5 - Clinic Operations

Management of the predoctoral and baccalaureate clinical program is the primary responsibility of the Assistant Dean for Clinical Affairs, the Director of Quality Assurance, the Director of Compliance, the Clinic Administrator, and the Business Office, which monitors or directs the following:

• Clinic and rotation schedules
• Patient assignments
• Clinical finances
• Equipment and supplies inventory/requisition
• Patient questions and information
• Patient record-keeping and chart audits
• Sterilization
• Infection control protocols
• Hazard communications training
• Adverse incident reports
• General clinic policies
• Third-party insurance claims
• Patient account management.

OFFICE HOURS:  8:00 a.m. – 4:30 p.m.

Assistant Dean for Clinical Affairs:  
Nan Shadid, D.D.S., Dean’s Office - Room 504
Responsibilities include the overall management of the predoctoral and baccalaureate clinic programs.

Clinic Administrator:
Crystal Farrimond, M.P.H., Room 321
Responsibilities include the overall management of the PSCs, Communications Center, and Dispensaries.

Predoctoral Materials Control Manager:
Joni Jenkins, Room 305
Responsible for supervising the Inventory Associates, product procurement for the pre-doctoral clinics, student locker assignments, external dental assisting rotation, and small equipment for clinics.

Predoctoral Clinics Manager:
Tracy King, Room 307B
Oversees all Patient Services Coordinators for the predoctoral clinics.

Director of Compliance:
Kim Graziano, R.D.H., M.P.H., Room 234
Responsible for managing all adverse incident reports, faculty/staff training in infection control and hazardous waste management, HIPAA point of contact, and liaison for OUHSC Environmental Safety, OSHA, and other regulatory agencies. Supervisor for Central Sterilization staff.

Compliance Coordinator:
Maria Carter, Room 238
Performs Compliance onboarding for all new employees, report preparation and follow up for all HIPAA-related issues, maintains key inventory and building access logs, assists students with all Compliance-related enrollment requirements in Complio, coordinates CPR courses for all workforce members, updates policies, protocols, and informational material for all faculty, staff, and students,  and supports the Director of Compliance. 

Compliance Administrative Support:
Rebekah Bargewell, Room 238
Performs report preparation and follow-up for all OSHA and Infection Control-related issues, maintains Emergency Cart checklists and Safety Data Sheets, coordinates Fit Testing, updates policies, protocols, and informational material for all faculty, staff, and students, and supports the Director of Compliance.  

Director for Quality Assurance and Director of Patient Relations:
Susan W. Shelden, R.D.H., Room 232
Works with the Assistant Dean for Clinical Affairs in the overall management of the predoctoral and baccalaureate clinic programs. Responsible as the Patient Liaison. 

Quality Assurance Coordinator:
Sabrina Savage, Room 238
Responsibilities include the coordinator for Clinic Operations payroll, managing the forms inventory, UVS chart storage, invoice processor, and supporting the Director for Quality Assurance and Patient Relations and the Assistant Dean for Clinical Affairs.

Scheduling Coordinator 
Staci Wekenborg, R.D.H., M.Ed., Room 593
Responsible for predoctoral and dental hygiene clinical scheduling and predoctoral rotation schedules.

Room 321

OFFICE HOURS: 8:00 a.m. - 5:00 p.m.

The Communication Center is the first line of contact for prospective and existing patients for the College of Dentistry. This department assists patients, students, or faculty with patient scheduling, appointment confirmations, and by facilitating communications between patients and dental providers. The Communication Center will collaborate with Patient Service Coordinators, Clinic Managers, the Clinic Administrator, the Director of Quality Assurance and Patient Relations, and the Assistant Dean for Clinical Affairs to streamline the delivery of quality dental care. Predoctoral dental students in their 2nd and 3rd years will utilize the Communication Center for planner maintenance and patient scheduling. This department provides additional coverage for the main entrance reception area as needs arise. 

Manager: Clinic Administrator

Supervisor: Assistant Dean for Clinical Affairs

Many of the more commonly requested numbers can be found in the online phone directory. If calling from off campus, the extensions beginning with 1 can be dialed as 405-271- XXXX. For example, the extension is 17744, dial 405-271-7744. All other extensions are reached by calling 405-271-8001 and entering the extension number. 

