Clinical Guidelines

MISSION STATEMENT:

To provide an integrated approach to maintenance of consistent quality dental and oral health care for Residents in Skilled Nursing Facilities with the mission of overall health and quality of life enhancement.

 

PrevMED Clinical Guidelines

PreMED provides a comprehensive training program to all clinicians associated with the company. Staff clinical personnel are thoroughly trained in the areas of the specific needs of the long-term care community, HIPAA, and Protected Health Information.

Training will be completed prior to a PrevMED dentist’s initial on-site visit to a facility for the delivery of care.

The goal of the PrevMED facility dentist is to provide preventive care, palliative care and emergency care. With this in mind the PrevMED facility dentist will triage the skilled nursing facility resident in an attempt to alleviate present and potential pain, suffering and infection without committing them to treatment plans that will cause them more duress.

PrevMED will therefore focus its scope of dental care to oral hygiene, extractions when deemed necessary, and fabrication and repair of removable prosthesis when such prosthesis have a measurable benefit to the patient’s health and self esteem.

 

Record Keeping

Dentists are required to maintain individual records, which fully disclose the type and extent of services provided to the PrevMED resident. These records shall be available and maintained in accordance with State and Federal Regulations.

The dentist shall also document services in facility records. Such information shall be readily available for review by the PrevMED Quality Coordinator.

The records shall include, but not limited to the following:

  1. The name, facility address and resident’s date of birth.
  2. Pertinent dental/medical history. (Where indicated, the Dentist will make contact with the attending physician to consult with him/or her with regards to physical conditions including pre-medications, medications and blood thinners)
  3. Detailed clinical examination data to include where applicable:• Resident’s chief complaint• Oral Risk Assessment• Periodontal examination• Diagnosis• Carious lesions

    • Missing teeth

    • Abnormalities

  4. The number and type of radiographs should be entered on the resident’s record.
  5. Treatment plan with description of treatment rendered to include:• Tooth number• Surface involved• Materials used• Date(s) of service(s)• Description of treatment or services rendered at each visit to include the dentist or hygienist rendering the care

    • All phoned conversations with facility health care providers regarding resident care

    • All phoned prescriptions and orders

    • Written prescriptions for hygienists

    • All medications

    • Copy of dental prosthetic work authorization(s) and prescription(s)

    • Reason for discontinuation of services if applicable

    • Referral and consultation reports

  6. According to Regulations, the Dentist of Record shall remain primarily responsible for all dental treatment on patient of record regardless of whether treatment is rendered by a Dentist other than the Dentist of Record or by a dental hygienist or assistant. The name or initials of such person shall be placed in the record of the patient with the exception of referrals to Dentists outside the facility. The purpose shall be to ensure that responsibility for PrevMED patients who are examined by our staff Dentists is assigned to one Dentist alone and to assign primary responsibility to a Dentist for treatment rendered by a dental hygienist under her or his supervision.
  7. A complete description of treatment, as noted above, shall be entered into the resident’s facility records. These entries must also satisfy that specific facility’s regulations and ensure that fellow health care providers involved in the care and treatment of the resident have access to the oral exam record, diagnosis, treatment plan and medical orders. The written chart shall be kept as well with the Dentist of Record. To conform to HIPPA guidelines, charts are to be maintained in a locked file. Patient records are confidential and may not be released unless authorized by the patient or (resident’s guarantor) in writing. This confidentiality prohibits review of records by a Dentist other than the Dentist of Record or by other health care providers unless they are actually involved in the care or treatment of the patient.
  8. PrevMED will also rely on a communication platform that provides multimodal access to critical information at the point of care. This base technology has been in use in the medical profession for over 40 years and has been awarded contract certification by the States and Federal Government for sensitive information for criminal and civil investigations. Staff Dentists will organize patient record information onto a proprietary template. Information will be transmitted to a HIPPA compliant data center encrypted to 256 bit keys. This will guarantee that PreMED staff is always in touch with their immediate tasks as well as the measurable goals they work towards in effectively delivering care to residents of long- term care facilities. It is the goal of PrevMED to establish a “chain of trust” with the elder care facility.

 

Comprehensive oral evaluation-new or established patient (D0150).

[2011-2012 ADA Current Dental Terminology]

 

Used by a general dentist/or a specialist when evaluating a patient comprehensively. This applies to new patients; established patients who have significant change in health conditions or other unusual circumstances, by report, or established patients who have absent from active treatment for three or more years. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately.

This includes an evaluation for oral cancer where indicated, the evaluation and recording of the patient’s dental and medical history and a general health assessment. It may include evaluation and recording of dental caries, missing teeth, restorations, existing prostheses, occlusal relationships, hard and soft tissue anomalies, etc.

PrevMED dentists providing services to a Skilled Nursing Facility resident (regardless of the place of service) shall maintain his or her records and also provide the nursing facility with an entry for the resident’s clinical record that includes the following.

  • The results of the Comprehensive Oral Examination (COE), which will establish an admission record of the resident’s dental status.
  • A time frame established on an individual basis, for the next periodic examination of the resident.
  • A record of the dental treatment provided at each treatment encounter.

 

Standards of Service

The dental treatment plan provided shall be in accordance with the ethical and professional standard of the dental profession and meet the same high standard of quality normally provided to the Skilled Nursing Facility resident at large.

Experimental procedures that are not approved by the State Board of Examiners are not accepted care for the resident.

The standard of service is based on sustainable oral health care and modified by the overall health of resident.

The goal of improved function and well being as a result of all dental services provided will be based on the prevention of oral disease.

Caries Assessment

The caries assessment tool was developed for use by dental and medical providers for SNF residents. The assessment tool is a part of an overall approach to prevent and treat the caries infection.

  • Caries disease indicators – low socioeconomic status, developmental problems, presence of cavities, white spots, and restorations placed in the previous 3 years
  • Caries risk factors – visible plaque; exposed roots; saliva reducing factors and inadequate saliva flow; diet.
  • Caries protective factors – systemic and topical fluoride sources; adequate saliva flow; and regular use of chlorhexidine, xylitol, and calcium and phosphate paste
  • Clinical examination – presence of white spots, decalcification, root and coronal decay, restorations and plaque

Based on risk factors for caries and physician referrals, dentists will perform a comprehensive oral examination. Disease indicators and risk factors such as current decay condition, current bacterial challenge, decay history, dietary habits, current prescription medications, saliva flow, medical conditions, and oral hygiene habits will be included in assessing the resident’s oral risk factors.

Residents at high risk may require medical intervention in the form of oral rinses, gels and sprays. High risk patients may also receive recommendations to put off elective dental procedures until risk levels can be decreased.

Residents at low risk may receive recommendations for oral home care preventive products to keep risk levels low. Given Skilled Nursing Facility treatment population, key risk factors present themselves:

  • Increased prevalence of decay
  • Severe attrition to dentition and posterior bite collapse
  • Fractured clinical crowns and failing restorative dentistry
  • Ill fitting removable prosthesis
  • Prevalence of Candida infections
  • Hyperplasic tissues and Oral cancer
  • Xerostomia

 

Patient’s Maintenance Therapy

Fluoride treatment

All adult patients need multiple sources of fluoride each day to remineralize teeth and prevent decay. The latest research findings have indicated that decay is a dynamic process caused by the continuous process of demineralization and remineralization of enamel. In addition to brushing and good home care, Fluoride is the most effective and safest method of caries prevention today –it provides an important source for remineralization of subsurface and early surface demineralized areas. Caries incidence increases with age, and root caries has been identified as particularly affecting adults over the age of 50. Fluoride therapies have an additive effect in reducing decay. Combining topical fluoride treatments with home fluoride use and the PrevMED line of oral infection control products can greatly impact the health of residents and result in decay reductions of up to 40% in adults according to numerous research studies.

