Download DELINEATION OF CLINICAL PRIVILEGES IN DENTISTY AND

DELINEATION OF CLINICAL PRIVILEGES IN DENTISTY AND DENTAL HYGIENE
DUBAI HEALTH CARE CITY
Name: ____________________________________________________________________________
GENERAL DENTISTRY
Requires a D.D.S./D.M.D. degree or equivalent from dental school, and a current and valid license to practice in a country on
the list of accepted jurisdictions (attached to the application).
Requested
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Granted
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Dubai Health Care City
DIAGNOSTIC PROCEDURES:
Clinical Oral Examination
Intraoral Radiograph Interpretation
Panoramic Radiograph Interpretation
Cephalometric Radiograph Interpretation
Request and Interpretation of Clinical Pathology Examinations
Diagnostic Casts
Other (specify):
PREVENTIVE PROCEDURES:
Dental Prophylaxis
Topical Fluoride Application
Fabrication of Custom Fluoride Trays
Application of Sealants to teeth
Oral Hygiene Instruction
Passive Space Maintenance Procedures
Other (specify):
RESTORATIVE PROCEDURES:
Conventional Restorative Dentistry Procedures
Indirect Pulp Capping
Direct Pulp Capping
Other (specify):
ENDODONTIC PROCEDURES:
Pulpotomy
Pulp Extirpation
Conventional Root Canal Therapy
Endodontic Apical Curettage
Apicoectomy
Retrograde Filling of Tooth
Apexification
Root Amputation
Hemisection
Bleaching of Discolored Teeth
Other (specify):
Delineation of Clinical Privileges
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Name:____________________________________________________________________________________________
GENERAL DENTISTRY (continued)
Requested
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No
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Granted
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ORAL AND MAXILLOFACIAL SURGERY PROCEDURES:
Extraction of Erupted Teeth
Surgical Extraction of Erupted Teeth
Surgical Removal of periapical granuloma/cyst in conjunction with extraction
Routine Alveoloplasty
Removal of tori and exostoses
Intraoral Biopsy - Soft Tissue
Intraoral Biopsy - Hard Tissue
Closure of Oral Mucosal Lacerations
Management of Dentoalveolar Infection with Oral Antibiotics
Incision and Drainage of Intraoral Abscess
Excision of Hyperplastic Tissue
Frenectomy
Other (specify):
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OTHER PROCEDURES
Administration of Local Anesthesia
Diagnostic Local Anesthesia Procedures
Treatment of Geriatric Patients
Treatment of Medically Compromised Patients
Surgical Placement of Endosseous Dental Implants
Minor Tooth Movement Procedures
Diagnosis & Non-Surgical Treatment of TMJ Disorders
Dubai Health Care City
PERIODONTAL PROCEDURES:
Gingivectomy
Scaling and Root Planing
Gingival curettage
Gingival Flap Curettage
Crown Lengthening
Osseous Grafting Procedures
Provisional Splinting of Teeth
Other (specify):
PROSTHODONTIC PROCEDURES:
Tooth Replacement with Conventional Removable Prosthodontic Procedures
Tooth Replacement with Conventional Fixed Prosthodontic Procedures
Construction of Precision Attachments for Retention of Prostheses
Replacement of Teeth with Implant Retained/Supported Abutments
Repairs to Removable Prosthodontic Appliances
Repairs to Fixed Prosthodontic Appliances
Denture Rebase Procedures
Denture Reline Procedures
Other (specify):
Delineation of Clinical Privileges
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Name:____________________________________________________________________________________________
GENERAL DENTISTRY (continued)
Requires a D.D.S./D.M.D. degree from an ADA-accredited dental school or equivalent.
Requested
Yes
No
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Granted
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Occlusal Adjustment
Desensitization Procedures
Occlusal Guard Fabrication
Other (specify):
ANESTHESIA
Requires documentation of appropriate training and experience for requested privileges.
Requested
Yes
No
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Granted
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No
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Local Anesthesia
Diagnostic Blocks with Local Anesthesia
Nitrous Oxide/Oxygen Inhalation Conscious Sedation
Enteral Conscious Sedation
Intravenous Conscious Sedation (* requires proof of training and current competency)
ENDODONTIA
Restricted to individuals with advanced training in Endodontia. Requires educational qualification, board eligibility or board
certification in Endodontia.