Online Phone Directory link: OUHSC Phone Directory  

Main Entrance, First Floor

FRONT DESK HOURS:  7:30 a.m. – 4:30 p.m.

Responsible for greeting all patients and visitors, confirming patient appointments, and preparing correspondence to be mailed to patients. The Front Desk Receptionist can help you locate specific faculty, staff, or areas you are seeking.

Facilitator: Front Desk Receptionist

Supervisor: Clinic Administrator

Room 321

OFFICE HOURS: 8:00 a.m. - 5:00 p.m.

Responsible for answering telephones and documenting patient information. Obtains patient demographics on new patients and updates demographics on established patients. Collaborates with dental students and faculty.

Supervisor: Clinic Administrator

Room 321

OFFICE HOURS: 8:00 a.m. - 5:00 p.m.

This department is responsible for a complex, high-volume bookkeeping/accounting system for all predoctoral dental students, dental hygiene students, Graduate Periodontics, and OU Dentistry (Faculty Practice). 

Manager: Departmental Billing Manager

Supervisor: Director of Finance

Room 321

OFFICE HOURS: 8:00 a.m. - 5:00 p.m.

Responsible for managing patient transactions, processing insurance claims, coordinating payments from public service agencies, refunds, and collections.

Manager: Departmental Billing Manager

Room 131A

OFFICE HOURS: 7:00 a.m. - 5:30 p.m.

This area oversees the sterilization needs of the entire College, which include the predoctoral and baccalaureate programs, all graduate programs, and the intramural faculty practice.

Facilitators: Inventory Associates

Supervisor: Director of Compliance

OFFICE HOURS:  8:00 a.m. – 5:00 p.m.

Each clinic on the third floor (Shillingburg, Robertson, and Miranda) is staffed with two Patient Services Coordinators (PSC). The Pediatric/ Orthodontic Clinic and the Dental Hygiene Clinic each have one PSC. These individuals are responsible for assisting the student with appointments, scheduling, patient communications, and any other general patient/student interactions to best accommodate the delivery of dental care at COD.

Each PSC is responsible for a certain number of assigned students and their patients.  As you progress through the curriculum at COD, you will eventually be assigned to a dental group practice and at that time you will receive the PSC to whom you are assigned.  Each PSC is responsible for the scheduling of DS2, DS3, and DS4 students. Below are the locations of the PSCs within their assigned clinics:

Shillingburg Clinic (Room 306)
Room 307A and Room 307B

Robertson Clinic (Room 330)
Room 331A and Room 331B

Miranda Clinic (Room 370)
Room 371A and Room 371B

Third Floor Checkout

Green Clinic (Room 406)

Miller Clinic (Room 436)

Supervisor: Predoctoral Clinic Manager

Manager: Clinic Administrator

CLINIC HOURS: 9:00 a.m. - 12:00 p.m. and 1:00 p.m. - 4:00 p.m.

All clinic dispensary staff are employees of the Office of the Department of Clinic Administration except those in Oral Diagnosis, Oral Surgery, the graduate programs, and the intramural faculty clinic. Each clinic has a central dispensary found in the back of the clinic staffed by one or two clinical Inventory Associates responsible for the distribution of instruments, supplemental equipment, anesthetic, radiographic sensors, electronic signature pads, and other materials and supplies checked out by request.

Room 117

OFFICE HOURS: 7:00 – 4:00 p.m.

Primarily responsible for the service, maintenance, and replacement of pre-clinical laboratory equipment in Rooms 433 and 301, and clinical equipment throughout the school.

Facilitator: Maintenance Specialist

Supervisor: Facilities Sr. Project Manager

Room 433

OFFICE HOURS: 7:00 a.m. – 4:00 p.m. 

Responsible for stocking and cleaning the preclinical simulator lab, and general areas throughout the school.                             

Supervisor: Building Operations Manager 

Training on the Electronic Record System (axiUm) will be provided during the initial stages of your dental career. Students will be informed of these sessions by the Department of Dental Informatics.  Initial training begins during your first year with continued advanced training as you progress through your college education and advanced aspects of axiUm occurring during your second year.