PreMED believes that oral care for residents is a necessity; however we are also conscious that given residents’ life and medical conditions, treatment plans for ancillary care are to be categorized by priority to make access and delivery of care relevant to the population’s needs.

 

PrevMED Maintenance Tool Kit

  • Topical Fluoride-Enhances the natural remineralizationo Inhibits bacterial metabolismo Inhibits demineralizationo Enhances demineralization
  • Fluoride Sourceso Fluoride Dentifriceso Fluoride Rinses & Gelso Professional Fluoride Treatments -5% NaF varnish◦ Adheres to tooth to maximize contact◦ High concentration in small quantity of material

    ◦ Safe for young children & special needs patients

  • Antibacterial Agents0.12% Chlorhexidine gluconate- Most studied for carieso Effective on MS but not LB1% Iodineo Effective on children in the operating room (high contact time) but not soeffective on adults with a one minute exposure time
  • Hypochlorite-based producto Work quicker clinically on both MS, LB and low pH non MS bacterialBalances pH as well
  • XylitolXylitol is a natural sugar (usually from Birch trees) that can not be utilized by acid producing bacteria and has unique anti-caries properties. It inhibits bacterial attachment of MS to the tooth surface and has been shown to disrupt the vertical transmission of pathogens from caregiver to child. Studies have demonstrated an effective dose of 6-10 grams of Xylitol per day to be effective. Xylitol is low caloric and diabetic safe for humans but not safe for pets
  • Calcium Phosphate TechnologiesIncrease the amount of Ca & PO available to surfaces to increase concentration gradient and promotes remineralization
  • Amorphous calcium phosphate ( ACP) Uses milk protein casein phosphopeptide as a carrier by releasing Ca & PO during acid challenge
  • Calcium Sodium Phosphosilicate (CSP) Releases Ca & PO immediately upon interaction with saliva and directly forms HCA – hydroxycarbonate apatite
  • Tri Calcium Phosphate (TCP) Stable with fluoride so products are using it to combine F and Ca delivery
  • Sealant TechnologyResin-based (Mechanical retention)Glass Ionomer (chemical seal, internal remineralization, and surface F recharging)Glass Ionomer- Atraumatic Restorative Treatment

 

Periodontal Assessment Guidelines

Periodontal disease is a chronic inflammatory disease caused by the bacteria of dental plaque forming oral biofilm. It results in the progressive destruction of the tissues that support the teeth namely the gingivae and the periodontal ligament and underlying bone.

The prevalence of periodontal diseases increases with age, from 6 percent among persons 25-34 years to 41 percent among those 65 years and older.

Untreated periodontal disease has contributed to the emerging crisis related to acute respiratory admissions to hospitals from Skilled Nursing Facilities.

The review of oral health linkages with general health reveals implications for the clinical practice of both medicine and dentistry. The recognition of well-known and established signs and symptoms of oral diseases may assist in the early diagnosis and prompt treatment of some systemic diseases and disorders.

 

Antibiotic Prophylaxis Recommendations

New guidelines regarding antibiotics to prevent infective endocarditis

The American Heart Association recently updated its guidelines regarding which patients should take a precautionary antibiotic to prevent infective endocarditis (IE) before a trip to the dentist.

The guidelines, published in Circulation: Journal of the American Heart Association, are based on a growing body of scientific evidence that shows that, for most people, the risks of taking prophylaxis antibiotics for certain procedures outweigh the benefits. These guidelines represent a major change in philosophy.

The new guidelines show taking preventive antibiotics is not necessary for most people and, in fact, might create more harm than good. Unnecessary use of antibiotics could cause allergic reactions and dangerous antibiotic resistance.

Only the people at greatest risk of bad outcomes from infective endocarditis (IE) — an infection of the heart’s inner lining or the heart valves — should receive short-term preventive antibiotics before common, routine dental and medical procedures.

Patients at the greatest danger of bad outcomes from IE and for whom preventive antibiotics are worth the risks include those with:

  • Artificial heart valves
  • History of having had IE
  • Serious congenital (present from birth) heart conditions, including: unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter interventions, during the first six months after the procedure-any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device
  • Cardiac transplant which develops a problem in a heart valve.The current practice of giving patients antibiotics prior to a dental procedure is no longer recommended EXCEPT for patients with the highest risk of adverse outcome resulting from endocarditis.The American Heart Association has concluded that an exceedingly small number of cases, if any, of endocarditis may be prevented by giving antibiotics prior to a dental procedure. If such benefit from prophylaxis exists, it should be reserved ONLY for those patients at highest risk (listed above) who would have the worst outcomes if they contract endocarditis.The American Heart Association recognizes the importance of good oral and dental health including regular brushing and flossing and regular visits to the dentist for patients at risk of endocarditis.The American Heart Association no longer recommends administering antibiotics solely to prevent endocarditis in patients who undergo a GI or GU tract procedure.

 

PrevMED staff Dentists will follow the latest American Heart Association Guidelines

Prophylactic Regimens for Dental Treatment for High Members ONLY

I. Standard general prophylaxis for patients at risk:

Amoxicillin: Adults, 2.0 g given orally one hour before the visit.

II. Unable to take oral medications:

Ampicillin: Adults, 2.0 g given IM or IV within 30 minutes before procedure.

III. Amoxicillin/ampicillin/penicillin allergic patients:

Clindamycin: Adults, 600 mg given orally one hour before procedure. -ORCephalexin*

or Cefadroxil*: Adults, 2.0 g orally one hour before procedure. -ORAzithromycin

or Clarithromycin: Adults, 500 mg orally one hour before procedure.

IV. Amoxicillin/ampicillin/penicillin allergic patients unable to take oral medications:

Clindamycin: Adults, 600 mg IV within 30 minutes before procedure. -ORCefazolin*:

Adults, 1.0 g IM or IV within 30 minutes before procedure.

*Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction to penicillin.

 

Oral cancer screening

Seventy-five percent of all head and neck cancers begin in the oral cavity. According to the National Cancer Institute’s Surveillance, Epidemiology, and Ends Results (SEER) program, 30 percent of oral cancers originate in the tongue, 17 percent in the lip, and 14 percent in the floor of the mouth (11). Many other studies support this finding that oral cancers appear most often on the lower lip, tongue, and floor of the mouth.

A thorough, systematic examination of the head and neck need only take a few minutes and can detect these cancers at an early and curable stage. The PrevMED goal is to discover oral, head and neck cancers early, before patients present complaining of pain, a mass, bleeding, otalgia, or dysphasia. Errors in diagnosis are most often ones of omission, and therefore the importance of a systematic approach to the oral, head and neck cancer examination cannot be overstated.

It is critical to remember that any person with a history of tobacco and alcohol use or prior head and neck malignancy has a significant risk of developing oral, head and neck, cancer. In fact 75 percent of these cancers are related to alcohol and tobacco use.

Age is another important risk factor, for almost 90 percent of oral cancers occur in people 45 years and older.

 

Examination Guidelines adopted from the National Oral Cancer Awareness Foundation

Refer case to senior Dentist when questions arise. PrevMED will take the necessary steps to obtain a Maxillo-Facial Oral Surgery referral for exam, biopsy and definitive diagnoses and treatment. In some cases staff Dentist may use Oral CDX  prior to referral. Definitive diagnosis will based on incisal biopsy or they will be referred to an outside dentist for treatment.

