Download Ballot A (PDF: 220KB/8 pages)

Ballot A
At the October 31, 2008 meeting, the procedures proposed to be added to, or not allowed under
general supervision were discussed. The procedures proposed to be excluded from the OHP
scope of practice were not discussed, due to time limitations. Ballot A summarizes the group
discussion about the procedures to be added or not to be allowed under general supervision, as
well as written input for the procedures proposed to be excluded, describing the benefits and
risks of including them in the OHP scope of practice and under what level of supervision.
Note that extractions of permanent and primary teeth have been grouped together, as have
examination and rendering a diagnosis, in an effort to reflect the group’s discussion. Also, a new
section on medication prescribing authority has been added, based upon the Board of Pharmacy’s
recommendation about how to approach this issue.
Please review and “vote” on each item and fax your signed and dated ballot to Kris Gjerde
by 5pm on Wednesday, November 12th at 651-201-3830.
For each of these procedures, a collaborative management agreement will be negotiated between
a licensed dentist and the OHP. Your vote will indicate:
1. Whether the procedure should be in or out of the OHP scope of practice, and
2. The least restrictive level of supervision that your support for the OHP providing this
procedure.
1. Space maintainer placement/removal
Benefits
• Improved access
• Improved system capacity
• Improved cost
• Avoids delays in care
• Can be performed at time of extraction
In
Out
Risks
• Timing/delays
• Needs close CMA guidance
• Adds significantly to training time and cost
• Requires diagnosis to remove
• Usually placed at time of extraction
• Minimal with appropriate training
General
Indirect
Direct
Placement
Removal
2. Preparation and placement of preformed crowns of any material
Benefits
• Is considered a basic restorative procedure
• Needed to meet patient needs
• Complications if not treating are avoided
• Improved access and systems capacity
• Decreased cost
• Efficient and effective care
• Avoids delays in care
Risks
• Needs close CMA guidance
• Risk of pulpal violation
• Minimal with appropriate training
• None
Proposed settings include: Schools, Nursing homes, HeadStart, Homeless shelters, Group Homes, Indian Reservations, Non
profit dental clinics, Children’s Hospital, Pediatric clinics, Hospitals, Rural Clinics and Federally Qualified Health Care Centers.
In
Out
General
Indirect
Direct
Preparation
Placement
3. Tooth re-implantation/stabilization/referral
Benefits
• Provides preparation for further treatment
• Can save the tooth
• OHP trained to know what is out of their scope
• Is consistent with current care delivery system
assuming appropriate training, supervision,
and guidance through CMA
• Multiple degrees to trauma
• Timely access to urgently needed care
• Avoids delays in care
In
Out
Risks
• Complicated procedure
• Burden on educational system for general supervision
• Needs close CMA guidance
• Minimal with appropriate training and adequate
supervision
General
Indirect
Direct
Re-implantation
Stabilization
4. Atraumatic Restorative Technique (ART)
Benefits
• Benefits outweigh risk
• Temporary solution until patient can access
needed care
• Consistent with current care delivery system
assuming appropriate training, supervision,
and guidance through CMA
• Improved access and system capacity
• Improved cost performance
• Improved disease management capability
• Avoids delays in care
In
Out
Risks
• Patients often have multiple problems/complications
• Minimal with appropriate training and adequate
supervision
• Pulpal exposure
• Rarely used
General
Indirect
Direct
Indirect
Direct
ART
5. Sealants
Benefits
• Currently done by DH under general
supervision
• Improved access and system capacity
• Improved cost performance
• Improved disease management capability
• Avoids delays in care
In
Out
R
isks
• None
General
Sealants
Proposed settings include: Schools, Nursing homes, HeadStart, Homeless shelters, Group Homes, Indian Reservations, Non
profit dental clinics, Children’s Hospital, Pediatric clinics, Hospitals, Rural Clinics and Federally Qualified Health Care Centers.
