilization needs of the entire College, which include the pre-doctoral and baccalaureate programs, all graduate programs, and the intramural faculty practice. This area is staffed by 2-3 personnel. Supervisor: Ms. Linda Tarlton, Dental Clinics Staff Supervisor

Environmental Compliance Coordinator: Mary Gowin Room 232 Responsible for managing all adverse incident reports, faculty/staff training in infection control and hazardous waste management, liaison with OUHSC Environmental Safety, OSHA, and other regulatory agencies. Supervisor: Ms. Kathryn F. Miller, Assistant Director for Clinics

CLINIC DISPENSARIES Each clinic is staffed by 1-2 dispensary clerks who manage equipment/supplies inventory, storeroom restocking, cleaning of clinics, and student needs when clinics are in session. All clinic dispensary staff are employees of the Department of Clinic Operations except those in Oral Diagnosis, Oral Surgery, the graduate programs, and the intramural faculty practice. Supervisor: Ms. Linda Tarlton, Dental Clinic Staff Supervisor CLINIC HOURS: 8:30 a.m. – 12:00 p.m. and 12:30 p.m. – 4:00 p.m. Clinic staff must clean the clinic and inventory and stock supplies before and after clinic sessions. Please do not request clinic instruments and equipment before 8:30 a.m. and 12:30 p.m. to allow clinic personnel to make these preparations uninterrupted. Dental Clinics Staff Supervisor: Linda Tarlton Room 232 Responsible for primary supervision of pre-doctoral clinic staff, management and monitoring of daily work schedules, clinic management upkeep, chart forms, and equipment inventory. Coordinates coverage for the information desk. Supervisor: Ms. Kathryn F. Miller, Assistant Director for Clinics

A-4

MAIN TELEPHONE/ ROOM NUMBERS

The Front Desk Receptionist can help you locate specific faculty, staff, or areas you are seeking. Some of the more commonly requested numbers are listed below. To reach any in-house number, press "1" if the extension is four digits. AREA (ROOM NUMBER) EXTENSION Clinic Operations: Assistant Dean for Clinics, Dr. Jeanne C. Panza (240A) 34134 Assistant Director for Clinics, Ms. Kathryn F. Miller (240) 34143 Senior Administrative Assistant, Janet Jones (232) 34136 Office of Patient Management: Staff Assistant, Supervisor, Linda Hale (239) 34135 Patient Services Representative Patty Dodson (238) 1-5422 Dental Hygiene Coordinator (Room 238) 34145 Dental Hygiene Scheduler (Room 238) Robin Vinson 34149 Central Business Office: Technical and Billing Administrator, Tammy Vogt (265) 34137 Billing (295) 1-4711 Insurance, Tina Miller (267) 1-4840 Patient Records (266) Rick Stuecken, David Railback 34147

Clinics:

Dental Clinic Staff Supervisor, Linda Tarlton (232) 34131

Blue (306) 1-5056/ 1-4839 Brown (261) 1-6332/ 1-6333 Burgundy (330) 1-4008/ 1-4009 Gold (370) 1-6532/ 1-6533 Green (406) 1-6953 Oral Diagnosis - Dispensary (289) 1-4945 Oral Diagnosis - Radiology (281) 1-5687 Oral Diagnosis - Reception Desk (280) 1-6056 Oral Surgery (206) 1-4079 Yellow/Orange - Dispensary (431) 1-4899 Yellow/Orange - Reception Desk (436) 1-2360

Equipment Servicing: Rocky Polk, Darryl Vogt (135) 1-6326

Information Desk: Jo Rumley (101) 1-6326 Sterilization: Diana Gorham, Victor McDaniel, Lisa Anderson 1-5350

A-5

Other: Dean's Office (507) 1-5444 Dental Support Laboratory (349) 1-4565 Pre-Clinic Laboratory (433) 1-6462 Graduate Programs AEGD (305) 1-5222 Graduate Orthodontics (449) 1-4148 Graduate Periodontics (274) 1-6531 Oral Surgery (206) 1-4079 Student Store (133) 1-5560

A-6

ARRANGEMENT OF CLINICS The pre-doctoral clinics are discipline-specific. That is, the nature of services needed determine in which clinic treatment would be rendered. Located on the second, third, and fourth floors of the Dental Clinical Sciences Building (DCSB), these clinics are as follows:

FLOOR CLINIC DISCIPLINE 2nd Oral Surgery Oral Surgery Oral Diagnosis Screenings/Emergencies/Radiology Brown Periodontics 3rd Gold Operative Dentistry Blue Fixed Prosthodontics Burgundy Removable Prosthodontics/ Implantology 4th Yellow/Orange Pediatric Dentistry/ Orthodontics Green Endodontics/ Dental Hygiene Four graduate/residency clinical programs maintain clinical facilities in certain clinics. Graduate Periodontics - Brown clinic; Advanced Education in General Dentistry (AEGD) - Blue clinic; Graduate Orthodontics - Yellow/ Orange clinic; and Oral Maxillofacial Surgery in Oral Surgery clinic.

Clinic Dispensaries Each clinic has a central dispensary staffed by one or two clinic dispensary clerks responsible for the distribution of instruments, equipment, charts, anesthetic, and other materials and supplies checked out by request. Dispensary areas are off limits to students at all times. Each dispensary is stocked with the equipment and supplies necessary for all dental procedures governed by the respective discipline. Certain supplies (additional anesthetic carpules, radiographic film, amalgam capsules) require faculty approval before they will be dispensed. For other items (electro surgery kits, nitrous oxide, retentive pin kits, and temporary crown kits, etc.) you must fill out a checkout slip. You must return all checkout items by the end of the clinic period. If you do not, you will be charged the current replacement cost.

If you request nitrous oxide (written faculty permission in the chart is required), the dispensary clerk will check out a mobile unit assembly and key. When the key is issued, the clerk will stamp the Treatment Progress Notes section of your patient's chart with a Nitrous Oxide Analgesia Record (see below). This form must be filled out and signed by both you and the attending faculty. If you use nitrous oxide, remember to generate a fee under ADA procedure code #9230 (9000 in Pediatric Dentistry). NOTE: Mobile units are available in all clinics except Brown and Oral Surgery. In these two clinics, nitrous oxide is piped; each operatory has quick disconnects to the nitrous oxide and oxygen lines.

A-7

NITROUS OXIDE ANALGESIA RECORD

CLINIC LABORATORIES

The main student laboratory (Room 433) is used for most clinic-related laboratory work. However, most of the general clinics have an adjacent clinic laboratory area that provides convenient and quick access from your clinic operatory. Each area has sit-down bench spaces with air and gas outlets and quick-connects for hand pieces (tubing required). Also available are burnout ovens, casting wells, air-gas torches, model trimmers, vibrators, vacuum mixers, polishing lathes, and work sinks. Clinic laboratories are available for use Monday through Friday, 8:00am to 5:00pm. Evening and weekend laboratory work is limited to Room 433 and hours of access are from 6:00 a.m. – 12:00 a.m. To keep the clinic laboratories in a presentable condition, the following rules will apply:

1. Use white lab paper (available in each clinic laboratory) on counter tops. 2. Use water with model trimmers at all times. Flush with copious water to prevent

clogging. Turn off model trimmers when not in use. 3. Keep sinks free of excess stone, plaster, and impression material. 4. Do not change burnout oven settings. 5. Keep personal possessions, instrument boxes, articulators, casts, etc. to the

minimum necessary to do your work. 6. Bring your own mixing bowls, spatulas, and hoses for vacuum mixers and hand

pieces. 7. Do not use these areas for social gathering. These activities should be confined to

the Student Commons. 8. Please pick up after yourself.

A-8

CLINIC HOURS Clinic sessions are 9:00 a.m. to 12:00 p.m. and 1:00 p.m. to 4:00 p.m. Every effort should be made to complete treatment, fill out all paperwork and have it signed by attending faculty, and turn in your instruments for sterilization by within the allotted clinic time as a courtesy to attending faculty and clinical staff. Good time management builds patient confidence. You are not permitted to provide any clinical treatment at times other than during the normal clinic periods without specific permission by a faculty member and that faculty member must be present in the clinic. Treating patients without direct faculty supervision is a serious infraction of OUCOD clinic policy that will result in loss of clinic privileges for a period of no less than 2 weeks and up to 1 month depending on the severity of the incident.

CLINIC ATTENDANCE

“Attendance in clinic is required unless the student is excused by the Course Director or the Director of Clinics. If not treating a patient, the student will be expected to be in the laboratory, or assisting other students in clinic”. (Source: OUCOD Student Handbook 2008-2009, page 33, “Attendance, Clinics”) You are expected to make use of every available clinic session. The minimum clinical experiences you must complete for promotion or graduation are easily attainable if your clinic time is used regularly and consistently. Departmental minimum clinical experiences have been structured with the understanding that every student will experience an occasional patient cancellation or no show. However, other unanticipated circumstances (illness, weather, etc.) may also result in some clinic sessions not being utilized.

PROCEDURE FOR REPORTING ABSENCES Unanticipated absences, (i.e., personal illness, family emergency, transportation problems, etc.) are to be reported to Carla Lawson, Office of the Dean 271-5444 on the date the absence occurs and before the missed class/clinic ends on that date. In the case of unanticipated absences necessitating cancellation of a patient or patients, it is your responsibility to notify the patient directly and the office of the Director of Clinics 271-5422. Anticipated absences, (i.e., family events, advanced program interviews, personal business, doctor appointments, official University business etc.) should be discussed with appropriate faculty prior to the time of the absence so arrangements can be made for make-up work. The absence should also be reported to the Dean’s Office as soon as you are aware of the event. (Source: OUCOD Student Handbook 2008-2009, “Proper Procedure for Reporting Absences”) All absences are to be reported to the Office of the Dean for documentation; however, this does not excuse the absence; arrangements must be made with individual course directors for make-up. A-9

DRESS REGULATIONS

The doctor/patient relationship is a cornerstone of your future professional career. The faith and trust of your patients is directly related to their assessment of your professional decorum, your habits and attitudes, and your personal appearance. Because patient care is delivered in the College of Dentistry throughout the year, it is important that all students, whether in clinic, pre-clinic, or classroom areas maintain a professional appearance at all times. Therefore this policy is in effect from 7:30 a.m. to 5:30 p.m. Monday through Friday. (Source: OUCOD Student Handbook 2008-2009, “College of Dentistry Dress Code”)

General Appearance Although there is no restriction on a student’s hair length, long hair must be kept pinned up while in clinic and in the pre-clinic laboratory. Hair must be kept clean, neat, and out of the patient’s face and operator’s eyes. Moustaches and beards must be neatly trimmed. The remainder of the face must be clean-shaven. No jewelry worn in facial body piercing (other than ear lobes) is allowed.

General Attire

Acceptable: Dresses, skirts of professionally appropriate length, dress slacks, casual or dress shirts with collars or blouses (long or short sleeve), polo type shirts with collars, and sweaters. Most types of footwear are acceptable as long as they are clean and presentable. Socks or hosiery must be worn when appropriate. Jeans are discouraged; however, if worn, they must be neat and clean, with no holes, tears or frayed fabric. Unacceptable: Rubber flip-flops, shorts, T-shirts, baseball caps or other hats. Bare midriffs, exposed undergarments, and improperly fitting clothing are expressly prohibited

Clinical Attire Professional appearance should be maintained at all times by all students. Going to and from a clinic laboratory will require the appropriate clinic attire. Hands must be clean and well manicured with fingernails short and free of nail polish to ensure efficient work and cleanliness. Artificial nails are not permitted. Certain jewelry, rings (with the exception of smooth surface wedding rings), watches, long necklaces, or large earrings must be removed during patient treatment to avoid any unnecessary collection of microorganisms and possible cross-contamination. Clothing such as jeans, shorts, and open-toed sandals and bare ankles are not allowed in clinics.

Scrub tops and pants are required as general clinic attire; you are to wear the color assigned to your class. Scrubs are issued as part of your student kit; you are responsible for laundering them. A white short-sleeve tee shirt or a tee shirt matching the color of the scrub top may be worn under the scrub top provided no writing or design is visible and the shirt hem of the tee shirt is worn inside the scrub pants. Shoes must be white, clean and in the judgment of the attending clinical faculty, appropriate for clinic. High-tops, clogs, sandals, and heels are expressly prohibited. Socks covering the ankles are required. To protect your family at home, these scrubs and shoes should not be worn as part of your normal dress.

A-10

If replacement scrubs are required, they must be purchased from The Uniform Shoppe and be identical to the original issued scrubs in both manufacturer and color. They must also be monogrammed with the student’s name above the pocket. You must wear a long-sleeve gown (provided in each clinic) for procedures where splatter with blood or saliva is likely. Gowns may not be worn outside the patient treatment area! Contaminated gowns must be turned in at the end of the clinic session in the designated container. The College will provide and launder these gowns, but will assume no responsibility for protecting or laundering street/work clothes worn under the gowns. Violations of this policy will be handled in the following manner:

First offense: Written warning (copy to Assistant Dean for Clinic Affairs). Second offense: Written reprimand (copy to Director of Admissions and Student Affairs). Third offense: Appearance before the appropriate Periodic Review Committee, which could result in further disciplinary action.

PAIRING OF STUDENTS

All freshman and sophomore dental students must work in pairs while in clinic. Junior and senior dental students work solo during all clinic sessions except when in the pedo/ortho clinic where pairing is required. Additionally junior students may be paired for specific courses involving patient treatment in Removable Prosthodontics. For dental hygiene students, pairing is required only during the fall semester of the first year. The Department of Periodontics determines the initial pairing of students in the freshman class; the Department of Dental Hygiene pairs hygiene students. You are required to work with your designated partner at all times when pairing is required. Failure to observe the clinic pairings in scheduling patients will result in clinic suspension the length of which will be at the discretion of the Clinical Course Director. You are also expected to share available clinic sessions so that you and your partner have access to an equal amount of time for treatment of your respective patients. Because student pairings are used in the development of rotation schedules, you may not switch partners without the approval of the Director of Clinics. For pairs wishing to change partners, all four students involved must personally inform the Director of Clinics that they agree to the switch. Even if all parties agree, the request will be postponed if there is any potential adverse impact on rotation schedules. If your partner is absent during a clinic session when pairing is required, notify the attending faculty member in that clinic who will determine the appropriate course of action. In most instances, you will be required to find another classmate to assist you.

A-11

CLINIC SCHEDULES

A clinic schedule is published each semester that indicates the disciplines providing clinic coverage on each half-day of the week and when specific clinics are closed for cleaning and re-stocking supplies. The schedule will also indicate the student academic class (DS II, DS III, DS IV) and the maximum number of students that can sign up in each clinic session. Copies of the clinic schedule will be distributed to the students either through their student mailbox or e-mail. Additional copies can be obtained from Linda Hale in the Office of Patient Management in Room 239. Clinics are restricted solely to the academic classes designated on the clinic schedule. You may not use clinic at any time that your class is scheduled to be in lecture or laboratory. If one of your patients needs emergency care during a time when you do not have access to clinic, you must get written permission from [1] the course instructor to be excused from class and [2] the attending clinical faculty to be allowed into clinic to treat the emergency.

A-12

BLOCK ROTATIONS

During the third and fourth years, each dental student is required to participate in a number of clinical rotations. The Assistant Director of Clinics develops rotation schedules with input from the departments involved. Scheduled rotations always take precedence over regular clinic time; when you are on rotation, you must attend every assigned session. You may not treat patients in other clinics when you are on rotation without the permission of the department conducting the rotation and the department covering the clinic in which you wish to work. Once published, rotation schedules are final. Any requested changes in the schedule will be considered only if approved by the involved department and the Assistant Director of Clinics and if such changes will not compromise the student coverage necessary to staff the rotation. Current rotations are listed below (subject to annual change). Your personal schedule will identify which weeks of the semester you are assigned. The actual number of sessions devoted to a rotation during a given week will be determined by the department involved. Unless otherwise indicated, rotations are one week in length.

FALL - 3RD YEAR SPRING - 3RD YEAR Oral Diagnosis Oral Diagnosis Oral Surgery Oral Surgery Pedo Screening Pedo Emergency Pedo Emergency Pedo Screening Dental Support Lab Hospital

SUMMER - 3RD YEAR Oral Diagnosis Pedo Screening Pedo Emergency Implantology

FALL - 4TH YEAR SPRING - 4TH YEAR

Oral Diagnosis Oral Diagnosis Oral Surgery Implantology Implantology Externship (2 weeks)

Oral Diagnosis rotation: either DS III spring or summer (not both). Implantology: Monday a.m., Tuesday a.m. & p.m., Wednesday a.m., Thursday p.m., Friday a.m. and p.m. either DS III summer or DS IV fall, or DS IV spring (not all).

The Assistant Director of Clinics schedules all rotations except externships. Externships are scheduled by the Department of Dental Services Administration.

A-13

MINIMUM CLINICAL EXPERIENCES

The minimum clinical experiences in periodontics, operative dentistry, endodontics, removable prosthodontics, and fixed prosthodontics are summarized in the next few pages. Other clinical disciplines (oral diagnosis, orthodontics, pediatric dentistry, occlusion, and oral surgery) also have specific expectations; however, their minimum clinical experiences are generally managed in conjunction with other departments or through clinic rotations. For specific information regarding these disciplines, consult with the individual departments and/or appropriate clinic manuals*.

PERIODONTICS Minimum clinical experiences are based on a given number of periodontal patients treated and competency examinations. Patients must be classified as Case Difficulty II or greater to count toward periodontal graduation minimum clinical experiences. Patients are assigned a Case Difficulty level based on their diagnosis and degree of instrumentation difficulty. Refer to your perio manual and to information posted in the Oral Diagnosis clinic regarding criteria for classification of periodontal patients. Current minimum cumulative clinical experiences are as follows:

NO. OF COMPETENCY SEMESTER TREATMENT PATIENTS EXAM DS-2 Fall Diagnosis and treatment planning 1 Instrumentation Two quadrants scaling/root planing (S/RP) DS-2 Spring Diagnosis and treatment planning 3 Videotaped Phase I reevaluation 1 Plaque Control

DS-3 Fall Diagnosis and treatment planning 5 Diagnosis & Phase I reevaluation 3 Treatment MT/CMT/case credit 1 Planning

DS-3 Spring Diagnosis and treatment planning 6 Phase I reevaluation 4 Phase I re-eval or MT/CMT/case credit 3 S/RP First surgery + a 1 week post-op DS-3 Summer Diagnosis and treatment planning 6 Phase I reevaluation 6 Phase I re-eval MT/CMT/case credit 4 or S/RP

DS-4 Fall Diagnosis and treatment planning 6 Phase I reevaluation 6 MT/CMT/case complete 5 Second surgery (including post-op visit) DS-4 Spring Case Credit 6 Mock Board

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At least two sextants of periodontal surgery on your own patients are required for graduation. At least two of your six cases required for graduation must be Case Difficulty III. You must maintain all assigned MT/CMT patients at the faculty recommended interval (usually every three months) up to the time you graduate to receive full perio case credit. Three half-days of assisting or observation in perio surgery will count as one perio case credit. Perio surgery assisting/observation must follow the "Periodontal Surgery Protocol" lecture presented in Periodontics II (PERI 7791). This option can only be used once. Assisting/ observation does not have to involve your own patients.

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MT - PERIODONTAL MAINTENANCE THERAPY

CMT - COMPROMISED MAINTENANCE THERAPY

The maintenance phase is an essential component of successful periodontal treatment. The benefits of active periodontal treatment - both surgical and non-surgical - may be eroded over time without continuing patient assessment and appropriate care. The overall objective of maintenance therapy is to preserve health and prevent recurrence of disease. The appropriate time interval (normally 3 months) to the next maintenance appointment (CMT/MT) should be clearly written on the grade slip and in the patient's treatment progress notes. This interval will be confirmed by the instructor's signature on these documents. Students should consult with the instructor regarding any questions that they may have about establishing the proper time interval for each patient. A. COMPROMISED MAINTENANCE THERAPY (CMT) 1. At Phase I reevaluation, a decision may be made to place a patient ideally

requiring periodontal surgery on CMT instead due to one of the following: a. Plaque index > 20%. b. Inadequate financial resources for surgery. c. Medical or psychological contraindications to surgery. d. Disease so advanced that periodontal surgery would provide minimal improvement in long-term prognosis. e. Patient availability problem. 2. Protocol for placing patients on CMT: a. The informed consent for compromised maintenance treatment form must be signed by the patient. This form may be obtained in Brown Clinic and is to be placed in the Perio Section of the patient's chart. b. The patient must be maintained at the maintenance interval specified by the Periodontics faculty member as long as the patient is assigned to the student. Reasons for any variance must be documented. 3. The treatment at each compromised maintenance appointment will include

plaque index, OHI, tissue evaluation, probing depths, removal of all supra and sub-gingival plaque, scaling and root planing, as needed, polishing, and fluoride treatment.

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B. PERIODONTAL MAINTENANCE (MT) Patients who do not require any periodontal surgery at - phase I re-evaluation

and surgical patients who are determined at their 12-week post-surgical re-evaluation appointment not to need any more surgery will be placed on MT. The student must continue to see the patient for MT at the prescribed interval as long as the patient is assigned to the student.

The treatment at each periodontal maintenance appointment including the 12

week post-surgical reevaluation appointment will include plaque index, OHI, tissue evaluation, probing depths, removal of all supra and sub-gingival plaque and calculus, scaling and root planing as needed, polishing and fluoride treatment.

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OPERATIVE DENTISTRY

Minimum clinical experiences are based on a point system where more credit is assigned for increasingly complex procedures. There are three major categories of minimum clinical experiences: Class II restorations (110 points), Composite restorations (60 points), and other restorations. The Class II restorations category includes all restorations including at least one proximal surface, there is an additional requirement that at least 20 of these points are Class II restorations and at least twenty of these points are composite Class II restorations. The Composite restoration category includes Class I, III, IV, V, and VI composite restorations. The Other restoration category includes all other types of restorations, including those that exceed minimum clinical experiences required in the Class II and Composite categories. We require a certain minimum requirement for clinical experiences during each semester in an effort to prevent the student from falling behind in their clinical development. Current minimum clinical experiences are as follows:

SEMESTER TREATMENT # OF POINTS* DS-2 Fall No minimum clinical experiences 0 DS-2 Spring As necessary; no specific categories required* 15 (Up to 16 pts may be satisfied by assisting upper classmen) (Must complete 6 patient Master Treatment Plans prior to initiating any restorative treatment in the operative clinic) DS-3 Fall As necessary; no specific treatment categories required* 50 DS-3 Spring As necessary; no specific treatment categories required* 120 DS-3 Summer As necessary; no specific treatment categories required* 170 DS-4 Fall As necessary; no specific treatment categories required* 250 DS-4 Spring Class II restorations (110 points)* 410 20 points must be amalgam Cl II 20 points must be composite Cl II Composite restorations (60 points)*- Class I, III, IV, V, VI Other restorations (240 points)*

*During the accumulation of the above minimum Treatment Experiences, the student must complete a total of at least four pin-retained restorations. Specific clinical performance examinations are required during each grading period beginning with the DS-3 fall semester. Points earned for these examinations count towards the cumulative totals. If a student completes the minimum points of clinical experience required during a clinical grading period, they will receive the grade they earned based on the quality of the work observed in their daily and clinical performance examinations. If a student does not complete the minimum clinical experiences required for a grading period, they would receive a grade of “F”, or “I”, based on their specific situation.

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While there are no specific “category” minimum clinical experience required for any grading period except the DS-4 Spring semester, it is strongly recommended that the student work toward satisfying some of the minimum clinical experiences for each category during each grading period.

ENDODONTICS

SUMMARY MINIMUM CLINICAL EXPERIENCES TREATMENT MINIMUM CLINICAL EXPERIENCES BY COURSE NUMBER

Course Title Course No. # of Canals # of Recalls (suggested)

Endo I 8205 2* 0 Endo II 8305 3** 0

Endo III 8405 3*** 0 Endo IV 9205 6*** 0 Endo V 9305 5*** 6

Cumulative Totals 19 6 recalls Minimum Clinical Experience Totals for Graduation: 19 Canals 11 Points (for miscellaneous endodontic procedures), of which 3 Recall points / 3 Endodontic Recalls (one point each for an endo recall) 4 Post & Core points / 2 P&C’s* (2 points each for a post & core) 4 Points from any of several possible miscellaneous endo procedures (SEE SECTIONS I, E-G of the Endodontic Clinic Manual) * Class I - Anteriors and premolars preferred, molars by faculty approval. ** Class I - Anterior, premolar, and molars. Class II - Anteriors and premolars by faculty approval. *** Any tooth - Class I or Class II Note accepted Class III Cases may be performed in Specialty Assisted Care Clinic with faculty prior approval during any semester. *Post and core credits for Endodontics must be completed in green endodontic clinic under the supervision of endodontic faculty

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FIXED PROSTHODONTICS FPD utilizes a point and category system similar to Operative Dentistry. However, point credit is based not only on type/complexity of treatment but also on the grade received. Any restoration earning an overall grade of less than 7.2 receives no point credit. The current minimum requirement is 224 points, which are assigned based on the grade earned, multiplied by a difficulty factor for the given procedure. Consult your FPD clinic manual for further details. Accumulated points must include at least one bridge. All other restorations in FPD are your choice, dependent on the needs of your patients. Current minimum clinical experiences (semester/cumulative) are as follows:

# OF POINTS SEMESTER TREATMENT Semester/Cumulative DS-3 Fall/ Spring As stated in the FPD clinic manual 21 This is a yearlong course DS-3 Late Spring As stated in the FPD clinic manual 21/45 DS-4 Fall As stated in the FPD clinic manual 21/69 DS-4 Spring As stated in the FPD clinic manual 21/224 The departmental manual equates the 224-point requirement to approximately 29 units of FPD work, but this is complicated by the grading factor. For example, if you earn a “C” for a metal-ceramic crown (difficulty factor 1.5), you will earn 11 points. A grade of “A” for the same crown would earn 13.5 points. Early planning for FPD is required since virtually all other needed treatment (except dentures) usually precedes crowns and bridges. Since FPD procedures require multiple appointments and laboratory work, many weeks (and sometimes months) are involved before any credit is earned. You must anticipate FPD needs at least one semester in advance. Goals for DS III’s in Blue Clinic Fall/Spring Semester 21 cumulative points (2-3 crowns) At the very least, you should have finalized treatment plans for all of your current FPD patients and complete your initial crown by the end of the fall semester junior year. Late spring Semester 21 semester points, 45 cumulative points (3 crowns or 3-unit FPD) Clinical Competency Exam

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REMOVABLE PROSTHODONTICS GRADUATION REQUIREMENTS: Complete dentures and immediate dentures 12 units (4 arches) Removable partial dentures 12 units (2 arches) Relines, repairs, TX partials, misc. 13 units Competency Examinations 3 units Total Units Required 40 units MINIMUM CUMULATIVE QUANTITY OF CLINICAL EXPERIENCES BY SEMESTER TO BE ELIGIBLE FOR GRADE OF:

“C” “B” “A” CUMULATIVE UNITS

FALL JUNIOR YEAR 1 UNIT 5 UNITS 8 UNITS 8 UNITS SPRING JUNIOR YEAR 9 UNITS 13 UNITS 16 UNITS 16 UNITS SUMMER JUNIOR YEAR 17 UNITS 21 UNITS 24 UNITS 24 UNITS FALL SENIOR YEAR 25 UNITS 29 UNITS 32 UNITS 32 UNITS SPRING SENIOR YEAR 33 UNITS 37 UNITS 40 UNITS 40 UNITS

*INFORMATION PRESENTED ABOVE CURRENT TO 07/08 FOR THE 2008-2009 YEAR

TREATMENT PLANNING CLINIC

Treatment Planning Clinic (TPC) is designed to expedite the treatment planning process and provide complex treatment planning experience. Unlike the regular discipline-specific clinics that are staffed only by faculty of one department, the Treatment Planning Clinic is staffed by faculty from six disciplines: Oral Diagnosis, Periodontics, Operative Dentistry, Occlusion, Fixed Prosthodontics, and Removable Prosthodontics. This clinic allows you to determine treatment needs without having to take your patient to a number of different clinics. Limited availability of faculty restricts this clinic to two half-days per week. It is available to DS III and DS IV students only; DS II students are expected to use regular clinics for their limited treatment planning needs. A maximum of 14 students may use the TPC each session. The intent of this clinic is to expedite the treatment planning process by making multiple disciplines available in one area, therefore you may not schedule patients in the TPC if consultation with only one or two disciplines is needed (Exception: RPD which requires all treatment planning in this clinic). Treatment plan such cases with the general clinics so that TPC chairs are available for more complex treatment plans.

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GENERAL CLINIC PROTOCOL

During clinic appointments remove all items not related to treatment (books, knapsacks, notes, etc.) from operatory counter tops and place them on the floor or tucked under counters. Reserve counter tops for instruments and supplies needed for treatment and for the patient's chart. Never seat your patient until after your armamentarium is set up and your operatory prepared. For prosthodontic procedures done at the operatory, place white lab paper on the counter tops. Use the adjacent clinic laboratory for routine laboratory procedures; do not do laboratory work in clinic operatories. Refer to Section G (Care of the Operatory and Clinic Setup) for the appropriate infection control procedures to use for each clinic appointment. After your patient has been dismissed, reposition your operatory equipment as follows:

1. Return dental chair to an upright position, place rheostat on a paper towel and place on the chair seat then raise the chair to at least the length of the rheostat cord.

2. Reposition dental lamp and hand-piece unit over the center of the chair seat. 3. Return assistant carts to their position under the operatory counter. Position

assistant cart to its lowest level so that it will fit under counter. 4. Position operator and assistant stools next to counters.

As health care facilities, the clinics must be kept as clean as possible and must present a desirable, safe, and professional image to the public. You are responsible for the cleanliness of the operatory assigned to you and for any clinic laboratory space you use. Food and drink may not be taken into operatories, reception areas, dispensaries, consultation rooms, and x-ray facilities. The College is a smoke-free environment; the use of tobacco in any form is strictly prohibited. No animals of any kind are allowed in the dental building (especially patient treatment areas) at any time without express written permission from the Dean.

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STERILIZATION

Central Sterilization (CS), located on the second floor, is responsible for the sterilization of all items and materials related to patient care in the College. The primary sterilization method is steam under vacuum pressure. Routine sterilization of instruments, burs, and hand-pieces is required for safe patient care in all clinic areas. All students are responsible for sterilization of their own equipment that is stored in Central Sterilization when not in use. Each student has a personal storage bin in the sterilization area where sterilized items are kept until requested. You may personally check out your student-owned items at any time. CS personnel will retrieve them for you; you are not allowed in the sterilization area at any time. You may not check out any equipment, instruments, or hand-pieces belonging to another student unless you present written authorization from that student. If you wish to give another student access to your equipment, you must notify the Supervisor of Central Sterilization in writing. The instrument delivery/pickup system in Central Sterilization is designed to minimize cross-contamination. This process is as follows:

1. Pick up sterilized burs, hand-pieces, cassettes, and other equipment from the Sterile Instrument Pickup window (Room 205).

2. If you have checked out an item from the dispensary, reconcile the checkout slip

when the item is returned. 3. Clean and package your hand-pieces. Clean your burs and any extra instruments

you may have. Place in sterilization bags. Bags are provided in each clinic or at the contaminated instrument return window. Identify all bags with your name and DS I, DS II, DS III or DS IV.

4. Deposit used cassettes and bagged items in contaminated return window 2nd floor,

room 264 located across the corridor from the Brown Clinic. Central Sterilization has automated washers to clean and dry instruments that are in cassettes. Cassettes are then bagged and sterilized. Sterilized cassettes and bagged items are returned to student storage bins.