 

General Examination- Oral Cancer

A thorough oral, head and neck cancer examination can easily be completed in less than 5 minutes. It primarily consists of inspection and palpation. Once good rapport has been established with the patient, the clinician is ready to begin the exam. It is important to explain to the patient exactly what you are doing before doing it. Not only will this help put the patient at ease, but it also gives you the opportunity to educate your patient about the signs and symptoms of oral, head and neck cancer and how to detect

it at an early stage.

It is important for clinicians to understand the complex systemic effects of malignancy on the body. Commonly changes noticed in a person’s face and body pertaining to weight loss, anorexia and/or fatigue, may be the first sign of a malignancy. The initial physical evaluation of a patient actually begins as soon as you meet the patient. While taking the patient’s history it is helpful to note any facial asymmetry, masses, skin lesions, facial paralysis, swelling or temporal wasting. Inspection of the lips, both moving and at rest, can also be performed while first meeting the patient. Again, look for any asymmetry or gross lesions on the lips. Listening in an important part of this examination. The sound of one’s voice and speech are important in consideration of the location of tumors as a “hot potato” voice may signal the presence of an oropharyngeal tumor whereas a raspy, hoarse voice could be the first sign of a laryngeal neoplasm. Throughout this oral, head and neck cancer examination, it is helpful to remember to look, listen, AND feel every site that is being examined.

 

The Face

Position the patient so that he or she is comfortably sitting and is at your eye level. Inspect the face for asymmetry, swelling, discoloration or ulceration. The entire face should be examined with an external light source (overhead light or headlight) to evaluate for pigmented (red, brown, black), raised, ulcerated, or firm areas of the skin, including the hair bearing regions of the face and scalp.

The facial bones, skeleton and soft tissue should be palpated particularly noting asymmetry or masses.

 

The Oral Cavity

For this portion of the exam patient positioning can vary. Dental patients tend to lie on their backs, while their Dentist exams their oral cavity. Physicians, on the other hand, usually have their patients sit up straight and face them eye-to-eye during the exam. It is imperative that the mouth be examined with an external light source, which allows both hands free for bimanual palpation or to hold gauze or tongue blade(s) for improved visualization. If a hands free light source is not available, an assistant may provide invaluable help in visualization of difficult areas such as the posterolateral border of the tongue and floor of mouth. Before beginning this part of the examination, ask the patient to remove all dental appliances. When examining mucosal surfaces, it is important to gently dry those surfaces with a gauze or air syringe, so that color or texture changes will become more obvious. Multiple studies have consistently shown that the earliest manifestation of many oral and oropharyngeal Squamous cell cancers is a persistent erythroplastic lesion. Clinicians must therefore be on the lookout for both red and white (leukoplakia) lesions on the oral mucosa.

 

Lips

The lips should not be overlooked as part of the oral cavity. They may be involved with Squamous cell carcinoma (SCC) of the aero-digestive tract or both SCC and basal cell carcinomas (BCC) of the skin. The lips should be evaluated with the mouth open and closed noting any abnormalities in symmetry, contour, color or texture. Pay special attention to the vermilion border of the lower lip, as this is a prime site for oral cancers. First open the lower lip and inspect the inner surface. The labial mucosa should be smooth and uniform in color. Notice the frenum of the lip in the midline. Note any signs of smokeless tobacco use (ulcers, red or white discolorations, texture variations) on the labial mucosa. With the lip still retracted, one can also inspect the gingivolabial sulcus, the gingival mucosa, and the teeth. Next palpate the lip with your thumb and index finger, noting any firm or nodular submucosal areas. Repeat these steps for the upper lip.

 

The Neck

Have the patient sit so that his face is at your eye level; support the head with a headrest. Bimanually palpate the neck, comparing both sides simultaneously for signs of enlargement. Palpate carefully for enlarged lymph nodes. Examine the jugular chain first. With two deeply placed fingers, palpate along the course of the sternomastoid muscles, underneath the mandible and down to the clavicle. Palpate the supraclavicular spaces on either side. Next, examine the parotid groups lying anterior and inferior to the ears, the submental, and finally the submaxillary chain. To palpate a mass in the submaxillary area, insert a gloved finger in the patient’s mouth and press structures against your other hand, positioned under his chin. Next, palpate along the course of the larynx for signs of immobility or enlargement.

 

Thyroid

First inspect the thyroid gland before proceeding to palpation. In normal patients the thyroid gland is often difficult to feel. Some clinicians prefer to palpate the thyroid while positioned behind their patients, but it is perfectly acceptable to examine the gland from the front as well. Attempt to palpate the entire gland, and note the characteristics of any nodules or masses. Having the patient swallow while your fingers are positioned adjacent to the gland, will elevate the thyroid gland and may facilitate your examination. Note and record tenderness. Check the consistency of any abnormality. Is it hard? Cystic?

Have the patient deviate his head toward the examining side to relax the muscles during palpation. After the lobe has been palpated, and with the fingers still, ask the patient to swallow. The gland will move upward during deglutition and any abnormality will become more apparent. On swallowing, the inferior pole of the lobes is elevated and can be outlined. Inability to palpate the inferior pole may suggest substernal extension of the thyroid gland on that side. Examine each lobe in this manner. If the patient has a very heavy neck, it may be helpful to stand behind him and palpate each lobe with his head deviated toward the examining side.

 

Nasopharynx:

Examination of the nasopharynx is one of the more difficult portions of the oral, head and neck cancer examination. Instruct the patient to open widely and breathe through his or her mouth. This should cause the soft palate to rise. With a tongue blade, carefully depress the mid-portion of the tongue. Then insert a warmed nasopharyngeal mirror over the tongue blade and into the oropharynx. Ask the patient to now breathe through his or her nose. This should cause the soft palate to fall forward, allowing the examiner to see the nasopharyngeal region reflecting in the mirror. First inspect the posterior choanae and posterior part of the nasal septum. The inferior and middle turbinates should also be visible, and note the superior/posterior surface of the soft palate. By slowly rotating the mirror, visualize both Eustachian tube openings, the pharyngeal tonsil, and walls of the nasopharynx.

Look for any masses, swellings, ulcerations, or discolorations. If your patient is unable to tolerate this procedure, then some topical anesthetic spray can be used. Please note that the nasopharynx can also be examined via a fiberoptic scope. (This will be discussed below).

 

Hypopharynx and Larynx

Like the nasopharyngeal examination, this part of the exam can be challenging. A thorough inspection of the hypopharynx and larynx is a critical component to the oral, head and neck cancer examination. All of the key laryngeal structures need to be closely inspected for any signs of malignancy. This examination can be accomplished with either a laryngeal mirror or a fiberoptic scope.

 

Mirror Exam

Traditionally the laryngeal mirror has been the instrument of choice for examining the hypopharynx and larynx. Ask the patient to sit up straight and slightly protrude the chin upward and forward. Next have the patient open widely and protrude the tongue.