6. Dental Examination (evaluation, assessment and treatment planning)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Benefits Can serve settings without a dentist
Includes evaluation and assessment
This is a primary care dental exam-system
will determine quality
PA can order diagnostic tests
OHP will be licensed
OHP will be trained to scope of practice,
diagnosis is within the scope
OHP needs to assess/evaluate and develop a
treatment plan
OHP will practice under CMA
Improved access and system capacity
Reduces cost
Increase dentist time available for other care
Improves ability to provide care in non
traditional settings
Consistent with current care delivery system
assuming appropriate training, supervision,
and guidance through CMA
Avoid delays in care
Risks
If OHPs doing diagnosis, requires highest supervision
level
Potential for mis-diagnosis
Increases burden on educational system
Complex patient mix
Needs additional training and adequate supervision
•
•
•
•
•
7. Rendering a Diagnosis
Benefits
A critical factor to:
• Improved access and system capacity
• Improved cost performance
• Improved ability to provide care in non
traditional settings
• Avoids delays in care
• NONE: should be under a DDS purview only
• No benefit. OHP will be trained to recognize
normal from abnormal, but will not be educated
to make any level of definitive diagnosis
• Consistent with current care delivery system
assuming appropriate training, supervision, and
guidance through CMA
•
In
Out
•
•
•
•
•
Risks
Given a more systematic approach to supervision,
care guidelines and quality assurance one could
make a plausible argument that the level of risks
associated with unexplained variation in diagnosis
and treatment would be reduced
More education required for comprehensive
diagnosis
Diagnosis must include medical, periodontal,
pulpal, soft tissue, dentition, etc. to render a
treatment plan
Additional training requirement not achievable in
educational scope
Patients require a comprehensive diagnosis before
treatment: medical, psychological, and dental
General
Indirect
Direct
Examination
Evaluation
Assessment
Treatment
plan
Rendering a
diagnosis
Proposed settings include: Schools, Nursing homes, HeadStart, Homeless shelters, Group Homes, Indian Reservations, Non
profit dental clinics, Children’s Hospital, Pediatric clinics, Hospitals, Rural Clinics and Federally Qualified Health Care Centers.
8. Placement of Sutures
•
•
•
•
•
Benefits If during an extraction, efficient/effective
Consistent with current care delivery system
assuming appropriate definition of scope, training, supervision and guidance through CMA Include suture with only non-surgical extraction
Improved access to urgently needed care
Avoids delays in care
In
•
Out
Risks
Need to do it routinely to maintain skill
General
Indirect
Direct
Placement of
Sutures
9. Repair of Defective Appliances
•
•
•
•
•
•
•
Benefits
Improved access and system capacity
Improved cost performance
Improved ability to provide care in nontraditional settings
Avoids delays in care
Repairs have esthetic and functional benefits
Dentist could delegate portions of the
evaluation and treatment to OHP, allowing
time to care for other patients
Consistent with current care delivery system
assuming appropriate training, supervision,
and guidance through CMA
In
•
•
•
•
•
•
Out
Risks
Repair could result in poor fit, failure of repair
Appliances break for a reason; a dentist needs to
determine why it broke
An appliance repaired incorrectly can result in trauma
and affect occlusion
Would adversely affect amount of training required
Malocclusion, fracture and lack of follow up care
Without thorough pre and post treatment exam of
prosthesis and tissues, patients are at risk for greater
problems
General
Indirect
Direct
Repair of
Defective
Appliances
10. Re-cementing of Permanent Crowns
•
•
•
•
•
•
Benefits
Improved access and system capacity
Improved cost performance
Improved ability to provide care in non
traditional settings
Avoid delays
Consistent with current care delivery system
assuming appropriate training, supervision,
and guidance through CMA
None
Re-cementing
In
Out
•
•
•
•
Risks
Decay left under crown
Malocclusion; pulpal decay may be present and may
result in pulpal involvement warranting further
treatment
If cemented without proper occlusion, may be
difficult to remove or adjust
Causes of crown dislodgement are always indicative
of a serious underlying problem; diagnosis is critical
General
Indirect
Direct
Proposed settings include: Schools, Nursing homes, HeadStart, Homeless shelters, Group Homes, Indian Reservations, Non
profit dental clinics, Children’s Hospital, Pediatric clinics, Hospitals, Rural Clinics and Federally Qualified Health Care Centers.