Requested
Yes
No
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Granted
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Dubai Health Care City
Direct Pulp Capping
Indirect Pulp Capping
Therapeutic Pulpotomy
Pulp Extirpation
Conventional Root Canal Therapy
Apexification
Apical Curettage
Root Amputation
Apicoectomy
Retrograde Filling
Hemisection
Recalcification Procedures
Bleaching of Discolored Teeth
Other (specify):
Delineation of Clinical Privileges
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Name:________________________________________________________________________________
ORAL AND MAXILLOFACIAL SURGERY
Restricted to individuals with advanced training in Oral and Maxillofacial Surgery. Requires educational qualification,
board/college eligibility or board/college certification in Oral and Maxillofacial Surgery.
Requested
Granted
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No
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No
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____ Extraction of Erupted Teeth
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____ Surgical Exposure of Unerupted tooth to Aid in Eruption
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eruption
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____ Biopsy of Oral Hard Tissue
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____ Surgical Repositioning of Teeth
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____ Alveoloplasty
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____ Apicoectomy, Apical Curettage, and Retrograde Filling
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____ Maxillary Sinusotomy for Retrieval of Tooth or Foreign Body
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____ TMJ Arthrocentesis
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____ Closure of Intraoral Soft Tissue Lacerations
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____ Oral Mucosal Grafts
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____ Frenectomy
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____ Excision of Pericoronal Gingiva
Dubai Health Care City
Delineation of Clinical Privileges
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Name:____________________________________________________________________________________________
ORAL AND MAXILLOFACIAL SURGERY (continued)
Restricted to individuals with advanced training in Oral and Maxillofacial Surgery. Requires educational qualification,
board/college eligibility or board/college certification in Oral and Maxillofacial Surgery.
Requested
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No
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Crown Lengthening Procedures
Sialolithotomy
Surgical Placement of Endosseous Implants
Surgical Placement of Subpereosteal Implants
Guided Tissue Regeneration
Autogenous Bone Graft
Maxillary Sinus Floor Grafting
Ridge Augmentation with Autogenous Bone Grafting
Nonsurgical Management of Trigeminal Neuralgia
Nonsurgical Management of Diseases of the Oral Region
Other (specify):
Privileges for the following procedures require that the practitioner perform the procedures in a
hospital or recognized outpatient surgical center:
Requested
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No
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Granted
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Dubai Health Care City
Vestibuloplasty
Vestibuloplasty with Skin or Mucosal Grafting
Surgical Removal of Malignant Tumors (Stage I & II)
Surgical Destruction of Lesion by Physical Methods
Open Reduction of Facial Fractures
TMJ Manipulation under Anesthesia
TMJ Arthroscopy
Orthognathic Surgical Procedures – List procedures:
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Surgical Rapid Palatal Expansion
Skin Grafts
Osteoplasty
Surgical Peripheral Nerve Repair Procedures
Peripheral Neurectomy
Ankylotomy
Sialodochoplasty
Coronoidectomy
Ridge Augmentation with Alloplastic Materials
Management of Cleft Lip and Palate Deformities – List Procedures
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Temporomandibular Joint Surgery – List Procedures
Maxillofacial Bone and Soft Tissue Reconstructive Surgery
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Delineation of Clinical Privileges
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Name:____________________________________________________________________________________________
ORAL MEDICINE, ORAL RADIOLOGY, AND ORAL PATHOLOGY
Restricted to individuals with advanced training in Oral Medicine, Oral Radiology, or Oral Pathology. Requires educational
qualification, board/college eligibility or board/college certification in the appropriate specialty.
Requested
Yes
No
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Granted
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Intraoral Biopsy - Soft Tissue
Intraoral Biopsy - Hard Tissue
Administration of Local Anesthesia for Diagnostic Purposes
Treatment Benign Tumors by Intralesional Injection
Treatment of Oral Mucosal Lesions by Intralesional Injection
Request and Interpretation of Clinical Laboratory Examinations
Diagnostic Microscopic Histopathology
Diagnostic Microscopic Cytology
Diagnostic Immunofluorescence Microscopy
Nonsurgical Management of Diseases of the Oral Region
Diagnosis and Nonsurgical Management of TMJ Disorders
Diagnosis and Nonsurgical Management of Atypical Facial Pain
Interpretation of Conventional Intraoral Radiographs
Interpretation of Panoramic Radiographs
Interpretation of Extraoral Diagnostic Radiographs, CT, MRI
Sialography
Tomography
Other (specify):
ORTHODONTIA
Restricted to individuals with advanced training in Orthodontia. Requires educational qualification, board/college eligibility or
board/college certification in Orthodontia.