Grasp the tip of the tongue with a gauze and gently pull it forward. The patient should be concentrating on breathing in and out through the mouth. Carefully insert a warmed laryngeal mirror into the oropharynx, using the back of the mirror to elevate the soft palate. If the patient cannot tolerate this maneuver without gagging, some anesthetic spray can be used as a last resort. Be aware that the topical anesthetic will suppress the patient’s gag reflex, increasing the risk of aspiration. Once the mirror is in place, examine the base of the tongue. By tilting the mirror, examine the pharyngeal walls, vallecula, and piriform sinuses noting any masses or other abnormalities. The epiglottis should be seen in the midline; closely inspect both surfaces for any lesions. The laryngeal structures are often brought into better view by having the patient say a high pitched “e-e-e-e-e”. Examine the arytenoids, aryepiglottic folds, false vocal cords, and true vocal cords for any hints of malignancy. It is important to assess the mobility of the true vocal cords by having the patient phonate. The superior portion of the trachea is often visible below the vocal cords. Once you are satisfied that all of the important structures have been visualized, slowly remove the mirror and release the patient’s tongue.

www.oralcancerfoundation.org/dental/screening.htm

 

Diagnoses

Determine and note in PrevMED patient chart diagnoses of conditions to be treated by  hygienists and Dentist or by a local Dentist to which the resident can be referred.

 

Outlined treatment to manage soft tissue

FLORIDA

A written prescription for prophylaxis by PrevMED dental hygienist valid for (STATE SPECIFIC) years to treat the periodontal condition serving as authorization by an PrevMED dentist for procedures to be performed under general supervision and without direct supervision by registered dental hygienists. As defined by the Florida Board of Dentistry Rule 64B5-16001 (6), levels of supervision for hygienists: “general supervision requires that a licensed Dentist examine the patient, diagnose a condition to be treated, and authorize the procedure to be performed. “ The Dentist “need not be present when such procedures are being performed; authorization to be valid for a maximum of 2 years” (Florida Statute 466.023); after which no further treatment can be performed without another clinical exam by an OHCS Dentist, [Board of Dentistry Rule 54B5-16.001 (7)].

Under general supervision dental hygienists are authorized to “[remove] calculus deposits, accretions and stain from exposed surfaces of teeth and from tooth surfaces within the gingival sulcus (prophylaxis),” and [instruct] patients in oral hygiene care and [supervise] patient oral care [Board Rule 64B5-16007 (3a, 3c)] and without supervision “[provide] educational programs, faculty or staff training programs, authorized fluoride rinse programs, and other services which do not involve diagnoses and treatment of dental conditions, [Board Rule 64B5-16007 (4)], “in licensed public and private health facilities. (Florida Statute 466.023).”

For the purposes of satisfying Board Rule 64B5-9.010, a Dentist’s prescription for his patient

of record for dental hygiene services shall contain the following information:

Patient’s name and address or facility name; Dentist’s name, business address and professional license number; The name, business address and professional license number of the dental hygienist who is being authorized to perform the service and A statement of the specific services authorized and the frequency of the services authorized (a two year maximum term and with appropriate recall times stipulated)

The prescription must be printed, hand written or typed on the Dentist’s prescription pad or on his professional letterhead stationery. The original prescription shall be given to the patient, and a copy shall be maintained in the patient’s file in the office of the prescribing Dentist Ancillary needs: Removable prosthodontic suggestions will include maxillary and mandibular complete and partial dentures, laboratory hard and soft relines of existing dentures, and permanent hard and soft chairside relines of existing prosthesis, Simple extractions and Referral to an outside Dentist for restorative needs. Any procedures that the Dentist believes should not be done PrevMED will be referred to an outside Dentist.

 

Ancillary services will be categorized as follows:

Urgent

Patients who have dental problems that require immediate attention

  • Treatment or follow-up indicated for dental caries, symptomatic tooth fracture.
  • Defective restorations that cannot be maintained by the patient.
  • Interim restorations or prostheses that cannot be maintained for a 12-month period.
  • Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months:Acute gingivitis or pericoronitis, active progressive moderate or advanced periodontitis, periodontal abscess, progressive mucogingival condition, periodontal manifestations of systemic disease or hormonal disturbances, heavy supra and sub gingival calculus.
  • Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication, or acceptable esthetics.
  • Chronic oral infections or other pathologic lesions including:Lesions requiring biopsy or awaiting biopsy reports, emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections or provide timely follow-up care (e.g. drain or suture removal) until resolved.

 

On a Needs Basis

Treatment will be rendered as needed, given residents’ health condition. Patients with a current dental examination, who require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months or Patients with a current dental examination, who do not require dental, treatment or reevaluation for needs that will not pose the resident harm if untreated (i.e. to include but not limited to failing restorations that have discolored or have defective margins, teeth with permanent restorations that ideally require cusped coverage) will not be considered in need of urgent treatment.

 

Emergency Visits

PrevMED strongly believes that emergency needs within a facility will decrease once we have established working relationships with long term care residences and improved their access to the scope of dental services. It is, however, the responsibility of every Dentist practicing in Florida to provide reasonable twenty-four hour emergency services for all patients under our continuing care. (Florida Board Rule 64B5-17004) If the Dentist of record is not available to examine, diagnose and treat a resident, coverage will be provided by another PrevMED staff Dentist, the Regional Director of Dental Services, or the Chief Dental

Officer so that residents’ needs are always met.

 

Phoned Prescriptions

Should a resident require pre-medication prior to an oral exam or hygiene visit, or an order to suspend medication prior to extractions, (cleared by the resident’s physician), a PrevMED dentist will call facility and contact Director of Nursing or Director of Wellness and place prescription or order and make an appropriate entry into the PrevMED patient record.

 

Blood Thinners

Blood thinner is the common name used for medications that prevent the formation of blood clots.  Blood-thinners do not really thin the blood. They prevent it from clotting.  They are given to people with an increased tendency for thrombosis (blood clot formation) inside blood vessels or to prevent the formation of further clots in those who have had them before.  Blood clots that break free can travel through the bloodstream and then lodge in a vessel blocking blood flow. When a blockage occurs in a vessel to the brain, a stroke occurs. Blockage to the heart causes a heart attack. Blood thinners help prevent the serious risk of heart attack and stroke that clotting poses.

 

Aspirin

Since the 1980s, aspirin has been used as a preventive treatment for heart attacks and strokes. Aspirin has an anti-clotting effect and is used in long-term, low doses to prevent heart attacks, strokes and blood clot formation in people at high risk for developing blood clots. It has also been established that low doses of aspirin may be given immediately after a heart attack to reduce the risk of another heart attack or of the death of cardiac tissue.

 

Coumarines (Vitamin K antagonists)

Coumarines are a class of anticlotting pharmaceuticals prescribed for more than one million Americans each year.  Coumarines act by blocking the action of the Vitamin K necessary for the production of prothrombin, which is needed for blood clotting. It takes at least 48 to 72 hours for the anticlotting effect to develop fully.  The most common coumarine medication used is warfarin (also known under the brand names Coumadin, Jantoven, Marevan, and Waran).  Generally, warfarin and other coumarin drugs are used to treat patients with atrial fibrillation [the heart’s two upper chambers fibrillate or beat out of normal rhythm], deep venous thrombosis [clotting in the deep leg veins] and pulmonary embolism [blood clots moving into the lungs]. Warfarin is also routinely given to patients who have artificial heart valves.

Warfarin can cause serious bleeding. To avoid this, people who take this medication must have routine blood testing to monitor their INR, or International Normalized Ratio. This is an international measure of clotting, which attributes a value of 1.0 to people with a normal ability to clot. As the INR increases, it reflects that a person is less likely to form blood clots. Patients with atrial fibrillation must maintain an INR of 2-3 in order to effectively decrease their risk of stroke.

 

Heparin

Heparin acts by inactivating thrombin and several other clotting factors required for a clot to form.  Heparin is used in the hospital intravenously in order to prevent blood clot formation, and to enhance the body’s ability to break down existing blood clots.  Heparin works immediately at the site used to prevent clotting.