Permanent
Crowns
11. Behavior Management
•
•
•
•
•
•
Benefits
Improved access and system capacity
Improved ability to provide care in non
traditional settings
Avoids delays in care
Aid in treatment of patients
Would allow OHP to treat an additional group
of children who need preventive and
restorative care/ treatment
Consistent with current care delivery system
assuming appropriate training, specific
attention to physical restraint in the care
guidelines and access to experienced dentist
consultation
In
Risks
Risk of physical or psychological harm; non-physical
and pharmacological methods
• If not done properly, could cause physical and/or
psychological harm
•
Out
General
Indirect
Direct
Behavior
Management
12. Extractions – Primary/Permanent Teeth
•
•
•
•
•
•
•
•
•
•
•
•
Benefits
Improved access and system capacity
Improved cost performance
Improved ability to provide care in non
traditional settings
Consistent with current care delivery system
assuming appropriate definition of scope,
training, case selection, supervision, and
guidance through CMA
Avoids delays in care
Relief of pain
Primary teeth only
More treatment could be provided to children
Needed to meet needs of underserved
Other countries allow
Setting is really relevant as this will reach
those not able to see dentist
Geriatrics will be part of the education
In
Out
•
•
•
•
•
Risks
Patient inconvenience for treatment of specific
complication
Longer training required if permanent teeth included
Not for permanent teeth
Patient safety at risk if under general supervision
Extraction of permanent teeth too complex. Risks
include: root fractures, damage to adjacent teeth,
bleeding from a major blood vessel, nerve damage,
sinus perforation, etc.
General
Indirect
Direct
Primary
Permanent
13. Root Tip Removal
•
Benefits
Improved access and system capacity
Risks
• Primary risk is related to the scope of training
Proposed settings include: Schools, Nursing homes, HeadStart, Homeless shelters, Group Homes, Indian Reservations, Non
profit dental clinics, Children’s Hospital, Pediatric clinics, Hospitals, Rural Clinics and Federally Qualified Health Care Centers.
•
•
•
•
Improved cost performance
Improved ability to provide care in nontraditional settings
Avoids delays in care
No benefit
In
•
•
•
•
•
Out
and whether this is part of the training programs
or not
Nerve damage, damage to permanent tooth
Hemostasis
Very difficult to do
Training limitations
Potential infection, sinus involvement
General
Indirect
Direct
Root Tip
Removal
14. Incision/Drainage of Abscess
•
•
•
•
•
•
•
Benefits
Improved access and system capacity
Improved cost performance
Improved ability to provide care in non
traditional settings
Consistent with current care delivery system
assuming appropriate training, supervision,
and guidance through CMA and access to
appropriate medical or dental consultative
service
Avoids delays in care
Relief of pain
None
In
•
•
•
•
•
Out
Risks
Inadequate drainage, tissue damage
Nerve damage; hemorrhage; spread of infection
Delays in appropriate care
Spreads infection
Acute problem that needs diagnosis to include
medication, medical condition of patient and history
General
Indirect
Direct
Incision/Drainage
of Abscess
15. Perio-maintenance
•
•
•
•
•
•
Benefits
Improved access and system capacity
Improved cost performance
Improved ability to provide care in non
traditional settings
Avoids delays in care
None
Already in DH scope under general
supervision
In
Out
•
•
•
Risks
Consistent with current care delivery system – under
DH scope of practice, so abundant supply
Adds to educational cost, increased length of training.