Proper understanding and use of the axiUm system are critical to your education and dental care delivery to our patients. The student is responsible for ensuring all supervising aspects are completed for each procedure performed and/or record entry. 

SECOND FLOOR CLINICS  

THIRD FLOOR COMPREHENSIVE CARE CLINICS 

Clinic hours are 8:00 a.m. to 12:00 p.m. and 1:00 p.m. to 5:00 p.m. Clinic sessions are 9:00 a.m. to 11:45 a.m. and 1:00 p.m. to 3:45 p.m. Every effort should be made to have all electronic/evaluation forms completed, procedure codes entered, session notes completed, and authorized/approved by the attending faculty. Students should turn in instruments for sterilization within the allotted clinic time. Organized and efficient time management builds patient confidence. 

You are not permitted to provide any clinical treatment outside regular clinic periods without specific permission from a faculty member and that faculty member must be present in the clinic. Students may bring their patients back into the clinical area 5 minutes before the clinic session begins with expressed verbal permission of a faculty member on the floor. Treating patients without direct faculty supervision is a serious infraction of COD clinic policy resulting in the filing of a Professionalism Concerns Report (PCR). The PCR will be given to the Assistant Dean for Clinical Affairs, the Director for Quality Assurance, the Director of Compliance, and the Dean of Student Affairs. There will be a loss of clinic privileges for no less than 1 week, resulting in a loss of RVUs for that week.

Attendance in the clinic is mandatory unless the student is excused by their attending supervising Course Director, Group Practice Director, Director for Quality Assurance, Director of Compliance, or Assistant Dean for Clinical Affairs. The request for absence must be submitted in the format requisite to the course. If not treating a patient, the student will be expected to assist another student, working under the direction of their Course Director, Group Practice Director, or assigned supervising faculty. Students who "No-Show" in the clinic will result in a zero grade for the clinic session missed.

Students are expected to use every available clinic session and your assigned PSC will help you maintain a consistent schedule. The minimum clinical experiences you must complete for promotion or graduation are easily attainable with regular clinic attendance. Comprehensive Care and Departmental minimum clinical experiences have been structured with the understanding that every student will experience patient cancellations or no-shows. However, other unanticipated circumstances (illness, weather, etc.) may also result in some clinic sessions not being utilized; it is your responsibility to notify the proper supervising authorities, whether it be your Course Director, Supervising Faculty, or Group Practice Director when this occurs. 

Unanticipated absences, (i.e., personal illness, family emergency, transportation problems, etc.) are to be reported:

DS1               Student Affairs in the Dean’s Office, all course directors
DS2               Student Affairs in the Dean’s Office, all course directors
DS3 & DS4       Student Affairs in the Dean’s Office, all course directors, and assigned Group Practice Director.

This is necessary so that your coursework, pre-clinical courses, and patient care courses (patient appointments) can be addressed during your absence. However, as a caretaker, it is your responsibility to notify your assigned PSC and your supervising clinical faculty in the case of these unanticipated absences.

Anticipated absences, (i.e., family events, advanced program interviews, personal business, doctor appointments, official university business, etc.) should be discussed with the appropriate faculty (Course Director) and a Student Request for a Clinic Absence form should be completed prior to the time of the absence so arrangements can be made for make-up work. The absence should also be reported to the Dean’s Office as soon as you are aware of the event. 

All absences are to be reported to the Office of the Dean for documentation; however, this does not excuse the absence; arrangements must be made with individual Course Directors, Group Practice Directors, or supervising faculty for make-up.

STUDENT REQUEST FOR A CLINIC ABSENCE form is found in axiUm Links in the Clinical Forms section or from an available PSC. The location is axiUm / Links / Clinic Forms.

See Dental Hygiene Reference Documents for attendance policy.

Dental Students:

A clinic schedule is published each semester that indicates the disciplines providing clinic coverage on each half-day of the week and when specific clinics are closed for cleaning and re-stocking supplies.  The schedule will also indicate the student academic class (DS2, DS3, and DS4) and the maximum number of students that will be scheduled in each clinic session. The clinic schedule will be e-mailed to all students at the beginning of each semester.