 

Dental Treatment for Patients on Blood Thinners

Blood thinners do not affect most dental procedures.  However, blood thinners can have an effect on blood clotting during dental surgery. Depending on the medication, the dosage and the extent of dental surgery, bleeding can be a concern. The low level of aspirin use for blood thinning is rarely a concern.  However, stopping aspirin use the day before dental surgery is usually recommended.

Warfarin use presents the most common potential bleeding problems that dentists encounter. Stopping coumarin medication prior to dental treatment is controversial.  Since it takes 48 to 72 hours for warfarin to be effective, it must be stopped 2-3 days before treatment, which puts the patient at risk for serious blood clotting complications.   So the risk-benefit has to be determined, that is, uncontrolled bleeding verses blood clot formation in the vessels.

Warfarin should not be stopped for most dental procedures including most extractions and implant placements.  But with any dental surgery, a consultation with the patient’s physician and a recent INR blood test should be reviewed.  Usually an INR up to 2.5 is acceptable and safe for dental surgery, thus coumarin does not need to be stopped or lowered.  With a common sense approach, I ask my patients if they clot, that is, the bleeding stops, in a reasonable amount of time with direct pressure on a skin cut.  During dental surgery, treatment can be done to enhance clotting, such as, the use of clotting agents, stitches, bone grafts and membranes.  Bone grafts and membranes preserve bone in an extraction site as well as reduce bleeding.

While a risk-benefit assessment, bleeding verses clotting, must be made for each patient, dentist can perform most dental treatments safely for patients taking warfarin without the need for stopping warfarin therapy.

ADA Statement: Some medications may influence dental treatments.  For example, blood thinners taken to prevent blood clots can cause prolonged bleeding after some procedures.  However, before asking a patient to discontinue use of these medications, consult with the prescribing physician.

The PrevMED dentist should always confirm execution of orders to suspend medication prior to treatment with the prescribing physician.

 

PolyPharmacy

Multiple medications are common because chronic diseases are so prevalent among older adults who take both prescribed and over the counter medications.  It is not unusual for at least one of these medications to have a side effect that is detrimental to their oral health.  Antihistamines, diuretics, antipsychotics, and antidepressants can reduce salivary flow.  Having a dry mouth can cause difficulty chewing, speaking, and swallowing. It also increases the risk of developing cavities and soft tissue problems. Dry mouth may also decrease the ability to wear dentures.

Residents in skilled Nursing Facilities are prescribed an average of eight drugs.

There are currently more than 42 drug categories comprising 400 drugs that have xerostomia or dry mouth as side effects. Drugs that can cause oral side effects include antidepressants, antibiotics,  antispasmodics, analgesics,  anticonvulsants, antihistamines, antihypertensives, benzdiazepines, diuretics and sedatives. The growing numbers of effective pharmacilogical agents and the complexity of chronic disease management can only reinforce the need for effective multidisciplinary approach to health care for the aging population.

Judicious application of drug therapies by medical and dental providers as well as heightened awareness of poetential adverse oral effects is necessary to providing quality care for the elderly. Collaboration by all health care professionals offers the best opportunity for meeting the health care objectives of safe and quality care for residents in skilled nursing facilities.

Frequently Prescribed Medications Associated with Xerostomia

 

ANTICHOLINERGIC / ANTISPASMODIC

  • Anaspaz ……………………………………………. hyoscyamine
  • Atropisol. Sal-Tropine ………………………….. atropine
  • Banthine …………………………………………… methantheline
  • Bellergal …………………………………………… belladonna alkaloids
  • Bentyl ……………………………………………… dicyclomine
  • Daricon …………………………………………….. oxyphencyclimine
  • Ditropan …………………………………………… oxybutynin
  • Donnatal, Kinesed ……………………………hyoscyamine with atropine, phenobarbital, scopolamine
  • Librax ………………………………….. chlordiazepoxide with clidinium
  • Pamine ……………………………………………. methscopolamine
  • Pro-Banthine ……………………………………… propantheline
  • Transderm-Scop ………………………………….scopolamine

 

ANTIDIARRHETIC

  • Imodium AD ………………………………………. loperamide
  • Lomotil …………………………………….diphenoxylate with atropine
  • Motofen …………………………………… difenoxin with atropine

 

ANTIHISTAMINE

  • Actifed ………………………… triprolidine with pseudoephedrine
  • Benadryl ……………………………………………. diphenhydramine
  • Chlor-Trimeton ………………………………….. chlorpheniramine
  • Claritin ……………………………………………… loratadine
  • Dimetane ………………………………………….. brompheniramine
  • Dimetapp ………….brompheniramine with phenylpropanolamine
  • Hismanal ………………………………………….. astemizole
  • Phenergan ………………………………………… promethazine
  • Seldane …………………………………………….. terfenadine

 

ANTIINFLAMMATORY ANALGESIC

  • Dolobid ……………………………………………. diflunisal
  • Feldene ……………………………………………. piroxicam
  • Motrin, Advil …………………………………… ibuprofen
  • Nalfon …………………………………………….. fenoprofen
  • Naprosyn …………………………………………. naproxen

 

ANTI-PSYCHOTIC

  • Clozaril ……………………………………………. clozapine
  • Compazine ……………………………………….. prochlorperazine
  • Eskalith …………………………………………… lithium
  • Haldol ……………………………………………… haloperidol
  • Mellaril ……………………………………………. thioridazine
  • Navane ……………………………………………. thiothixene
  • Orap ……………………………………………….. pimozide
  • Sparine ……………………………………………. promazine
  • Stelazine ………………………………………….. trifluoperazine
  • Thorazine ……………………………………….. chlorpromazine

 

DIURETIC

  • Diuril ……………………………………………… chlorothiazide
  • Dyazide, Maxzide ……………. triamterine and hydrochlorothiazide
  • HydroDIURIL, Esidrix ……………………… hydrochlorothiazide
  • Hygroton ……………………………………….. chlorthalidone
  • Lasix ……………………………………………… furosemide
  • Midamor ………………………………………… amiloride

 

NARCOTIC ANALGESIC

  • Demerol ………………………………………… meperidine
  • MS Contin …………………………………….. morphine

 

ANTIANXIETY

  • Atarax, Vistaril ………………………………. hydroxyzine
  • Ativan …………………………………………….. lorazepam
  • Centrax ……………………………………………. prazepam
  • Equanil, Miltown ………………………….. meprobamate
  • Librium ………………………………….. chlordiazepoxide
  • Paxipam …………………………………………. halazepam
  • Serax ………………………………………………. oxazepam
  • Valium …………………………………………….. diazepam
  • Xanax …………………………………………….. alprazolam

 

ANTICONVULSANT

  • Felbatol ………………………………………….. felbamate
  • Lamictal ………………………………………… lamotrigine
  • Neurontin ………………………………………. gabapentin
  • Tegretol ………………………………………… carbamazepine

 

ANTIDEPRESSANT

  • Anafranil ………………………………………. clomipramine
  • Asendin ………………………………………… amoxapine
  • Elavil …………………………………………… amitryptaline
  • Luvox ………………………………………….. fluvoxamine
  • Norpramin ……………………………………. desipramine
  • Prozac …………………………………………. fluoxetine
  • Sinequan ………………………………………. doxepin
  • Tofranil ………………………………………. imipramine
  • Wellbutrin ……………………………………. bupropion

 