Stay at the return window until you can hand your items directly to CS staff. If you leave your items unattended at the window, they will be logged in and sterilized; however, Central Sterilization will assume no responsibility for any reported loss, theft or damage of any items not properly logged.

Sterilization turn-around time is approximately 30-45 minutes for burs and hand-pieces and 1/2 day for prophy kits and cassettes. An initial morning load is run at 7:30am daily to accommodate morning clinic needs. Between 12:00 and 1:00pm, three loads are run to address afternoon clinic needs. All other loads are non-scheduled -- they are run when the cart is full or when there is a need for immediate sterilization. While turn-around times are short enough to accommodate sterilization between patients, there may be a few instances when hand-pieces are needed between sterilization cycles. In such instances, use of the STATUM STERILIZER located in Central Sterilization may be requested. Unwrapped instruments can be sterilized in 6 minutes and wrapped instruments in 12 minutes. Only 3 or 4 instruments can fit into the STATUM at a time. If necessary loaner hand-pieces may be checked out from the Central Sterilization (room 264). Immediately after patient use, they must be cleaned, bagged for sterilization and returned to room 264.

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Instrument Kits

Students will be issued instrument kits from Central Sterilization. Each student will be responsible for checking out his/her kit(s) and responsible for returning them to Central Sterilization for washing, sterilizing, and storing. Students will be responsible for any lost instruments and will be required to replace them as soon as possible. If an instrument is broken or defective it is the responsibility of the student to let a staff member in Central Sterilization know about the instrument, so that it can be replaced. Instrument Kits are not opened by Central Sterilization Staff once they are packaged and submitted for sterilization. STUDENTS ARE RESPONSIBLE FOR MAKING CERTAIN THAT ANY VISIBLE DEBRIS IS REMOVED FROM THEIR INSTRUMENTS PRIOR TO STERILIZATION, CENTRAL STERILIZATION STAFF DOES NOT CLEAN INSTRUMENTS AND WILL NOT ACCEPT INSTRUMENTS OR EQUIPMENT THAT IS VISIBLY SOILED. Student kits/instruments provided by The College of Dentistry are as follows: Composite Burs Exam Kit Fixed Burs Fixed Prosthodontics Kit I Fixed Prosthodontics Kit II Handpieces Operative Kit Operative Finishing Kit Operative Burs Prophy Kit I Prophy Kit II Restorative Kit I Restorative Kit II Removable Burs Student kits provided by the Student are as follows: Endodontics Kit

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DENTAL SUPPORT LABORATORY The College has an in-house dental laboratory to process crowns, fixed and removable partial dentures and complete dentures for student patients. These services are obtained via prescription (work authorization) only.

Support laboratory services are critical to the timeliness of patient care and hence to your attainment of minimum clinical experiences. To better ensure that your cases are expedited, be sure your submitted work authorizations are filled out properly and completely, including description of the required work, patient name, type of restoration and material required, case design, faculty and student signatures, and due date. If you need a case completed sooner than the published number of days normally required (refer to laboratory service schedule), you must obtain approval from the laboratory supervisor. Do not enter the laboratory area without permission; always check in at the receiving desk first. To submit an acrylic case to the laboratory, the Central Business Office must indicate the patient has a payment plan and must stamp the work authorization form.

Policies/Procedures Regarding Gold All cast gold used for patient treatment must be obtained from the Dental Support Laboratory. Do not use your own gold! The support laboratory will not replace any personally owned gold. To use the laboratory for your gold work:

1. Fill out a Casting Alloy Requisition ("gold card") form located in the forms rack in every clinic (see next page). Include your name and student number, patient's name and chart number, date issued (date turned in to the laboratory), and type alloy requested. The card must be signed by attending faculty who will determine the initial amount of gold needed.

2. Take the card to the Central Business Office to get it stamped. The

laboratory will not accept your gold card without this stamp. Stamping is required for all gold cards used for gold crowns, bridges, inlays, onlays, metal ceramic restorations, and cast dowel cores.

3. Present the gold card and FPD grade sheet to the laboratory (Room 346) at

which time the requested amount of gold will be issued. A work authorization is required if the support laboratory will be doing the casting; it is not required if you are casting your own restoration (e.g., Type III gold).

4. After casting, cut the gold button off as close to the restoration as possible

without distorting it. Return the casting, button, and any scrap retrieved from the casting well and/or crucible to the support laboratory. The gold will be weighed, the weights of the casting and button entered on the gold card, and the casting returned to you. You are responsible for all gold issued to you. Any gold loss exceeding the allowance of 0.20 dwt will be charged to you at the current school cost for replacement.

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Recasts: If you need gold for a recast, all gold from the original issue must be returned to the laboratory. A brief statement indicating a miscast will be entered on the original gold card. You must then present a new gold card (including faculty signature). The card does not have to be re-stamped by the cashier. New gold will be issued and a recast notation made on the new card referring back to the original card. This process can be repeated as necessary until a suitable casting is obtained.

Requisitioning Artificial Teeth

To request artificial denture teeth for partial dentures, complete dentures, denture repairs, etc., you must fill out a Tooth Order Form along with any other required documents. This form must include your name, patient's name, attending faculty signature, and the necessary information regarding the requested teeth (mold, shade, cusp form, porcelain or plastic, etc.). All Masel tooth requests must be paid in full prior to ordering (consult lab for current prices).

Working Time/ Service Schedule

The schedule below indicates the average time (in school days) necessary to complete the services listed. Any request for "rush" service requires the approval of the laboratory supervisor and at least 24 hours advance notice. Approval will be contingent on work volume in progress and faculty endorsement of the request.

DESCRIPTION OF SERVICE COMPLETION TIME

Occlusion rim................................................................................................... 3 Stabilized record base .................................................................................... 3 Tooth arrangement for try-in........................................................................... 5 Repairs 1 to 3 Crown/bridge burnout, cast & cut sprue (Olympia & Type III gold) 1 to 3 Porcelain/metal (MCR) - single units only ..................................................... 5 to 10

(Over 5 units will require additional time) Porcelain application bridge…………………………………………………….10 to12

(Over 5 units will require additional time) Soldering.......................................................................................................... 2 Veneers (NOTE: Check with lab in advance) ............................................... 10 min. Model work (pour & Pindex die) ..................................................................... 4 MCRs and FGCs (wax, cast & finish) - single units only.............................. 5 to 10

(Over 5 units will require additional time) Process/finish complete dentures .................................................................. 5 RPD framework ............................................................................................... 7 to 10

(Additional time required for tube teeth) RPD process/finish.......................................................................................... 5 Alter casts ........................................................................................................ 3 Reline/rebase (case received in lab before 12:00 noon).............................. 1 Microwave reline/rebase (in by 12:00 noon out by 10:00 a.m. next day) ... 1 Orthodontic appliances ................................................................................... 7 Relines and Repairs need to be scheduled with RPD.

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PATIENT PARKING

Your patients may park in the Children’s Physician’s Parking Garage, northeast of and across the street from the College. To the garage without being charged, the cashier on the second floor must validate your patient’s parking ticket. All patients must be escorted to the cashier’s area for payment upon dismissal. (If no payment is due and/ or no fee is assessed, the patient must still be escorted to the cashier). Patients may not park in the drive in front of the building. This area is reserved for handicapped parking and loading/unloading of patients only. If your patient is handicapped or has other legitimate reasons to park in this area, notify the Information Desk Receptionist who will provide an appropriate parking slip. Parking in this area without proper permission may result in your patient's car being towed at his/her expense.

CLINIC GOVERNANCE

The Director of Clinics has ultimate responsibility for clinic administration; however, advice and input is received from many clinic-related committees. Student representation on these committees that help govern clinical affairs and set clinic policy better ensures attention to student interests and concerns.

The Clinic Policies Committee The purpose of the Committee is to set policies and procedures for the operation of the

student clinics in the College of Dentistry. The Committee shall also review the composition of the dental instrument kits and coordinate procurement of instruments with the Dental Student Store.

The Committee shall consist of the clinical department chairs or designee recommended by the chair; the Assistant Director of Clinics, one junior and one senior dental student and one senior dental hygiene student. The Associate/Assistant Dean for Clinics will serve as the chair.

Health and Safety Committee

The Committee shall be responsible for establishing policies and procedures in infection control, hazardous waste management, and employee, student, and patient safety. The Committee shall ensure compliance with the various local, state, university, and national policies that regulate these areas. The Committee will annually review and revise the Health and Safety Manual as necessary.

The Committee shall be composed of selected clinical staff and faculty from each clinical division who shall serve three-year terms. The Assistant/Associate Dean for Clinics, the Environmental Compliance Coordinator, and Supervisor of Clinical Staff are permanent members of the Committee. The Chair is appointed by the Dean from membership of the Committee to serve a three-year term. Two student members are appointed by the Dean from nominations submitted by the Class Presidents of the dental and dental hygiene classes. Students serve one-year terms.

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Section B

Patient Management Policies

PATIENT SELECTION AND ASSIGNMENT

Patient Selection

All prospective patients are required to receive a screening examination in Oral Diagnosis to determine their suitability as patients in the clinical program. After a preliminary evaluation of the medical/dental history and status, he/she will either be accepted, rejected, or referred based on an assessment of many factors including potential value to the teaching program, ability to pay for treatment, availability for regular appointments, ability of dental students to provide necessary care, etc. The purpose of screening is to select suitable patients for treatment and to provide the student with diagnostic experiences. The student dialogue with the patient during initial screening is critical to their understanding and acceptance of the program and its parameters. Accepted patients are placed in the unassigned patient file to await future assignment. Screening charts are given to the Chart Room for chart assembly, then the Office of Patient Management staff for computer entry of the screening information into a Patient Profile. The screening forms are then photocopied and a sampling of the radiographs taken during screening are kept with the copied screening forms in an assignment book. Access to this book is limited to the Class Faculty Advisor making patient assignments. The charts are then returned to the Chart Room for filing. DS II / IV Faculty Advisor: Jeanne C. Panza, D.M.D. Assistant Dean for Clinic Affairs Course Director, OD 7615/ 7792 Patient Contact DS III Faculty Advisor: Kay S. Beavers, D.D.S. Associate Professor

Oral Diagnosis and Radiology

B-1

Patient Assignment

To request a patient, fill out a "Request for Patient Assignment" form (HSC -6295) located at the counter across from Room 238. Enter the student name, date, and student Quick Recovery number. There are several variations of the form; be sure to use the one that is designated for your class and appropriate semester. SOPHOMORE (DS II)- FALL SEMESTER: Patients are assigned early in the semester to build the student’s patient family and are made in an arbitrary way to distribute assignments evenly throughout the class. “Request for Patient Assignment” forms are generally not necessary unless requested by the Class Faculty Advisor. SOPHOMORE (DS II)- SPRING SEMESTER: Patient assignments made during this semester continue to satisfy limited requirements in the Periodontics and Operative departments. A student may fill out a “Request for Patient Assignment” for specific needs if assigned patients pose a problem with compliance. Return completed “Request for Patient Assignment” forms directly to the Faculty Advisor; do not give them to a staff member as this may delay the request being filled.

B-2

Patient Assignment Process

The Request forms should be submitted directly to the Class Faculty Advisor when completed as they are responsible for matching student requests with the needs of the patient through review of the information provided on the patient’s screening sheet and the patient’s available radiographs. While most requests can be assigned within a short period of time (several days), the process can take up to several weeks depending on the nature and specificity of the request, number of students making similar requests, and number of patients in the unassigned pool. Do not fill out another patient request form just because the initial request has not been addressed immediately unless instructed to do so by a Faculty Advisor. The student is to fill out one request and include all requirements needed. Do not request more than one patient on the same form. To ensure fairness, requests for patients are filled in the order received. If more than one unassigned patient can satisfy the student’s request, the patient with the earliest date of screening will be assigned first. While students are on scheduled rotation in Oral Diagnosis clinic, they may screen a patient whose needs match their clinical requirement needs. A request for specific assignment of a patient that a student has personally screened will not be honored unless there are no other students with similar requests outstanding and no other patient in the unassigned pool can satisfy their request. This prevents "leapfrogging" over other students or patients awaiting assignment. Students are not to make promises to any patient regarding when or to whom assignment will be made. A student may personally screen and request assignment of family members, friends, or relatives of patients already in your patient family. Such assignment requests will usually be honored provided the patient’s dental needs meet the student’s level of ability. Personal patients are NOT to be screened during the student’s rotation; this must be done on the student’s clinic time. Once a patient assignment has been made, a preliminary treatment plan is entered in Quick Recovery™ and the assigned student is designated as the primary provider of the patient’s dental care. A copy of the screening sheet is then placed in the student’s mailbox. The student will then have two weeks (10 school days) to contact the patient to arrange an appointment. Undocumented attempts to contact the patient within two weeks and failure to initiate treatment within 2 months may be considered as neglect and could result in loss of clinic privileges. The chart makeup process requires at least 3 business days. Students are not to schedule their first appointment until at least three days after request for chart makeup has been made. If this has occurred the student will be asked to re-appoint their patient. Family members and/or friends are no exception to this policy!

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DENTAL HYGIENE PATIENT MANAGEMENT

Patient Assignments Patient assignments are included in your orientation packet. The patients are assigned in the QR system and in the Filemaker database and the student’s name has been written on the outside of the chart. Each student has been assigned seven A and/or B recall patients including one new patient. Be sure to read any notes in the scheduling Patient Message box on your assignment print out. Additional patients will be assigned upon written request to the DH Coordinator. This includes those patients obtained on the web site as fill-in patients for cancellations. A patient pool of unassigned patients will be available to the dental hygiene students on the Filemaker database that is accessible via a web site that the students will be trained for with IT personnel. Five patients that are most overdue will be made available at a time. If a student contacts, or attempts to contact a patient, an entry must be made in the contact field. If a student schedules the patient, he/she must contact the DH Coordinator ASAP so that she can assign the patient to the student. If a student needs additional patients, a Dental Hygiene Patient Request Form must be completed and submitted to the DH Coordinator. Please complete one form for each patient requested. Please note in the comments section if a specific patient is requested. Patient request forms must be date/time stamped. The student will be notified of filled patient requests by email from the DH Coordinator. Types of DH Patients A. DH Plus Other Treatment – these patients have been accepted to the College of

Dentistry for complete treatment. When possible, these patients are assigned to Dental Hygiene students for their initial prophylaxis or scaling and root planing. These patients must be seen and completed by the DH student ASAP because they are also waiting for their restorative treatment to be completed by a dental student.

B. DH Only – These patients have been accepted to the College of Dentistry for dental hygiene treatment only. They do not receive a dental exam or dental restorative treatment.

C. Recall – These are patients who have completed their restorative treatment at the College of Dentistry and have been placed on recall.

Scheduling Patients Students are responsible for scheduling their own patients and confirming their patients’ appointments. Students will turn in appointment request slips to the DH Scheduler who will enter the appointment into the QR program. Appointment request slips must have the chart number, procedure codes and date/time stamp. Leave no blanks on the slip.

B-4

Students need to complete a cancellation slip for those patients that cancel their appointments. A late tray request must be completed to schedule a replacement patient if it is after 7:00 a.m. on the day of the appointment. A replacement patient cannot be scheduled if a cancellation slip was not submitted to remove the original patient from the schedule. Be sure to follow up on the need for antibiotic pre-medication when scheduling a patient. The DH Scheduler will ensure that the students’ charts and encounter forms are delivered to clinic prior to the beginning of clinic. Chart Documentation Be sure to read any Patient Advocate notes inserted in the chart. Remember to include the “CDI at next recall” and “recall interval” information at the top of the recall form. Use white treatment progress note pages for additional documentation needed. Include a dental hygiene divider if one is not present and insert all dental hygiene documents behind the divider. Dental Hygiene information follows the Oral Diagnosis section. The student should ask each patient if he/she has had any changes in his/her phone and/or address. If he/she has, an information update form should be completed and given to the DH Coordinator. If restorative treatment has been prescribed, the limited treatment form should be placed inside the chart. The DH Coordinator will make arrangements for the treatment needed with Linda Hale after dental hygiene treatment has been completed. If a patient is in pain, take the chart and limited treatment form to the DH Coordinator on the same day the patient is examined. Chart documentation must be complete and accurate. The student will be contacted for clarification if the documentation is incomplete or unclear. Upon completion of the patient’s appointment, the student must walk the patient, chart and yellow copy of the encounter form to the cashier on the second floor for payment (Clinical faculty will keep the white copy in the clinic). The charts of each dental hygiene patient are turned in at the Central Business Office upon patient dismissal with the exception of (1) the patient needing urgent restorative treatment and (2) on the last visit. If the appointment is the patient’s last visit until returning for recall, the chart is turned in to the DH Coordinator (if after hours, place in the drop slot outside the DH Coordinator’s office). The DH Coordinator and Scheduler will enter the data from the chart and forward the limited treatment form to the Director of Clinics for approval and assignment.

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Releasing Dental Hygiene Patients If the student is unable to contact the patient with the phone numbers available in the chart and in Filemaker, he/she must complete a postcard obtained from the DH Coordinator or Scheduler who will co-sign the student’s TPN entry and mail the card. The student’s entry must include what numbers were called and what the result was when each number was called.

a. If there is no response within 10 business days or if the card is returned

with no change of address label, the patient may then be released. The student is required to follow up at the end of the 10 business day period.

• If the card is returned with a change of address label, the DH Coordinator or Scheduler will send a corrected one, with a new entry in the chart and a new response date and email the student.

All dental hygiene patients that need to be released must have Mrs. Miller’s signature in the TPN’s authorizing release. The only exception to this is those recall patients that are released by supervising dental hygiene faculty at chair side in the clinic when they are deemed no longer a teaching case. Proper release of a patient includes a complete and accurate entry in the TPN’s stating the reason for release and any information to substantiate release. The chart is brought to Mrs. Miller who will authorize the request for release in the chart or instruct the student to provide more follow up. Once Mrs. Miller’s authorization is documented in the chart, it is taken to the DH Coordinator who will enter the data into the required programs and send the patient a release letter notifying the patient that his/her care is being discontinued at the College of Dentistry, and why, and that he/she must seek care elsewhere. Emergency Appointments for Dental Hygiene Recall Patients It is the student’s responsibility to make arrangements with Linda Hale for emergency dental appointments (i.e. toothache, swelling, etc.) for patients assigned to you. During regular hours, see Linda Hale (Room 239, Ext. 34135) for all patient emergencies. During weekends and after hours, call 271-6326 and you will receive a recorded message with a pager number or cell phone number to contact the resident who is on call.

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DENTAL HYGIENE STUDENTS PLEASE NOTE: Current policy in the Department of Dental Hygiene in conjunction with the Office of Patient Management regarding patient requests/assignments is as follows:

1. A dental hygiene student may transfer a patient to another student with the

approval of the respective Clinic Coordinator. This information should be immediately forwarded to the Dental Hygiene Coordinator so that the patient packets of the involved students can be modified accordingly. A student cannot treat a patient who is not appropriately assigned.

2. Screened patients identified as DH only may be seen for one complete

cleaning only unless the patient is deemed an appropriate teaching case and continued recalls are recommended. If the patient requires scaling and root planing, he/she will also be seen for re-evaluation and continuing periodontal maintenance until deemed no longer a teaching case. Once the patient has completed his/her course of dental hygiene treatment, the chart must be turned in to the Dental Hygiene Coordinator for release.

3. All assigned dental hygiene patients (new patients or recall) will remain in the

care of the assigned dental hygiene student until transferred to another student or released from the program. Phase I patients who have been accepted for limited or complete treatment must have their records turned in to the Dental Hygiene Coordinator once the dental hygiene treatment has been completed (including re-evaluation if indicated). This will allow the coordinator to make the necessary arrangements to have the patient assigned to a dental student for restorative care.

PEDIATRIC/ ORTHODONTIC PATIENT MANAGEMENT The management of pediatric/orthodontic patients is addressed through the department of Pediatric Dentistry. Ms. Romano coordinates patient assignments and the release of patients.

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Student Responsibility with Patient Case Acceptance

The College of Dentistry, as a teaching institution, is strongly committed to providing its students with the best educational experience possible and as such makes every effort to provide patients for students that offer a wide range of clinical experiences. More importantly the College is also committed to providing its patients comprehensive care that is patient-centered and affordable. Patients are accepted based on their educational value and assigned to students based on the student’s educational requirements. There may be instances when an assigned patient does not exactly match the assignment request made by the student; this is unavoidable as treatment needs and the patient’s treatment expectations are subject to change with time. Students are expected to act with professionalism, responsibility, and accountability in accepting patient assignments; repeated complications in the assignment process with a particular student will ultimately result in the student becoming responsible for procuring his/ her own patients for treatment.

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Initial Patient Contacts Initial interactions with patients will determine the success or failure of all subsequent patient relations. Patient confidence and trust will be reflected in their first impressions of the student and the perception of the student’s interest in their needs.

1. Students are to call the patient as soon possible (preferably within 24 to 48 hours of

assignment). For local calls, use any available clinic or Student Commons telephone. For long-distance calls, use the designated student telephone near the Central Business Office.

2. The student should call at reasonable hours. If the student needs to contact a patient in

the evening, they should do so at least by 9:00pm. Calling very late at night or early in the morning is discouraged. Elderly patients should be called relatively early in the evening.

3. Check the patient's chart for other phone numbers if attempts to reach the patient at home

are unsuccessful. If the patient cannot be contacted within two weeks, the student should complete a beige “Task Sheet” and submit the chart and sheet to the Office of Patient Management for follow-up.

4. If someone other than the patient answers the phone, the student should find out when the

patient will be available and call again. It is appropriate to leave a message; however, do not assume that the message will be forwarded to the patient.

5. The student should identify himself or herself once the patient is reached and state the reason

for their call. The patient should be asked if he/she is still interested in being treated at the College of Dentistry. If yes, an appointment that is convenient for the student and the patient should be scheduled. If no, the student should document the reason in the patient's chart and return it to the Office of Patient Management for release. NOTE: If the patient is still interested but is unable to begin treatment within a month, inform him/ her that he/ she will be released until he/ she is able to make the time commitment to treatment. The patient will then be responsible for notifying the College of Dentistry consideration for re-instatement.

6. The student should avoid identifying his/ her class status and they should spell his/ her name

if necessary; patients often call the College of Dentistry and give a distorted or garbled version of a name that can make it difficult to identify who the student is.

7. Students should remind their patients to review the information in their copy of the “Patient

Consent to Treatment” form (required availability for appointments, payment policies, etc.) and remind them that appointments will be 2-3 hours in length.

8. The patient should be provided with two numbers at which the student may be contacted (a

cell phone number and the information desk number at school [271-6326]) and the best times to reach you. Do not provide a home phone number and do not provide the number for the Director of Clinics’ office. Your cell phone number should not be long distance for the Oklahoma City area.

9. All scheduled patient appointments should be confirmed by the student the evening before.

This is a helpful reminder to the patient and allows the student an opportunity to contact another patient if the original patient must reschedule.

10. At the end of the clinic appointment, the student should arrange his or her patient’s next

appointment if possible. This is preferable to having to contact the patient again on a separate occasion and possibly having difficulty doing so.

11. If a particularly involved or complex procedure was performed, the student should call their patient that evening to inquire how well he/ she is doing. Their concern and interest will be greatly appreciated!

IMPORTANT! Record all phone contact attempts in the chart B-9

PATIENT RELEASE

Release involves removal of a patient from the program and discontinuation of treatment. This action requires the authorization of the Director of Clinics and will only be implemented for legitimate reasons including (but not limited to):

Inability to pay for treatment Lack of interest in the program Unwillingness to accept treatment recommendations Moving out of the area Three or more cancellations and/or failed appointments Severe behavioral management problems Unavailability for regular appointments Formal referral to collection agency Patient request to discontinue treatment Treatment not within the scope of the program- too complex

NEVER threaten a patient with release without justifiable cause. Discuss the matter with the Director of Clinics or Patient Advocate before informing the patient that he/she is being released. To request release:

1. Sufficient documentation on the nature or reason for the release must be in the chart; if not, release will be denied. Make an entry in the chart requesting release from the pre-doctoral program and identifying the reasons. If in doubt that release from the program is the appropriate action, consult with the Director of Clinics before making chart entries.

2. Take the chart to the Office of Patient Management who will research and

process the release if applicable by either sending the patient a letter of impending release based on problems that can be rectified with some effort on the part of the patient; or a letter of final release if the patient was already contacted regarding these issues and despite the warning, the problems still continue. If the letter is one regarding final release, the patient's name will be removed from your patient family.

3. The Central Business Office is then contacted regarding the release and will

pursue collection of any remaining balance or issue a refund on the account.

A patient whose account is referred to the College's collection agency is automatically released even if you have not requested this action. You may not have access to any chart in collections without the permission of the Director of Clinics. Re-instatement of a patient referred to a collection agency will not be allowed. The Director of Clinics must approve all re-instated patients.

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Release of patients from the pre-doctoral program must be accompanied by appropriate documentation, which should include any information that may impact the future interactions of both the student and the College of Dentistry with the patient (financial difficulties, scheduling conflicts, unwillingness to accept planned treatment, mutual agreements to defer treatment, lengthy unavailability for treatment, etc.). Patient release requires authorization by the Director of Clinics. It is extremely important that the student establish authority in regard to College of Dentistry policies early in the relationship. Therefore the student should be very familiar with the information in this manual and be able to respond to questions regarding school policies. The student should tactfully dictate the frequency of appointments, determine treatment sequencing, and inform the patient when his/ her actions may jeopardize their status in the program (frequent cancellations/ no shows, failure to pay account balance, etc.). Once a patient is officially assigned, the student must have legitimate cause for release. Examples include inability to pay for treatment, unavailability for appointments, unwillingness to accept treatment recommendations, behavior management problems, chronic lateness for appointments, and frequent cancellations or failed appointments. It is not acceptable to release a patient because of race, sex, age, or occupation. It is also not acceptable to deliberately neglect a patient whose needs to do not coincide with your expectations or academic requirements. Patient neglect is a punishable offense and will be discussed in another section. Moreover, a single cancelled or missed appointment is not reasonable grounds for release. While patients must be available at least two half-days per week, students will seldom see any patient more than once a week. If a patient is only available once every week or two, this may not be grounds for dismissal provided that their schedule coincides with a student’s available clinic time. The student should be reasonable and flexible with their expectations. A patient should never be threatened with dismissal unless the student has sufficient evidence that a valid reason exists. Always consult with the Director of Clinics or the Assistant Director of Clinics before you consider these actions and certainly before the patient is informed. Patient release is also a form of patient reconciliation and will be mentioned again in a later section.

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INFORMED CONSENT

After screening is completed and upon acceptance into the pre-doctoral program, each patient is given the following information: Patient Consent to Treatment Form: This form provides the patient with information regarding patient acceptance, appointment availability, financial responsibility, follow-up care in dental hygiene recall, and eligibility for further treatment at the College of Dentistry. The consent form must be signed by the patient (or the patient's parent/ guardian if a minor child) and a copy is given to the patient for their records. This confirms an understanding and acceptance of the responsibilities of participation in the student program at the College of Dentistry. Informed consent is an important legal concept that protects the student and the College of Dentistry against any allegation that work was performed without permission. To ensure that informed consent is fully protective, the patient must be made aware of the [1] nature of the existing medical/dental condition to be treated, [2] prognosis of the condition if left untreated, [3] any and all risks involved in treatment, [4] alternative methods of treatment, and [5] reasons for any subsequent changes in treatment. To comply with the College of Dentistry’s informed consent policy, each patient must sign both the Patient Consent to Treatment form at the time of screening and the Master Treatment Plan following full diagnosis and workup. Additionally patients must sign financial documents outlining their financial responsibility for treatment involving lab-fabricated restorations. A patient accepted for emergency care or limited treatment is also required to sign a statement of understanding of the parameters under which care is being rendered. It is the responsibility of the student to ensure that all appropriate documents relating to informed consent are complete, signed, and made a permanent part of the patient's record. Patient Bill of Rights: Outlines the patient’s specific rights and responsibilities as a patient of the College of Dentistry including quality and timeliness of treatment, confidentiality of records, alternative treatment avenues, expected costs of care, etc. College of Dentistry Payment Policy: The patient will also be required to sign the College of Dentistry’s Payment Policy that outlines the financial responsibilities of the patient and a statement regarding fee reductions for pediatric patients based on income level. The patient is given the yellow copy of this form for their records. Samples of these documents are shown on the following pages.

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THE UNIVERSITY OF OKLAHOMA COLLEGE OF DENTISTRY

CONDITIONS OF TREATMENT

Please read the following information carefully and sign where indicated. Your signature confirms your understanding and acceptance of this information.

I hereby apply for and consent to diagnosis and treatment at the College of Dentistry for myself or for the (minor) patient named below. In doing so, I fully understand and accept the following conditions: My provisional acceptance does not guarantee that I will be assigned for treatment. My acceptance and ultimate assignment to a student for treatment depend on my dental needs being of educational value to the students. If at any time my treatment is no longer considered suitable for teaching purposes, the College may discontinue treatment and release me as a patient. If I cannot schedule appointments or repeatedly miss appointments, my treatment will be discontinued. Successful treatment is dependant on my ability to keep scheduled appointments. The educational process requires the students to complete specific procedures in a timely manner as they gain experience. Significant delays in the progress of treatment as a result of missed appointments will not only jeopardize the student’s ability to complete treatment requirements but will also decrease the success of the treatment rendered. As a rule, patients must agree to be available at least two (2) half days per week. Payment in full is expected at the time services are rendered even if I have dental insurance except in cases where the insurance company is contracted with the College of Dentistry. Failure to pay on account within thirty (30) days of the delivery of service will classify my account as delinquent, of which I will be notified by letter. Failure to pay within another thirty (30) days will result in referral to a collection agency and automatic release from the program at the College of Dentistry. Upon completion of my treatment, I will have an opportunity to participate in the dental hygiene recall program. The recall program will be offered for a period of one (1) year from the date of treatment completion. During that time I will have my teeth cleaned, checked, and x-rays will be taken as necessary according to the appropriate recall interval. If further treatment is required, I will be informed and can expect the treatment to be performed at the College of Dentistry. At the end of the one (1) year recall program, I will be released from the College of Dentistry to seek continuing care by a private dentist. I understand that once I have completed the program with the College of Dentistry I may no longer be eligible to be a repeat patient in the program. As a teaching institution that provides care on a large scale, the College of Dentistry is unable to function as a long-term care facility for patients who have completed their treatment. The specificity of the dental education process requires that patients be accepted for their educational significance, which may no longer be valid once treatment is complete. Therefore, the decision to allow patients whose treatment is considered complete to return to the program will be considered on an individual basis and only in cases where the need for treatment is relevant to the educational purpose of the College of Dentistry. The College of Dentistry or its authorized representative(s) has my permission to make and use any audiovisual materials for myself or the (minor) patient named below for any educational purpose and in the interests of health education, knowledge, or research by the College. In any publication that uses or reproduces these materials, I or the (minor) patient named below will not be identified by name. Patient Signature______________________________ Print Name_______________________ Guardian Signature____________________________ Print Name_______________________ Relationship to Patient______________________________Witness__________________________ Date______________________________

University of Oklahoma College of Dentistry

Patient Rights and Responsibilities

The University of Oklahoma College of Dentistry recognizes the importance of developing a relationship of mutual trust between the patient, the student-doctor, and the teaching faculty as dental care providers. As such the College of Dentistry offers it’s patients the following guidelines to form a structure within which successful, timely, and satisfying dental care may be given and received. Patient’s Rights The patient has the right to receive treatment from students, faculty, and staff that is considerate of the patient’s dental needs, respectful of their dignity, and mindful of the confidentiality that rightfully exists between the patient and the College of Dentistry. The patient has the right to expect reasonable continuity of care and completion of treatment in a timely manner upon acceptance and assignment to a student. The patient has the right to emergency care in accordance with the conditions of their acceptance as a patient. The patient has the right to be given a clear and understandable explanation of the treatment recommended sufficient to obtain an informed consent including alternatives to treatment, benefits and risks (if any) of recommended and alternative treatment, and the consequences of refusing treatment. The patient has the right to refuse treatment however upon rejection, the College reserves the right to discontinue the patient’s treatment in the program if such alternative care is inconsistent or incompatible with the College’s mission or treatment philosophy. The patient has the right to be fully advised in advance, of the expected cost (estimated) of the total treatment planned and of the treatment to be rendered at each scheduled appointment. The patient has the right to know the rules of the College of Dentistry and the regulations that apply to his or her conduct as a patient. The patient has the right to receive treatment that always meets or exceeds the profession’s standard of care. Patient Responsibilities The patient shall provide, to the best of their knowledge, accurate and complete information about present conditions, past illnesses, hospitalizations, medications, and other matters pertaining to the patient’s health. It is also the patient’s responsibility to report any changes in the condition of their health to the student and supervising faculty. The patient is responsible for following any recommended post treatment instructions given by the student, on behalf of the supervising faculty including follow-up visits. The patient is responsible for the consequences of their actions in refusing treatment or in failing to follow post treatment instructions provided by the student on behalf of the supervising faculty. The patient is responsible for keeping scheduled appointments, and when unable to do so for any reason, to notify the student of there need to reschedule. The patient (or legally responsible party) is responsible for assuming the financial obligation is fulfilled promptly. The patient is responsible for being considerate of the rights of other patients, staff, students, and faculty of the College of Dentistry. The patient should expect the College of Dentistry to provide only that treatment which supervising faculty deems to be appropriate given the information provided and circumstances observed.