Requested
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Granted
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Dubai Health Care City
Minor Tooth Movement with Removable Appliance
Minor Tooth Movement with Fixed Appliance
Minor Treatment to Control Harmful Habits
Interceptive Orthodontic Treatment
Comprehensive Orthodontic Treatment - Transitional Dentition
Comprehensive Orthodontic Treatment - Permanent Dentition
Comprehensive Orthodontic Treatment - Extended Skeletal Case
Other (specify):
Delineation of Clinical Privileges
6
Name:____________________________________________________________________________________________
PEDIATRIC DENTISTRY
Restricted to individuals with advanced training in Pediatric Dentistry. Requires educational qualification, board/college
eligibility or board/college certification in Pediatric Dentistry.
Requested
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Granted
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Dental Prophylaxis
Topical Fluoride Application
Passive Space Maintenance Procedures
Removal of Dental Caries
Conventional Restorative Dentistry Procedures
Pulpotomy
Root Canal Therapy of Primary Teeth
Conventional Root Canal Therapy
Prosthetic Tooth Replacement with Removable Prosthodontic Procedures
Prosthetic Tooth Replacement with Fixed Prosthodontic Procedures
Routine Dental Extraction
Intraoral Biopsy
Incision and Drainage of Intraoral Abscess
Minor Tooth Movement with Removable Appliance
Minor Tooth Movement with Fixed Appliance
Minor Treatment to Control Harmful Habits
Interceptive Orthodontic Treatment
Other (specify):
PERIODONTIA
Restricted to individuals with advanced training in Periodontia. Requires educational qualification, board/college eligibility or
board/college certification in Periodontia.
Requested
Yes
No
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Dubai Health Care City
Scaling and Root Planing
Gingivectomy
Gingival Curettage
Gingival Flap Curettage
Crown Lengthening Procedures
Mucogingival Surgery
Periodontal Osseous Surgery
Osseous Grafting Procedures
Pedicle Soft Tissue Graft Procedure
Free Soft Tissue Graft Procedure
Apically Positioned Flap Procedure
Guided Tissue Regeneration
Surgical Placement of Endosseous Dental Implants
Provisional Splinting of Teeth
Maxillary Sinus Floor Grafting
Other (specify):
Delineation of Clinical Privileges
7
Name:____________________________________________________________________________________________
PROSTHODONTIA
Restricted to individuals with advanced training in Prosthetic Dentistry. Requires educational qualification, board/college
eligibility or board/college certification in Prosthetic Dentistry.
Requested
Yes
No
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Granted
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Replacement of Teeth with Conventional Removable Prostheses
Replacement of Teeth with Conventional Fixed Prostheses
Replacement of Teeth with Implant Retained/Supported Abutments
Repairs to Complete Dentures
Repairs to Partial Dentures
Repairs to Fixed Prostheses
Denture Rebase Procedures
Denture Reline Procedures
Construction of Precision Attachments for retention of Prostheses
Maxillofacial Prosthetic Replacement for Intraoral Acquired or Congenital Defects
Maxillofacial prosthetic Replacement for Extraoral Acquired or Congenital Defects
Other (specify):
DENTAL HYGIENE
Requires Certificate, Diploma, or degree in Dental Hygiene from an accredited school and a license to practice in a country on
the list of accepted jurisdictions.
Requested
Yes
No
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Dubai Health Care City
Obtain Medical History
Examination of Teeth and Oral Structures
Dental Prophylaxis and Polishing of Clinical Crowns of Teeth
Scaling and Root Planing
Application of Sealants to Teeth
Topical Fluoride Application to Teeth
Polishing of Dental Restorations
Patient Education in Oral Health Maintenance
Diet Counseling
Exposure of Dental Radiographs
Community Dental Health Program Implementation
Obtain Alginate Impressions
Placement of Temporary Dental Restorations
Other (specify):
Delineation of Clinical Privileges
8
I hereby request the specific privileges as indicated on this delineation of privileges listing.
Signature of Applicant
Date
APPROVED:
Medical Director/Dentist
Dubai Health Care City
Date
Delineation of Clinical Privileges
9