ANTIHYPERTENSIVE

  • Capoten ………………………………………. captopril
  • Catapres ………………………………………. clonidine
  • Coreg ………………………………………….. carvedilol
  • Ismelin ………………………………………… guanethidine
  • Minipress …………………………………….. prazosin
  • Serpasil ……………………………………….. reserpine
  • Wytensin …………………………………….. guanabenz

 

ANTINAUSEANT/ANTIEMETIC

  • Antivert ……………………………………… meclizine
  • Dramamine …………………………………. dyphenhydramine
  • Marezine …………………………………….. cyclizine

 

ANTIPARKINSONIAN

  • Akineton …………………………………….. biperiden
  • Artane ………………………………………… trihexyphenidyl
  • Cogentin ……………………………. benztropine mesylate
  • Larodopa …………………………………….. levodopa
  • Sinemet ……………………………… carbidopa with levodopa

 

BRONCHDILATOR

  • Atrovent ……………………………………… ipratropium
  • Isuprel …………………………………………. isoproterenol
  • Proventil, Ventolin ……………………….. albuterol

 

DECONGESTANT

  • Ornade …….. phenylpropanolamine with chlorpheniramine
  • Sudafed ………………………………………… pseudoephedrine

 

MUSCLE RELAXANT

  • Flexeril ………………………………………… cyclobenzaprine
  • Lioresal ……………………………………….. baclofen
  • Norflex, Disipal …………………………….. orphenadrine

 

SEDATIVE

  • Dalmane ………………………………………. flurazepam
  • Halcion ………………………………………… triazolam
  • Restoril ………………………………………… temazepam

 

Extraction Protocols

Prior to Extractions

  • PrevMED dentist will confirm execution of prescriptions for antibiotic prophylaxis, orders for suspension of medications, medical alerts, and allergies with facility Charge Nurse, Director of Nursing or prescribing physician.
  • OHCS Dentists will have resident or responsible party review and sign the PrevMED consent to treatment form to be kept in PrevMED patient records.

 

Post procedure

  • Review post operative instructions form with both resident and, regardless of resident’s apparent cognitive skills, with Charge Nurse to ensure optimal healing and post operative care.
  • A copy of the PrevMED Post-Operative Instructions will be left on file in the resident’s medical record.
  • Schedule a post operative reevaluation with Director of Nursing or Wellness Nurse if case-relevant.
  • A follow up phone call will be made to the facility’s Director of Nursing or Wellness Nurse the day following extractions and 4 days following extractions to the DON.
  • Record phoned conversations in OHCS patient record.

 

Chart documentation

Document consent, extractions performed, without complications, amount and type of anesthetic, type of injection, any adverse occurrences and follow up care, (i.e. hemangioma following administration of LA), post op instructions review, sutures if needed and type and possible date for post op reevaluation.

Please note: Given the possibility that a resident may be moved from a facility, sutures should be limited to absorbable sutures.

 

Biohazards

Extracted teeth and tissue fragments not required for microscopic examination shall be discarded as biohazard waste or as a sharp in accordance with Board of Dentistry. All sharps shall be discarded in facility or PrevMED sharps containers.

 

Armamentarium

In addition to the instruments a PrevMED dentist deems necessary to perform extractions, such dentist will have access to and use eye protection glasses for him/herself, for assistant, and for patient.

Updating PrevMED Coordinator

 

Following initial or emergency exams, delivery of ancillary care or attempted visits to resident’s dentists shall always update Coordinators soon as possible. Coordinator will assist in keeping log of phone calls to be made by PrevMED staff (Dentists, hygienists) to facilities for follow up care, confirm visits, and act as liaison between PrevMED support, and management staff at headquarters and PrevMED dentist / assistant / hygienist teams.

Adverse Occurrences Notification / Procedures

Regardless of the circumstances or incident, if an exam or treatment is interrupted because a resident becomes uncooperative or because of adverse medical complications induced or not by our procedures, contact Charge Nurse. There are protocols in place at all facilities to handle uncooperative residents or medical emergencies. Make a record of occurrence in the PrevMED patient record, resident’s facility medical record, and depending on the gravity of the circumstances, fill out a facility unusual occurrence / accident/ incident report and contact PrevMED Director of Resident Services.

Scheduling and Treatment Duration

PrevMED is committed to ensuring that the dental team delivers informed thorough and caring models of service– please keep in mind residents’ time constraints when scheduling appointments for removable prosthetic clinical steps. Consult the PrevMED Coordinator to avoid conflicts. It is important that residents are not late for meals, do not miss social activities planned by the facility, and that the residents’ health status is considered for the duration of appointments as well as the need to maintain the residents’ privacy when carrying out procedures.

Removable Prosthodontic Protocols

 

PrevMED will employ the below procedures to obtain necessary impressions and interocclusal records. To reduce treatment duration and case turnaround time without compromising quality of prosthesis or quality of care, proceed with modality for treatment in following order:

  • Take appropriate alginate impressions for casts to fabricate separate custom trays and occlusal rims with thermoplastic or other acceptable trays and wax rims
  • Proceed with border molding, final impression, and occlusal rim try in.
  • Occlusal rims should at all time’s approximate contours of arches and act as an accurate guide for location of acrylic teeth in arches and interocclusal relationships
  • Mark midline, smile line, and distal of canine lines on wax
  • Select shade and mould of acrylic teeth and when pertinent, shade of patient’s gingival

NB: Occlusal rims should not be combined with custom trays for final impressions because there is higher likelihood for error when pouring cases, articulating and transferring records to casts.

Lab steps

 

When lab tech is onsite with the dentist, lab tech will pour models, fabricate custom trays and occlusal rims thereby freeing up the dentist time and providing break for resident present onsite.

Should resident’s health not permit—break and provide lab tech onsite or send to lab impressions, occlusal rims etc. with appropriate and clear instructions on lab work order form for subsequent step.

Wax up try in appointments

 

Will be scheduled regardless of resident’s cognitive abilities to ensure correct articulation, set up, acrylic teeth shade, and to make adjustments when necessary and thus maintain our overall quality of care. Residents’ input when possible is paramount, charged nurse, or care giver may be consulted as well.

Shipment of Impressions to Dental Laboratories

 

Impressions, appliances and contaminated dental models sent to dental laboratories must be sealed in an impervious container and labeled “treat as infectious material” prior to shipment from PrevMED (64B5-25.008).

Records of Work Order Forms

 

All cases whether handled by PrevMED labs or shipped to outside labs shall be entered into the dentist’s respective laboratory prescription pad noting resident name, facility, date, case, and expected return date and instructions so that we may monitor lab orders and cases in progress. Empty Laboratory pans with the doctor’s copy from the duplicate lab work order will remain at the PrevMED lab office until the case is completed for all cases in progress (outside labs or PrevMED lab). Duplicates for the lab work orders, will

be placed into patients’ records as well. This will allow PrevMED to keep correct records of all information both in lab / office logs and patients’ records and will make it possible to track lab turnaround times and expected delivery dates.

Florida

To comply with Board Rule 64B5-17006 work order forms will include:

Title: “Laboratory Procedure Authorization”, Name address and license number of the registered dental laboratory

Name, PrevMED address and license number of the FL licensed Dentist who owns the work order form and is authorizing the procedure

Name of the patient, Date sent to lab, Signature of the licensed Dentist, Work orders will be sequentially numbered duplicate forms, Work orders are non-transferable, Copies of work order forms will be maintained by PrevMED for a period of two years.