CLINIC SIGN UP PROCESS

The OUCOD Clinic Schedule, which is published at the beginning of the semester, indicates which disciplines provide clinic coverage during each half-day of the week, the number of clinic spaces available, and the groups of students that are eligible to schedule in these clinics. When an appointment is scheduled, a clinic space is reserved by the student in Quick Recovery™ and the patient's chart and encounter slip (fee form) will be available in the appropriate clinic for the scheduled appointment date and time. Students can schedule appointments in Quick Recovery, but cannot cancel them. With this responsibility comes the expectation that students will maintain a level of honesty and integrity in their scheduling practices. Students will have the ability to schedule appointments for their patients but in order to effect cancellations (to accommodate late tray requests or schedule another patient) they will need to fill out a “Cancellation Request” (HSC 7871) and place it in the drop box outside of the Office of Patient Management (Room 239). The drop box is periodically checked for slips throughout the day.

Patient Cancellation: If your patient cancels in advance of the appointment, fill out a patient cancellation slip and place it in the drop box as described above. If the patient cancellation occurs after 5:00 pm the day before the scheduled appointment or you do not report it until the day of the appointment, it will be considered a “No Show” and requires that the student note the incident (including the reason) in the patient's chart. *

Late Trays: Late tray options are designed to assist you in fully utilizing available clinic time when unplanned circumstances arise. The daily clinic schedule is generated each day at 3:00 p.m. for the following day's business. A request for a clinic chair after the schedule has been generated requires the use of a “Late Tray Request” form (HSC 2323) that has been signed by either faculty (or staff when appropriate) confirming that space is available and faculty coverage is sufficient based on the proposed procedure. Late trays are often used for the following reasons:

-To appoint a patient on short notice (whether due to cancellation or no show of scheduled patient). Appropriate chart documentation and signatures must accompany request. -To allow students the ability to schedule in more than one clinic (with the same patient) in a morning or afternoon session.

Late Tray requests are not to be used to correct poor patient or time management habits.

*No shows have traditionally been regarded as broken appointments within 24 hours however in regard to the “cancellation slip” policy, a broken appointment after 5:00pm the day before the appointment will be considered a no show.

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Treatment Planning Clinic (TPC): Sign-up for TPC is done via Quick Recovery™ and is scheduled in Gold clinic on Tuesdays morning and afternoon during the semester. Chairs are labeled TPC and the student should use one of the 150-1 through 4 codes “Comp Oral Eval Cont”. You must also list the disciplines (Perio, Oper, Occl, FPD, RPD, OD) you require for treatment planning in the comment section. Students not choosing any departments for treatment planning will be considered as unprepared and will not be seen. Maintaining Honor in the System Every student is expected to have cancellations; however, misuse of the ability to appoint your patient and following improper protocol in canceling the patient will result in poor utilization of clinic space. Students who indiscriminately sign up for a chair and do not cancel that chair until it is too late to appoint another patient contribute to problems related to poor clinic utilization, loss of revenue, intolerant faculty, angry classmates, and patients being neglected. The Office of Patient Management will be monitoring the number of late trays and cancellations per student and should the number become excessive, the student will be placed on clinic suspension while the Director of Clinics reviews the circumstances.

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Chart Task Form

The Office of Patient Management Room 239 can be a very busy place, having noted that most of the clinical policies and protocols revolve around procedures that are monitored through this area. As such students are asked to complete a “Chart Task Form” that will allow the student to leave the chart in this area with instructions for a specific task so that it can be completed or if questions arise, the student can be notified regarding their request. Chart Task forms can be found in the hall at the counter outside of the Office of Patient Management. A sample of this form is on the following page.

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OFFICE OF PATIENT MANAGEMENT CHART TASK FORM

Patient Name: ____________________________ Chart Number: __________________________ Student Name: __________________________ Student Number: __________ Date: ____________ Student Contact Number: __________________________

ACTION REQUESTED

Unable to Contact Patient; Send Warning Letter (refer to Dr. Panza)

Enter Master Treatment Plan Worksheet in Quick Recovery Limited Treatment Form Needed (automatic referral to Dr. Panza) Patient Next Appointment: _____________________ For This Procedure?: Y N Limited Treatment Complete, (remove from patient family) Request for Release (sufficient documentation must be charted*)

*Sufficient documentation implies at least three documented instances of missed appointments or unsuccessful attempts to schedule/ contact patient. An explanation of unsuccessful contact for each of the patient’s published contact numbers must be included in the note entry.

Request staff follow-up on release for the following: (check all that apply) Unable to contact Missed appointments Unavailable for Appointments Patient Request Non-Compliance with Treatment Recommended Financial Difficulty

Additions to Master Treatment Plan (need completed “MTP Revision Request” form with faculty signature) Other Request: _________________________________________________________________________ Additional Comments: __________________________________________________________________________ __________________________________________________________________________

CLINIC OPERATIONS USE ONLY

Referred to: Dr. Panza Mrs. Miller Linda Hale Tammy Vogt

PSR ___________________________

ACTION TAKEN

Master Treatment Plan Entered (date_____________________) Revisions/ Additions to Master Treatment Plan Entered (date_________________) Release Request Recommendations: _______________________________________________________________________ Task Completed by: _________________________ Date: _____________________ Revised 06/07

PATIENT RECONCILIATION

In addition to completing minimum clinical experiences for graduation consideration, the student must also reconcile all assigned patients including all those originally assigned for complete treatment, those accepted as a transfer, and those who were provided limited care. Reconciliation involves planning the process for continued care (or removal from the program) prior to graduation and is expected of every student in order to complete the graduation sign-out process. There are four methods for patient reconciliation: [1] Completion of Treatment; [2] Transfer to Another Student; [3] Patient Release; or [4] Limited Care.

Patient Completion of Treatment

A patient is considered "complete" when [1] all treatment as indicated on the Master Treatment Plan is completed, [2] the account balance is zero, [3] the Case Complete appointment has verified that all needs have been addressed, and [4] the patient has either been placed in dental hygiene recall or has been given the option to which they may decline participation. To reconcile a completed patient: 1. The student will schedule a Case Complete appointment for their patient in Oral

Diagnosis. At this appointment, the student will present all completed records; attending faculty will verify completion of treatment and make an appropriate designation in the chart requesting removal of the patient from the student’s patient family. NOTE: Patients that are Type II perio and above require a Case Complete appointment in the Periodontics department prior to scheduling a Case Complete in Oral Diagnosis.

2. Confirm with the Central Business Office that the account balance is zero. If

necessary, have account status updated in the chart. 3. The patient is placed in dental hygiene recall through Oral Diagnosis. Hygiene

Recall patients are usually scheduled at six-month intervals (or three months for compromised maintenance therapy [CMT]) and the program is optional for the patient. If the patient declines the option of dental hygiene recall, he/ she is released as treatment complete.

4. The chart is then processed in the Office of Patient Management for removal from

the student’s active patient family. Patients whose treatment is complete may be scheduled for the Case Complete appointment at any time (for Type I Perio patients, as early as the fall semester of the junior year) that is convenient for the student and the patient. If additional needs are noted by attending faculty, the student will be required to treat those needs and then schedule a second Case Complete appointment. Details on Case Completing patients can be found in the student’s Oral Diagnosis Clinical Instruction manual. Completion of patient treatment is the most desirable method of patient reconciliation and it is therefore highly recommended that students make patient assignment requests based on their ability to manage the patient’s care until completed. If a student requires counseling regarding their ability to manage their patient family, an appointment should be made with his/ her Faculty Advisor.

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Patient Transfer

Transfer of a patient allows students who cannot complete treatment on their patients, due to time constraints, to assign them to other students without discontinuity of care and is intended to occur at the end of the transferring student’s academic tenure. Transfers between students in the same class are discouraged and will be considered as “Reassignments” and made only under specific circumstances and with special permission of the Director of Clinics. In order for a student to transfer a patient whose care cannot be completed prior to graduation the student will be asked to identify these patients at the time of their final chart audit with Linda Hale. A “Transfer Authorization Form” will be filled out during the chart audit for these patients and will be held until after the auditing process is finished. For the duration, the student is required to continue treatment until it no longer is possible or reasonable to do so. Once the “Transfer Authorization” forms are returned to the student the student will have several weeks to complete the forms on their transfer patients. To reconcile a transfer patient, complete the form as follows: Section I To be completed by Linda Hale at Chart Audit. Section II “Department of Periodontics” The student is to complete this section with any full-time perio faculty, have them approve and sign it. Full-time faculty must order radiographs. Section III “Department of Operative Dentistry” The student will complete this section and have it approved with Dr. Fruits only. Section IV “Department of Fixed Prosthodontics” The student will complete this section and have it approved with Dr. Blanco only. Section V “Department of Removable Prosthodontics” The student will complete this section and have it approved with either Dr. Cain or Dr. Wiebelt. Section VI “Department of “ The student will complete this section for any additional treatment remaining that is not included in the above sections. Section VII Clinic Operations This section is to be completed by Dr. Panza once the form is turned in. Section VIII Central Business Office This section is to be completed by members of the Central Business Office as the last step in the process.

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Upon satisfactory completion of all sections the chart (if no further treatment can be completed) with the form should be returned to Ms. Linda Hale in Room 239. The deadline for completion of all patient transfers will be determined at the beginning of each semester and reported to students in advance with the distribution of the transfer forms for completion. This process is done without the patient being present (unless a specific request by faculty is made to see the patient) and therefore should not depend on patient appointment availability. Additionally the senior student should avoid arranging for a student to transfer the patient to. This will be done by Clinic Operations during the summer semester months. The information contained in this form will be used in assessing the needs of the patients to be transferred and assisting the Director of Clinics in assigning these patients to students who are adequately prepared to continue the process of providing the patient’s treatment. Each department must approve the transfer of the patient, if the transfer is not approved it is the student’s responsibility to seek the means necessary to get approval and the individual department will determine this. The student’s ability to sign out of Clinic Operations is therefore determined by their ability to meet the approval of each individual department in satisfying not only their requirements but managing the follow-up care for patients that are to be transferred. Deliver any study casts for transfer patients to Linda Hale, Room 239, to be given to the student receiving the transfer patient. A sample of the Transfer Authorization form is shown on the following page.

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PATIENT RELEASE Release involves removal of a patient from the program and discontinuation of treatment. This action requires the authorization of the Director of Clinics and will only be implemented for legitimate causes including (but not limited to):

Inability to pay for treatment Lack of interest in the program Unwillingness to accept treatment recommendations Moving out of the area Three or more cancellations and/or failed appointments Severe behavioral management problems Unavailability for regular appointments Formal referral to collection agency Patient request to discontinue treatment Treatment not within the scope of the program- too complex

Never threaten a patient with release without justifiable cause. Discuss the matter with appropriate faculty and the Director of Clinics before informing the patient that he/she is being released. To request release: 1. Make an entry in the chart requesting release from the undergrad program and identifying the

reasons. If in doubt that release from the program is the appropriate action, consult with the Director of Clinics or the Patient Advocate before making chart entries.

2. Take the chart to the Director of Clinics who will research and process the release if

applicable and return it to the Central Business Office for processing. The patient's name will be removed from your active roster. This may take up to a month to occur as the Director of Clinics does this process once monthly.

3. Copies of release letters are forwarded to Robin Barnes in the Perio Department for removal

from the student’s active roster of patients in treatment. A patient referred to the College's collection agency is automatically released even if you have not requested this action. You may not have access to any chart in collections without the permission of the Director of Clinics. A patient may request reactivation if the reasons for the original release no longer apply, reactivation of a patient referred to a collection agency will not be allowed. The Director of Clinics must approve all reactivation of released patients. Infrequently patients may be notified through a letter of pending release regarding the nature of one of the above listed problems that may be cause for release if the circumstances do not change. Patients are given 2 weeks (10 business days) to appeal the release, if no response is received; the patient is processed for final release. If the patient responds before the proposed deadline, the student is notified by e-mail and given any additional information on contacting the patient. Samples of the release notification letter and pending release notification letter follow.

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The University of Oklahoma College of Dentistry

Office of Patient Management

Patient Name:___________________________ Chart Number:_______________________ Address:________________________________ Date:_______________________ Dear:__________________________________ The Office of Patient Management at the University of Oklahoma College of Dentistry is sending this letter to inform you that your care is being discontinued at the College of Dentistry. As such, you are no longer being considered eligible for further treatment and are being released from the program. This action has been taken for the following reasons: ______Student inability to contact the patient by phone- The College of Dentistry requires that all patients accepted for treatment have some form of phone service and that the patient will provide the most current contact number available. ______Current financial hardship- The College of Dentistry makes every effort to inform the patient of their financial responsibility and as such expects that payment shall be received in a timely manner. You may be considered for continued treatment once your financial responsibility has been met. Please be aware that this may jeopardize the progress of your return to active treatment by requiring that you be re-screened when a lengthy time interval has lapsed. ______No longer interested in program- Infrequently the College of Dentistry may receive notification from a patient that he/she no longer wants to continue their treatment in the program. We will prepare and forward copies of your records to another provider upon written authorization. ______Patient Relocation- The College of Dentistry is sensitive to the flexibility of our patients’ needs to move suddenly or relocate either temporarily or permanently. Even in situations where the relocation is temporary, we require that the patient’s records be inactivated and their treatment be considered discontinued. You are encouraged to contact the College of Dentistry Office of Patient Management 271-5422 when you are able to again participate in the program.

______Scheduling Difficulties- Successful treatment at the College of Dentistry is dependant on the patient’s availability for appointments and ability to keep scheduled appointments. The educational process requires the students to complete specific procedures in a timely manner as they gain knowledge and experience. Repeated missed or broken appointments will jeopardize the success of treatment for both the student and patient. Patients accepted for treatment at the College of Dentistry have agreed to be available at least two (2) half days per week. ______Account Sent to Collection- Failure to pay on account within thirty (30) days of the delivery of service will classify your account as delinquent, failure to pay within another thirty (30) days will result in referral to a collection agency and automatic release from the program at the College of Dentistry. ______Non-Compliance with Treatment Recommendations- A patient may freely reject any recommended treatment at the University of Oklahoma College of Dentistry. Upon rejection however, the College of Dentistry reserves the right to refuse the provision of alternative care and to release a patient from the program if it is determined that such alternative care is inconsistent with the College’s treatment philosophy. ______Other Circumstances- ________________________________________________________________ If the above information is incorrect or if you have any questions regarding the action taken, please contact the University of Oklahoma College of Dentistry Office of Patient Management at 271-5422 within 10 business days of the above listed date. Thank You.

Sincerely, Jeanne C. Panza, D.M.D. Kathryn F. Miller, R.D.H., B.S. Assistant Dean for Clinic Affairs Assistant Director for Clinics

The University of Oklahoma College of Dentistry

Office of Patient Management

Patient Name:___________________________ Chart Number:_______________________ Address:________________________________ Date:________________________ Dear:__________________________________ The Office of Patient Management at the University of Oklahoma College of Dentistry is sending this letter to notify you of your impending release from the College of Dentistry. This action has been taken for the following reasons: ______Student inability to contact the patient by phone- The College of Dentistry requires that all patients accepted for treatment have some form of phone service and that the patient will provide the most current contact number available. ______Current financial hardship- The College of Dentistry makes every effort to inform the patient of their financial responsibility and as such expects that payment shall be received in a timely manner. You may be considered for continued treatment once your financial responsibility has been met. Please be aware that this may jeopardize the progress of your return to active treatment by requiring that you be re-screened when a lengthy time interval has lapsed.

______Scheduling Difficulties- Successful treatment at the College of Dentistry is dependant on the patient’s availability for appointments and ability to keep scheduled appointments. The educational process requires the students to complete specific procedures in a timely manner as they gain knowledge and experience. Repeated missed or broken appointments will jeopardize the success of treatment for both the student and patient. Patients accepted for treatment at the College of Dentistry have agreed to be available at least two (2) half days per week. ______Non-Compliance with Treatment Recommendations- Patients are expected to proceed with accepted treatment in a timely manner to avoid delays that may jeopardize the success of the treatment to be rendered. In cases where a referral has been made to a private practitioner for treatment that cannot be performed at the College of Dentistry it is expected that the patient will either complete the treatment referral or provide information regarding their inability to do so. ______Other Circumstances- ________________________________________________________________ __________________________________________________________________________________________

We would be pleased to have you continue your treatment with us as we realize the initial commitment you have made to do so; however, this will require your full cooperation. If the above information is incorrect or if you have any questions regarding the action taken, please contact the University of Oklahoma College of Dentistry Office of Patient Management at 271-5422. If we have not received a response from you by ____________________________ , you will be released from the program with no opportunity for re-instatement.

Sincerely, Jeanne C. Panza, D.M.D. Kathryn F. Miller, R.D.H., B.S. Assistant Dean for Clinic Affairs Assistant Director for Clinics

Limited Care Treatment If a patient cannot be reconciled by either of the aforementioned methods, and requires a limited amount of care, the patient may be considered for Limited Care. Limited Care is offered through the Office of Patient Management for patients with one or more relatively minor treatment needs noted during a periodic recall examination or as a result of recently graduated seniors who have patients with minor treatment needs that do not make them suitable for transfer to another student. Senior dental students may request assignment of a Limited Care patient at any time by completing a “Limited Care Patient Request” form (OU 5005). Junior dental students will be given the opportunity to begin requests in the spring semester:

1. Completed “Limited Care Patient Request” forms are to be submitted to Linda Hale in the Office of Patient Management, Room 239. While assignment requests will be filled in the order they are received, there will be times when a request that is too specific will delay the process and other requests will be considered for assignment in the interim. If assignment cannot be made within 30 (school days) the student will be notified and he/ she must consider other options to achieve the requested treatment.

2. Once an assignment has been made, Linda Hale will notify the student and

they are to report to the Office of Patient Management to sign a “Limited Care Approval” form.

3. When the Limited Care is completed, the chart (containing the white copy of

the Limited Care Approval form dated with the completion date) along with a completed “Chart Task Form” requesting reconciliation is to be returned to Linda Hale in the Office of Patient Management who will forward the chart to Dr. Panza for review and removal from your patient family. This last step is extremely important. If the student re-files the chart in the Chart Room, the patient will continue to be listed in the student’s patient family and the student will be held accountable for him/her.

Once the student has accepted a Limited Care patient, they are responsible for every procedure specified on the form including any required follow-up care. Limited Care patients may be taken directly to the appropriate clinic(s) for treatment or consult as necessary; a work-up and treatment planning is not required unless requested by consulting faculty. If additional needs are discovered during treatment, supervising faculty should make a treatment progress note outlining the additional treatment and reason why treatment is needed and sign it. The chart is then turned in with a Chart Task form (example next page) to the Office of Patient Management for completion of another Limited Treatment form. If the student cannot complete all treatment on his/ her patient and have been unable to effect transfer, the patient may be a candidate for Limited Care. The Director of Clinics will make this decision. B-20

You may not request either of these options until you have exhausted all efforts to transfer your patient. Further, neither option will be considered until the last few weeks prior to graduation to provide maximum time to fully explore transfer possibilities. No patient reconciliation is considered complete until the Office of Patient Management has removed the patient's name from your active roster! EVERY PATIENT ASSIGNED TO YOU MUST BE RECONCILED THROUGH ONE OF THE FOUR OPTIONS DESCRIBED ABOVE BEFORE YOU WILL BE CONSIDERED ELIGIBLE FOR SIGNING OUT OF CLINIC OPERATIONS PRIOR TO GRADUATION.

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UNIVERSITY OF OKLAHOMA COLLEGE OF DENTISTRY

LIMITED CARE APPROVAL FORM Patient Name______________________________________ Chart #: _____________________________

Date: __________________ Student: _______________________ Department(s): ________________________

Treatment Proposed: TOOTH # SURFACE DESCRIPTION TX CODE FEE

Treatment Completed:

TOOTH # SURFACE DESCRIPTION TX CODE FEE DATE

COMPLETED

Departmental Faculty Signature (upon completion) ___________________________ Date: _________________ Director of Clinics’ Signature of Approval for Assignment____________________________ Date: ____________

As the student providing care for this patient my signature confirms my understanding that I will provide the above care in its entirety in a timely manner and that I will be responsible for providing the follow-up care that may result from any complications related to the above treatment.

Signature of Student Providing Care_________________________________ Date: ____________________ My signature as the patient named below indicates that I have agreed to have the above listed treatment performed by the College of Dentistry and that I am financially responsible for this and any additional costs that may be incurred. If you have not been contacted by a student for treatment within 2 weeks of diagnosis, call Ms. Linda Hale at 271-5422.

Patient Signature_______________________________________ Date ______________________

Referral source: Hygiene recall _______ Unassigned _______ Assigned _______ Assigned Student Signature___________________________________________________ Date Reconciled in QR: ________________________ Initials: __________________ Financial Class Changed: Y N

White Copy- CHART Yellow Copy- DR. PANZA Pink Copy- PATIENT

TREATMENT ON UNASSIGNED PATIENTS

No patient may receive treatment at the College unless officially assigned. Obvious exceptions include patients seen on block rotations (Screening/Emergency, Oral Surgery, etc.). If you are on rotation and perform an emergency procedure (for example, temporization) that will require further treatment, you must secure limited care assignment from the Office of Patient Management. Such assignment will only be granted if it does not compromise or conflict with assignment priority policies in specific disciplines. RENDERING ANY PATIENT CARE WITHOUT THE EXPRESS WRITTEN APPROVAL OF THE DIRECTOR OF CLINICS (EXCEPT AS NOTED) IS A SERIOUS VIOLATION OF CLINIC POLICY AND WILL RESULT IN LOSS OF CREDIT FOR PROCEDURES PERFORMED WITHOUT AUTHORITY AND LOSS OF GENERAL CLINIC PRIVILEGES.

TREATMENT ON OTHER STUDENTS

A student providing treatment to another student must follow the same policies that govern treatment rendered to traditional patients. While a fully developed treatment plan is usually not required, the student patient must have a chart that includes a completed health history, appropriate radiographs, and verification of the treatment being rendered. A “Limited Care Approval” form is required for any work rendered by one student on another and the treatment must be approved in the chart by the faculty overseeing the procedure. The student-patient usually will not be assigned as a regular patient to the student providing treatment. However, if a student intends to provide comprehensive care to another student, a Master Treatment Plan will be required and the student-patient will be assigned as a regular patient.

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PATIENT ABANDONMENT

“The relationship between physician and patient generally continues until it is terminated by mutual consent of both parties. However, a relationship can be discontinued through dismissal of the physician by the patient, or physician withdrawal from the case, or at such time that the physician’s services are no longer required. Failure to follow up on patient care after the acute stage of illness has subsided, or neglect to give patient warnings of necessary instructions, may involve the physician in serious legal difficulties. Premature termination of treatment is quite often the subject of a legal action. Abandonment defined as unilateral termination of the patient-physician relationship by the physician without notice to the patient. Closely related to this type of problem is one which occurs when the physician, though not intending to end the relationship with the patient, fails to insure the patient’s understanding that further treatment of the complaint is necessary. “Legal Aspects of Health Administration”, Pozgar, G.D. 2nd Ed. Aspen Publications, pages 55, 103-104 The following elements must be present in order for a patient to recover damages for abandonment:

1. Unreasonable discontinuance of medical care. 2. Discontinuance of medical care against the patient’s will: termination of the

physician-patient relationship must have been brought about by a unilateral act of the physician. There can be no abandonment if the relationship is terminated by mutual consent or dismissal of the physician by the patient.

3. Physician’s failure to arrange for care by another physician; refusal by a physician to enter into a physician-patient relationship by refusing to respond to a call or render treatment is not considered abandonment. A plaintiff will not recover damages unless it can be established that a physician-patient relationship has been established (i.e., Buttersworth v. Swint, 186 E.E. 770 (Ga. 1936);

4. Foresight that discontinuance may result in physical harm to the patient; and 5. Actual harm suffered by the patient.

The relationship between a physician and patient, once established, continues until it is ended by mutual consent of the parties, revoked by the patient’s dismissal of the physician, or by the physician’s withdrawal from the case, or until the physician’s services are no longer needed. A physician who decides to withdraw his services must provide the patient with reasonable notice so that the services of another physician can be obtained.

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The Office of Patient Management will not tolerate willful abandonment, and has joined the Department of Pediatric Dentistry in establishing the following guidelines to aide in determining if abandonment has occurred. In cases where abandonment has occurred, a grade of “F” will be given for the DSA course Clinical Record-keeping and Patient Management for the semester during which the incident has occurred.

1) Willful or undocumented failure to see patients with treatment needs within the semester assigned.

2) Failure to see any patient for two consecutive semesters without sufficient

documentation in the chart to justify such failure to see the patient.

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CLINIC INCIDENT REPORTING FORM

The purpose of the Clinical Incident Reporting Form is to improve the quality of care at the OU College of Dentistry, enhance and promote patient safety, minimize the risk of recurrence of a similar incident, and to prepare for future litigation. This document is available in all clinic dispensary areas and should be completed in situations where clinic outcomes of treatment are less than desirable. A copy of the Incident Reporting Form follows. Each form is attached to a protocol for use of the form. Supervising faculty should assist you in completing this form and sign it prior to submission. Mrs. Kathy Miller, Assistant Director of Clinics, and Patient Advocate in Room 240 will keep this document on file at the College of Dentistry.

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UNIVERSITY OF OKLAHOMA COLLEGE OF DENTISTRY CLINICAL INCIDENT REPORTING FORM

This report is a privileged document, subject to the work product, attorney-client, and peer review privileges. DO NOT PHOTOCOPY, FAX OR PLACE IN DENTAL RECORD

Department________________ Clinic____________Chair #_______ Date_________Time_________ Patient Name_____________________________ Chart Number_________________ Supervising Faculty________________________ Student Provider___________________________ Procedure_____________________________________Informed Consent? Y N Written Verbal I. OCCURRENCE: (Include FACTS ONLY) may be continued on reverse side Brief Description of Incident- _________________________________________________________________________________ II. DISCOVERY: Incident Acknowledged by (check all that apply) Supervising Faculty __________ Other Faculty __________ Student Provider __________ Patient __________ Incident Acknowledged to: Patient___________ Family____________ Other______________ Brief Description of Information Given- _________________________________________________________________________________ Long-term Prognosis: Good Fair Poor Undetermined Recommended Follow-Up Care- _________________________________________________________________________________ None Somewhat Complete Perceived level of Patient Understanding of Incident: 1 2 3 Perceived level of Patient Satisfaction with Explanation for Incident: 1 2 3 Resolution Proposed? Y N If Yes… Brief description of terms discussed- _________________________________________________________________________________ III. RESOLUTION: Type of resolution offered to the patient? Verbal Recognition by: Faculty Student Other Reimbursement: Remake Replace Other________ If reimbursement, requested by: Supervising Faculty Student Patient Clinic Operations Approval-___________________ None Somewhat Complete Perceived level of Patient Satisfaction with Resolution/Reimbursement Offered: 1 2 3 Perceived Disposition of Patient upon Appointment Dismissal:

Worried/Angered Mild Concern/Responsive Unchanged Patient Comments (in patient’s own words)- ________________________________________________________________________________ Arrangements made for resolution, including reimbursement- ________________________________________________________________________________ Additional Concerns- ________________________________________________________________________________ Faculty Signature/ Stamp: ____________________ Student Signature/ Stamp:_____________Date: _________

Attach copy of Treatment Progress Notes and submit to Ms. Kathy Miller, Assistant Director of Clinics and Patient Advocate, Room 240

OU College of Dentistry Referral Process

Referrals between the pre-doctoral program and post-graduate programs occur infrequently to enhance the continuity of care in situations where the treatment needs of the patient are beyond the limitations of the pre-doctoral program. This referral process involves the various post-graduate clinics AEGD, Grad Ortho, Grad Perio, and Oral Surgery as well as the Adult pre-doctoral program and must be initiated through a consultation with and signed by full-time faculty from the referring department. The referral form (HSC 7505) is available in each of the post-graduate clinics and Oral Diagnosis. A sample of this form is on the following page.

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OU College Of Dentistry Referral Form

Original: Patient Chart Yellow Copy: Patient Advocate Pink Copy: CBO Billing Administrator Patient Name:_________________________Chart #: ______________ Date:_________

Parent Name (if patient is a minor): ________________________________________________

Primary Phone Number: ________________________ Home Cell Work (circle one) Secondary Phone Number: ______________________ Home Cell Work (circle one) Assigned Student:_____________________________ Referred From: ADULT AEGD PEDO GRAD ORTHO GRAD PERIO Referring Dentist:________________________________(required) Consulting Faculty:_______________________________ Referred To: ADULT AEGD GRAD ORTHO GRAD PERIO ORAL SURGERY Reason for referral: (Please Circle All Applicable)

1. Beyond the Predoctoral Program to treat. 2. No students available to treat this patient. 3. Patient requests second opinion within the College of Dentistry. 4. Referring department does not provide this type of treatment.

Emergency Non-Emergency Treatment Requested: ______________________________________________________ Date of Patient’s Last Visit: ___________________________ It is our request that you treat this patient at the expense of Clinic Operations. It is our request that you charge and bill this patient your normal fees. It is our request that you charge and bill this patient Pre-doctoral fees. It is our request that you not charge this patient (please call if you consider this inappropriate). ……………………………………………………………………………………………….

To Be Completed By Department Accepting Referral

Date(s) Patient Contacted/Came In: ___________________________________________ Appointment Date: ______________________ Comments:____________________________________________________________ FOLLOW UP CARE: No follow up needed Follow up needed: _________________________________________________ Chart including referral form with follow up care section completed should be returned to the referring dentist.

Section C

Patient Records Policies

THE PATIENT RECORD

Accurate and complete documentation of your patient interactions is an integral and critical part of your training. The written record (patient chart) is a legal document; it affords protection to you, your patient, the faculty, and the College should any questions arise about your treatment of or interaction with a patient. It c ontains all pertinent information regarding the patient's medical, dental, emotional, and behavioral background that might impact the type/extent of treatment rendered. Without such information, the possibility of providing inappropriate care is increased. It is also the primary source of information for decisions about the patient's status in the program. Releases, reassignments, transfers, or referrals cannot be ma de or defended without sufficient chart documentation. Proper records management is also important for monitoring treatment sequencing, facilitating departmental interaction in the treatment decision-making process, and providing accurate data to those to whom patient referrals are made.