Clinics are restricted solely to the academic classes designated on the clinic schedule. You may not use the clinic at any time that your class is scheduled to be in a lecture or laboratory. If one of your patients requires emergency care during a time when you do not have access to a clinic, you must get written permission from [1] the course instructor to be excused from class and [2] the attending clinical faculty (Department Faculty or GPD, as applicable and the Clinic Manager) to be allowed into the clinic to treat the emergency.

Dental Hygiene Students:

A clinic schedule is published each semester that indicates where and when the hygiene students will provide clinic coverage on half-days each week. The clinic schedule will be e-mailed to all students at the beginning of each semester, as well as, made available on D2L under the appropriate clinic course. Clinics are restricted solely to the academic classes designated on the clinic schedule. You may not use the clinic at any time that your class is scheduled to be in lecture.

During the third and fourth years, each dental student is required to participate in several clinical rotations. Scheduled rotations always take precedence over regular clinic time; when you are on rotation, you must attend every assigned session. You may not treat patients in other clinics when you are on rotation without the permission of the department conducting the rotation and the department covering the clinic in which you wish to work.

Once published, rotation schedules are final. Any requested changes in the schedule will be considered only if approved by the involved department and the Division Head of Comprehensive Care and if such changes will not compromise the student coverage necessary to staff the rotation.

Dental Students:

The minimum clinical experiences in periodontics, operative dentistry, endodontics, removable prosthodontics, and fixed prosthodontics are summarized in the next few pages.  Other clinical disciplines (oral diagnosis, orthodontics, pediatric dentistry, occlusion, and oral surgery) also have specific expectations; however, their minimum clinical experiences are generally managed in conjunction with other departments or through clinic rotations. For specific information regarding these disciplines and their current requirements, consult with the individual departments and/or appropriate clinic manuals.

The following are the current clinical divisions:

Comprehensive Care 
Endodontics
Occlusion
Operative
Oral Diagnosis
Oral Surgery
Orthodontics
Pediatric Dentistry
Periodontics
Prosthodontics

During clinic appointments remove all items not related to treatment (books, backpacks, notes, etc.) and place them in your assigned locker. Reserve countertops for instruments and supplies needed for treatment. Never seat your patient until after your armamentarium is set up and your operatory is prepared. 

For prosthodontic procedures done at the operatory, place white lab paper on the countertops. Use the adjacent clinic laboratory for routine laboratory procedures; do not perform laboratory work in clinic operatories. 

Refer to Section 5.8 Health and Safety/Infection Control for the appropriate infection control procedures to use for each clinic appointment. After your patient has been dismissed and the dental unit has been disinfected, reposition your operatory equipment as follows: 

1. Return the dental chair to an upright position, place the rheostat on a paper towel and place it on the chair seat, then raise the chair to at least the length of the rheostat cord. 

2. Reposition the dental lamp and handpiece unit over the center of the chair seat. 

3. Return the assistant cabinet to its position under the operatory counter. 

4. Position operator and assistant stools next to counters. 

5. Report any problems with your assigned operator unit to the Inventory Associate. 

As healthcare facilities, the clinics must be kept as clean as possible and must present a desirable, safe, and professional image to the public. You are responsible for the cleanliness of the operatory assigned to you and for any clinic laboratory space you use. 

Food and drink may not be taken into operatories, reception areas, dispensaries, consultation rooms, or x-ray facilities. The College and University are tobacco-free environments; the use of tobacco in any form including E-cigarettes is strictly prohibited. 

No animals of any kind are allowed in the dental building except for service animals. See Service Animal Policy. 

Clinical Appearance: All workforce members and students must comply with the following guidelines for clinical participation.  

Clinical Appearance: 

1. Hair should be clean, well-groomed, of a neutral or natural color, kept secured away from the face and front of the over-gown, and out of the field of operation so that it does not require handling during a procedure. 

2. Men must be clean-shaven, or beards and mustaches must be clean, neatly trimmed, and well groomed 

3. Personal body hygiene is required so that offensive body odor is avoided 

4. Avoid strong perfumes, colognes, or aftershaves 

5. Fingernails must be kept clean, short, and well-manicured 

6. Fingernail polish/gel nails must be free of any chips or wear 

7. Artificial nails are strictly prohibited 

8. Jewelry should be kept out of the field of operation. Watches must be covered by the over gown, earrings cannot hang past the bottom of the ear lobe, rings can be worn if smooth and do not compromise the glove’s integrity 

9. Visible tattoos must be covered 

Clinical Attire: 

1. COD ID badges must always be worn and visible. 

2. Scrub top and pants must be clean, wrinkle-free, and matching. Scrub sets must be in the same color as the student's class.

