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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 Yes No Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 1 Name:____________________________________________________________________________________________ GENERAL DENTISTRY (continued) Requested Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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): ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 2 Name:____________________________________________________________________________________________ GENERAL DENTISTRY (continued) Requires a D.D.S./D.M.D. degree from an ADA-accredited dental school or equivalent. Requested Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Occlusal Adjustment Desensitization Procedures Occlusal Guard Fabrication Other (specify): ANESTHESIA Requires documentation of appropriate training and experience for requested privileges. Requested Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 3 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 Yes No Yes No ____ ____ ____ ____ Extraction of Erupted Teeth ____ ____ ____ ____ Extraction of Exposed Tooth Roots ____ ____ ____ ____ Surgical Removal of Erupted Teeth ____ ____ ____ ____ Surgical Removal of Impacted Teeth ____ ____ ____ ____ Surgical Removal of Residual Tooth Roots ____ ____ ____ ____ Surgical Repair of Oro-Antral Fistula ____ ____ ____ ____ Surgical Exposure of Unerupted tooth to Aid in Eruption ____ ____ ____ ____ Surgical Exposure of Unerupted Tooth and Placement of Orthodontic Appliance to aid eruption ____ ____ ____ ____ Biopsy of Oral Hard Tissue ____ ____ ____ ____ Biopsy of Oral Soft Tissue ____ ____ ____ ____ Surgical Repositioning of Teeth ____ ____ ____ ____ Alveoloplasty ____ ____ ____ ____ Surgical Excision of Hyperplastic Tissue ____ ____ ____ ____ Surgical Removal of Benign Tumors ____ ____ ____ ____ Surgical Removal of Odontogenic or Non-odontogenic Cysts ____ ____ ____ ____ Apicoectomy, Apical Curettage, and Retrograde Filling ____ ____ ____ ____ Removal of Tori and Exostoses ____ ____ ____ ____ Intraoral Incision and Drainage of Abscess ____ ____ ____ ____ Extraoral Incision and Drainage of Abscess ____ ____ ____ ____ Removal of Foreign Body ____ ____ ____ ____ Sequestrectomy ____ ____ ____ ____ Maxillary Sinusotomy for Retrieval of Tooth or Foreign Body ____ ____ ____ ____ Closed Reduction of Facial Fractures ____ ____ ____ ____ Closed Reduction of Mandibular Dislocation ____ ____ ____ ____ TMJ Arthrocentesis ____ ____ ____ ____ Nonsurgical Management of TMJ Disorders ____ ____ ____ ____ Nonsurgical Management of Atypical Facial Pain ____ ____ ____ ____ Closure of Intraoral Soft Tissue Lacerations ____ ____ ____ ____ Closure of Extraoral Soft Tissue Lacerations ____ ____ ____ ____ Oral Mucosal Grafts ____ ____ ____ ____ Frenectomy ____ ____ ____ ____ Chieloplasty ____ ____ ____ ____ Excision of Pericoronal Gingiva Dubai Health Care City Delineation of Clinical Privileges 4 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 Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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: __________________________________________ __________________________________________ 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 ___________________________________________ ___________________________________________ Temporomandibular Joint Surgery – List Procedures Maxillofacial Bone and Soft Tissue Reconstructive Surgery Other______________________________________________ Delineation of Clinical Privileges 5 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 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Granted Yes No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 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