CHART SECURITY All charts are the property of the College and must always be readily available when needed. Under no circumstances are c harts to be removed from the building. If it has been determined that a student has removed a p atient chart from the building, the student will automatically lose their clinic privileges for a period of no less than three (3) weeks. Charts should not be kept in your locker. Lockers will be searched when a chart is needed and cannot be readily found. Except during times of patient treatment, chart audits, consultation with faculty, or necessary review of patient information, all charts must be kept in the Chart Room. There may be occasions when a patient record is needed relatively immediately (emergency treatment, account reconciliation, etc.). Make sure that any charts in your possession have been returned to the Chart Room as soon as it is practical. It is also recommended that patient charts and casts not be studied or transported to the commons area due to infection control concerns.

REQUESTING/ FILING CHARTS Students may request charts in their patient family using Quick Recovery™. The Chart Room staff will pull the chart and file an out-guide with a computer-generated chart request in its place. When the chart is returned for re-filing, the request will be pulled and discarded. Until the chart is returned, the student who originally requested it is fully responsible for its security and should avoid giving the chart to anyone else. If another person needs the chart for any reason, they will need to request it through Quick Recovery™ to replace the request on file for you.

C - 1

TYPES OF CHARTS AND RECORDS The chart refers to the entire patient folder and all contents collectively. Records refer to individual documents in the chart. There are three general categories of charts used at the College of Dentistry: Emergency, Screening, and Comprehensive Care charts.

Emergency charts are generated for emergency visits of patients not otherwise in the system or assigned. These are gray charts with a limited number of records that document the emergency visit(s) -- health history, consent form, record of treatment etc. An emergency chart is incorporated into a Comprehensive Care chart upon screening and acceptance into the pre-doctoral program as a comprehensive care patient. Screening charts are temporary folders that are assembled specifically for use during screening. They contain all screening information, health history, patient consent form, screening radiographs, etc. For patients who are accepted, the folder is sent to the Chart Room to be assembled as a Comprehensive Care chart for patient assignment . Comprehensive Care charts are charts assembled from information collected during the screening visit and are made up with department tabs and records once a patient is accepted in the pre-doctoral program.

In the pre-doctoral Comprehensive Care chart, there are two general categories of records:

Generic records are the basic documents common to all patients. They include the original screening sheet, patient consent to treatment form, master treatment plan, any emergency records, medical alert sheet, radiographic log, and the treatment progress notes (TPN). Departmental records are documents specific to individual disciplines that are kept behind color-coded departmental tabs.

CHART ARRANGEMENT Proper arrangement of the various documents in the chart ensures that anyone required to review specific data can readily find the information needed. The location of chart documents is fairly standardized: 1. Department documents should be maintained behind each designated department tab,

Treatment Progress Notes (TPN) with the most recent sheet on the top. 2. All radiographs must be kept in the chart pocket. No other documents such as grade

slips, encounter form copies, etc. should be kept there. With the chart closed, the patient's name and chart number must be readily visible. Loose or improperly inserted pages or improperly punched pages can obscure this information and should be corrected when noted.

C-2

MASTER TREATMENT PLAN The Master Treatment Plan (MTP) is the record of all planned treatment developed after departmental routing and specialty faculty consultation. It is also the document of "informed consent" -- the patient's signature on the MTP gives consent to the treatment listed and protects the student and the College of Dentistry against any allegation of work being performed without permission. It is also a key element in providing a finance plan for patients who require extensive treatment. The Master Treatment Plan and the Patient Consent to Treatment Form are the two major documents that require the patient’s signature. Patients seen for limited treatment and/or emergency care must also sign appropriate documents. Since Master Treatment Plans are generated and approved between patient visits, a patient signature may be deferred until the next appointment when an appointment with a Finance Representative from the Central Business Office is needed. TREATING A PATIENT WITHOUT HIS/HER SIGNATURE ON THE MTP IS A SERIOUS RECORDKEEPING OMISSION THAT WILL ADVERSELY AFFECT YOUR EVALUATION DURING YOUR SCHEDULED RECORDS AUDITS.

TREATMENT PROGRESS NOTES Treatment Progress Notes (TPN) make up the major portion of your chart entries. While documentation of actual clinical interactions with patients is mandatory, all interactions should be recorded. Decisions regarding releases, transfers, referrals, etc. are often based on non-clinical activities such as cancellations, failed appointments, and telephone conversations. Clinical interactions are actual appointments during which treatment is planned and/ or rendered. Non-clinical interactions include all other activities relevant to your patient (telephone conversations, consultations with faculty, appointment arrangements, cancellations or failed appointments, personal observations, etc.). Treatment progress notes should contain factual information and avoid the use of statements that convey judgment of the patient or their behavior. When appropriate you may quote the patient in the progress note to be certain that you have accurately conveyed their sentiment. The TPN sheet has a space at the top for the patient's name and chart number. Every newly added sheet must be identified with this information to ensure against loss should individual sheets become detached from the chart. The most recent sheet used is placed on top. The TPN sheet is arranged in seven columns:

Date: Enter the day, month, and year for every entry (both clinical and non-clinical). Procedure Number: Enter appropriate procedure codes as listed in the current clinic fee schedule (located in all clinic dispensaries). If you have questions regarding the proper code to use, consult with attending faculty or the Director of Clinics.

Certain procedures may require follow-up care or are a continuation of a previously initiated procedure in this case it would be appropriate to use a “111” code along with other identifying information.

C-3

Fee Form Number: Enter the number on the encounter slip (ES) generated for your appointment in this column (this may also be identified as the ticket number on your slip). This slip constitutes a financial record and allows tracking of fees and payments.

Encounter slips are generated for every clinic appointment, regardless of whether or not a fee will be assessed or a payment made. Virtually every clinical TPN entry should have a number entered in this column. Even if your patient cancels or fails the appointment, enter the ES number. Encounter slips must be turned in after each clinic session, students not reconciling their encounter slip on a daily basis will be notified by the Central Business office by e-mail and given several days to do so. If the slip is still un-reconciled after several contacts, the student will lose their clinic privileges for at least three weeks.

Tooth Number: Enter the tooth number treated. Surface(s) or Area: Enter the surface(s) or area. Clinical Notes: Enter a complete description of clinical activity. You cannot enter too much information in these notes. Keep abbreviations to a minimum and use only widely recognized acronyms. If in doubt, spell it out!

For every clinical appointment, your first entry in this section will be Permission to Proceed (PTP) that must be initialed by attending faculty. Indicate every material used in the procedure even if its use is automatically implied or assumed. Be specific with your description of anesthesia ("1.8cc xylocaine" rather than "one carpule of xylocaine"). If the anesthetic contains vasoconstrictor, indicate it. Record any adverse reactions to anesthetic and other parts of the procedure. Specific locations on a tooth may be as important as the tooth number itself. If you use retentive pins, for example, identify where they are placed. All clinical entries must be signed by you and countersigned by faculty. Cancellations and failed appointments are considered clinical entries. Non-clinical entries (phone conversations, personal observations, etc.) must be signed by you but do not require faculty countersignature.

Sample Chart Entry

You plan a two-surface DO amalgam restoration on the mandibular right first molar to replace a defective DO amalgam. During preparation, the mesial surface must be included and the distolingual cusp removed. One retentive pin is indicated for the missing cusp. Zinc oxide-eugenol is applied as an overlying base. All-Bond bonding agent is used. One carpule of anesthetic (xylocaine with epinephrine) is administered. No adverse reactions are experienced by the patient throughout the procedure. The patient was instructed that some minor sensitivity to cold might be experienced for a few days due to the depth of the preparation. The patient is re-appointed for 10 October 2001 at 9:00 AM when an MO amalgam on the maxillary second premolar is planned. Your entry might appear as follows:

Reviewed Health Hx, Vital signs noted, No changes in meds. PTP #30-DO (replacement) #30- MODL amal. Removed DL cusp and placed one threaded pin (DL). Placed IRM & All-Bond. Restored with amal (Valiant PhD). Checked occlusion and prox contact. 2% xylo 1:100,000 epi. 1.8 Pt tolerated procedure well. Post-op instructions given. Patient dismissed in good condition NV: 10-10-07am (Planned: #4-MO amal)

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Always escort your patient to the cashier's window. The cashier should validate the patient’s parking ticket. All encounter slips must be turned in on the same day they are issued -- no later than 1:00 pm for a morning appointment or 5:00 pm for an afternoon appointment. Failure to reconcile an encounter slip within five (5) school days of issuance will result in suspension of clinic privileges for a time period to be determined by the Director of Clinics.

If you anticipate your patient will not be dismissed before 5:00 pm due to complications in the clinic contact the Central Business Office prior to 5:00 p.m. at x14711 to inform the staff that you have a patient that will require a late dismissal and a staff member will stay to check out that patient. Do not send your patient down to the second floor alone. Always escort your patient to ensure an appropriate exit from the building including validation of his or her parking ticket.

C-5

CHART AUDITS An integral part of the student’s education in delivering patient care is learning to properly and completely document all interactions with patients. The primary vehicle for this documentation is the patient chart. Proper management of records is important for a number of reasons. The patient chart is a legal document; it affords liability protection to the patient, to the student delivering the care, the faculty supervising the care, and the College of Dentistry should any questions arise about the treatment rendered. The accuracy and completeness of patient records are also important aspects of the College of Dentistry’s Accreditation process through the American Dental Association. Evaluating the student’s capabilities in these areas is accomplished through participation in an auditing process of their patient charts. Beginning in the fall semester of the junior year, each student will be evaluated during an audit of all his/ her adult patient records once each semester. The audit includes a review of all charts, an identification of deficiencies as per criteria published in this handout, a personal interview to discuss findings of the audit, and the assignment of a grade in the spring The audit includes a review of all charts, an identification of deficiencies as per criteria published in this handout, a personal interview to discuss findings of the audit, and assignment of a grade. The Office of Patient Management has assembled this handout with all the information necessary to assist the student in preparing for this process. Students should be thoroughly familiar with its contents as each audit approaches.

OVERVIEW OF CHART AUDIT PROCESS*

One week prior to your Chart Audit, see David Railback in the Chart Room to pick up your charts. (Your charts and paperwork will be ready for you to pick up anytime the week before your chart audit).

1. David will print a list of your patient family and dispense your self-assessment form to you when

you pick up your charts.

2. David will pull and check out all of your charts to you (including Limited Treatment charts). You do not need your Pedo charts.

3. After you have finished your self-assessment form and review of your charts, return the self-

assessment, charts, and the patient family list with your Limited Treatment and Pedo patients identified to David in the Chart Room.

4. David will check the charts out to your assigned auditor, two days before your chart review

appointment.

5. Be sure to observe the appointment time table to ensure your charts and self-assessment is available for review by your auditor.

6. Your chart audit will be graded according to the attached scoring key and assigned a letter grade

for the course “Clinical Recordkeeping and Patient Management”.

7. Please be on time for your appointment, which will last approximately 30 minutes. If you cannot keep your appointment or will be late, please contact your scheduled auditor as soon as possible.

8. Failure to show up for your appointment or your charts and self-assessment are not ready

by the designated date will result in a grade of “0” and you cannot earn a higher remediated grade than a “C”.

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APPOINTMENT TIME TABLE

Monday Audits Tuesday Audits Wednesday Audits Thursday Audits Friday Audits

Student assessment and review must be

completed by 4:30 p.m. Wednesday preceding

the Monday Audit.

Student assessment and review must be

completed by 4:30 p.m. Thursday preceding the

Tuesday Audit.

Student assessment and review must be

completed by 4:30 p.m. Friday preceding the Wednesday Audit.

Student assessment and review must be completed by 4:30

Monday preceding the Thursday Audit.

Student assessment and review must be completed by 4:30 Tuesday preceding

the Friday Audit.

SCORING COLUMN DEFINITIONS

1. Progression of Patient Care and Documentation of Treatment Progress Notes

a. Minimum of monthly treatment entries (exception is when the patient is due for perio maintenance only).

b. Student demonstrates reasonable progression of patient care. The scoring column titled “Demonstrates Reasonable Progression of Patient Care” will use the following codes: 5 = No lapse in patient care or notes exist to reflect justification for lapse in care. 4 = 2 month lapse in patient care (no notes). 3 = 3-4 month lapse in patient care (no notes). 0 = Greater than 4 month lapse in patient care (no notes). 2. Master Treatment Plans

a. A current Master Treatment Plan is present in chart or being revised by the Central Business Office.

b. All signatures are present.

3. Student Professionalism a. Preparation for chart audit. b. Accurate self-assessment. c. Professionalism at Chart Audit.

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4. Appropriate Signatures and Procedure Numbers a. Appropriate use of Procedure and Fee Form numbers in Treatment Progress Notes. b. Treatment Progress Notes are complete and signed/ stamped by the faculty and student. c. Radiographic Log is complete with appropriate signatures and entries. d. Radiographs labeled and properly mounted. e. Health History is signed and dated. f. Medical Alert Sheet is complete. g. Chart forms identified with Patient Name and Chart Number. 5. Chart Organization- (If you have questions regarding how a chart should be organized,

please see Linda Hale to review a chart that is organized correctly) a. Patient documents are placed behind the appropriate department tabs in the chart

(Treatment Progress Notes should be placed together and patient consent for treatment forms should be placed behind the appropriate departmental tabs).

b. Unnecessary grade sheets and miscellaneous documents should be removed from the pocket of the chart.

The scoring definitions for questions 2, 3, 4, and 5 will use the following codes: 5 = 0 errors 4 = Satisfactory 1 -2 errors 3 = Needs improvement 3 -5 errors 0 = Unacceptable More than 5 errors Auditors have weighed each scoring column as follows: 1. Master Treatment Plans are present and appropriately signed - 25 points. 2. Student demonstrates reasonable progression of patient care - 25 points. 3. Student professionalism - 20 points. 4. Appropriate procedures and signatures documented - 15 points. 5. Charts properly organized - 15 points. Letter grades will be defined as follows: A = 90 - 100 points B = 80 - 89 points C = 70 - 79 points

*CHART AUDIT INFORMATION REVISED 07/08 FOR THE 2008- 2009 YEAR

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OTHER CHART GUIDELINES While specific guidelines about proper chart management will be presented in many clinic-related disciplines, the following are key factors in successful documentation to be used in all clinic situations.

1. Never make chart entries in pencil, document in either blue or black ink. 2. Always make your own entries; do not delegate them to someone else. Sign and stamp your

entries. 3. Be consistent in TPN entries. Leave no spaces between entries. 4. Do not include topics of a sensitive or personal nature (e.g., suspicion of drug use, confidential

revelations of the patient, personal comments on patient's mental state) in TPN entries. They should be kept on a separate page and kept apart from TPN sheets.

5. Write legibly! Remember that others will eventually read every entry you make. 6. Distinguish between cancellations and failed appointments. By definition, cancellation occurs

when the scheduled appointment is broken at least 24 hours ahead of time. A cancellation the night before or the day of the appointment is more accurately designated a failed appointment (no-show). Always accompany cancellation/no-show entries with an explanation. "Patient cancelled" is insufficient to justify any subsequent release or inactivation decisions.

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Section D

Financial Policies

CLINIC FEE SCHEDULE

The Clinic Fee Schedule lists the fees for dental procedure in the pre-doctoral program. It is

reviewed and revised periodically. A copy of the schedule is kept in every clinic dispensary.

The fee schedule is available to all faculty, staff and students by e-mail. Limited copies are available through the Office of Patient Management.

The fee schedule applies to all patients in the pre-doctoral program. Despite periodic increases,

all fees average 25% to 50% of those in private practice. Since clinic fees provide a substantial part of our operating funds, the student’s close attention to and strict application of published

fees is required. Refer to the schedule as often as necessary to insure that appropriate fees are

charged at all times and for all procedures. Dental services provided at the College are not free.

A 5-digit procedure code number identifies each procedure in the fee schedule. This code is

important to identify the nature of treatment, determine the appropriate fee to charge, and facilitate the insurance filing process. The first digit identifies the health profession - dentistry is

designated "D". The second digit identifies the discipline (restorative dentistry = "2",

endodontics = "3", periodontics = "4", etc.). The last three digits identify the specific procedure.

Each major code section ends with a "999" code to be used for any procedure that cannot be identified by a specific descriptive code. The “999” codes are not to be used for no charge or

follow up visit codes.

Some codes in the schedule are presented in two formats. Codes with the letter “D” are ADA-

recognized codes. Other codes are for internal school use to provide departments the means to

differentiate and monitor specific procedures for requirement purposes. Only the ADA codes

are used to file insurance claims.

Fees listed are based on the nature and complexity of the procedure. Such fees are to be

determined by attending faculty only. The schedule also contains explanatory notes under some code descriptions to help determine when the use of a particular code is appropriate.

Although you are not expected to memorize procedure codes and fees, many of them will become familiar with repeated use. You are expected to consult the fee schedule as necessary

to ensure that the appropriate fees are charged. If in doubt about which code to use or what fee

to assess, consult with attending faculty or the Technical and Billing Administrator of Clinic

Operations.

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PATIENT FEE REDUCTIONS/ REFUNDS Although published fees are standard for a given procedure, a fee reduction, waiver, or refund may be warranted on occasion. Only faculty can make suggestions for these reductions or refunds or a designated administrative staff appointed by the Director of Clinics. The amount of the reduction, waiver or refund must be entered in the patient's chart and on fee slip with both entries signed by the attending faculty. Secondly, an explanation must be given for the adjustment, procedure identified, amount for adjustment, and date of service to adjust. This can be completed on an adjustment form and/or on an encounter form. If an adjustment form is used a copy of the chart notes needs to be attached which includes faculty signature. Unless circumstances warrant otherwise, full refunds on Prosthodontics or other work involving laboratory charges will not be allowed. The Director of Clinics must approve all fee reductions, waivers, and refunds or designated administrative staff appointed by the Director of Clinics.

COLLECTION OF FEES Patients are expected to pay for services when rendered unless a financial plan has been established. All services that are rendered are charged to the patient account at the start of the procedures. All payments, except as noted below, may be made by cash, personal check, or approved credit card (VISA, MasterCard, or Discover.) Screening fees must be paid in cash or credit card. Patients who are not patients of record but who present for treatment (walk-in emergencies, extractions, etc.) are also required to pay cash or credit card for services rendered in advance of procedure to be performed. The student may be held responsible for the account balances of all patients assigned to them unless the patient has been financially planned and the plan payments are not delinquent. Patients who have delinquent financial plan payments or an account balance over two hundred and fifty dollars, will be suspended from further treatment (and subject to release from the pre-doctoral program) until their account balance is satisfied. When the financial plan is current or the account balance is brought below two hundred and fifty dollars, treatment can be continued. The student assigned for a Limited Care procedure is responsible for the collection of fees assessed for that procedure. Students will not be eligible to sign out of Clinic Operations (required for graduation) until all account balances outstanding have either been paid in full or the financial plan is current. Beware of "creeping" balances. If a patient pays regularly but pays only part of the fees that are charged at each appointment, the balance will increase over time. Unless the student monitors his/ her patients' accounts regularly, balances can grow insidiously and create a possible reconciliation problem later. The student should review the patient’s encounter form at each visit and assess the patient’s payment status. The last payment date prints on the encounter form plus the ageing of the patient’s account balance.

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D-3

MANAGEMENT OF DELINQUENT ACCOUNTS

If there is no payment activity on an account, a letter of delinquency is sent to the patient. If

no payment is received within the next 15 days, the account is turned over to collections and

the patient is automatically released from the program. Reinstatement is considered only if the

patient agrees to [1] pay the total amount outstanding on the account, [2] pay all collection agency charges, and [3] maintain a zero balance during the remainder of treatment. The

Director of Clinics or the Assistant Director of Clinics can only approve reinstatement. Chart

requests for these charts must be approved through Linda Hale in the Office of Patient Management in order to make any non-clinical entries as necessary. This policy ensures that

the student does not provide any additional treatment that may worsen the account status.

The student will be notified when a delinquency letter or collection referral is sent to one of his/

her patients so that they can assist in collection efforts, where possible. The student should

inform his/ her patient that even if payment cannot be made, he/she should at least respond to

statements or letters received so as to avoid formal collection efforts and future credit issues.

ENCOUNTER SLIPS The encounter slip (fee form) is used to record all charges assessed for treatment rendered.

Whether or not a payment is expected or a fee assessed, an encounter slip is required for all

clinic appointments. The Central Business Office automatically generates an encounter slip

when the student signs up for clinic in Quick Recovery™. Each encounter slip is identified by a number in the upper right corner (see next page). This number must be entered in the

appropriate column of your Treatment Progress Notes so that services rendered and accounting

information can be cross-referenced as necessary.

The current account balance is recorded on the encounter slip, which lets the student know at

each appointment what the account balance is. The student should get into the habit of checking this balance routinely at the start of every appointment.

The student must account for every encounter slip generated and must accompany their

patient to the cashier's window at the completion of every appointment to ensure that the encounter slip is properly reconciled. Encounter slips are managed as follows:

1. Before seating the patient, enter the encounter slip number in Treatment Progress Notes column marked "Fee Form". This column should have an encounter slip entry for every appointment.

2. At the end of the appointment, the student should enter the appropriate treatment information

(tooth number, surfaces involved, procedure code, treatment description, and fee) on the slip. Enter in status column A, B, C, or D. A= Started but not completed. B= In progress, C= Completed and D = Started and completed in the same appointment. Fees will be charged out with either an A or D status.

3. Written faculty approval, including a brief explanation for the discounted fee is required on the

encounter form or an adjustment form and in the patient’s chart. 4. Have attending faculty verify accuracy of encounter slip information. Faculty signature is

required on every encounter slip, including cancellations or failed appointments.

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5. The student must accompany the patient to the cashier’s window to ensure that payment is made and that the encounter slip is properly reconciled. Students who fail to accompany their patient to the cashier’s window on more than one occasion will risk losing their clinic privileges for a period of at least 2 weeks. The only exception to this rule is for DENTURE PATIENTS ONLY who is paid in full for dentures or partials (D5213, D5214, D5110, D5120) and has a $0 balance. If the denture patient has a $0 balance but will have new charges, Example: D0150 Evaluation, the patient must be escorted to the cashier window.

6. Encounter slips must be turned in on the same day they are issued in e ach department.

Each department is responsible for all encounter slips generated for scheduled patient s .

University of Oklahoma College of Dentistry Financial Policies Regarding Staff and Student s

Effective May 15, 2006

Clinical Fee Discounts

Students and staff of the College are eligible for the following discounts: 1. S tudents:

• 100% discount to students for any treatment rendered by another student, provided there is no support laboratory assistance/materials used.

• 25% discount for all other fees including treatment that involves support laboratory assistance/materials. Discount will be applied after insurance.

2. S tudent Family: • 25% discount for immediate family members of students. Discount will be applied after

insurance. • No discount of screening fees for immediate family.

3. S taff:

• 100% discount of screening fees for all College Staff. • 25% discount of all other fees for College Staff and to custodial staff who are assigned to the

College of Dentistry. Discount will be applied after insurance.

4. S taff Family: • 25% discount for immediate family members of College Staff. Discount will be applied after

insurance.

• No discount of screening fees for immediate fami ly.

Immediate Family

Immediate family is defined as follows: Student immediate family if married: 1 . P a r e nts of the student 2 . Spouse 3 . C h i l d r e n and stepchildren up to age 18 (to age 24 if child is full-time student) Student immediate family if single: 1 . P a r e nts 2 . S i b lings and stepsiblings up to age 18 (to age 24 if child is full-time student) Staff immediate family if married: 1 . Spouse 2 . C h i l d r e n and stepchildren up to age 18 (to age 24 if child is full-time student) Staff immediate family if single: 1 . P a r e nts if living in same household

2. S i b lings and stepsiblings if living in same household up to age 18 (to age 24 if sibling is full-time student)

D-5

DENTAL INSURANCE If the student’s patient has dental insurance coverage, it is their responsibility to ensure that the Patient Account Representative receives the necessary information to file claims on the patient's behalf. For certain procedures and/or anticipated large claims, most insurance companies will require pre-authorization of the procedure. A proposed treatment plan (with estimated costs) should be given to the patient. The patient should submit the proposed treatment plan to the patient’s insurance carrier for estimated costs and payment for each procedure to be rendered. For the insured patient very few procedures are paid in full with many companies allowing only 1 or 2 of these procedures during a specific time period. Most insurance carriers have deductibles ranging from $25-$50 and maximums ranging from $1000-$1500 per calendar year. Patients are expected to pay for treatment when rendered even though they have insurance. They are required a minimal co-payment at the time of service for companies the College of Dentistry has a participating agreement. Those companies are Delta Dental of Oklahoma, Health Choice and Medicaid for children and adolescents. The CBO files with all other insurance carriers as a courtesy to the patient. Many of these carriers pay the patient directly since the College of Dentistry is non-participating. In many cases, even though the patient has dental insurance coverage the patient may not have any benefits if provided by a non-participating provider. One example is Federal Blue Cross and Blue Shield. In general, any major restorative work is paid at a rate of 50% or could be a non-covered benefit. All insurance claims are filed automatically once the procedure has been completed (‘C’ or ‘D’ status). There are rare occasions an insurance carrier may require insurance claims to be filed on the preparation date versus the seat date. Although the student provides the dental services, the student is not authorized to sign insurance forms as a provider. The Director of Clinics signs all claims filed for work performed in the pre-doctoral clinics. Please keep in mind insurance carriers need the following information to file claims and should be documented in the chart. If crowns and fillings are replaced, insurance carriers require the original date the crown or filling was placed initially. If dentures or partials are replaced, insurance carriers require the original date denture or partials were placed, as well, the date and tooth numbers originally extracted. MetLife insurance carriers require a pre-determination claim for a crown when billing for a core build up prior to services rendered.

D-6

OTHER FINANCIAL POLICIES As mentioned, patients are expected to pay in full for services when rendered (initial appointment). For fixed and removable prosthodontic treatment, 50% of the fee must be paid when the procedure is initiated and the other half before delivery or cementation. For single crowns and bridges, the gold card, laboratory prescription, and departmental grade form must be stamped "1/2 paid" before the Support Laboratory will issue any gold for casting procedures. The student is not allowed to use their preclinical gold to fabricate a patient's prosthesis. It is an inferior metal. Complete and partial dentures must be paid in full prior to sending the case to the lab for processing. Any follow up visits after delivery will warrant a generic internal code at no charge $0. For dental services that span multiple appointments (fixed/removable prostheses, scaling/root planing, complex endodontics, etc.), the total fee must be charged at the initial appointment. Do not make partial charges. If a patient terminates his/her association with the College, it is much easier to refund a credit balance than it is to collect for services that have not been charged. When the Master Treatment Plan is completed, the patient will be provided with a copy, which is an estimate of the total fees involved in performing the recommended treatment. Stress the word estimate and make sure the patient understands that quoted fees may change if treatment is modified during the course of care. The patient should also understand that fee increases apply to all patients even if original treatment estimates were developed from a previous fee schedule. Any exception to this policy requires the approval of the Director of Clinics or the Assistant Director of Clinics. All payments on an account are always applied to the oldest account balance. If you perform a limited treatment procedure and the patient makes a payment, the money will be applied to any existing outstanding balance. Patients scheduled for endodontics treatment only will be required to pay for services in full by cash or credit card at the initial appointment. The patient will be required to check in for payment in full prior to presenting to the clinic for treatment. To be eligible for graduation, all patient account balances must be zero or any financial payment arrangements must be current. This also includes limited treatment by a secondary student. The student should pay close attention to account balances throughout their clinical tenure and especially during their senior year. THE STUDENT WILL BE HELD ACCOUNTABLE FOR ALL ACCOUNT BALANCES OUTSTANDING AT THE TIME OF GRADUATION. PRIOR TO SIGN-OUT FROM CLINIC OPERATIONS STUDENTS WILL BE REQUIRED TO MEET WITH TAMMY VOGT IN THE CENTRAL BUSINESS OFFICE.

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Section E

Management of Patient/ Visitor Medical Emergencies

INITIAL EMERGENCY MANAGEMENT Adverse incidents may be either unusual events or unanticipated outcomes. An unusual event is a physical accident not directly caused by or the result of treatment rendered. The event may or may not cause an injury. Example: a patient who trips and falls while being seated in the dental chair. An unanticipated outcome is the result of treatment rendered where the outcome is not expected and/or is outside the "normal" range. Example: vertigo or anaphylactic reaction to local anesthetic. Report all adverse incidents, whether emergency or non-emergency in nature, to the Environmental Compliance Coordinator, Mary Gowin (ECC) at 1-3083 (Room 232) who will assist you with completion of the appropriate Incident Report. The student must also make complete and detailed entries of all such incidents in the patient's chart. If a patient reports an adverse incident to the student by telephone during off-hours, it should be reported on the following clinic day. If an accident (falling down the stairs, or falling in or around the building) occurs to a visitor or patient not involved in dental treatment, contact the ECC and/or the Campus Police to investigate. All medical bills, hospitalization, ambulance transportation, etc. will be the responsibility of the visitor or patient. Avoid comments to a visitor or patient about responsibility for costs associated with non-dental accidents. During the provision of dental care there is always the possibility, however slight, that a medical emergency may arise. While the specific nature of the emergency may vary from case to case, the following constitutes a standard protocol for the initial management of all medical emergencies:

1. Position the patient properly (varies with the type of emergency) and make sure he/she is breathing. Insure that airway and circulation are adequate. Be prepared to administer basic life support and cardiopulmonary resuscitation (CPR) as necessary.

2. Monitor vital signs; assess level of consciousness, pulse, and blood pressure. 3. Alert clinic staff or another student to notify both attending faculty and the ECC.

If the emergency is life-threatening: 1. Notify the clinic faculty.

They will remain with your patient and institute basic life support if needed.

2. The clinic faculty will: a. Send someone to retrieve the Automated Electronic Defibrillator (AED). b. Send someone to the 1st floor main entrance to meet the EMS.

3. The student will: Call 1-4911, DO NOT call 1-6326.

Campus Police will connect you to the EMS. a. Identify yourself. b. Identify the College. c. Give the floor number. d. Give the name of the clinic. e. Remain on the telephone until the EMS arrives. E-1

PROCEDURES FOR MEDICAL EMERGENCIES

Emergency numbers must be posted by each clinic and laboratory telephone. The supervising clinic faculty must remain with the person needing emergency treatment, as they are responsible for the life support of the person until appropriate help arrives. The Campus Police must then be contacted at 1-4911 they will dispatch EMS. The person making the call must provide the exact location and as much information about the nature of the emergency as possible to Campus Police. If the patient has had a cardiac arrest (not breathing and/or no pulse), CPR should be instituted immediately and a bystander should retrieve the (AED) from the nearest location. Inform the Environmental Compliance Coordinator (1-3083) or call cell number 550-3643 as soon as possible. Either the student treating the patient or the Information Desk receptionist may be at the South Entrance to direct the ambulance crew to the proper location. The attending faculty member associated with the case, the Environmental Compliance Coordinator, as well as the student should accompany the patient to the emergency room. The faculty member or the ECC should not leave the emergency room until he/she has obtained the name of the physician who assumes responsibility for the case. Document the specifics of the emergency and the actions taken in the patient's chart. The chart will be taken to the emergency room with the patient so that emergency service personnel will have access to all pertinent information. It must be returned to the College by whom-ever has accompanied the patient to the emergency room. Following proper disposition of the emergency, the student treating the patient, and the attending faculty member must prepare a detailed report of the incident including names, dates, times, circumstances of occurrence, treatment rendered, condition of the patient, and final disposition of the case. Include the name of the physician assuming responsibility for any patient transported to the emergency room. File this report with the Environmental Compliance Coordinator. A copy of the report will be forwarded to the Dean. Neither the student treating the patient nor the faculty involved should make any statements to the patient regarding the final disposition of any medical, ambulance, and treatment fees. The OUHSC Office of Risk Management will determine if financial responsibility rests with the College of Dentistry or the patient.