Identification of Removable Prosthetic Devices

 

In compliance with 64B5-17005 and recognizing that the inadvertent misplacing or switching of removable prosthodontic devices for elderly in long term care facilities complicates ongoing dental care and enhances the transmission of communicable diseases, dentists will offer the patient for whom the removable prosthesis is intended the opportunity to have the prosthesis marked with the patient’s name at the time of fabrication, marking to be permanent, legible and cosmetically acceptable.

If the dentist determines that identification is not practicable or clinically safe, the offer to mark the prosthesis need not be made.

Insertion

 

When delivering cases a PrevMED Dentist shall make all necessary occlusal adjustments, review care instructions with resident and, if applicable with Charge Nurse or caregiver, as well as. Educate resident about their new prosthesis and manage their expectations.

Follow -up Appointments

 

On the day of insertion residents will be scheduled for their follow up appointments for adjustments in the follow sequence; (a) one day after insertion, (b) three days after delivery and (c) one week following delivery to provide support to residents with their new prosthesis.

Soft relines of immediate prosthesis following extractions throughout healing period and permanent soft or hard relines following full healing period.

Disinfection and Sterilization Procedures

 

[In an effort to ensure correct operating protocols and to comply with 64B5-25.002]

  • Prior to autoclave sterilization, all instruments will be cleaned to remove debris by scrubbing them with a detergent and water and by soaking them in the appropriate solution in an ultrasonic cleaner.
  • All instruments not intended to penetrate oral soft tissue or bone, but that may come into contact with oral tissues, will be sterilized after each use.
  • All surgical instruments penetrating soft tissues or bone will also be sterilized.
  • Oral prosthetic appliances received from a dental laboratory must be washed with soap or a detergent and water, rinsed well, appropriately disinfected with Cavicide and rinsed well again before the prosthetic appliance is placed in the patient’s mouth.
  • At the completion of dental treatment, all surfaces that may have become contaminated with blood, saliva or other bodily fluids must be disinfected using a procedure recommended by the CDC.
  • Surgical or examination gloves and surgical masks shall be worn by all PrevMED dentists, dental hygienists, and dental assistants while performing or assisting in the performance of any intra-oral dental procedures on a patient in which contact with blood and/or saliva is imminent. Surgical or examination gloves must be changed between patients.
  • Hands shall be washed with soap and water and dried immediately after removing and prior to replacing gloves. Gloves are never to be washed and reused.
  • Surgical or examination gloves that are punctured or torn must be removed and replaced immediately with new gloves following rewashing of provider’s hands with soap and water. It is recommended that eye protection be worn by all staff Dentists, dental hygienists, dental assistants and patients while performing procedures on a patient in accordance with CDC recommendations.

Delegable Duties — Hygienists

 

Remediable tasks according to 64B5-16001 (1) are those intra-oral tasks which do not create unalterable changes in the oral cavity or contiguous structures, are reversible and do not expose a patient to increased risks.

According to Board Rule 64B5-16.006 (4) the following remediable tasks may be performed by a dental hygienist who has received training in these procedures in pre-licensure education or on-the-job training and who performs the tasks under general supervision:

  • Applying topical anesthetics and anti –inflammatory agents which are not applied by aerosol or jet spray
  • Taking or recording patient’s blood pressure, pulse rate, respiration rate, case history and oral temperature
  • Placing or removing temporary restorations with non-mechanical hand-instruments only.
  • Hygienists will not be assigned task of removing sutures (should non-resorbable sutures be used), performing temporary soft tissue relines to immediate prosthesis or making adjustments to residents’ prosthesis. Hygienists shall not be assigned the task of delivering and inserting prosthesis.

Emergency Remediable Task for Hygienist

 

According to Board Rule 64B5-16.008 (3), in an emergency in which the Dentist of record is unable to be physically present to pre-examine the patient, and the patient will be seen by a OHCS staff Dentist within three days, the following remediable task may be performed by a dental hygienist who holds a current CPR certification from the American Red Cross, the American Heart Association or an equivalent CPR training agency and who is formally trained pursuant to rule 64b5-16002, the dental hygienist may take the following actions:

  • Inserting or removing dressings from alveolar sockets in post-operative osteitis when the patient is uncomfortable due to the loss of dressing from the alveolar socket in diagnosed cases of post-operative osteitis.
  • Cementing temporary crowns or bridges using temporary cement when the patient is uncomfortable due to the loss of a temporary crown or bridge
  • Placing temporary medicinal restorative when the patient is uncomfortable due to the loss of a temporary medicinal restoration.

Tasks Delegable to Dental Assistants

 

Because we are dealing with an at-risk population and frail elderly who may need supervision or lack cognitive skills, no tasks should be delegable to assistants involving direct intra-oral interactions specifically but not limited to:

  • Performing preliminary charting of missing teeth or existing restorations
  • Taking preliminary alginate impressions intra-orally for the purposes of fabricating study models

It is always the sole responsibility of the dentist to ensure correct history taking and recording prior to, during and after an exam, and to ensure that all relevant information is relayed to appropriate health care providers either in person or by phone

  • Responsibility for appointment scheduling, reminders to call facilities for follow up calls, and conflict resolutions should be handled by the PrevMED Coordinator

Review of Patient Charts Following Hygiene Visit

 

Hygienists will document in PrevMED patient chart and facility medical record their hygiene visits and note any new developments in patient’s oral condition to be brought to Dentist of record’s attention. Hygienists will note decay that may not have been visible to dentist of record because of the presence of supragingival plaque and therefore not taken into account in the treatment plan.

Flagged charts will be reviewed by dentist of record within twenty four hours of the hygienist’s visit. PrevMED shall advise the resident of any proposed treatment change.

PrevMED Oral Hygiene Program

 

The oral health of Skilled Nursing Facility residents is an integral part of their overall health. Good oral health facilitates effective chewing, contributes positively to speech, social confidence and is associated with cognitive and functional capacity in older persons.

The objective of the Hygiene Program is to provide greater attention to daily oral hygiene needs of the Skilled Nursing Facility resident in order to aid their overall health.

Brushing

  • A tooth brush is used and replaced minimally every three months
  • Brushing is done in gentle circular motion
  • A scrapper is used to remove bacteria and debris from the tongue
  • An automatic tooth brush is the option of choice and is given to all patients when indicated for proper oral hygiene maintenance

Oral Hygiene Maintenance for Denture Patients

  • Before dentures are placed in the mouth, it is important that the gums and roof of the mouth are gently brush with a soft bristle tooth brush
  • The dentures are cleaned daily
  • The PrevMED dental staff will evaluate the denture fit and need for adjustments on the initial visit as part of the comprehensive oral evaluation and examination

Denture Care Monthly

  • The steps needed for effective denture cleaning involves mechanical removal of debris followed by chemical cleansing of the appliances
  • Rinse dentures to remove loose debris
  • Scrub both inner and outer aspects of the denture using a denture brush with denture cream or denture toothpaste
  • Rinse the dentures thoroughly
  • Partial dentures should be maintained in similar manner
  • Dentures should not be worn when sleeping
  • Dentures are very delicate and will break if dropped

Denture Safety Tips

  • Dentures should be cleaned over a sink that has been filled with several inches of water to avoid damage if dropped.
  • Or hold the dentures over a towel that has been folded to avoid damage if dropped.

Denture Loss

  • Examine food trays, tissues or paper napkins before removal.
  • Shake out bed sheets and pillow cases prior to sending to laundry.