3. Scrubs must be properly fitted. They cannot be excessively tight or baggy. Scrubs must permit bending, leaning, and squatting while preserving modesty. 

4. Student scrub tops must be embroidered using the following criteria:
   a. 1 centimeter tall
   b. Full block font
   c. White thread
   d. First and last name

5. Scrub pants can be a jogger or traditional style and must reach the ankles when standing. 

6. White- or solid-colored T-shirts or long-sleeved shirts can be worn under the scrubs as long as they are tucked inside the scrub pant 

7. Socks are required 

5. Shoes must be protective, clean, closed-toed, solid upper sole (no visible perforations), with a rubber or leather sole 

6. Outer garments may be worn if the jackets have been purchased through The Uniform Shoppe. They must be embroidered with the first and last name of the student. They may be worn in the clinic, but not at chairside during patient treatment. They may be worn outside of the clinical environment as they are not treatment jackets. 

7. Workforce members are responsible for laundering their scrubs.

If a student wants to purchase additional scrubs, the scrubs must comply with the above criteria. The student may be sent home to change if purchases of scrubs do not meet the dress code criteria.

A long-sleeve protective gown (provided in each clinic) is required for procedures when aerosols are anticipated. Gowns may not be worn in public areas including bathrooms, PSC offices, and reception areas. They may be worn from clinic to clinic on the 3rd floor but may not be worn outside of the clinic on the 2nd and 4th floors. 

Violations of this policy will be handled in the following manner: 

For students: 

First offense: Written warning (copy to Assistant Dean for Clinical Affairs and Director of Compliance). 

Second offense: Professional Concerns Report (PCR) filed (copy to Assistant Dean for Clinical Affairs and Director of Compliance). 

Third offense: Appearance before the appropriate Periodic Assessment Committee, which could result in further disciplinary action. 

For workforce members: 

First infraction: e-mail written warning from Director of Compliance to workforce member cc’d to workforce member’s supervisor. 

Second infraction: a review with Supervisor and Director of Compliance; potential training: review on D2L and quiz within 10 days of notification of infraction. 

Third infraction: reviewed by the Dean of the College of Dentistry.  

Fourth infraction: disciplinary measure up to and including dismissal. 

Any incident involving patient endangerment may result in immediate disciplinary action. 

All freshman and sophomore dental students must work in pairs while in the clinic. Junior and senior dental students work solo during all clinic sessions except when in the pediatric or orthodontic clinic, where pairing is required. Additionally, DS3 students may be paired for certain courses involving patient treatment-specific disciplines (check with individual departments for further clarification). For dental hygiene students, pairing is required only during the fall semester of the first year.

The Department of Periodontics determines an initial pairing of students in the freshman class, however, your clinic partner assigned for the 2nd, 3rd, and 4th year will be assigned by the Director of Comprehensive Care. The Department of Dental Hygiene pairs hygiene students. Students are required to always work with their designated partner when pairing is required. Exceptions must be authorized by the Course Director, Group Practice Director, or the Director of Clinics as applicable. Failure to observe the clinic pairings in scheduling patients will result in clinic suspension, the length of which will be at the discretion of the clinical course director. You are also expected to share available clinic sessions so that you and your partner have access to an equal amount of time for the treatment of your respective patients.

Because student pairings are used in the development of rotation schedules, you may not switch partners without the approval of the Director of Comprehensive Care. For pairs wishing to change partners, all four students involved must personally inform the Director of Comprehensive Care that they agree to the switch. Even if all parties agree, the request will be postponed if there is any potential adverse impact on rotation schedules. 

If your partner is absent during a clinic session when pairing is required, notify the attending faculty member in that clinic who will determine the appropriate course of action. In most instances, you will be required to find another classmate to assist you. 