E-2

INGESTION OF A FOREIGN BODY

If a patient swallows a foreign body (gold casting, broken instrument, rubber dam clamp, etc.), immediately notify the ECC (1-3083) who will provide the student with the necessary incident report forms for documentation. Enter a full description of the event in the patient's chart. The student will then accompany the patient and ECC to the Family Medicine Clinic (1-2577) for radiographs; it is not necessary to report to the emergency room. If a piece of broken instrument has been ingested, take the broken instrument (and an intact instrument of the same design) along. The clinic radiologist will advise the student about any further course of action.

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EVENING/ WEEKEND EMERGENCIES

It occasionally may be necessary to manage an emergency that occurs during an evening, weekend, or holiday when the College is not open. The student is responsible for providing their patients with a telephone number to contact them should any after hour emergency occur. If a student plans to be out of town or unavailable for extended periods of time, they should always make arrangements with a classmate to receive calls from their patients should any emergencies arise. If a student receives an emergency call that requires faculty advice or aid, determine as fully as possible the nature of the emergency:

1. If related to treatment recently rendered, the student should e-mail the faculty member who supervised treatment. If he/she has not responded, then the student should e-mail another faculty member from the same department. If not related to treatment rendered, the student should e-mail a faculty member in the discipline they feel would be involved in treatment.

2. The faculty member will determine the appropriate action, which may involve

calling in a prescription or rendering emergency care. If treatment is indicated, the faculty member may refer the patient to a private practitioner, the emergency dental clinic of an area hospital, or another available treatment facility.

3. If a faculty member is unavailable you may contact the Dentist-On-Call for

assistance by calling 1-6326. The Dentist-On-Call will not see the patient for you but may be of assistance in prescribing medications as well as advice.

The student is encouraged to maintain a notebook for calls they receive at home or out of town to record emergency calls, measures taken, and therapeutic advice given. Once they have returned to school the student must also retrieve the patient's chart as soon as possible after treatment to appropriately document the incident and obtain a faculty signature. These policies pertain only to currently assigned patients under the care of dental or dental hygiene students.

E-3

After Hours Protocol for Emergencies Involving Student Clinic Patients

Case 1

Case 2

E-4

Patient Contacts Student Dentist

Student Assesses Patient Need/ Reviews Medical History

Student Contacts On-Call Dentist for the College of Dentistry and Recommends Appropriate Action (647-1259)

Documentation Made and E-mailed to Ms. Kathy Miller and Dr. Jeanne Panza

Patient Contacts On-Call Dentist (647-1259)

Page OMS at 271-5656 or 271-4949

On-Call Dentist Contacts Student Documentation Made and E-mailed to Ms. Kathy

Miller and Dr. Jeanne Panza

Medical Emergency – Go Directly to Emergency Room

Refer to Emergency

Room Action Taken

Case 3

EMERGENCY EQUIPMENT/SUPPLIES Emergency (crash) carts are available in every clinic. They are checked monthly to replace outdated medicines and drugs, replenish oxygen tanks, etc. The basic emergency equipment listed below constitutes the contents of each emergency cart.

EMERGENCY CART SUPPLIES EMERGENCY DRUG KIT Oxygen delivery system (tank, mask) I.V. lidocaine Pocket Mask Atropine Sulfate Blood pressure cuff and stethoscope Nitrostat (nitroglycerin) aerosol Tongue retractor Benadryl(diphenhydraminehydrochloride) Flashlight Solumedrol(methylprednisonesodium Pair of scissors succinate) Pencil and note pad Adrenalin (epinephrine) - 1: 1000 Airway (adult and child) 22 gauge needles IV connecting tubing set Trachea needle 500 mg dextrose solution (1 bag) 3 cc syringe (3)

Tonsil suctions 10 cc syringe (2) Tongue blades Albuterol oral inhalation Tourniquet Alcohol and prep packs Roll of paper tape Band Aids Angiocath 22-gauge Nasal Canula Prongs

E-5

The information on the pages that follow represents the most current policies adopted by the OU College of Dentistry regarding treatment of patients with hypertension. Included in this information are the current guidelines for Endocarditis Prophylaxis.

E-6

University of Oklahoma College of Dentistry Guidelines for Treatment of Patients with Hypertension

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has issued new guidelines for classification of hypertension for purposes of prevention and management as of May 2003. Blood Pressure Scheme for Adults:

• Normal Systolic BP < 120 and Diastolic BP < 80

• Pre-hypertension Systolic BP 120 - 139 or Diastolic 80 - 89

• Stage 1 Hypertension Systolic BP 140 159 or Diastolic 90 - 99

• Stage 2 Hypertension Systolic BP > 160 or Diastolic > 100 For patients with hypertension, the basic BP control target is < 140/ <90, but the target is < 130/ < 80 for patients with diabetes or renal disease. Pressure Range OUCOD Dental Therapy Considerations <120 Routine dental management, recheck every recall. < 80 120 - 139 80 - 89 Routine dental management. Recheck on subsequent

visits. Stress reduction protocol if indicated. Refer to physician if in this range for 3 consecutive appointments.

140 - 159 90 - 99 Recheck in 5 minutes. If still elevated, other factors (age,

apparent health, apprehension, history of hypertension, etc.) will determine if dental treatment is possible at this time or medical referral is necessary.

160 - 180 100 - 110 Recheck in 5 minutes. If still elevated, medical consult

prior to dental treatment is indicated. After medical clearance, routine dental care with indicated stress reduction.

>180 110 Recheck in 5 minutes. Immediate medical consultation if

still elevated. No dental therapy until elevated blood pressure under control.

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The following is a summary of the 2007 American Heart Association revisions for recommendations for endocarditis antibiotic prophylaxis.

Endocarditis Antibiotic Prophylaxis IS Indicated for the Following Cardiac Conditions

• Prosthetic cardiac valves

• Previous infective endocarditis

• Congenital heart disease (CHD)*

• Unrepaired cyanotic CHD, including palliative shunts and conduits.

• Completely repaired congenital heart defect with prosthetic material or device,

whether placed by surgery or by catheter intervention, during the first six months after the procedure.‡

• Repaired CHD with residual effects at the site or adjacent to the site of a

prosthetic patch or prosthetic device (which inhibits endothelialization).

• Cardiac transplantation recipients who develop cardiac valvulopathy. *Except for the conditions listed above, antibiotic prophylaxis is not longer recommended for any other form of CHD. ‡Prophylaxis is recommended because endothelialization of prosthetic material occurs within six months after the procedure.

Dental Procedures for Which Endocarditis Prophylaxis IS Indicated

All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa*. (See Below)

Dental Procedures That Do Not Require Endocarditis Prophylaxis

*The following procedures and events do not need prophylaxis: routine anesthetic injections through non-infected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa.

E-8

Antibiotic Regimens for Endocarditis Prophylaxis Regimen: Single Dose 30 - 60 minutes

Before Procedure Situation Agent

Adults Children

Oral Amoxicillin 2 grams 50 milligrams/ kilogram

Unable to Take Oral Medication

Ampicillin OR

Cefazolin OR ceftriaxone§

2 g IM* or IV+

1g IM or IV

50 mg/kg IM or IV

50 mg/ kg IM or IV

Allergic to Penicillins or Ampicillin Oral

Cephalexin‡ OR Clindamycin OR Azithromycin or Clarithromycin

2g

600mg

500mg

50 mg/ kg

20 mg/ kg

15 mg/ kg Allergic to Penicillins or Ampicillin and Unable to Take Oral Medication

Cefazolin or ceftriaxone§ OR

Clindamycin

1 g IM or IV

600 mg IM or IV

50 mg/ kg IM or IV 20 mg/ kg IM or IV

* IM: Intramuscular + IV: Intravenous ‡ Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage § Cephalosporins should not be used in a person with a history of anaphylaxis, angioedema, or urticaria or ampicillin.

Antibiotic Prophylaxis is not routinely indicated for most dental patients with total joint replacements. The above regimen is acceptable when indicated. Indications are for the following groups of patients: 1. All patients within the first two years of joint replacement. 2. Patients with immunocompromised status, SLE, rheumatoid arthritis, etc. 3. Patients with compromising medical conditions such as cancer, type 1 diabetes, HIV infection/ AIDS, previous prosthetic joint infections.

E-9

Section F

Guidelines For the Use of Ionizing Radiation

Purpose

This policy has been developed to assure the safe and effective use of ionizing radiation in the University of Oklahoma College of Dentistry and to minimize any potential risk to the patients, faculty, staff and public. The appropriateness of dental care is intimately related to the accuracy of diagnosis. Dental radiographs constitute a vital diagnostic tool in dental practice. While the risks of ionizing radiation to patients and operators are not fully understood, statistical estimations of risk must be weighed against specific benefits. Risk analysis is usually based on the biological effects seen in laboratory studies and at higher doses. These data are then extrapolated and inferences made about the hazards to human beings exposed to x-radiation. It is generally accepted that diagnostic levels of x-radiation have the potential to cause harmful effects. This concern alone demands that professional judgment always be used when handling radiation. One should also be sensitive to the economic costs associated with radiographic exposures. The radiation use philosophy is based on the following principles: (1) ALARA -radiation use as low as reasonably achievable, (2) justification for the radiographs supported by clinical findings, and (3) optimization to allow maximum diagnostic yield. The objective is to elimination unnecessary radiation exposure to the patient. The ionizing radiation guidelines in this section are reviewed and revised as necessary. They incorporate those procedures and protocols that improve the risk-benefit ratio by maximizing the diagnostic yield from radiography and minimizing exposure to unnecessary radiation. You are expected to be thoroughly familiar with these guidelines and to apply them in every instance of radiation use.

F-1

ADMINISTRATION OF THE POLICY 1. The College's ionizing radiation guidelines comply with the University of

Oklahoma Health Sciences Center Radiation Use Policy, Consumer-Patient Radiation Health and Safety Act of 1981, the National Council of Radiation Protection and Measurements Report #145, the Oklahoma Department of Health Rules and Regulations, and the Oklahoma State Dental Practice Act. The Director of Oral Radiology shall serve as the College's Radiation Protection Representative (RPR) with advice and input from the Clinic Policies Committee.

2. The RPR is responsible for establishing, implementing, and monitoring

policies on radiographic practices for all diagnostic radiation sources in the College. He/she will also work in cooperation with established university radiation standards and radiation protection programs to coordinate, monitor, and control the use of x-ray and other imaging equipment.

3. Only faculty, students, and those staff certified by training and under the

supervision of dental faculty may make radiographic exposures. Dental faculty will personally establish tentative diagnoses and prescribe the appropriate radiographic procedures.

4. While at the College of Dentistry, all intraoral and panoramic radiographs

made by the students are formally evaluated by faculty or trained radiology staff. Any required retakes are made. Students with numerous retakes may be supervised directly by Radiology Staff. If a student is judged to lack required technical skills, he/she will be required to complete additional learning exercises, a competency review in technique and knowledge of radiation protection principles. Only after the completion of the additional requirements, the student will be allowed to work on patients.

5. Radiography shall be confined to the Oral Radiology clinic whenever

possible. Reasonable exceptions are made as part of treatment in other clinics, off-site training programs, and student externships.

6. The RPR will conduct periodic continuing education programs for all staff

operating x-ray generating and processing equipment as needed. All such staff must be familiar with radiation safety practices.

7. The Radiation Protection Representative and the Clinic Policies Committee

are responsible for controlling the use of ionizing radiation and for ensuring the consistent application of this policy by all clinical departments and programs. Every entity with radiographic capacities is expected to monitor daily compliance with this policy. Applicable portions of this policy must be posted or otherwise available in each satellite area.

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PHYSICAL FACILITIES 1. All equipment and facilities are upgraded as necessary to meet the

regulations and recommendations of the Radiation Control for Health and Safety Act of 1969; NCRP Report Number 35 on Dental X-ray Protection; and the ADA recommendations on acceptable radiographic practices of 1984.

2. Radiographic facilities shall be designed to maximize student, operator, and

patient protection from unnecessary exposure to ionizing radiation.

3. Film processing shall take place using the time/ temperature processing method and shall be monitored on daily basis to assure film quality.

4. Digital imaging equipment shall be monitored on a regular basis to assure

image quality.

5. Because portable x-ray machines present radiation protection difficulties, they should be used only when the patient cannot be transferred to a permanent radiographic facility.

6. Average kVp, mA, and exposure times must be posted by each x-ray unit.

7. Radiographic film will be provided only when a prescription for specific

radiographs has been signed by a dental faculty member.

8. Radiograph viewing should be accomplished under ideal conditions, including dim background lighting, masked view-boxes of adequate and uniform intensity, opaque film mounts, and magnifying glasses.

9. As part of quality assurance program, annual (or more frequent as needed)

inspection of all x-ray equipment will be done to maintain performance standards with inspection reports kept in a logbook.

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INSTRUCTIONAL SUPPORT 1. Supporting technical staff shall be knowledgeable and skillful in oral radiography procedures and the safe use of ionizing radiation. 2. Director of radiology shall possess appropriate training in oral and

maxillofacial radiology including radiation physics, radiation biology, radiation protection, radiographic techniques, and levels of radiographic interpretation appropriate for the group being instructed.

3. Students shall be closely supervised by faculty or staff during all clinical

radiographic procedures conducted on patients. Exposures shall be made only after faculty authorization. The retaking of radiographs shall be authorized by dental faculty and supervised by a faculty or radiology staff member.

4. Techniques that will minimize patient exposure shall be emphasized (e.g.,

long open, shielded beam indicating devices (BID's), lead aprons, film holding devices high-speed receptors and appropriate collimators.

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CRITERIA FOR RADIOGRAPHIC EXPOSURES 1. It is considered unprofessional and inappropriate to order or conduct a

radiographic examination for the patients without a conducting a clinical examination. All radiographs must be prescribed in writing in the patient's record on the Radiographic Log and signed by the attending dental faculty member. Prior radiographs, if available, should be evaluated before new radiographs are ordered. Only those additional views needed for complete diagnosis/treatment planning will be exposed. This does not preclude making a new intraoral survey if it is appropriate to the diagnosis.

2. The need for all radiographs, as established through history and clinical

examination, is based on the professional judgment of dental faculty. The frequency and type of radiographs which are taken to aid in routine maintenance of a patient’s dental health varies and the decision shall be made based on individual needs.

3. Radiographs ordered on a routine basis or for screening purposes only are

prohibited. Screening radiographs will be kept to the number needed to determine the acceptance of a patient for treatment and will become part of any subsequent diagnostic radiograph series.

4. When the need for radiographs is established, students will be required to

produce a minimum number of radiographs consistent with an adequate diagnosis of disease.

5. Radiographs should only be made on patients capable of compliance or under

appropriate sedation.

6. The need for radiographs during and/ or after treatment, and the frequency of recall radiographs, will be based on the patient's needs and the professional judgment of the attending dental faculty.

7. Radiographs will not be made only for administrative purposes (including

insurance claims or legal proceedings). However, diagnostic radiographs may be used for administrative purposes. Radiographs of patients will also not be made merely for the purpose of training or demonstration.

8. Students must demonstrate technical proficiency in radiographic technique on

skulls and manikins before being allowed to expose patients.

9. Students shall be assisted with all patients requiring three or more retake radiographs or a complete intraoral radiographic survey. Such surveys shall demonstrate each root apex, periapical bone, and each crown with minimum overlapping.

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CRITERIA FOR RADIOGRAPHIC EXPOSURES (CONTINUED)

10. Radiography shall not be attempted when the patient shows an inability or unwillingness to cooperate. If a patient or parent or guardian denies the necessary radiographs, the rejection must be noted in the progress notes. Dental care can be refused based on rejection of the radiographs with faculty approval.

11. Radiation History: At the initial appointment for planning treatment, a history of previous radiation experience shall be obtained. The site exposed or treated should be noted in the patient's history.

12. Pregnant patients: When properly conducted, dental radiographic examinations present no additional hazard to the developing embryo/ fetus. Consequently, there appears no rationale to preclude justified dental radiographs because of pregnancy. However, some dental care can be considered elective and other care less urgent. If the patient chooses to postpone certain procedures, then the radiographs associated with those procedures can also be delayed. This applies to all patients.

13. Patients shall not be subjected to retakes to satisfy technical perfection.

14. Dental auxiliary personnel shall not take radiographs without prior prescription by faculty.

15. Approval by the Institutional Review Board shall be obtained for radiation applied for research purposes.

16. Licensing examination patients: Since all state/regional licensing boards

require radiographic evidence of specific types of lesions, there is a potential for abuse of this policy as students prepare for these examinations. Radiographs made for, or as a part of, any board examination must be made in compliance with this policy. All requests for radiographs on board patients must be approved in writing and signed by a dental faculty member. There must be a need for radiographs based on clinical indication and professional judgment; they must contribute to the proper diagnosis and treatment of the patient. Radiographs may not be made for testing purposes alone.

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OPERATING PROCEDURES FOR RADIOGRAPHIC EXPOSURES 1. Exposures are to be determined individually on the basis of the size, age, gender,

race and presenting dentition of the patient. Kilovoltage, milliampere and exposure times are determined with the Oral Radiology faculty and staff or as posted in clinics.

2. To minimize risks associated with radiation exposure, the fastest system

appropriate to the diagnostic need will be used. Only F-speed intraoral film or corresponding digital exposure levels shall be used in routine practice.

3. All x-ray generators must meet federal requirements for collimation and

filtration 4. Film-holding devices during standard technique shall be used.

5. Use of leaded aprons and thyroid shields for all intraoral radiographic procedures is required. Thyroid collars also shall be used on children and adult patients to minimize any unnecessary radiation. Thyroid collars shall not be used whenever they interfere with the film exposure. For example, thyroid collars shall not be used on panoramic and mandibular occlusal radiographs since they are in the path of the x-ray beam.

6. Operators shall not hold patients or films during any radiograph exposures. If assistance is required for children or disabled patients, an adult member of the patient's family or other non-radiation staff may help. He/she must wear a leaded apron and gloves when stabilizing the patient and must stay out of the primary beam.

7. During each exposure, the operator must stay out of the cubicle behind the wall;

or stand out of the primary beam and behind an adequate protective barrier that permits observation of and communication with the patient.

8. The exposure control switch must be in a fixed position behind the barrier and it

requires continuous pressure throughout the exposure.

9. If a malfunction is detected in an x-ray generating unit, do not use the unit until the necessary corrections have been made and the equipment recalibrated. The tube head must not vibrate or drift during exposure.

10. For extra oral radiography, restrict exposure to the area in question and with the beam collimated equal to or smaller than the size of the film. Use the fastest extraoral film-screen speed combinations appropriate to the diagnostic need. The patient must wear leaded aprons and thyroid shields during extraoral radiography when diagnostic yield is not reduced.

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OPERATING PROCEDURES (CONTINUED)

11. Skull radiographs are to be made with rare earth screen-film systems or

digital systems.

12. Any technical deviations must be approved by the attending dental faculty.

INFECTION CONTROL 1. All patients of the College must be treated as potentially infectious. Each

patient's medical history must be evaluated for indications of infectious disease prior to any radiographs being made.

2. Wear protective gloves, glasses and masks during film and tube placement.

Wear gloves during film processing while handling contaminated film packets.

3. Keep all supplies and film packets on a covered work surface. Charts and

forms must be kept away from the work area.

4. Cover all control panels, chair adjustments, beam-indicating devices (cones), and tube heads with disposable plastic. Wipe them down with an EPA- or ADA-certified surface disinfectant before and after use. Cover the exposure control switch with a disposable piece of plastic.

5. Film holders must be sterilized. Disposable items may also be used. 6. Place contaminated items in red biohazard bags.

7. Place lead liners from film packets in the designated container in the dark room. Place remainder of the film packet in the red biohazard bag.

8. To reduce contamination, all radiographic supplies will be dispensed rather

than stored in a common drawer. The appropriate number and type of films must be obtained from the attending dental faculty or staff in the dispensing stations. Radiographic log must be completed.

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RADIATION SAFETY

1. Radiographic equipment and technical procedures shall be in compliance

with State and Federal radiation safety standards, rules and regulations. 2. Technical procedures will be utilized according to the ALARA-principle (As

Low As Reasonably Achievable) in order to limit the radiation exposure to a level, which is sufficient to obtain adequate radiographic information for patient diagnosis, treatment planning and follow-up.

3. Only qualified and authorized persons shall expose patients to ionizing

radiation e.g., DDS, RDH, CDA, RT's or dental assistants. Students who have obtained radiographic pre-clinical competence will be allowed under faculty / staff supervision.

4. Personnel radiation monitoring will be offered to those individuals who

frequently make exposures or supervise radiography students and request such service. Personnel radiation monitoring is not required by Oklahoma regulations governing dental radiation exposures as practiced in the College of Dentistry.

5. Quality assurance procedures shall be utilized to establish the integrity of

equipment as recommended by the American Academy of Oral and Maxillofacial Radiology. All x-ray producing devices shall be tested for compliance annually. All deficiencies shall be corrected within a reasonable time frame.

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RECORDS

1. All radiographs are the property of the University of Oklahoma College of

Dentistry with the permanent patient chart. A mechanism exists to make duplicate copies of radiographs, if requested.

2. All radiographic exposures for each patient must be documented on the

Radiographic Log in the patient's chart. All intraoral radiographs must be mounted and labeled with the patient's name and the date of exposure, and stored in the radiographic pocket of the chart.

3. All extraoral and duplicate radiographs must be labeled with the patient's

name, date of exposure, and right/left side orientation. 4. When radiographs are temporarily removed from a chart, a note to this effect

should be made in the chart and signed by the individual.

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Section G

Patient Care Guidelines

University of Oklahoma College of Dentistry Patient Care Guidelines

I. Patient Management

A. Patient Admissions

a. Patients will be accepted into the pre-doctoral program when the patients’ treatment needs are within the scope of the educational experience provided. This assures that the delivery of care can be affected in a timely manner and with a certain degree of predictability based on the range of expertise of the students and supervising faculty. Patients who are not eligible for treatment will either be informed at the time of the screening consultation or after consultation with a specialty faculty member and shall be documented in the patient record.

b. Each prospective patient will be offered the earliest available screening

appointment after completion of the application process. Each patient will be offered an initial oral examination during the scheduled screening appointment.

c. No prospective patient will be denied admission to the program or provision

of care on the basis of race, color, creed, religion, national origin, sex, age, marital status, disability, public assistance status, veteran’s status, or sexual orientation.

d. Patients will receive considerate, respectful and confidential treatment at all

times.

e. Patients will be notified of personal responsibilities and all applicable College policies and procedures prior to the initiation of treatment. Each patient will receive a copy of the “Patient Bill of Rights and Responsibilities”, “Conditions of Treatment”, and “Financial Policies” and will have the opportunity to ask questions and be provided understandable answers.

B. Patient Assignment

a. Patients who are assigned to pre-doctoral students will receive diagnostic and treatment services that are consistent with their medical capacity along with any dental and/or medical consultations. These would include oral pathology consultations, appropriate pre-medications, timing of the procedures, post-operative medications, choice of anesthesia and pain control, and selection of the services to be rendered. Appropriate behavior management techniques may be employed to manage anxiety.

b. Patients, or their legal guardian, will have reasonable, informed participation

in decisions concerning their dental health; be informed of reasonable treatment alternatives; benefits and risks of treatment including the consequences associated with refusing or delaying treatment, and the prognosis in terms they can understand. Patients will receive a copy of the treatment plan and any documents related to financial liability once appropriate faculty consultations have been completed.

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C. Treatment

a. The frequency of treatment for each patient will be determined on an individual basis and is dependant on patient availability, the complexity of treatment required and clinic availability. Active comprehensive care patients will be offered an appointment at least one time per month until treatment is completed or other mutually agreeable arrangements have been made. Therefore it is prudent to select patients whose treatment needs can be accomplished within a reasonable amount of time based on the time constraints of the educational program.

b. Patients will receive treatment in a sequence appropriate to their treatment

needs.

c. Patient care will be provided under the supervision of or by faculty members.

d. Patients will have access to complete and current information about their oral health status.

e. Patients will receive treatment that meets the Care Guidelines as outlined

and monitored by the Faculty and Quality Assurance Committee.

f. If a patient’s needs require skills beyond those of a pre-doctoral student, Faculty will refer those patients to an appropriate graduate student, or private practitioner.

g. Patients’ health histories will be updated and modified to reflect changes in

the clinical conditions and needs, patient response to therapy, financial factors, and patient availability.

D. Completed Care

a. Upon completion of all treatment, each patient will receive an exit examination including:

a. Assessment of the treatment provided to ensure that the applicable

Guidelines of Care have been met.

b. Assessment of the patient’s level of comfort and satisfaction with the treatment provided.

c. Assessment of the patient record for compliance with record-

keeping standards.

d. Assessment of the patient’s current oral health status.

e. Determination of the patient’s interest in, and appropriate interval for, examination as a participant in the dental hygiene recall program.

f. Determination of the patient’s commitment to continue care at the

College of Dentistry or the indication for referral or discontinuation of care.

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E. Limited Care

a. Limited care services are available to patients who seek treatment for

specific needs such oral surgery or endodontic therapy as long as the treatment sought is within the scope of the pre-doctoral program, is congruent with the philosophy of the College, and serves to improve the oral health status of the patient.

b. Patients seeking limited services that are within the scope of the pre-doctoral

clinical programs will be admitted for care when they consent to limited treatment, the limitation of care is clearly documented, and such limitations are not detrimental to their health and well-being.

F. Emergency Services

a. Emergency dental care will be available during designated clinic hours for unassigned patients on a space available, fee for service basis.

b. The College will provide a twenty-four hour dental emergency service for

active patients of record via an answering service accessed with the assistance of their assigned student-doctor and managed by graduate residents within the College who are familiar with College policies and protocol.

G. Patient Release

a. Faculty may elect not to accept patients for treatment or to refer patients who

request care that is inappropriate relative to these Guidelines of Care; who are non-compliant; or whose behavior poses a threat to a student, employee, other patients, and/or the College.

b. Patients whose treatment is discontinued in accordance with the “Conditions

of Treatment” agreement will be informed in writing and will have the opportunity to appeal the decision through the Patient Advocate in the Office of Patient Management. In doing so the College will ensure that the dental status of the patient is stable, and suggest the patient seek an alternate provider for their dental care and completion of treatment.

c. Comprehensive and/or limited care patients will be notified in writing of any

discontinuance of care or of a severance of the professional relationship between the College and the patient.

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H. Examination Guidelines

a. Patients accepted for comprehensive care will receive a comprehensive clinical examination including the following:

a. Complete extra-oral head and neck exam and an intra-oral

examination including periodontal and pathology screening to detect the presence of odontogenic and other orofacial pathosis. The assessment will include a thorough medical, familial, social and dental assessment of risk factors for oral and systemic disease.

b. Additional testing when such testing is indicated and justified by

symptoms or findings of the comprehensive examination.

c. Professional consultations as indicated when patients with a history or clinical findings suggest the need. Patients will be informed of the need for a consultation in terms they can understand and may be given a copy of the consultation order upon request.

I. Radiographic Guidelines

a. The frequency and extent of each radiographic examination will be determined by the professional judgment of a faculty member based on guidelines established by the Food and Drug Administration (FDA) and recommended by the American Dental Association (ADA).

b. Radiographic examinations will be ordered and interpreted by a faculty

member and documented in the patient’s dental record.

c. Patients will be protected with a leaded apron that includes a thyroid collar unless prohibited by the technique.

d. The fastest film speed that provides radiographs of acceptable diagnostic

quality will be used according to FDA and ADA guidelines.

e. Exposure techniques will be established to ensure that processed radiographs are of diagnostic density.

f. Films will be processed with regard to time and temperature and under

proper conditions of safe lighting.

g. Radiographic examinations will be identified with the date, patient’s name and chart number.

h. X-ray generating equipment in the College will be inspected on an annual

basis by a certified radiation physicist to assure compliance with Oklahoma Regulations for Control of Radiation.

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J. Patient Dental Records

a. A dental patient record will be generated and maintained that documents all

diagnostic and therapeutic actions as well as significant communication related to patient care. The record will include the health history, treatment consultation reports, dental charting, progress notes, correspondence related to care, laboratory reports, prescription data for medications, radiation history, and radiographs.

b. Active patient dental records will be stored in the Central Records Office.

c. Archiving and retaining inactive patient dental records will follow the

accepted policies of the College to comply with State and Federal regulations.

d. The medical alert status of each patient will be readily available as indicated

by the completion of a Medical Alert Form that is located directly on top of all other chart notes and forms. The medical alert form indicates an increased risk of complications to dental care due to a medical condition that requires alteration of routine dental treatment methods in order to maximize the safety of the anticipated results.

e. Patient records will remain confidential and managed in accordance with

Federal laws. All individuals who have access to patient records will be properly trained according to guidelines established by the Health Insurance Portability and Protection Act of April 2004.

f. Copies of the patient’s record will be made available to the patient or parent/

legal guardian when proper written authorization is received by the Office of Patient Management. A minimal charge is required to cover the cost of materials.

g. A chronological narrative summary of each appointment will be recorded in

the progress notes, including a description of services rendered, special precautions or adaptations, unusual occurrences or observations, materials and products used, patient instructions and pertinent comments by the patient.

K. Management of Medical Emergencies

a. Any medical emergency should be reported to the faculty member in attendance in the clinic/ area in which the incident occurs.

b. The faculty should handle minor problems such as syncope, nausea, sinus

tachycardia, etc. in attendance.

c. Should the emergency appear life threatening the assigned student would stay with the patient while another student calls Campus Police at 271-4911. Faculty should be prepared to initiate basic life support including use of an automated electronic defibrillator located on each floor.

d. All clinical students, staff, and faculty will be currently trained in CPR.

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e. All clinical areas will be stocked with emergency resuscitation equipment and drugs, including devices to maintain the airway and administer positive pressure oxygen. In areas where deeper levels of sedation are practiced, more advanced life support devices and drugs will be maintained. This will include the equipment necessary for IV drug infusion, intubation, and defibrillation.

I. Infection and Biohazard Control

1. Patients will receive care consistent with the policies and procedures in the College’s Exposure Control Plan, Infection Control Manual, and the OSHA Hazard Communication Program.

2. Universal precautions for infection control will be utilized for all patient care.

3. Nitrous oxide/ oxygen will be inspected annually for proper function.

Personal exposure to nitrous oxide/ oxygen will be monitored in accordance with NIOSH guidelines.

4. Potentially hazardous chemicals will be labeled in accordance with NFPA

704, stored and dispensed in accordance with applicable OSHA and EPA standards. Individuals who handle potentially hazardous materials will receive appropriate training in the risk, hygiene, and emergency procedures applicable in the event of injury or exposure, and have access to MSDS information upon request.

5. Eyewash stations will be accessible in accordance with OSHA regulations.

6. An annual fire safety inspection will be conducted by the Oklahoma City Fire

Department.

7. An on-going compliance assessment program will assure that the standards for infection and biohazard control are met and that mechanisms are in place to document corrective actions.

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II. Clinical Guidelines A. Anesthesia/ Sedation

1. Prior to the administration of any anesthetic or sedative agent, the patient’s current medical status and dental diagnosis will be reviewed, as well as the treatment plan for the intended procedure. Guided by these considerations, the proper anesthetic will be chosen by the student and approved by the faculty.