Staff Oral Hygiene Protocol

  • Wash hands and put gloves on prior to assisting in oral hygiene
  • Provide privacy by pulling the curtain
  • Introduce yourself to the resident and explain what you are going to do
  • Verify the identity of the resident
  • Maintain the safety of the resident at all times
  • Chose the most convenient time for the resident to assist in their care
  • Report any unusual findings to a facility nurse

Voice of PrevMED –Caring Hygienists

 

PrevMED staff has made caring bedside manner very much a part of the Company’s culture. The close relationship between the PrevMED dentist and hygienist and the residents makes possible to significantly improve oral hygiene and helps establish a model for continuity of care. PrevMED will utilize hygienists onsite who are innovative lifetime counselors dedicated to making daily oral hygiene a priority. Our message will have impact because it is uplifting and views the patient foremost as an

individual.

PrevMED CAMBRA Program

CAries Management By Risk Assessment

“A caries management program for Skilled Nursing Home Residents”

Introduction

Nearly thirty three percent of senior adults have untreated caries. The treatment, management and prevention of oral disease will result in the reduction of oral related pain and weight loss for residents living in Skilled Nursing Facilities. Not only will conditions improve in their mouth but also their overall health and well being.

The acronym CAMBRA stands for “CAries Management By Risk Assessment”. CAMBRA is a method of assessing caries risk and determining treatment based on the Skilled Nursing Facility resident’s PrevMED risk assessment. The dental caries experience and the management of dental caries incidence are the focus of PrevMED’s Caries Management by Risk Assessment (CAMBRA).

Caries management by risk assessment (CAMBRA) represents a paradigm shift in the management of dental decay for the geriatric patient. It treats dental caries as an infectious disease that is curable and preventable. The science supporting CAMBRA has been present for quite some time; however, its clinical adoption in particular for the elderly, until recently, remains slows.

 

CAMBRA Assessment Tool

The caries assessment tool was developed for use by dental and medical providers for SNF residents. The assessment tool is a part of an overall approach to prevent and treat the caries infection.

  • Caries disease indicators – low socioeconomic status, developmental problems, presence of cavities, white spots, and restorations placed in the previous 3 years
  • Caries risk factors – type and quantity of Mutans streptococci (MS) and lactobacilli (LB); visible plaque; exposed roots; saliva reducing factors and inadequate saliva flow; diet.
  • Caries protective factors – systemic and topical fluoride sources; adequate saliva flow; and regular use of chlorhexidine, xylitol, and calcium and phosphate paste
  • Clinical examination – presence of white spots, decalcification, root and coronal decay, restorations, plaque, bacterial culture and saliva flow tests

Based on risk factors for caries and physician referrals, dentists will perform a comprehensive oral examination, radiographic examination and test for oral bacteria levels.  Disease indicators and risk factors such as current decay condition, current bacterial challenge, decay history, dietary habits, current prescription medications, saliva flow, medical conditions, and oral hygiene habits will be included in assessing the resident’s oral risk factors.

Residents at high risk may require medical intervention in the form of oral rinses, gels and sprays.  High risk patients may also receive recommendations to put off elective dental procedures until risk levels can be decreased.

Residents at low risk may receive recommendations for oral home care preventive products to keep risk levels low.

 

Clinical Guidelines

  1. Caregiver or patient answers the questions on the risk assessment form
  2. Determine the overall caries risk as low, moderate, high, or extreme risko Low risk – no dental lesions, no visible plaque, optimal fluorideo Moderate risk – dental lesion in previous 12 months, visible plaque, suboptimal fluoride, irregular dental careo High risk – one or more cavitated lesions, visible plaque, suboptimal fluoride, no dental care, high bacterial challenge, impaired saliva, medications, frequent snackingo Extreme risk – high risk patient with special needs or severe hypo-salivation
  3. Perform bacteria and saliva testing as indicated by risk level
  4. Determine the plan for caries intervention and preventiono Skilled Nursing Facility Residents – consider the following based on patient risk level: frequency of radiographs; frequency of caries recall examinations; oral hygiene instructions; saliva and bacterial testing; antibacterial rinses such as chlorhexidine and xylitol; fluoride use and professional application of fluoride varnish; pH control; calcium and phosphate application.
  5. Discuss home care recommendations based on risk level with the Certified Nurse Assistant and Nurse
  6. Provide follow-up care and reassess risk level

 

Team Approach

CAMBRA protocols are more likely to result in successful patient outcomes when the entire health professional team including the dentist, primary care physician, certified nursing assistant, nurse and hygienist are involved. Each team member is therefore required to have foundational knowledge and communication skills which take the evidence-basis for CAMBRA.

SNF Oral Risk Assessment / COE Form
Patient Name: Date:
Disease Indicators LOW HIGH
Visible Caries
Periodontal Disease
Radiographic Lesions
Risk Factors
Visible Plaque
Visible Soft Tissue Lesions
Hypo Salivary Drugs
Sugar Intake (diet)
Missing Teeth
Oral Hygiene
Treatment Notes:
Facility:
Dentist: Hygienist:

 

References

  1. Featherstone, J.D.B., Domejean-Orliaguet, S., Jenson, L., Wolff, M., & Young, D.A. (2007). Caries risk assessment in practice for age 6 through adult. Journal of the California Dental Association,35(10), 703-713.
  2. Featherstone, J.D., Adair, S.M., Anderson, M.H., Berkowitz, R.J., Bird, W.F., Crall, J.J., Den Besten, P.K., Donly, K.J., Glassman, P., Milgrom, P., Roth, J.R., Snow, R., & Stewart, R.E. (2003). Caries management by risk assessment: consensus statement, April 2002. Journal of the California Dental Association, 31(3), 257-269.
  3. Ramos-Gomez, F.J., Crall, J., Gansky, S.A., Slayton, R.L., & Featherstone, J.D. (2007). Caries risk assessment appropriate for the age 1 visit (infants and toddlers). Journal of the California Dental Association, 35(10), 687-702.
  4. Jenson, L., Budenz, A.W., Featherstone, J.D.B., Ramos-Gomez, F.J., Spolsky, V.W., & Young, D.A. (2007). Clinical protocol for caries management by risk assessment. Journal of the California Dental Association, 35(11), 714-723.
  5. Gutkowski, S., Gerger, D., Creasey, J., Nelson, A., & Young, D.A. (2007). The role of dental hygienists, assistants, and office staff in CAMBRA. Journal of the California Dental Association,35(11), 786-789, 792-793.
  6. Featherstone, J.D. (2006). Caries prevention and reversal based on the caries balance. Pediatric Dentistry, 28(2), 128-132.
  7. Featherstone, J.D.B. (2006). Delivery challenges for fluoride, chlorhexidine, and xylitol. BMC Oral Health, 6(Supp 1), S8.
  8. American Academy of Pediatrics Policy Statement. (2003, May). Oral health risk assessment timing and establishment of the dental home. Pediatrics, 111(5), 1113-1116.
  9. Young, D.A., Buchanan, P.M., Lubman, R.G., Badway, N.N.(2007).New Directions in Interorganizational Collaboration in Dentistry: The CAMBRA. Coalition Model. Journal of Dental Education,71(5),595-600.

Journal Links

November 2007 CDA Journal: http://www.cda.org/library/cda_member/pubs/journal/jour1107/index.html

October 2007 CDA Journal: http://www.cda.org/library/cda_member/pubs/journal/jour1007/index.html

March 2003 CDA Journal: http://www.cda.org/page/Library/cda_member/pubs/journal/jour0303/index.html

February 2003 CDA Journal:http://www.cda.org/page/Library/cda_member/pubs/journal/jour0203/index.html