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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.