2. The type of local anesthetic and the total dosage of anesthetic and

vasoconstrictor will be recorded in the dental record as a part of the procedure.

3. Other medications, including pre-medication and post-operative analgesics

will be prescribed by a faculty member and documented in the patient’s dental record. All patient’s receiving agents which may result in any degree of post-procedural sedation must be accompanied by a responsible adult who will transport the patient from the clinic.

4. Nitrous oxide/ oxygen sedation will be administered only after a faculty

member gives permission. Monitoring of a patient receiving nitrous oxide sedation will include pre- and post-operative vital signs as required in accordance with department guidelines. Patient monitoring needs will be required in the patient’s dental record.

B. Dental Hygiene

1. The periodontal status of each patient will be assessed.

2. Assessment/ treatment will be based on patient history and pertinent clinical data.

3. Dental hygiene services will be provided in conjunction with the Case

Complete examination performed by Oral Diagnosis faculty.

4. Treatment will be performed in a sequenced and timely manner as a component of the overall dental master treatment plan.

5. Appropriate preventive measures for optimum oral health will be discussed,

demonstrated, and reinforced at each appointment.

6. Adjunct services will be provided as needed according to the rules and regulations of the Dental Practice Act.

7. Services will be documented in the treatment progress notes following each

appointment.

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C. Endodontics

1. Diagnosis will be based upon history and the use of appropriate clinical tests.

2. A comprehensive treatment plan will include vital pulp therapy, non-surgical,

and surgical treatments.

3. Difficulty levels will be established for all treatment situations and those with difficulties beyond student capability will be referred for care.

4. Emergency and limited treatment cases will be evaluated for restorability

prior to providing care.

5. Treatment will be completed in an efficient and timely manner using accepted anesthesia, isolation, cleaning, shaping and obturation techniques.

6. Post-retained build-ups will be provided as a final endodontic closure when

indicated in the treatment plan or requested by another restorative department.

7. Release of a patient following treatment will require faculty inspection of a

final radiograph and acceptance of the closure.

8. Post treatment medication will be administered when indicated and approved by the attending faculty.

D. Fixed Prosthodontics

1. Diagnosis of treatment needs will be based on patient history, clinical examination and the use of recognized diagnostic aids.

2. Treatment plans will provide optimal function, longevity, and esthetics, when

appropriate, reasonable alternatives will be offered.

3. Active disease of the hard and/ or soft tissues will be controlled prior to initiating definitive restorative care.

4. Tooth preparation design will follow accepted biomechanical principles.

5. Definitive restorations will be esthetically pleasing, function well occlusally,

and have contours that promote good oral hygiene.

6. Patients will receive instructions in the proper care of prostheses to maximize longevity and maintain healthy supporting and adjacent tissues.

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E. Occlusion/ TMD

1. Evaluation and diagnosis of occlusal disorder and TMD will be based on an adequate patient history, examination of intra and extra oral structures and the use of recognized diagnostic aids.

2. Patients who might benefit from relatively simple treatment modalities such

as equilibration or occlusal splint therapy may receive such.

3. An occlusal guard may be fabricated for patients who exhibit evidence of excessive parafunctional activity in the apparent absence of TMD.

4. Patients with more advanced TMD or occlusal disorders may be referred for

faculty or private care.

F. Operative

1. Operative diagnosis and treatment planning will be based upon a complete patient medical/ dental history and the use of appropriate diagnostic aids.

2. Operative dental treatment will be provided as an integral art of the science

of preventive dentistry as it relates to other disciplines of the dental profession.

3. The proper application of correct temporization methods in the treatment of

emergencies and disease processes of the hard and/ or soft tissues will be provided as necessary prior to initiation of definitive operative care.

4. Proper principles of isolation of the operating field for optimum moisture

control, access, and visibility will be applied during all operative procedures.

5. There will be an understanding and application of appropriate pulp protection methods in all instances of operative dental treatment.

6. Teeth will be restored to health and function by placing properly indicated

restorative materials under the best biomechanical conditions possible with respect to the teeth and surrounding tissues.

7. The correct principles and procedures of asepsis, sterilization, infection

control, and proper care/ maintenance of dental instruments, equipment, and supplies will be applied during all clinical treatment.

8. Principles of correct record keeping for the medico-legal protection of both

practitioner and patient will be applied and regularly monitored.

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Oral and Maxillofacial Surgery

1. The surgical removal of teeth and other hard and soft tissues from the oral

cavity and adjacent areas will be performed; for teeth that are deemed to be nonfunctional, non-restorable or involved with caries or periodontal disease; to facilitate Orthodontic, Prosthodontic or Restorative care; to improve Oral hygiene; to treat acute or chronic infection; to prevent or eliminate pain and/ or pathology; to repair traumatic or congenital defects; and to improve esthetic, cosmetic, or functional deficiencies.

2. The pre-operative diagnosis will be identified prior to any surgical

intervention. The diagnosis will be based on the history, clinical examination and any appropriate diagnostic aids. For tooth extraction, this must include an adequate, current radiograph.

3. Faculty must review proposed treatment and an informed consent obtained

in writing from the patient before any treatment is initiated.

4. Any tissue that is removed will be grossly examined at the time of surgery. The faculty member in attendance will decide which tissue will be forwarded to the Oral Pathology department for microscopic examination. A copy of the microscopic diagnosis will be placed in the patient’s dental record.

5. All patients will be given written and verbal post-operative instructions,

prescriptions, and follow-up appointments as indicated.

G. Orthodontics

1. Patients will be screened to determine the nature of their orthodontic problem, if and when treatment is indicated, and by whom.

2. Diagnosis will be based on an adequate patient history, clinical examination

and the use of appropriate diagnostic aids.

3. Treatment plans will be directed toward the management of orthodontic problems that are primarily dental in nature with treatment that should improve function, enhance esthetics, and/ or facilitate prosthetic replacement.

4. Patients will receive information about proper maintenance of their

appliances.

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H. Pediatric Dentistry

1. Diagnosis will be based upon patient history, examination, and radiographs

appropriate for age, caries pattern and developmental stage of the dentition.

2. Treatment plans will be developed to preserve primary teeth for function and space maintenance utilizing appropriate restorative procedures.

3. Restoration contour of primary and permanent teeth will restore anatomic

form with acceptable cavosurface margins. Deep restorations will have documented pulp protection.

4. Anesthesia selected and administered is appropriate to the patient’s history.

5. Any pre-medication and/ or sedation administered is monitored and

documented properly.

I. Periodontics

1. The periodontal condition of each patient will be determined using the patient history and recognized diagnostic aids.

2. Each patient will be fully informed regarding his/ her periodontal status,

etiology of disease, and recommended treatment.

3. Periodontal treatment will be performed appropriately as a part of the patient’s overall dental plan.

4. Patient tissues that are removed during surgical procedures will be submitted

for microscopic examination by the attending faculty as indicated.

5. Oral hygiene instructions will be individualized and provided for each patient.

6. Treatment will focus on creating an environment conducive to periodontal health through elimination or control of etiologic factors.

7. The importance of supportive periodontal therapy (SPT) will be explained,

and an individualized program of SPT will be recommended for each patient.

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J. Preventive Dentistry

1. A risk assessment involving collection and interpretation of data relating to general and oral health status will be conducted for each comprehensive care patient.

2. Each patient will be informed of his/ her risk level for medical emergency and

oral disease, and preventive measures for both will be incorporated in the patient’s treatment plan.

3. Preventive services and their effectiveness will be documented in the

patient’s treatment progress notes.

4. Recall appointments, incorporating preventive treatment, will be recommended for patients at an interval appropriate for his/ her level of risk.

K. Removable Prosthodontics

1. Diagnosis will be based upon patient history, clinical examination, and the use of recognized diagnostic aids.

2. Treatment plans will be developed that provide function, esthetics, and

reasonable service life.

3. The prosthesis will restore reasonable form, function, and esthetics relative to the psychological, physiological, and anatomical limitations of the patient and abilities of the student.

4. Patients will receive instructions about proper care of the prosthesis and

surrounding tissues.

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POLICY COMPLIANCE

All faculty, students, and staff who may come in contact with blood, body fluids, or tissues must adhere to the guidelines as set forth in this section. Failure to comply with policy provisions will result in disciplinary action that may include one or more of the following: STUDENTS, FACULTY, STAFF

a. Written warning with explanation of breach of policy. b. Remedial training measures. c. Disciplinary procedures/ suspension, leave without pay. d. Review by the supervisor and the Dean. e. Dismissal.

PATIENTS

a. Verbal and/ or written warning. b. Discontinuation of treatment at the College Of Dentistry.

Approved by Executive Committee Printed in the Clinic Operations Manual and distributed to all clinical faculty, staff, and students.

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UNIVERSITY OF OKLAHOMA COLLEGE OF DENTISTRY

INFECTION CONTROL POLICY

HEALTH AND SAFETY MANUAL 2008-2009

TABLE OF CONTENTS Blood borne Pathogen Training 5 Clinic Attire 9 Chemical/ Disinfectant Safety 41 Codes and Labels 30 Container Labeling 40 Exposure Control Plan 3 Emergency Responses 42 Fire Safety Training 42 First Aid Measures 44 Hazard Communication 32 Hazard Communication Training 46 Hazardous Chemicals 32 Immunizations 6 Laboratory Procedures 21 Laundry Protocol 10 Management of Regulated Waste 17 Material Safety Data Sheets 39 Occupational Exposure: Recordkeeping 27 Operatory Care and Clinic Set-up 14 OSHA Training Requirements 27 OUHSC Hazard Communication Inventory Form 46 Patients with Infectious Disease 2 Personal Protective Equipment 7 Policy Compliance 31 Post Exposure Evaluation and Follow-up 24 Post-Exposure Medical Evaluation Waiver 29 Radiology Procedures 20 Severe Weather 43 Sterilization/ Disinfection 10 Summary 1 Tuberculosis Directives 28 Work Restrictions 2

INFECTION CONTROL

POLICY SUMMARY This section outlines policies and procedures for the management of certain serious infectious diseases including but not limited to Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV). The College is committed to educational programs and institutional policies that will respond appropriately and effectively to these infections. These programs/policies are guided by regard for both public health interests and individual rights, and by the recommendations and regulations of the Occupational Safety and Health Administration (OSHA), the Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA), state regulatory agencies, and the OUHSC/ OU Tulsa Infectious Diseases Policy (10/04) and the University of Oklahoma Environmental Health and Safety Office. In summary:

1. The University of Oklahoma College of Dentistry is non-discriminatory with regards

to treating patients with infectious diseases. 2.

a. If infectious disease risk is present, the patient may be referred for further evaluation that may involve serologic testing.

b. Any patient with an active infectious disease will be assigned to the appropriate

clinic or program based on his/her medical condition, the experience level of the student or resident, and the need for and availability of dental allied personnel.

c. Departments or clinics wishing to modify this policy or add clinical equipment

must have such changes reviewed by the Infection Control Committee in advance of implementation.

d. The major objectives of the Infection Control Program are to:

[a] Reduce the number of pathogens so that normal resistance can prevent infections [b] Break the cycle of infection and eliminate cross-contamination, [c] Treat every patient and instrument as infectious, and [d] Protect all patients and personnel from infection

This policy applies equally to and must be complied with by all faculty, staff, students, and administrators. The HSC Environmental Health and Safety Office and the College of Dentistry’s Infection Control Committee, to ensure accordance with current medical information and regulations, will review this policy at least annually. Questions regarding any part of this policy may be directed to the Infection Control Committee or the Infection Environmental Compliance Coordinator Ms. Mary Gowin (Room 232), 271-3083.

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RESPONSIBILITIES TO PATIENTS WITH INFECTIOUS DISEASES

To be in compliance with the Infection Control Policy, all faculty, staff, and students must afford the following rights and opportunities to their patients:

Obligation to Treat: You may not refuse to treat a patient whose condition is within your realm of competence solely because the patient has an infectious disease. However, departments/ clinics may choose to defer non-emergency procedures on patients with airborne infectious diseases until such time as the patient is non-infectious. Records: All patient dental/ medical records must be kept confidential and must not be disclosed to others except as required or permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy regulations and other applicable laws or as authorized in writing by the patient. Oklahoma law specifically requires the good faith disclosure of infectious disease test results to the Oklahoma State Department of Health and to healthcare personnel having reasonable need to know about the infection for purposes of providing patient care. Patient Assignment: Patients with active infectious diseases will be assigned to the appropriate clinic or program based on the patient's medical condition, the experience level of the student, and the need for or availability of dental allied personnel.

Work Restrictions

1. Work restrictions for employees with patient contact shall follow the protocol established by the CDC and the Hospital Infection Control Practices Advisory Committee entitled, “Guidelines for Infection Control in Healthcare Personnel, 1998,” summarized in OUHSC Infection Control Policy Appendix E, Guidelines for Work Restrictions for Healthcare Personnel with Patient Contact

A copy is also available in the College of Dentistry’s Environmental Compliance Coordinator office, Room 232.

2. Work restrictions for employees with no patient contact and classroom restrictions

for students are in Appendix F, Guidelines for Work/ Classroom Restrictions for Employees/ Students without Patient contact found in OUHSC Infectious Diseases Policy of 10/ 04and in this manual between pages 2 & 3, for more information contact ECC Room 232.

3. Employees with infectious diseases, which require work restrictions according to

these tables, should notify their immediate supervisor. Individuals whose employment or academic responsibilities require the performance of exposure-prone activities and who know or who have reason to believe that they are infected have an obligation to immediately cease performing any and all exposure-prone activities. Seek counsel from an expert review panel. This panel should review and recommend procedures the worker can perform, taking into account specific procedure as well as skill and technique of the worker. Standard precautions should always be observed.

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EXPOSURE CONTROL PLAN Effective infection control procedures in the clinics and dental laboratories will prevent cross-contamination that may extend to faculty, staff, students, and patients. The Exposure Control Plan is based on the Blood borne Pathogens Standard issued by OSHA, whose authority is to protect workers (employees); students are not directly covered under OSHA regulations. Students must, however, follow the procedures or guidelines outlined in this policy except where indicated.

Standard Precautions The Foundation of the Exposure Control Plan is the use of standard precautions to prevent the transmission of blood borne and other diseases from healthcare workers to patients and vice versa. Medical histories and examinations cannot reliably identify all infected patients. Therefore all body fluids (with the exception of sweat) of all patients should be considered infectious. Standard Precautions are basic safety measures that must be used for all patients. They include the use of appropriate barriers such as gloves, masks, eyewear and a protective garment to prevent skin and mucous membrane exposure when contact with blood; saliva or other potentially infectious material (OPIM) is anticipated.

Patient Health History Preventive measures begin by thoroughly evaluating a patient’s health history. A complete medical and dental history provides the initial assessment of the patient and makes the practitioner aware of his or her current health status, adverse risks from dental treatment, medications, and the reasons for seeking care.

Pre-procedural Mouth rinse

The technique of pre-procedural mouth rinsing should be considered. It is important to select a mouth rinse containing an antimicrobial agent. Antiseptic properties help reduce bacterial counts on the surface of oral tissues and in turn reduce the number of microorganisms released through aerosols, spatter, or direct contact.

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Exposure Determination The OUCOD Infection Control Policy covers the following categories of employees and students at risk of occupational exposure defined as reasonably anticipated skin, mucosal, eye, or parenteral contact with blood, saliva, or other potentially infectious material (OPIM). The Infection Control Policy applies to full-time, part-time, temporary, and probationary employees and students.

Faculty: All dentists and dental hygienists employed by the College. Staff: All dental assistants, support laboratory personnel, central sterilization personnel, clinic dispensary clerks, radiology technicians, oral pathology/ histology technicians, and laundry personnel. Students: All pre-doctoral dental students, baccalaureate dental hygiene students, and postdoctoral students and residents.

Anyone who participates in any of the following tasks, even on a sporadic basis, should follow standard precautions, receive training, and receive the HBV vaccine.

Performing or assisting in clinical or laboratory dental procedures Cleaning and/or sterilizing contaminated equipment Handling potentially contaminated laundry Scrubbing contaminated counter tops and other environmental surfaces Disinfecting impressions Exposing radiographs Emptying trash receptacles used for disposal of contaminated materials Flushing water lines in the dental unit

Faculty, staff, and students must not eat, drink, smoke, apply lip balm/ makeup, or handle contact lenses where occupational exposure is likely to occur. Do not store food in refrigerators where blood, OPIM, or hazardous chemicals are stored.

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BLOODBORNE PATHOGEN TRAINING

Employees: All employees with anticipated occupational exposure are required to participate in a training program provided at no cost and during working hours. This training will occur at the time of initial assignment to the task where occupational exposure may occur, and at least annually thereafter. All employees must have access to a copy of the OSHA Blood borne Pathogens Standard and the College's Exposure Control Plan. Training records are maintained for three years. Training requirements may be met by; attending an Environmental Health and Safety Office (EHSO) training seminar, reading and testing through a web-based training program (http://main.ouhsc.edu/ehsotraining/), requesting a self-study packet from the EHSO / Mary Gowin or requesting an in-house training seminar through Mary Gowin (271-3083).

Hazard Communication

Fire Safety

Laboratory Safety

Blood borne Pathogens

Tuberculosis

Office Employees

♦ ♦

Laboratory Employees ♦ ♦ ♦ ♦

Healthcare Employees ♦ ♦ ♦

Students/ Residents: All students and residents with occupational exposure risks must receive training prior to clinical activity, and at least annually thereafter. In addition, they will receive information on infectious diseases and infection control throughout the dental curriculum. Students will receive a copy of the College's Exposure Control Plan and the OSHA Blood borne Pathogens Standard or be directed to a website on the intranet where they can obtain the information. The Environmental Compliance Coordinator (ECC) and appropriate designated faculty will be responsible for student training. To schedule in-house training, or for further information on training sessions, contact the ECC (271-3083).

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IMMUNIZATIONS Within ten (10) days of initial assignment and after appropriate training, the College must make Hepatitis B vaccination available on a voluntary basis and at no cost to employees performing tasks that involve a potential for exposure to blood, blood products, body fluids, tissues, or OPIM. Students will be required to pay for their own HBV immunization, which may be made available through the University. Such immunization will be administered to these employees or students only after they have been informed about HBV infection and the risks and benefits of HBV immunization and have signed consent to be vaccinated. Employees and students who choose not to be vaccinated must sign a waiver noting that they have been offered HBV immunization, have been informed of the risks and benefits of immunization, and have voluntarily declined vaccination.

HEPATITIS B VACCINATION WAIVER (EMPLOYEE)

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

________________________________________ (Signature) ________________________________________ (Date)

HEPATITIS B VACCINATION WAIVER

(STUDENT) I understand that due to my exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine. However, I decline vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination at cost. I understand I will be responsible for the cost.

________________________________________ (Signature) ________________________________________ (Date) All entering students are required to complete an immunization history for Student Health. This form will require verification of specific vaccinations. Students will be offered tuberculin skin testing on an annual basis.

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PERSONAL PROTECTIVE EQUIPMENT Personal protective equipment (PPE) includes gloves, eyewear, masks, and clinic attire. PPE will be provided to all employees and students for those tasks that put them at risk of occupational exposure. Always remove PPE before leaving the clinic area. PPE is not allowed in the hallways.

Hand Hygiene Each part of the hand washing process (rubbing, lathering, rinsing) is necessary. Rubbing gets the microorganisms out of skin crevices, lathering holds them suspended away from the skin surface, and rinsing washes them off the hands. Your hands should always be washed after gloves are removed, even if the gloves appear to be intact. The specific protocol for hand washing is as follows:

1. Put on mask and glasses before washing hands. 2. Remove all jewelry (including watches) from hands and wrists. 3. Initial Wash: Wet hands and forearms under running water and lather them with

soap/antimicrobial soap and lukewarm water for 15-20 seconds, paying particular attention to nails, fingertips, and inter-digital spaces.

a. Rinse thoroughly with cool water. b. Use paper towels to blot and dry hands, and to turn off faucet.

4. Subsequent washes: Wash hands with soap for 15 seconds after removing gloves, between patients, and before leaving the operatory area. If hands are not visibly soiled an alcohol-based hand rub may be used at these times. These rubs should be applied and all hand surfaces together for 15 seconds.

Before eating and after using the restroom wash hands with soap and water.

A body area that contacts blood, saliva, or OPIM must be washed immediately after contact with soap and water. Some departments for surgical procedures may require a more rigid “surgical scrub”.

Gloves There are many styles of gloves available with certain types being appropriate for specific tasks. Powder Free gloves are provided. Do not add powder. General categories of gloves are:

Non-sterile latex, vinyl, Nitrile or polyurethane disposable: Inexpensive single-use gloves appropriate for most examination and restorative procedures. Sterile: More expensive single-use gloves appropriate for surgical procedures such as extractions. These are sized and provide excellent protection. Over gloves: Very inexpensive similar to those worn by food handlers. They should be put on when doing tasks that would contaminate items during dental procedures. Examples: answering the phone, writing in a patient’s chart, or leaving the dental chair for any reason. Non-sterile vinyl: Inexpensive loose-fitting gloves appropriate for such tasks as patient examination and charting. 7

Chemical resistant, puncture resistant utility gloves: Made of neoprene or sterilizable polynitrile and appropriate for cleaning and decontaminating instruments, handling laundry, and other housekeeping tasks. They provide superior protection and can be decontaminated for reuse. However, they must be discarded if they are deteriorated or fail to function as a barrier. Puncture resistant rubber household gloves may be used

Faculty, staff and students must wear gloves whenever there is potential contact with blood, saliva, or mucous membranes during patient care, laboratory work, and disinfection procedures. Gloves must be changed between patients or when they are torn, cut, or punctured. If you leave the operatory during patient care, gloves must be removed and discarded (or protected with over gloves). Hands must be washed (or over gloves worn) prior to handling the patient record; charts should always be considered contaminated. Alternative gloves may be provided for those who cannot tolerate the gloves normally provided. If you feel you need alternative gloves, notify the Environmental Compliance Coordinator (271-3083) or your immediate supervisor. Appropriate care of gloves is critical to infection control. Disposable gloves must not be washed or decontaminated for reuse. This will increase the risk of infection to both patients and staff. In addition, washing latex gloves weakens them and can make them tacky. Send utility gloves to Central Sterilization for reprocessing. If you use hand cream, avoid petroleum-based creams, which can significantly deteriorate latex gloves. When removing contaminated gloves, grasp them around the wrist and pull them off so that they end up inside out. This will keep the contaminated areas away from your skin. Dispose immediately in a red bag or a biohazard trash receptacle (located in every clinic and laboratory area). DO NOT wear contaminated gloves outside the clinic area.

Masks and Protective Eyewear A disposable mask and eyewear must be worn when spray, spatter, or droplets of blood, saliva, or OPIM will be generated. Goggles or glasses with non-perforated side shields are required and are available in the appropriate work areas. Prescription glasses that can be fitted with side shields are acceptable. Face shields also provide good protection; they may be used in place of safety glasses but they do not replace the facemask. Contaminated eyewear should be washed with a disinfectant soap whenever visibly contaminated. Masks must be changed if they become soaked with moisture or visible spatter (and always between patients). Remove mask using ungloved hands. When removing a mask, handle it only by the elastic or cloth tie strings; the mask itself should not be touched. Treat all masks and glasses as contaminated. Eyewear must be disinfected at the end of each patient appointment with a surface disinfectant. Do not wear masks under the chin or dangling around the neck. DO NOT wear masks outside the clinic area. 8

Clinic Attire All faculty, staff and students must wear a long-sleeve garment when they reasonably anticipate that the forearms will be spattered with blood or saliva. Gowns must be worn routinely for the following procedures:

[1] Oral or periodontal surgery; [2] Periodontal/hygiene procedures; [3] Restorative procedures where an aerosol will be generated; [4] Cleaning instruments, biohazard trash cans, evacuation hoses, and lab equipment [5] Loading the clothes washing machine.

If there is no risk of exposure to blood or saliva, short-sleeve attire (scrub top) is acceptable. Such procedures would include patient screening/workup, oral radiology, dispensing sterile instruments or clean dental supplies and folding clean laundry. If you have any questions concerning appropriate attire, contact the Environmental Compliance Coordinator (271-3083). The college will provide long-sleeve gowns for all faculty, staff, and students, and will launder all contaminated gowns. Street clothes, work clothes, or scrubs worn under gowns are not considered personal protective equipment and will not be laundered by the College. Clinic Attire for Students: Students must wear school-issued scrub tops and pants. Students are responsible for laundering scrubs. Clean white crew socks (no exposed ankles) and white tennis or professional shoes are required as general clinic attire. Shoes must meet with the approval of the attending Faculty. An all white short sleeve T-shirt or a solid T-shirt that matches the scrubs may be worn under the scrub top as long as it is tucked inside scrub pants. To protect your family at home, these shoes should not be worn as part of your normal dress. Professional appearance should be maintained at all times. Hair must be kept clean and neat, out of patient’s personal space. Long hair must be pinned up while in clinic and out of operators eyes. Moustaches and beards must be kept neatly trimmed. Fingernails should be kept clean and sufficiently short. No artificial nails of any length allowed. A smooth wedding band is allowed. No jewelry worn in facial body piercing except ear lobes. Blue jeans, shorts, or open toed shoes are not allowed in clinic. Students must wear a long-sleeve gown (provided in each clinic) for those procedures in which spatter with blood or saliva is likely. At the end of the clinic session, contaminated gowns must be deposited in the designated containers. Gowns may be worn going from the clinic to the adjacent clinic laboratory area during patient care. Do not wear contaminated clinic jackets, gowns or coats outside the clinic area. Clinic Attire for Faculty/ Staff: Faculty and staff must wear long-sleeve garments (provided by the College) when rendering care, supervising in clinics or laboratories, or performing any task (assisting, cleaning instruments or equipment, etc.) when spatter with blood, saliva, or OPIM is likely. Contaminated outer garment must be deposited in the designated containers at the end of the day. Long-sleeve warm- up jackets worn in place of gowns are considered contaminated and must be turned in at the end of the day to be laundered at the College. The College will not launder scrub tops and pants or street clothes worn under the protective garment.

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Any department or program wishing to select alternative clinic attire may do so with approval from the Infection Control Committee. Such alternative attire will be at the sole expense of the department or program. Laundry Protocol The OSHA Blood borne Pathogens Standard defines contaminated laundry as laundry that is soiled with blood or OPIM or that may contain sharps. OSHA interprets the standard as prohibiting employees from taking contaminated laundry home to clean. However, employees may take uniforms or clothing they wear under PPE home to clean, as long as this clothing has not been contaminated. Contaminated laundry (clinic/lab coats or gowns, towels, etc.) should be handled as little as possible and placed in appropriately labeled biohazard containers or red laundry bags located in each clinic. Laundry bags are contaminated and therefore considered bio-hazardous. Contaminated laundry will not be sorted or rinsed in the area where it has been used; it will be transported to the laundry room in laundry bags or designated containers. All sorting and rinsing will be done in the designated laundry area located on the first floor. Those who clean contaminated laundry should wear gloves and a clean long-sleeve garment while loading the washing machine. After loading, remove the gown and place it with the load or in the contaminated cart. Remove gloves and wash hands before leaving or removing clean laundry from the dryer. Any sharps found in the laundry should be placed in the sharps container located to the right of the washing machine. Safety glasses and gowns must be worn when changing any laundry chemicals. Notify the Environmental Compliance Coordinator (271-3083) if any problems occur with laundry equipment.

STERILIZATION/DISINFECTION: CARE AND USE OF INSTRUMENTS

Sterilization destroys all forms of microorganisms (including viruses, bacteria, fungi, and spores). Disinfection virtually eliminates all recognized pathogenic microorganisms, but not necessarily all microbial forms. Criteria for sterilization and disinfection are dependent on the nature of the instrument or equipment:

Critical items are those that penetrate the oral mucosa or contact bone. These include needles, scalpels, burs, endodontic instruments, hand pieces, suture needles and materials, curettes, hand instruments, surgical suction tips, etc. Critical items must always be sterilized or discarded. Semi-Critical items are those that touch but do not penetrate the mucosa. They include impression trays, mouth mirrors, and air-water syringe tips. Hand pieces do not penetrate mucosa but must be heat sterilized. Semi-critical items must be sterilized when possible or disinfected with a high level disinfectant. Choose items that can be heat sterilized or disposed. Non-Critical items do not touch the oral mucosa but may come in contact with saliva or blood-contaminated hands. Examples include light adjustment handles, chair switches, counter tops, amalgamators, etc. Non-critical items should be disinfected with a complex phenol solution after each patient, using the modified spray-wipe-spray method.

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General Sterilization/ Disinfectant Procedures The following general procedures must be observed when in the clinic:

1. Discard or sterilize any instrument or other item dropped on the floor. 2. Do not touch glasses, mask, hair, or clinic attire during patient treatment. 3. Do not keep pens or pencils in the pockets of clinic gowns during patient treatment

if there is the potential for splash or spatter of blood or OPIM. 4. If the patient record must be consulted, remove gloves and wash hands before and

after handling. If already gloved, you may don over-gloves and discard after use. 5. Use over-gloves when developing endodontic x-rays. 6. Place all contaminated instruments in appropriate cassettes, metal containers or

plastic tubs in which they were initially dispensed. Student cassettes are to be covered in plastic for transport. A plastic head cover or the original sterilization bag can be used. Remove all trash, sharps, and equipment belonging to the clinic from plastic tubs before placing tubs on transport carts. At the end of clinic, loaded transport carts will be covered with plastic and taken to Central Sterilization; contaminated tubs will be removed and carts disinfected before returning to clinic.

7. When using ultrasonic cleaners, place manufacturers recommended cleaning

product in the machine with proper measure of water. During operation lids must be in place to prevent contamination of surrounding work areas. A basket must be suspended in the unit to keep instruments from damaging the tank. Clinic and laboratory staff must test ultrasonic cleaners at least once a month. Fill tank to about 1 1/2 “ from top, run unit for 5 minutes to degas. Cut a piece of foil about the length of the unit and an inch or so deeper than the tank. Next place the aluminum foil in the ultrasonic and turn unit on for 20 seconds. When foil is removed, it should be pitted uniformly. If foil has smooth areas, retest the unit. If un-pitted areas remain on the new foil the machine is in need of repair. These test records must be kept for one year.

Methods of Sterilization

Time Temperature Steam Autoclave: Gravity Displacement 30 min. 121°C / 250° F Pre-vacuum Sterilizer 4 min. 132° C / 270° F Dry heat Sterilizer:

Static Air 60 min. 170° C / 340° F 120 min. 160° C / 320° F

150 min. 150° C / 300° F Forced Air 12 min. 190° C / 375° F

Unsaturated Chemical Vapor Sterilizer 20 min. 132° C / 270° F Advantages: Fast turnaround time, less corrosive to instruments. Disadvantages: Uses toxic/hazardous chemicals; requires fume ventilation; cannot be used with many plastics.

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Monitoring Sterilization

The heat sterilization process used in clinics is checked weekly with spore tests to test effectiveness in killing all types of microorganisms. Integrator tests are used daily in the Central Sterilization Clinic to insure proper parameters of time, temperature, and the presence of steam are being achieved between spore tests. To run a spore test:

1. Put the correct type of test spores inside a pack and place pack near the center of a typical load. (NOTE: The spore Geobacillus stearothermophilus is used for chemical vapor and steam sterilizers; Bacillus atrophaeus is used for dry heat sterilizers.)

2. Place the test in an incubator or send to a designated lab for processing. A positive result means that not all spores were killed and the items processed in that load may therefore not be sterile. Positive results can be obtained with improper pack preparation, improper loading of sterilizer, malfunction of sterilizer, or too short a processing time.

3. If results are positive, repeat spore test and examine procedure to ensure that sterilizer is loaded properly (not overfilled), the pack is not too large, and manufacturer's instructions have been followed.