Cost; DH already do this
General
Indirect
Direct
Perio
maintenance
16. Scaling/Root Planing
Proposed settings include: Schools, Nursing homes, HeadStart, Homeless shelters, Group Homes, Indian Reservations, Non
profit dental clinics, Children’s Hospital, Pediatric clinics, Hospitals, Rural Clinics and Federally Qualified Health Care Centers.
•
•
•
•
Benefits Improved access and system capacity
Improved cost performance
Improved ability to provide care in nontraditional settings
Avoids delays in care
In
Risks
Consistent with current care delivery system
In Expanded DH scope of practice
Resembles the ADHT model, not the dental therapist
model or a restorative procedure; DH available to do
this
•
•
•
Out
General
Indirect
Direct
Scaling/Root
Planing
17. Opening of Permanent Tooth for Pulpal Debridement and Opening Chamber
•
•
•
•
•
•
Benefits Improved access and system capacity
Improve access to urgently needed care
Improved cost performance
Improved ability to provide care in nontraditional settings
Avoids delays in care
Relief of pain Consistent with current care delivery system assuming appropriate training, supervision, and guidance through
CMA Opening of
Permanent
Tooth for
Pulpal
Debridement
and Opening
Chamber
In
Risks
Perforation of chamber/loss of tooth
Possible perforation of chamber of tooth; potential for
infection; misdiagnosis
Pulpal debridement can be very difficult
Complications can include coronal perforation and
incorrect root canal treatment
•
•
•
•
Out
General
Indirect
Direct
18. Full Mouth Debridement
•
•
•
•
•
Benefits
Improved access and system capacity
Improved cost performance
Improved ability to provide care in non
traditional settings
Avoid delays
NONE, is in DH scope
In
•
•
•
•
Out
Risks
Consistent with current care delivery system
In DH scope
Cost, DH available to do this
Adds to educational cost
General
Indirect
Direct
Full Mouth
Debridement
Proposed settings include: Schools, Nursing homes, HeadStart, Homeless shelters, Group Homes, Indian Reservations, Non
profit dental clinics, Children’s Hospital, Pediatric clinics, Hospitals, Rural Clinics and Federally Qualified Health Care Centers.
19. Medication Prescription Authority – Vote For Either Option A or B
Mark each item that you recommend for OHP prescription authority, given a collaborative
management agreement.
Option A - OHP Independent Prescribing Authority
Authority to prescribe, dispense, or administer. A licensed oral health practitioner may
prescribe, dispense, or administer the following legend drugs to aid in the diagnosis, cure,
mitigation, prevention, treatment, or management of disease, pain, deformity, deficiency, injury,
or physical condition of the human tooth, teeth, alveolar process, gums or jaw, or adjacent or
associated structures:
Yes/No
Prescribe
Administer
Dispense
Analgesics
Anti
inflammatory
Antibiotics
Nitrous oxide
Nothing in this section shall allow controlled substances to be administered, dispensed, or
prescribed.
Option B - OHP Prescribing Per Protocol
Administering, dispensing and prescribing legend drugs. A licensed oral health
practitioner, who has a written agreement or protocol with a dentist that defines the
delegated responsibilities related to the prescription of drugs, may prescribe, dispense, and
administer the following drugs within the scope of the written agreement and within practice
as a licensed oral health practitioner:
Yes/No
Prescribe
Administer
Dispense
Analgesics
Anti
inflammatory
Antibiotics
Nitrous oxide
Nothing in this section shall allow controlled substances to be administered, dispensed, or
prescribed.
Printed name___________________________________________________
Signature______________________________________________ Date __________________
Proposed settings include: Schools, Nursing homes, HeadStart, Homeless shelters, Group Homes, Indian Reservations, Non
profit dental clinics, Children’s Hospital, Pediatric clinics, Hospitals, Rural Clinics and Federally Qualified Health Care Centers.