4. If results are again positive, do not use sterilizer until it has been inspected or repaired. Using another sterilizer, reprocess any items sterilized since the last negative spore test.

5. To reduce risk of post surgical infection, spore test all loads containing implant devices.

6. Log all negative test results and notify the Environmental Compliance Coordinator of any failures (271-3083).

Midwest Hand Piece Sterilization/ Asepsis The following outlines the accepted protocol for sterilization/asepsis of dental air-powered hand pieces. Fiber optics: Do not use strong solvents on fiber optic faces or the epoxy binder between the fibers may dissolve.

1. Before removing hand piece from the hose following treatment, wipe all visible debris from hand piece and briefly operate air/water system (20-30 sec’s) to flush out any patient material from turbine and

water and air lines. 2. Remove hand piece from hose and coupler; clean all external surfaces with gauze

or scrubbing brush. Scrub fiber optic port near head of hand piece and rinse under warm tap water. Keep head up to avoid getting excess water into back of hand piece. Dry thoroughly with gauze. Do not use an ultrasonic unit.

3. Stylus Easy Care hand piece - bag and autoclave. 4. Stylus Standard hand piece – holding can of Midwest Plus Aerosol Spray upright,

insert nozzle fully into back end of hand piece. Spray a short 1-second burst. Only if excess debris appears, spray another short 1-second burst.

5. Run hand piece, without bur, for 30 seconds on the hose or use a Midwest Air Station and a Maintenance Coupler until the hand piece reaches normal speed and all excess cleaner/lube is expelled. Dry hand piece, bag and autoclave.

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Midwest Shorty low speed dental hand piece. Maintenance procedure using Midwest Plus Hand piece cleaner and lubricant

9. Remove angle or attachment from motor: then disconnect motor from hose and put forward/reverse valve in Forward position.

10. Spray Midwest Plus Hand piece cleaner onto external surfaces of motor only. 11. Scrub and rinse external surfaces of motor under warm tap water with a soft brush

or sponge. 12. Dry thoroughly with a gauze pad or paper towel. 13. Place three drops of Midwest Plus Hand piece Lubricant into the drive air tube. The

drive air tube is the shorter of the two big tubes at the back of the hand piece, and is a gold color on newer hand pieces.

14. Run motor for 30 seconds on the hose or use a Midwest Air Station until the motor reaches normal speed and all lube has been expelled.

15. Wipe clean of excess lube. Dry hand piece, bag and autoclave.

Any item taken to the Equipment Servicer/ Installer for repair must be sterilized. Cleaning and sterilization of Star Dental hand piece “Solara” Highspeed Hand piece Lubrication is never required!

1. Following treatment - before removing the hand piece from the hose run water through hand piece for 20-30 seconds to remove any patient material

2. Remove all visible debris from external surfaces using a small toothbrush with isopropyl alcohol. Dry thoroughly.

3. Clean auto chuck daily by aerating with syringe air. 4. Clean chuck weekly with JUNK OUT High-speed chuck cleaner kit.

P/N 236790 new brush each week dip in bottle, remove excess and insert brush into bur end of turbine. Clean gently by rotating and inserting the brush in and out of turbine repeat if necessary.

5. Cleaning optical surfaces - clean all 7 optical surfaces with an alcohol soaked cotton tipped applicator using firm rubbing motion (caution, allow lamp to cool before cleaning).

6. Clean swivel and mating parts of swivel according to manufacturer NSK EX 204 motor is autoclavable.

1. Sterilize after each patient wipe off dirt with alcohol soaked cloth. 2. Lube motor with PANA SPRAY or Air Turbine Oil (if air turbine oil is used run

motor for a few seconds bag and autoclave.

Reusable Sharps Reusable sharps contaminated with blood or OPIM must not be stored or processed in a manner that requires employees to reach by hand into containers where they have been placed. Anything not sterilized (including any used instrument that has been cleaned) is considered "contaminated.” One of the most common practices in instrument re-circulating is picking up contaminated sharp instruments by hand, cleaning them with a brush, and placing them by hand into a receptacle. OSHA rules forbid this practice, even with protective gloves. Contaminated sharp instruments may be picked up with forceps and cleaned with a long-handled brush; sharp sterile instruments and non-sharp instruments may be picked up by hand.

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The following procedure will be used to handle contaminated instruments. Appropriate PPE will be worn at all times during this procedure. 1. Do not store used instruments or cassettes in your locker!

2. Place cassette in a protective covering to transport. The used head cover placed inside out with cassette in the contaminated side is acceptable or the original sterilization pouch (even if it is torn) is acceptable. Contaminated instruments are washed and bagged prior to autoclaving by clinic operations personnel.

3. Following sterilization, the bagged instruments are taken to the storage area.

CARE OF THE

OPERATORY AND CLINIC SETUP Proper care of the operatory involves initial cleaning, then disinfection known as modified spray-wipe-spray method (including care of dental unit waterlines) and asepsis measures prior to treatment, during treatment, and following treatment. Non-compliance with any of these phases during patient treatment is a serious violation of accepted infection control standards subject to established penalties as discussed later in this section. Dental Unit Waterlines Dental unit water that is unfiltered or untreated is not likely to meet drinking water standards. There are commercial devices/procedures that improve water quality. Self contained water systems with disinfectant or sterilization procedures, inline micro-filters, or chemical treatments have been shown to be effective. Flushing is no longer recommended as a water quality (biofilm) control measure. Flush water lines for at least 20 -30 seconds between patients to flush any patient material that may have entered turbine, air or water lines.

Back flow of a liquid from the low-volume suction line (saliva ejector) can occur when the patient creates a seal around the tip with his/ her lips. It is important to educate the entire dental staff to avoid this method of removing fluid from the mouth. Further, the presence of oral bacteria in saliva ejector suction lines indicates that it is important to clean and disinfect these lines on a regular basis. The use of high-volume evacuation is preferable to the use of the saliva ejector in most situations.

Dental Unit Disinfection For surface disinfection, use a modified spray-wipe-spray technique:

1.Spray/pour surface disinfectant on clean gauze or a disposable towel and clean the working surfaces from clean surfaces to most contaminated.

2. With another clean gauze or towel, again spray or saturate with disinfectant and apply to the surfaces.

3. Allow the disinfectant to stay in contact with the surface for the manufacturers recommended time (usually10 min.).

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Asepsis Prior to Treatment

* Do not disinfect keypads use barrier protection! Asepsis procedures prior to treatment are performed in a manner that minimizes splashing or spraying, that is consistent with patient care considerations, and that utilizes where possible such adjunctive aids as rubber dam, high speed evacuation, patient safety glasses, and mouthwash or water rinses for the patient. Rinsing with an approved mouthwash reduces number of microorganisms present on the surface of the oral cavity. Prior to seating the patient, use the modified spray-wipe-spray technique (wearing gloves) to disinfect the following:

Chair arms, seat, and headrest Light handles, evacuation system, and bracket table. NOTE: The foot control should be left on the floor; it does not require disinfection. Do not spray the back of the light or wipe it with disinfectant since this will damage the reflective paint. Light backs should be considered contaminated and should not be touched during treatment.

Operator and assistant carts and stools, height adjustment levers, seats, and backs

Counter tops and amalgamators

Writing instruments and bib clips

After pre-treatment disinfection of the operatory, place a sterile tip on the air/water syringe. Complete your operatory preparation as follows:

Place disposable plastic tips on high-speed evacuator and saliva ejector. Remove gloves and wash hands.

Place headrest cover over chair back, plastic wrap on air/water syringe Handle, patient napkins on operator and assistant carts, and plastic adhesive cover on light handles and keypads. Barriers eliminate the need for disinfection between patients. Barrier protected surfaces must be disinfected once daily at the end of the day. Obtain instruments from dispensary and lay out armamentarium for the procedure. Place radiographs on view box. Leave view box light on during treatment.

Place patient chart in chart holder. If there is no specific holder, keep chart away from immediate operating area to avoid contamination.

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Asepsis During Treatment Attention to aseptic technique during patient treatment includes the following:

1. Consider having patient rinse and expectorate with mouth rinse. 2. Seat and drape patient. 3. Give patient mandatory eye protection. (Patients may wear their own glasses or sunglasses, safety glasses or drape eyes with a towel). 4. Wash hands, don gloves.

5. DO NOT touch any areas outside immediate operating field during treatment (Hair, face, glasses, mask, patient chart, and/or radiographs).

6. Use over gloves to consult chart or radiographs. 7. DO NOT ask patient to close lips around the saliva ejector tip.

Asepsis Following Treatment After completing the procedure, proper asepsis is accomplished as follows:

1. Remove patient's napkin and safety glasses. Remove gloves and mask, wash hands before completing necessary paperwork and replacing radiographs in chart.

2. Dismiss patient. 3. Put on gloves, place all sharps in sharps container and all instruments in cassettes

and/or plastic tub. 4. Rinse evacuation system with water for 20 -30 seconds. Flush air/water syringe for

20 - 30 seconds. 5. Place all contaminated items (gauze, cotton rolls, gloves) and all disposable items

(saliva ejectors, evacuation tips) in red plastic biohazard bag attached to operator or assistant cart. Place this bag in the biohazard-labeled trash container in the clinic.

6. Disinfect/clean chair and all contaminated surfaces using the modified spray-wipe-spray technique.

7. Flush hand piece for 20 -30 seconds. Remove hand piece, clean, disinfect,

lubricate then reattach to hose and run hand piece to remove excess lubricant. Remove hand piece and package it for sterilization (following the manufacturer's directions). Proper maintenance is the responsibility of the student. Students must take their hand pieces, burs, and cassettes personally to Central Sterilization.

8. Place contaminated instrument tub on designated transport cart located near

dispensary. If you have checked out anything from dispensary, return it and make sure corresponding checkout slip is discarded.

9. Remove contaminated gown and place in contaminated laundry bag. Do not leave

clinic area in your gown. 10. Remove gloves, wash hands, and return unit to original storage position.

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MANAGEMENT OF REGULATED WASTE Regulated waste includes:

[1] Liquid or semi-liquid blood, saliva, or other potentially infected material, OPIM (all body fluids with the exception of sweat). [2] Items contaminated with blood or OPIM which would release these substances in a liquid or semi-liquid state if compressed, [3] Items caked with dried blood or OPIM and capable of releasing these materials during handling, [4] Contaminated sharps, and [5] Pathological and microbiological wastes containing blood or OPIM.

CONTAMINATED SHARPS

A contaminated sharp is any contaminated object that can penetrate the skin or mucous membranes. These include needles, scalpel blades, broken glass, broken capillary tubes, matrix bands, broken reusable sharps, anesthetic carpules, used burs, exposed ends of orthodontic wire and bands. Sharps may be reusable or disposable. If instrument is reusable (e.g., explorer) refer to the section on Care and Use of Instruments. If disposable, the following protocols apply:

1. Place needles in sharps container available in each clinic. a. Do not bend or shear. b. Do not recap a needle by hand. Use the scoop technique or re-

sheathing device. c. Do not allow your assistant to recap a needle while you hold it. d. Do not pass an unsheathed needle to your assistant.

2. Place all other disposable sharps (scalpel blades, used burs, orthodontic wire, jagged metal, broken glass, matrix bands, broken reusable sharps, endodontic files etc.) in the sharps container. Sharps containers are checked daily to prevent overflow; they are marked 3/4 of the way up the container wall. When this line is reached, the container is considered full and will be taken to Central Sterilization for proper disposal. These containers must be closed. Sterilization staff will discard the containers through a contracted medical waste disposal company according to local, state, and federal regulations.

Disposable Contaminated Items Discard all contaminated gauze, cotton rolls, gloves, masks, saliva ejectors, and high-speed evacuation tips in the red biohazard bag attached to the dental cart. Following treatment, remove this bag and place it in the larger biohazard container, labeled and centrally located in each clinic or laboratory area. Biohazard bags (which must be closed before transfer) will be sterilized in Central Sterilization before being discarded according to local, state, and federal regulations.

Liquid Waste (Blood/Saliva) Red Z is placed in the suction canisters prior to their use in the Perio Surgery and Oral Surgery areas. The blood-saliva mixture picked up during evacuation comes in contact with Red Z, congeals, and is disinfected. The canisters are discarded weekly by means of a medical waste disposal company.

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Tissue and Microbiological Waste Anyone who collects biopsy specimens should take the following precautions: 1. Use a sturdy leak proof container. Be careful not to contaminate the outside of the

container with blood or OPIM. Disinfect outside of container if it is visibly soiled. 2. Use appropriate personal protective equipment (PPE).

a. Place extracted teeth and pieces of teeth without amalgam in bleach then into sharps container for disposal (unless the patient desires them).

b. TEETH CONTAINING AMALGAM MUST NOT GO IN THE SHARPS CONTAINER. Store in bleach in jar and give to the Environmental Compliance Coordinator for disposal.

1. All microbiological specimens are sterilized in Central Sterilization prior to discarding.

Extracted Teeth for Educational Uses

Extracted teeth used for the education of DHCW (Dental Health Care Workers) should be considered infective and classified as clinical specimens because they contain blood. All persons who collect, transport, or manipulate extracted teeth should handle them with the same precautions as for biopsy specimens. Standard precautions should be adhered to whenever handling extracted teeth. Because pre-clinical educational exercises simulate clinical experiences, students should adhere to standard precautions in both settings. In addition, all persons who handle extracted teeth in educational settings should receive hepatitis B vaccine. Before extracted teeth are manipulated, the teeth first should be cleaned of adherent material by scrubbing with detergent and water or by using an ultrasonic cleaner. Heat sterilize teeth that have no amalgam using a liquid autoclave cycle for 40 minutes. Teeth containing amalgam cannot be heat sterilized and therefore should be immersed in a 10% formalin solution for 14 days to disinfect both the internal and external structures (preferably the amalgam should be removed and the teeth sterilized). Persons handling extracted teeth should wear gloves. Gloves should be disposed of properly and hands washed after completion of work activities. Additional PPE (face shield or surgical mask and protective eyewear) should be worn if mucous membrane contact with debris or spatter is anticipated when the specimen is handled, cleaned, or manipulated. Work surfaces and equipment should be cleaned and decontaminated with an appropriate liquid chemical germicide after completion of work activities. The handling of extracted teeth used in educational settings differs from giving patients their own extracted teeth. Several states allow patients to keep teeth, because they are not regarded as regulated (pathologic) waste and because they become the property of the patient and do not enter the waste system. Oklahoma regulations permit patients to keep their extracted teeth.

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Pathologic Examination of Surgically Removed Tissue

All removed hard and soft tissue must be examined grossly by attending faculty who will decide if microscopic examination is indicated. If yes, you must procure a specimen bottle from the clinic dispensary, label it appropriately (date, patient name and chart number, your name and number, specimen ID [tooth number, area location, etc.]), fill out a pathology request form, and personally deliver the specimen to the Oral Path Laboratory (Room 593). Record all findings of gross examination and all information regarding referral for microscopic examination in the Treatment Progress Notes of the patient's chart. Once the examination has been completed, the results will be returned to you and must be entered in the chart. NOTE: Microscopic pathological examination of tissue is a laboratory service that requires generation of a fee to the patient. For every specimen referral to the Oral Pathology Laboratory, the encounter slip should include Code #00501 soft tissue or #00502 hard tissue (Histopathologic Examination of Tissue). The current fee for this service is $25.00.

GENERAL HOUSEKEEPING The following are general infection control measures outlined for faculty, staff, and students and for housekeeping personnel:

1. Clean all contaminated surfaces in clinic operatory with a disinfectant after each patient.

2. All clinic floors and receptacles for non-contaminated waste will be cleaned and/or emptied by housekeeping each morning before clinics begin. Contaminated (biohazard) containers will be cleaned and disinfected by clinic personnel when the bags are emptied or whenever they are visibly soiled.

NOTE: Housekeeping personnel will receive training for hazards associated with the College and be informed on the Blood borne Pathogens Standard and how to protect themselves while working in the college.

3. Cleanup of spills of blood/OPIM: All spills of blood or body fluids are considered infectious. Standard precautions must be followed during cleanup. A blood and OPIM spill kit (with instructions for use) is available in each clinic. Housekeeping is not responsible for cleaning up blood spills.

4. Bulk cleanup of spills: Heavy-duty utility gloves are recommended for

large spills. Use high volume evacuation. If not available, sprinkle enough Red Z (a little goes a long way!) on spill to cover it; this will congeal and disinfect the spill. Sweep up mixture and dispose in red bag provided in the spill kit. Place the red bag inside large biohazard container located in each clinic. Disinfect the contaminated surface.

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RADIOLOGY PROCEDURES Attending radiology technicians are responsible for ensuring that the infection control measures outlined below are followed. Non-compliance will adversely affect your evaluations and/or future access to radiology facilities.

1. Store chart in file holder in interpretation area. Do not take charts to radiograph rooms.

2. Wash hands. 3. Cover exposure control-switch with small piece of plastic; prepare control panel

shelves. Top Shelf (non-contaminated): Cover with paper towels and secure with scotch tape. Lay films out on paper towels in the order in which they will be taken. Place bitewing tabs on films before starting exposures. Bottom Shelf (contaminated): Cover with a patient napkin and secure with scotch tape. Place paper cup on the shelf. Stabes and XCPs are also placed on this shelf. Follow this procedure for all full-mouth series. If only one or two films are being taken, a paper towel on top and bottom shelves with paper cup for exposed films will suffice.

4. Place headrest cover on chair. Check all exposure factors and test-fire the machine. Ask attending radiology technician for Permission to Proceed (PTP).

5. When making exposures, touch only the patient, x-ray cone, x-ray tube-head, film packets and holders. Keep all instruments and materials on covered work surfaces. Wipe exposed films dry before placing them in paper cup.

6. After making all exposures, push tube-head upward and towards wall into its storage position. Put on over gloves before removing lead apron. With over gloves on, carry exposed films (in the paper cup) to darkroom.

7. Place paper towel on darkroom counter, remove over gloves, and open film packets, letting films fall onto paper towel. Place lead foil liner in container provided for this purpose. Place the remainder of film packets in red biohazard bag. Remove gloves and wash hands. Place films in processor with ungloved hands. When finished, wash hands again.

8. After completing all radiographs and retakes, put on gloves and clean x-ray room as follows:

a. Remove protective coverings from control panel, shelves, and headrest.

b. Using the modified Spray-wipe-spray technique, clean all surfaces (including tube-head) with disinfecting solution.

c. Return tube-head to its highest position and place it against the wall.

RADIATION MONITORING Film badges or thermo luminescent personnel monitoring devices must be worn during working hours by all faculty and staff who regularly use x-ray equipment. Dosimetry reports on each employee must be kept as a permanent record available for inspection by the employee. No employee should receive more than 20 mSv (2REM) of radiation exposure each year. This is the radiation protection guide value. For added precaution, quarterly readings above 10 percent of the radiation protection guide (0.5 mSv, or 50 mREM) should be investigated. All radiation workers should receive as little radiation as reasonable possible. Any operator who is pregnant shall not be exposed to more than 2 mSv (200 mREM) during the entire term of her pregnancy.

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LABORATORY PROCEDURES

Any contaminated prosthesis, material, or equipment taken to or from a laboratory area must be disinfected. Mask, gloves, and protective eyewear are required whenever polishing or adjusting models or contaminated temporary or permanent prostheses. Individual pumice trays and sterile rag wheels must be used when making adjustments or polishing. If using the Dental Support Laboratory, all incoming cases should be taken to the laboratory's disinfection room in a sealed plastic bag. Preparation and disinfection procedures for various prostheses, equipment, and other materials are discussed separately.

Fixed and Removable Prostheses Any fixed or removable prosthesis that has been in the patient's mouth must be rinsed under running water to remove excess blood and saliva. Do not splash water excessively; droplet spatter can carry microorganisms. Place the prosthesis in an ultrasonic cleaner with Midwest Stain and Tartar Remover or A stone and plastic remover for the manufacturer’s recommended time. (Refer to the section on Cleaning Dentures) This is the pre-cleaning step of the disinfection procedure. Prior to adjustment or transport to the laboratory, disinfect the prosthesis as follows:

1. Rinse with water place in a plastic bag and spray with “Dispatch” solution. Allow 1 minute for disinfectant to work, and rinse with water.

2. Wrap prosthesis in plastic (or place in a plastic bag) and send to the laboratory. Do not add disinfectant to the bag.

3. If adjustments are to be made, use individual pumice trays and sterile rag wheels. Any adjusted acrylic prosthesis should be considered contaminated due to porosity of acrylic.

4. Appliances received from the laboratory will have been properly disinfected; merely rinse them in water before insertion in the mouth.

5. If possible, do polishing procedures at the operatory rather than in the clinical laboratory area. This will decrease possibility of cross-contamination and will eliminate the disinfection step for both entering and leaving laboratory areas.

Cleaning Dentures The following steps for cleaning dentures (by staff) do not constitute a disinfecting procedure; PPE must be worn. Students or faculty should place the dentures in a zip-lock bag prior to cleaning.

1. Use Midwest’s Stain and Tartar Remover or a brand of Stone and Plastic Remover follow manufacturer's directions for proper dilution.

2. With gloves and safety glasses on, pour Stain and Tartar Remover solution directly into bag containing dentures. Close bag and place in a glass cylinder. Fill cylinder with water.

3. Place cylinder in ultrasonic cleaner and vibrate for manufacturer’s recommended time.

4. Wearing clean gloves remove dentures from bag and thoroughly rinse with water. 5. Place dentures in denture cup containing mouthwash. Remove and discard gloves

and wash hands. Return denture cup to the student or faculty member.

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Disinfecting Impressions

Alginate: Rinse with water and spray with Dispatch solution. Place the impression in a plastic bag for 1 minute, rinse with water. Pour alginate impressions immediately. Polysulfide, silicone, polyvinylsiloxane, and polyether: Rinse with water, place in plastic bag and spray with Dispatch; allow to set for 1 minute. Remove and rinse again with water. Pour polysulfide and silicone impressions within 15-60 minutes; pour polyvinylsiloxane impressions within 15 minutes to seven days.

Cleaning/Disinfecting Prosthodontic Items Items contaminated only by handling or having minimal contact with oral fluids do not require sterilization for routine reuse, but should be cleaned and disinfected with an EPA-registered disinfectant. Such items include torches, face bows (not including the face bow fork), articulators, and rulers, mixing spatulas, knives, rubber bowls, shade guides, and mold guides. Any items such as impression trays and face bow forks that are placed in the mouth must be heat-sterilized.

Contaminated Stone Casts Contaminated stone casts transferred to or from a laboratory area or a clinic should be sprayed with a Dispatch solution and allowed to set for 1 minute, before rinsing thoroughly with water. A protective mask must be worn when using a model trimmer.

Other Work-Related Items All other work-related items (articulators, case pans, etc.) which are transferred from a clinic to a laboratory area or vice versa must be disinfected. Moving parts of the articulator should not be disinfected since this may impair function. The following items should be cleaned and heat-sterilized or chemically disinfected as indicated:

Clean and Heat Sterilize Clean and Chemically Disinfect All burs (including acrylic burs) Articulators Bristle brushes Casts Central bearing plates for articulators Compound heaters Compound heater trays Face bows (not including forks) Face bow forks Knives Metal-handle mixing spatulas Mixing bowls #7 Wax Spatula Plastic mixing spatulas Rag wheels Mold guides Stock impression trays Rulers Shade guides Torches Record bases

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Barrier Techniques Personnel/ Students for Laboratory Dental Support Laboratory personnel working in the receiving (disinfection) room must wear rubber utility gloves to open containers as they arrive. Work gowns should be worn over street clothes and should be changed daily. Masks and eyewear are not necessary to simply open a container as it comes into the laboratory. However, they must be worn when splash or spatter may result such as during cast trimming and during any grinding or polishing procedures. Additional safety measures in handling containers/packages are as follows:

1. Note any package labeling that indicates special handling precautions when opening cases.

2. After package is opened, handle bag containing prosthesis or impression carefully to avoid spilling any disinfectant present.

3. Discard all packing material that has been in direct contact with any prosthesis or impression that has been in the patient’s mouth.

4. Rinse all prostheses and rubber or silicone impressions before placing in a disinfectant solution. Rinse again before sending to the proper department for work. Suggested disinfection solutions are:

a. Household bleach (1/4 cup to 1 gallon of water) mixed and discarded daily; 10-minute immersion (nonmetallic items)

b. Complex phenol (such as Pro-Spray C -60 by Certol) 10 minute contact.

c. Dispatch spray (1 minute) or Clorox Clean-up spray (30 secs) 5. After items have been cleaned and disinfected, do not handle with the same gloves

used to open package or they will be re-contaminated. 6. Clean, package, and heat-sterilize all impression trays.

Protective eyewear and mask must be worn during trimming of casts as well as during other grinding and polishing procedures. Laboratory personnel may wear disposable gloves during these procedures taking care not to have the glove material "catch" in a lathe. Gloves are not necessary if the impression or cast has been adequately disinfected. Additional cleanup measures include the following:

1. Clean and disinfect sink and cast trimmer at end of day. 2. Clean and disinfect shipping bench immediately after it is cleared of incoming work

to avoid contaminating any outgoing work. Wear utility gloves during these procedures.

3. Clean and disinfect all work pans after each use and all workbenches at least daily. a. Use an antimicrobial hand wash with residual action to clean hands in the

laboratory. b. Iodophor solutions or diluted bleach (1:10 concentration) can be mixed with

one part green soap to wet pumice. Use separate pans of pumice for new (clean) work and contaminated repairs. Use separate lathes for clean and contaminated work. Pumice should be discarded after each case; pre-measured amounts of pumice in plastic bags will facilitate this rapid turnover of pumice.

4. Do not eat or drink at workbenches. 5. Never mix bleach with any solution containing alcohol or ammonia; a deadly gas

will be generated. 6. Observe conscientious housekeeping procedures in all areas of the laboratory.

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CLASSIFICATION/DECONTAMINATION OF EQUIPMENT, INSTRUMENTS, AND MATERIALS: SUMMARY

On the following page is a partial list of equipment, instruments, materials, and other commonly used items with recommendations for method and frequency of decontamination procedures.

ITEM METHOD FREQUENCY Air-water syringes Dispose After each patient Angle attachments Sterilize After each patient Dental materials, individual Disinfect containers After each patient Floors, clinic Wash Each morning Fluoride gel trays Dispose After each patient Hand pieces Sterilize After each patient Impression trays Sterilize After each patient Inhalation bags (nitrous/oxygen) Dispose After each patient Instruments, dental Sterilize After each patient Instruments, surgical Sterilize After each patient Light-curing units Disinfect After each patient Mouth props Sterilize After each patient Napkin (alligator) clips Disinfect After each patient Operatory lights Disinfect/Use barrier After each patient Operatory chairs Wash/ barrier After each patient Operatory carts Disinfect At end of clinic session Scalers, ultrasonic Disinfect/Sterilize tips After each patient Suction hoses Disinfect/outer surface After each patient Suction hoses Flush hose with water After each patient Telephones, clinic Disinfect Weekly Trash receptacles, biohazard Disinfect As necessary

POST-EXPOSURE EVALUATION AND FOLLOW-UP

(AFTER AN EXPOSURE INCIDENT) An exposure incident is a specific occupational incident involving the eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood, saliva, or OPIM. Minor occupational injuries such as paper cuts or injuries from sterile instruments are not considered exposure incidents. Immediate treatment/care of an exposure incident wound involves: [1] Cleaning the wound with soap and water. [2] Flushing involved mucous membranes with water or normal saline solution. [3] Applying other wound care measures (e.g., bandage). All exposure incidents require immediate notification of appropriate personnel. Students should notify attending faculty and contact Mary Gowin Environmental Compliance Coordinator (271-3083). Employees should notify their immediate supervisor and also contact the ECC. A report of the incident will be made documenting the route and circumstances of the exposure. The source patient should be identified, if possible; if unknown, the report will so indicate. Blood will be drawn on source patient with their consent and a consent form signed. The Family Medicine Center is currently using the Rapid HIV Test that gives results on source blood in 20-30 minutes and results are disclosed to the injured party only.

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Anyone who receives an occupational blood borne exposure will be encouraged to report immediately (following contact with appropriate personnel) to either the Family Medicine Clinic (students Judy Davis) or (staff and faculty Kathy Clinkenbeard). If they choose not to report immediately to the respective facility, they will be asked to sign a waiver form. An attending physician will analyze the incident and the student or employee may be offered post-exposure antiviral medications. When indicated a four week two drug regimen is followed. A third drug may be warranted if a large volume of HIV positive blood is involved. This is the protocol recommended by the CDC. Post-exposure prophylaxis has been associated with a decrease of approximately 79% in the risk for HIV seroconversion after percutaneous exposure to HIV-infected blood. Prophylactic administration is most effective within 1-2 hours following exposure. Early administration affords the most benefit. The faculty, staff or student shall receive hepatitis B surface antibody, hepatitis C antibody, and HIV antibody tests in order to determine immunity status, establish base lines, and guide treatment. Additional tracking measures for exposure incidents will include the following:

1. The employer will attempt to have the source patient’s blood tested as soon as feasible to determine hepatitis and HIV status. The patient will be asked to sign a form to either refuse or consent to a blood test (to be paid for by the college). Results of the blood test will be made available to the exposed individual, provided the source patient gives consent.

2. The employee/ student’s blood will be collected (with consent) for baseline testing. If there is consent to have blood collected but not tested, the blood will be kept for 90 days after the exposure incident to allow the individual to change his/her mind. The individual will be offered any medically indicated prophylaxis recommended by the U.S. Public Health Service. Counseling and evaluation of any reported illness will also be provided.

3. The exposed employee will be directed to The Family Medicine Center for treatment of any exposure or incident. Associated medical bills and testing will be paid through the OUHSC Personnel Office. The exposed student will be directed to The Family Medicine Center for treatment. Associated medical bills and testing will be paid by student or filed with the student's insurance company.

4. If the individual refuses follow-up evaluation, he/ she must sign an appropriate waiver.

5. If a student experiences a clinical exposure during after-hours, weekends, scheduled holidays, or other times when the Family Medicine Center's clinics are closed, he/ she should immediately go to the University Hospital/ nearest hospital Emergency Department to see a physician.

6. At that facility, the student should receive a hepatitis B surface antibody test to determine immunity status and guide treatment unless a positive titer has previously been determined. A tetanus-diphtheria vaccination may be indicated. Up to 72 hours dosage of HIV post-exposure prophylaxis may be prescribed if appropriate. The following weekday morning, the student should contact Mary Gowin 271-3083, at the College of Dentistry and Judy Davis at the Family Medicine Clinic to complete incident reports and receive instructions for further laboratory tests and medications.

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Clinical Incident Reports For any exposure incident incurred by a student, staff, or faculty member that is related to clinical patient care, the involved parties must prepare a Clinical Incident Report. The attending faculty, staff supervisor, or ICO must review, approve, and sign the report. The report must include [1] names and social security numbers of the patient and the individual involved, [2] date, time and location of the incident and the time it was reported; [3] a description of the circumstances and details such as name, size, and brand of instrument causing the injury, and [4] final disposition (including referral to The Family Medicine Center for medical care). This report will become part of the employee/student exposure record file. These records are confidential and will not be disclosed without the consent of the individual or as required by law. Any health care professional who performs an evaluation of an individual experiencing a clinical exposure incident will be provided with:

[1] A description of the exposed individual's duties as they relate to the exposure incident, [2] Documentation of the route and circumstances of the exposure, [3] Results of the source patient's blood testing, if available, [4] All medical records relevant to the appropriate treatment including vaccination status, and [5] A copy of the applicable OSHA standard.

The employer must be provided with a written opinion from the health care professional who provides the post-exposure evaluation within 15 days of the completion of the evaluation. The opinion must document that the individual has been informed of the results of the evaluation and of any medical conditions resulting from the incident that require further evaluation or treatment. All other findings or diagnosis are to remain confidential with the health care professional.

Testing the Source Patient If the source of the exposure is a known patient, his/her consent for hepatitis and/or HIV testing will be requested. Results of the patient's testing will be made available to the exposed individual. If consent is not obtained, the college must verify that legally required consent cannot be obtained. If the patient is already known to be infected with HIV or hepatitis, re-testing will not be required. The College will pay for the cost of the patient’s testing.

Costs For employees, all initial and follow-up testing, counseling and participation in medical protocols will be without cost under the workman's compensation program. For students, all costs for initial and follow-up testing, counseling, and participation in medical protocols will be paid by the student or billed to the student's insurance company, if applicable.

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OCCUPATIONAL EXPOSURES: RECORDKEEPING A confidential medical record is maintained for each individual with an actual or probable occupational exposure. This record includes the individual's name and social security number, a copy of hepatitis B immunization status, and any of the following that apply:

1. Exposure incident report 2. Written opinion of the evaluating health care professional 3. Form refusing hepatitis B vaccination (if applicable) 4. Form refusing post-exposure evaluation and follow-up (if applicable) 5. Documentation of the required training

These records are maintained in the office of the Environmental Compliance Coordinator (Room 232). They will be kept strictly confidential and maintained for the duration of employment plus 30 years. OSHA Standard 1910.20 gives all employees the right of access to their own medical and exposure records.

OSHA TRAINING REQUIREMENTS Training records require the dates of training, course content, name of the trainer, and names of all employees in attendance. Training must be provided before initial assignment to any tasks involving potential occupational exposure; it must also be provided annually and must be accessible to all employees. Training records will be maintained for three years in the Health Science Center's Environmental Health and Safety Office. Current records are also maintained by the OUCOD, ICO. The following topics and information will be covered during training sessions on OSHA’s Blood borne Pathogen Standard. Each session will offer opportunity for interactive questions and answers.

1. Review of the Blood borne Pathogens Standard and locations of copies of the Standard.

2. General information about the epidemiology and symptoms of blood borne diseases

3. Modes of transmission of blood borne pathogens. 4. Review of the college's Exposure Control Plan and how to obtain a copy.

5. How to recognize tasks involving occupational exposure. 6. Use and limits of engineering controls, work practice controls, and personal

protective equipment (PPE). 7. Where PPE is located and its selection and application, use, removal, handling,

decontamination, and disposal. 8. Effectiveness, safety, benefits, method, and costs of administering Hepatitis B

vaccine. 9. Procedures for management of emergency spills of blood or OPIM. 10. Protocol for management of exposure incidents; evaluation and follow-up

procedures for employees in case of exposure incidents. 11. System of labels and color-coding used to identify biohazards.

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TUBERCULOSIS

The college complies with the Health Science Center's Tuberculosis Infection Control Policy and Program. Tuberculosis is an airborne disease that is contracted by inhaling droplets produced by a cough or sneeze etc. from an infected individual. Patients with a cough of the duration of three weeks or more should be questioned, as this could be indicative of Tuberculosis. A coughing patient in the waiting area should be offered a tissue and be asked about the cough. The CDC recommends TB screening of students/employees to be done annually for at risk individuals. No individuals working in potential risk environments will be hired unconditionally until negative results for TB skin tests or chest x-rays are on file. The TB policy will be reviewed annually at the employee's OSHA training session. PPD Mantoux Tests will be given on an annual basis to Employees/Students. For further information or to schedule an in-house training date, contact the Environmental Compliance Coordinator at 271-3083 or the Environmental Health and Safety Office for the Health Sciences Center at 271-3000. 28

POST-EXPOSURE

MEDICAL EVALUATION WAIVER

I have been informed by the University of Oklahoma College of Dentistry that The Oklahoma

University Health Sciences Center policy on post-exposure advises me to be evaluated by a

physician at the Family Medicine Center [students and employees] immediately (i.e., within 1-

2 hours) following an occupational related blood borne exposure. This post-exposure policy is

also recommended by the Centers for Disease Control and Prevention (CDC).

I choose not to report to the designated clinic for evaluation of my exposure incident at this

time, even though this has been offered free of charge and will not jeopardize my attendance

in my academic or employment activities. ____________________________________ ___________________ Signature Date ____________________________________ Witness

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COLOR CODES AND LABELS All Red laundry carts are considered contaminated. All red containers and bags are considered contaminated. Red dots on laboratory containers indicate infectious content. The universally recognized biohazard sign is depicted below:

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POLICY COMPLIANCE

All faculty, students, and staff who do or may come in contact with blood, body fluids, or tissues must adhere to the guidelines as set forth in this section. Failure to comply with policy provisions will result in disciplinary action that may include one or more of the following: Faculty, students, staff

a. Written warning with explanation of breach of policy b. Remedial training measures c. Disciplinary measures d. Review by supervisor and/or Dean e. Dismissal

All personnel have the responsibility to report non-compliance with any portion of the Infection Control Policy. All reports will remain confidential with no repercussions or penalties for individuals who file such reports in good faith. 31

Hazard Communication

INTRODUCTION

The College is in compliance with the OSHA Hazard Communication Standard, Title 29, and Code of Federal Regulations 1910.1200 through

[1] Compilation of a hazardous chemical list, [2] Utilization of Material Safety Data Sheets, [3] Appropriate labeling of containers, and [4] Provision of training in procedures and protocols.

The purpose of the Hazard Communication Standard is to provide information and training that will help protect against hazardous substances in the workplace. Under this program, you will be informed of the contents of the Standard, the hazardous properties of substances with which you come into contact, and the handling procedures necessary to protect yourself from these substances. This program applies to all work operations in the College where you may be exposed to hazardous substances under normal working conditions or during emergencies. The Environmental Compliance Coordinator for the College of Dentistry, Ms. Mary Gowin (Room 232), is responsible for the complete Hazard Communication program and its review and update as necessary. Faculty, staff, and students must comply with all provisions of the Standard. In addition to its inclusion here, the OSHA Hazard Communication Standard is available in each clinic dispensary and in the office of the ECC. The written program includes a list of hazardous chemicals present in the college, a description of the labeling system used to warn employees and students against chemical hazards, a file of Material Safety Data Sheets (MSDS) and how to obtain them, and guidelines for the training of employees and students. Consumer products (products used in the same manner and frequency as they would be at home) and drugs in solid, final form are not included in the program.

HAZARDOUS CHEMICALS A hazardous substance is any substance regarded as a physical or health hazard. A physical hazard is any chemical that is a combustible liquid or compressed gas, organic peroxide, or a material that is explosive, flammable, oxidizing, pyrophoric, unstable (reactive), or water-reactive. A health hazard is any chemical or biological substance or agent considered to be a carcinogen, a toxic or highly toxic agent, a reproductive toxin, an irritant or corrosive, or an agent that acts on the circulatory system or damages the lungs, skin, eyes, or mucous membranes. All clinics and laboratories must compile a list of hazardous chemicals used in their areas. This list must be maintained and updated annually by a coordinator designated for each area. A copy of each current chemical list and the name of each coordinator must be forwarded to Ms. Mary Gowin, the Environmental Compliance Coordinator (Room 232).

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The following are standard safety precautions to use when working with hazardous chemicals:

1. Do not use a flame near flammable chemicals. 2. Do not eat or smoke in areas where chemicals are used. 3. When appropriate, wear protective eyewear and a mask. 4. Know the proper cleanup procedures for chemicals in your area. 5. Dispose of all hazardous chemicals in accordance with MSDS instructions and

applicable local, state, and federal regulations. Hazardous chemicals can enter the body by absorption through the skin (dermal), gastrointestinal tract (oral), and/or lungs (inhalation). To avoid dermal exposure, observe all protective measures recommended on the product label. If a label suggests protective clothing, use it. Protect your eyes with safety glasses or plastic shields. If any chemical gets into the eye, immediately wash the eye under running water for 15 minutes, call ECC at 271-3083 then seek medical attention. Poison Control can be called for advice 271-5454. For proper disposal all hazardous chemicals must be taken to the office of the Environmental Compliance Coordinator (Room 232).

HANDLING OF COMMON PRODUCTS IN DENTISTRY

The following is a partial listing of known hazardous chemicals used in dentistry and some of the products in which they may be found. CHEMICAL NAME MAY BE FOUND IN

Acid, nitric pickling solutions, some bleaching solutions Acid, phosphoric etching agents, phosphate cements Acid, picric pickling agents Acid, sulfuric etchants for alloy, copper -plating solutions Alcohol, isopropyl solvents; wiping agents Alcohol, methyl denatured alcohol Asbestos soldering investments, crucible linings Beryllium base-metal alloys Formaldehyde sterilizing solutions Iodine iodophor disinfectants, antimicrobial hand

cleaners Lead/inorganic lead compounds impression materials (some polysulfides) Liquid petroleum gas burners Mercury, inorganic amalgam Mercury, organic topical antiseptics Methyl acetate solvents Methyl methacrylate denture base resins Methylene chloride solvents Molybdenum, insoluble compounds chromium-cobalt alloys, stainless steel alloys Nickel steel orthodontic appliances

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CHEMICAL NAME MAY BE FOUND IN

Nitrous oxide nitrous oxide Oil mist, mineral hand piece lubricants Petroleum distillates solvents, waxes, jellies Phenol disinfectants Phthalic anhydride resins Platinum soluble salts impression materials (addition silicones Platinum casting alloys Propane burners Rouge polishing agents Silica, amorphous composite resins Silica, crystalline (quartz) composite resins, porcelain, investments Silicon carbide polishing disks, cutting wheels Silver amalgam, endodontic points, casting alloys, photographic solutions Talc, (non-asbestos form) gloves Tantalum nickel-chromium-cobalt alloys Tin, inorganic compounds amalgam, polishing pastes Tin, organic compounds impression materials (condensation silicones) Titanium dioxide porcelain, impression materials Toluene solvents Trichloroethane solvents Uranium, insoluble compounds porcelain Vinyl chloride maxillofacial plastics, mouth guard trays Xylene solvents Zirconium compounds porcelain, polishing pastes

♦ Acid-etch materials are solutions and gels used with the placement of composites, sealants, and orthodontic brackets. They usually contain phosphoric acid. Potential hazards include eye damage and acid burns with possible sloughing of tissue. Use the following precautions with these materials:

1. Handle acid-soaked material with forceps or gloves. 2. Clean up spills with a commercial acid spill cleanup kit. 3. Avoid skin or soft tissue contact. 4. Rinse with large amounts of running water in case of eye or skin contact.

♦ Flammable gases include nitrous oxide, oxygen, and liquefied petroleum gas. The

chief hazard with these materials is fire. To maximize safety:

1. Test periodically for leaks. 2. Avoid contact between compressed oxygen gas and lubricants or grease. 3. Keep sparks or flames away from flammable gases. 4. Secure oxygen and nitrous oxide tanks by chaining them to the wall or placing

them in approved cylinder holders to prevent toppling.

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♦ Flammable liquids include solvents such as acetone and alcohol. As with flammable

gases, the primary hazard is fire or explosion. To maximize safety:

1. Store in tightly covered containers. 2. Provide adequate ventilation. 3. Have fire extinguishers available at locations where these liquids are used. 4. Avoid sparks or flames in areas where flammable liquids are used. 5. Store any flammable liquid in excess of 10 gallons per location in a flameproof

cabinet.

♦ Beryllium dust and fumes can arise from melting, grinding, and milling some base-metal alloys. Associated hazards include contact dermatitis, inflammation and scarring of respiratory tissues, and corneal burns. When handling such alloys: 1. Use gloves, eyewear, and respirator during casting, polishing, or grinding. 2. Provide adequate local exhaust ventilation in casting areas. 3. Use power suction methods rather than air hoses to remove dust from clothing and

to clean machinery. 4. Dispose of wastes, storage materials, and/or contaminated clothing in sealed bags. Beryllium is no longer used in the College of Dentistry’s Support Lab.

♦ Mercury is extremely common in dentistry and is used most often in amalgam capsules. It is also available in bulk form and found in scrap amalgam. Associated hazards include nausea, loss of appetite, diarrhea, fine tremors, depression, fatigue, increased irritability, headache, insomnia, allergic manifestations, contact dermatitis, pneumonitis, nephritis, dark pigmentation of the marginal gingiva, and loosening of the teeth. When working with mercury:

1. Work in well-ventilated spaces and avoid direct skin contact. 2. Store mercury in unbreakable, tightly sealed containers away from all heat

sources. 3. Salvage amalgam scrap. Storage containers are kept in clinic dispensaries. 4. Clean up spilled mercury using Mini Mercury Spill kit available in ECC office. For

large spills, call the Environmental Health and Safety Office (271-3000). 5. Place contaminated disposable materials in polyethylene bags (small red bags

used for biohazardous waste) and seal.

♦ Nickel is found in some amalgam alloys, gold alloys, and solders; nickel particles can be released during grinding. Associated hazards include allergic manifestations and irritation to the eyes and respiratory system. When working with nickel-containing alloys, use protective eyewear, a mask, and high-velocity evacuation during grinding procedures.

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♦ Methacrylates Any product, which is said to contain “methacrylates,” should be

assumed to contain at least some methyl methacrylate. These products may also contain other methacrylates, which necessitates a more involved clean up procedure for spills than that needed for pure methyl methacrylate.

Hazards:

1. Prolonged and repeated exposure may cause brain and nervous system damage 2. May cause abnormal liver and kidney function 3. Vapor presents explosion hazard 4. Eye irritant 5. Skin irritant 6. Mucous membrane irritant 7. Moderately toxic by inhalation 8. Possible carcinogen 9. Possible teratogen

10. Allergen 11. May cause dermatitis In case of eye contact: ♦ Flush eyes with tepid water for 15 minutes ♦ Immediately seek medical attention.

In case of skin contact: ♦ Wash affected area with soap and water.

In case of spill: ♦ Remove all possible sources of ignition

Extinguish all open flames and lighted smoking materials Turn off all electric motors

♦ Ventilate area ♦ Remove personnel from immediate area ♦ Avoid breathing vapors ♦ Allow volatile components to evaporate and fumes to dissipate ♦ Put on gloves and eye protection ♦ Soak up remaining liquid with absorbent material ♦ Sweep up and containerize the absorbent material ♦ Mop up any residue ♦ Other metals are found in casting alloys (cobalt, chromium) and amalgam alloys (silver,

tin, zinc, copper). Metal dust and fumes may irritate the eyes and respiratory system; contact dermatitis is another potential hazard. With any metal containing alloys, always wear protective eyewear and a mask during grinding procedures.

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♦ Nitrous oxide is used in conscious sedation. High exposure may cause adverse effects,

especially neuropathies and spontaneous abortions. When using nitrous oxide/oxygen, use the minimal concentration necessary to achieve the desired level of sedation. Use a scavenging system and always maintain adequate ventilation. Periodically check nitrous oxide machines, lines, hoses, and masks for leakage.

♦ Organic chemicals include alcohols, ketones, esters, solvents, and monomers such as

methylmethacrylate and dimethacrylate. Halogen-containing organic liquids used in dental offices include chloroform, carbon tetrachloride, and some solvents and cleaners. Hazards associated with the use of these chemicals include fire, allergic manifestations, contact dermatitis, possible mutagenesis, respiratory problems, irritation to mucous membranes, nausea, liver and kidney damage, central nervous system depression, headache, drowsiness, and loss of consciousness. Use of organic chemicals require the following precautions:

1. Avoid skin contact and excessive inhalation of vapors. 2. Work in well-ventilated areas. 3. Use forceps or gloves when handling contaminated gauze or brushes. 4. Keep containers tightly closed when not in use and store on flat sturdy surfaces. 5. Clean outside surfaces of containers after use to prevent residual material from

contacting the next user. 6. Use a commercial flammable solvent cleanup kit in case of spills.

♦ Photographic and radiographic chemicals are used in developing and fixing radio-

graphic film. If used carelessly, they can cause contact dermatitis and irritation of the eyes, nose, throat, and respiratory system from vapors and fine particles. Proper manipulation of these chemicals includes the following:

1. Use protective eyewear; wear heavy-duty rubber gloves to avoid skin contact. In

the event of contact, wash off with large amounts of soap and water. 2. Minimize exposure to dry powder during the mixing of solutions. 3. Work in well-ventilated areas. 4. Clean up spilled chemicals immediately. 5. Regularly launder clothing that comes in contact with photographic solutions. 6. Store photographic solutions and chemicals in tightly covered containers. 7. Save the lead backing on radiographic film for recycling.

NOTE: A silver recovery system/ procedure is in place for all automatic processors to prevent silver from contaminating the sewer system. If you have any problems with this system, notify the Environmental Compliance Coordinator.

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♦ Pickling solutions are strong acidic liquids used to remove contaminants from the

surface of cast metals. They contain metal ions after use; the components may be volatile. They can cause burning and irritation of the skin and mucous membranes, damage to the eyes, and irritation to the respiratory system.

1. Wear safety goggles for eye protection and use forceps to hold the object being

pickled. 2. Avoid skin contact by wearing heavy-duty rubber gloves. 3. Use in well-ventilated areas to minimize the airborne droplet formation. Store

solutions in covered glass containers. 4. Avoid splattering; do not place hot objects into the solution. 5. Keep baking soda in the spill kit (located in each clinic and laboratory) for acid

spills. ♦ Plaster and other gypsum products are common dental materials used for diagnostic

casts, study models, working models, etc. They contain such compounds as silica and calcium sulfate. They can cause irritation and impairment of the respiratory system, silicosis, and irritation of the eyes. When handling these powders or trimming models, always wear protective eyewear and a mask, minimize the exposure to powder, and work in a well-ventilated area.

♦ Formaldehyde is found in Chemclave and Harvey sterilizing solutions and in

preservatives. It is a potential cancer hazard when levels exceed 0.5ppm (parts per mil- lion). Always wear rubber gloves, safety goggles or glasses, and a mask.

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MATERIAL SAFETY DATA SHEETS (MSDS)

A material safety data sheet (MSDS) contains safety and technical information about a specific product. The Infection Control Officer maintains MSDSs filed under product name for every hazardous chemical in the College. Employees and students may check an MSDS for safety information at any time. MSDSs will require some study to understand the information contained in them. They all must provide the same kind of information and in the same order. However, not all MSDSs contain the same detail of information; this varies depending on the degree to which the chemical is considered hazardous. A sample MSDS is reproduced at the end of this section. The nine parts of an MSDS and the information they contain are as follows:

♦ Section I: Product Identification Name, address and phone number of the manufacturer; trade name or brand name of the product; chemical name and formula of the product.

♦ Section II: Hazardous Ingredients Any substances present in the product listed

as hazardous by OSHA, and their exposure limits (if established). A high exposure limit of several thousand ppm is not very toxic. A low exposure limit of a few tens or hundred ppm means small amounts of the substance can cause harm.

♦ Section III: Physical Data Physical properties of the product, including physical

state, color, odor, boiling point, volatility, solubility in water, etc. ♦ Section IV: Fire and Explosion Hazard Data Whether the product will burn or

explode and its degree of flammability and explosivity. ♦ Section V: Health Hazard Data Effects of overexposure to the product; acute and

chronic health effects of the product, if known possible routes of entry into the body of the harmful substances in the product. This section will also contain emergency first aid procedures.

♦ Section VI: Reactivity Data Degree of stability of the product conditions to avoid

in handling or storing. This section tells if the product is incompatible with other materials. Information in this section will help determine the safe handling and storage conditions for the product.

♦ Section VII: Spill or Leak Procedures this section gives information on how to

contain and treat a spill or leakage of the product. It also has information on how to dispose of spilled material.

♦ Section VIII: Special Protection Information. Personal protective equipment

(PPE), recommendations on ventilation, and types of eye protection necessary for working with the product.

♦ Section IX: Special Precautions Directions for special handling and storing of

containers; labeling and posting of signs; any other information on health or safety not contained in other sections.

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CONTAINER LABELING

Under the Hazardous Communication Standard, all containers must be labeled with the identity of the contents and must show hazard warnings appropriate for employee protection. The hazard warning can be conveyed through words, pictures, numerals, or symbols that convey the hazards of the chemical(s) in the container. In most cases, the manufacturer, supplier, or distributor will label the containers. Make sure that the labels are adequate; they must include a chemical name or trade name corresponding to an MSDS on file, as well as appropriate hazard warnings. The manufacturer is responsible for labeling products properly. If a product is not labeled when it arrives in your department, you must label it yourself. Accepted guidelines for labeling containers are as follows:

1. All chemicals must retain the labeling on the original containers. 2. For highly toxic or flammable chemicals, attach a supplemental National Fire

Protection Association (NFPA) label with the appropriate number rating indicated for each hazard (Section IX of the product MSDS).

3. The designated coordinator for your department must ensure that all hazardous chemicals in the office are properly labeled and updated, as necessary. Labels should list at least the chemical identity, appropriate hazard warning, and name and address of the manufacturer, importer, or other responsible party. NOTE: Professional products regulated by the Food and Drug Administration (FDA) is exempt from the labeling requirement.

4. If you transfer chemicals from a labeled container to a portable container intended only for your immediate use, no labels are required.

HAZARD CATEGORIES OF CHEMICALS/DISINFECTANTS

Chemicals and disinfectants are divided into four categories, based on their toxicity to humans and animals. One method of expressing toxicity is the LD-50: LD means Lethal Dose and 50 refers to the dose required to kill 50% of the test animals in research laboratory experiments. The lower the LD-50, the more toxic the chemical. For example, a disinfectant with LD-50 of 30 would be highly toxic and carry the signal words DANGER-POISON on the label; a chemical with LD-50 of 600 would be only slightly toxic and would bear the signal word CAUTION. The four categories and the signal words, which must appear on labels, are:

♦ Category I: Highly Toxic Labels of chemicals in this category must bear: 1. The signal words DANGER and POISON printed in red. 2. A skull and crossbones symbol. 3. The instruction "Call a Physician Immediately" in case of accidental

poisoning. 4. An antidote statement. NOTE: This information is for the physician; it is

not to be used by another person to administer to the victim. Disinfectants in this category have an oral LD-50 of 0-50; the amount required to kill a person is about a teaspoon when taken orally.

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♦ Category II: Moderately Toxic The signal word WARNING must appear on labels

for these chemicals. Oral LD-50s for such chemicals are 50-500; death can result from taking between a teaspoon and an ounce orally.

♦ Category III: Slightly Toxic The signal word on these labels is CAUTION. They

have an oral LD-50 greater than 500; it would take between an ounce and a pint to kill a person.

♦ Category IV: Relatively Non-Toxic Category IV chemicals have little or no

toxicity. They must bear only the statement “KEEP OUT OF REACH OF CHILDREN”. However, other precautions might appear.

For certain chemicals, special caution statements such as the following may be required on the label:

1. Flammable 2. Use only in closed systems 3. Do not contaminate surfaces used in food preparation

CHEMICAL/DISINFECTANT SAFETY Chemicals/disinfectants can be effective and safe tools when used properly. If misused, they can be harmful to humans, animals, and the environment. Safety and first aid begins with an understanding of some definitions.

Toxicity: Acute (short-term) toxicity is a measure of how poisonous a chemical is after a single exposure. A chemical with a high acute toxicity can be deadly if even a very small amount is absorbed. Chronic (long-term) toxicity is a measure of how poisonous a chemical is after small, repeated doses over a period of time. Hazard: Is the potential for exposure to a chemical or other hazardous material. Even slightly toxic materials can be very hazardous if the person using them is careless during use and allows him/herself or others to come in contact with excessive amounts. This can happen, for example, when a person uses a certain chemical every day in his/her job and through familiarity becomes careless with use and handling. The person is at a much greater risk or hazard than one who handles a very toxic chemical with the proper safety equipment and procedures.

Storage

Always store chemicals in their original containers with readable labels. A warning sign should be posted in the storage room or on the cabinet. Keep lids tightened when containers are not being used. Check containers periodically for corrosion, leaks, breaks, etc. so that faulty containers may be disposed of or replaced before they constitute a hazard. If a container is damaged, transfer its contents to a container that has held exactly the same material or a properly labeled substitute. Never store chemicals near food or drugs, and never permit anyone to eat in a room where chemicals are stored.

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Before handling a chemical container, always put on gloves and eyewear. Every time you use a chemical, read the directions for mixing before opening the container. When pouring out a chemical, keep the container and chemical below eye level to avoid potential splashes on your glasses or face. Containers with chemicals in the form of powders should be opened with care to avoid inhaling the powder. Measure carefully when mixing chemicals using only the amount called for on the label. Do not mix or transfer chemicals unless there is good lighting and ventilation. Keep patients and other individuals out of the mixing area. When a container is empty, it should be rinsed at least three times with a diluent (generally water), with the rinses poured into the application equipment and used according to label directions. After being rinsed, containers can be buried in a sanitary landfill. Do not convert empty containers for other uses; they can never be completely decontaminated. For proper disposal of outdated chemicals send them to the Environmental Compliance Coordinator (Room 232)

EMERGENCY RESPONSES

♦ Chemical spills: A spill kit with instructions for use is available in each clinic and laboratory. Wear utility gloves and safety glasses during cleanup. For spills of less than one gallon, the nature of the cleanup depends on whether the chemical is acid-based or alkaline-based.

Acid-base spills: Pour baking soda on spill. After fizzing stops, sweep up mixture and dispose down the drain. Alkaline-base spills: Absorb with material provided in the zip-lock or brown paper bags. Sweep up mixture and dispose according to local, state, and federal regulations. If necessary, contact the ICO for proper disposal method.

For spills greater than one gallon, evacuate the area, call campus police (1-4911), and identify the building, room number, and name of the spilled chemical.

FIRE SAFETY TRAINING

♦ Fire: If the fire is small, you may choose to extinguish it. Determine what is burning

and which type of fire agent to use. The fire extinguishers in the College of Dentistry are classified as ABC and are deemed safe to use on any fire that might occur in the building. If the fire is large or near flammable material, call the fire department (1-4300) to report the fire and evacuate the building. DO NOT USE THE ELEVATORS! Elevators act as chimney shafts drawing poisonous gases and fumes into the elevator. Departments have predetermined meeting places outside the building and designated personnel responsible for roll call. Notify firemen if you think someone is left in the building.

NOTE: Physically challenged visitors or patients (including patients who receive IV sedation or general anesthesia during dental treatment) must be taken to the nearest stairwell landing. Stay with the patient until help arrives. According to the American Disabilities Act, a physically challenged person may not be taken down the stairs. Campus firemen have special equipment for this purpose.

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All employees and students should know the locations of fire extinguishers in the dental building and when and how to operate them. The following is a basic introduction on fire extinguishers:

Portable fire extinguishers are designed to put out small fires or contain them until the fire department arrives. They are not meant to fight large or spreading fires. There are four different types of fires:

Type A Ordinary combustibles such as wood, cloth, paper, rubber, and many plastics

Type B Flammable liquids (gasoline, oil, grease, tar, oil-based paint, and lacquer) and flammable gases

Type C Energized electrical equipment (wiring, fuse boxes, circuit breakers, machinery and appliances)

Type D Combustible metals such as magnesium, potassium, etc.

Be certain you are fighting a fire with the proper extinguisher. It is particularly dangerous to use water or a Type A extinguisher on a grease or electrical fire. To operate a fire extinguisher, pull the pin and aim low, pointing the nozzle eight to ten feet from the base of the fire. Squeeze the handle to release the extinguishing material and sweep from side to side and toward the fire until it appears to be out. Most fire extinguishers will discharge their contents within 8 to15 seconds.

Post Emergency Numbers by each telephone. Most campus extensions may be reached by dialing "1" followed by the four-digit extension number. Emergency number lists should include the following: Oral Surgery 1-4441 or 1- 4079 Fire 1-4300 or 1-4911 Poison Control Center 271- 5454 Campus Police 1-4911 Exposure/Injury Report 271- 3083 Ambulance 1-4911

Severe Weather – Tornado

Preferred location- Basic Science building downstairs and into the tunnel. Other designated shelter areas in the dental building are the first floor North hallway by the student store then locker rooms, first floor restrooms, and Northeast and Northwest Interior stairwells on the first floor.

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FIRST AID MEASURES:

CHEMICAL EXPOSURE/POISONING Ingestion / Aspiration In spite of precautions taken when handling and using hazardous chemicals, poisoning sometimes occurs through accidents or careless use. Individuals working with chemicals should be familiar with poison symptoms and first aid.

Mild poisoning: Headache, weakness, nausea, nervousness, and/or fatigue Moderate poisoning: Excessive salivation, lack of muscle coordination, muscle twitches, excessive perspiration, blurred vision, and difficulty breathing Severe poisoning: Intense thirst, rapid breathing, vomiting, uncontrollable muscle twitches, papillary constriction, convulsions, and unconsciousness

Do not induce vomiting except under a doctor’s supervision. Contact the Poison Control Center at 271-5454. Skin contact In cases of contact with the skin, drench skin and clothing with water, remove the clothing, cleanse the skin and hair thoroughly with soap and water, dry, and wrap the victim in a blanket. Eye contact Remove contact lenses (if present), wash the eye out as quickly as possible by holding the eyelid open and washing with a gentle stream of water for fifteen minutes or more.

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IN-HOUSE

LABELING SYSTEMS The National Fire Protection Agency (NFPA) sticker shown is used to indicate the level of

[1] Health hazard, [2] Fire hazard, [3] Reactivity, and [4] Other specific hazards associated with a given chemical.

Consult the product’s MSDS and mark the appropriate hazard rating number, 0 through 4 in each diamond-shaped area. When using an NFPA warning label, the chemical or product name must be written on a separate stick-on label.

Blue Diamond=Health Hazard Red Diamond=Fire Hazard 0 -- Normal material 0 -- Will not burn 1 -- Slightly hazardous 1 -- Flash point above 200o F 2 -- Hazardous 2 -- Flash point between 100o-200o F 3 -- Extreme danger 3 -- Flash point below 100o F 4 -- Deadly 4 -- Flash point below 73o F

Yellow Diamond=Reactivity White Diamond=Specific Hazard 0 -- Stable Special instructions or information 1 -- Unstable if heated (corrosive, oxidizer, acid, etc.) are 2 -- Violent chemical change indicated here 3 -- Shock and heat may detonate 4 -- May detonate

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HAZARD COMMUNICATION TRAINING Everyone who works with or is potentially exposed to hazardous chemicals will receive initial training on the OSHA Hazard Communication Standard and the safe use of those chemicals. Whenever a new hazard is introduced, additional training will be provided. The training plan will emphasize the following items:

1. Summary of the Standard and of this written program 2. Chemical and physical properties of hazardous materials and methods that can be

used to detect the presence or release of chemicals (including chemicals in unlabeled pipes).

3. Physical hazards of chemicals and health hazards associated with exposure to chemicals, including any medical condition(s) aggravated by exposure.

4. Procedures to protect against hazards (required PPE, proper use/maintenance, work practices and methods to assure proper use and handling of chemicals, procedures for emergency response, etc.).

5. Work procedures to follow to assure protection when cleaning hazardous chemical spills and leaks.

6. Location of MSDSs, how to read and interpret the information on both labels and MSDSs, and how to obtain additional information

Retraining will be required when a hazard changes or when a new hazard is introduced into the workplace. Training records will be kept on file for three years in the offices of the Environmental Compliance Coordinator and the OUHSC Environmental Health and Safety Officer. For in-house training, contact the ECC (271-3083).

OUHSC HAZARD COMMUNICATION

INVENTORY FORM On the next page is the Hazardous Chemical List Form used on the Health Sciences Center to inventory and keep track of any hazardous chemicals used in your area, along with instructions for proper inventory.

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