Patients may park in the Stonewall Parking Garage (P4), northeast of and across the street from the College. To park in the garage without being charged, the PSC or the receptionist on the third floor must validate your patient’s parking ticket.  All patients must be escorted to the PSC or 3rd-floor receptionist for payment upon dismissal (If no payment is due and/ or no fee is assessed, the patient must still be escorted to PSC or 3rd-floor receptionist for checkout).

Patients may not park in the driveway in front of the building. This area is reserved for the loading/unloading of patients only. Parking in this area without proper permission may result in your patient's car being towed at their expense. If your patient is handicapped and has the appropriate placard, they may park in the designated handicapped parking spaces.

The College of Dentistry has a patient shuttle service available to and from the P4 parking garage and the front door of the college. The shuttle service hours are Monday through Friday 7:45 am to 4:45 pm. 

CLINIC HOURS: 9:00 a.m. - 12:00 p.m. and 1:00 p.m. - 4:00 p.m.

Clinic staff must clean the clinic and inventory and stock supplies before and after clinic sessions. Please do not request clinic materials, supplies, and supplemental equipment before 8:30 a.m. and 12:30 p.m. to allow clinic personnel to make these preparations uninterrupted. 

Inventory Associates manage equipment/supplies inventory, storeroom restocking, cleaning of clinics, and student needs when clinics are in session. There are supplies, such as masks and gloves, which are now located in each individual clinic operatory chair unit.  Students are not allowed in the clinic dispensaries at any time.

Each dispensary is stocked with the equipment and materials necessary for all dental procedures governed by the respective clinic discipline.  Certain supplies (e.g., additional anesthetic carpules) require faculty approval before they will be dispensed.  The third floor contains clinic equipment where dental supplies to support the dental procedures are maintained in the assistants’ carts. For all other clinics, the supplies are available in the dispensary.

Additional dental equipment may be checked out in the clinic dispensary, such as nitrous oxide equipment, apex locators, etc. Failure to return the equipment at the end of the clinic session will result in the student being charged the cost to replace the item(s). 

Students requesting nitrous oxide must obtain faculty permission via axiUm; the Inventory Associate will assign you a mobile unit assembly. Students must obtain patient consent prior to the administration of nitrous oxide. Students will enter the D9230 code - Inhalation of Nitrous Oxide, and complete the required consent and the Nitrous Oxide Analgesia template note.

The axiUm section must be filled out and authorized by both you and the attending faculty. If you use nitrous oxide, remember to post it as a completed treatment code under ADA procedure code #9230 (9000 in Pediatric Dentistry is no charge). 

NITROUS OXIDE ANALGESIA RECORD EXAMPLE: 

The patient has been made aware of the reasons for and benefits of nitrous oxide/oxygen sedation and the potential complications related to its use as well as the consequences of not using nitrous oxide/oxygen sedation. The patient’s questions regarding nitrous oxide/oxygen sedation have been answered and consent was obtained (patient signature on file for Nitrous Oxide Consent). The following is a record of the nitrous/oxide oxygen administration for the visit. 

Start Time: {*}, End Time {*} Flow Rate: {*}, {*}%, N20 

Post-op: 110%02 administered for {*} Patient condition upon dismissal: {*} Adverse reactions/comments: {*} Student Name: {*} 

The main student laboratory (Room 433) is used for most pre-clinic-related laboratory work. However, as you transition into the third-floor clinics, each clinic has a clinic lab area associated with your assigned chair and clinic. Each area has sit-down chair spaces with air and gas outlets and quick connects for handpieces (tubing required).  Also available are model trimmers, vibrators, vacuum mixers, high and low-speed polishing lathes, and work sinks.

Clinic laboratories are available for use Monday through Friday, 6:00 am to 12:00 am, and must be accessed via your card access after 4:30 p.m. Each clinic is monitored, and clinic access will be restricted if clinical areas are not maintained in an acceptable manner. To maintain the clinical laboratories in a presentable condition, the following rules will apply: 

1. Use white lab paper (available in each clinic laboratory) on countertops. 

2. Always use water with model trimmers. Flush with copious amounts of water to prevent clogging. Turn off model trimmers when not in use. 

3. Keep sinks free of excess stone, plaster, and impression material. 

4. Keep personal possessions to the minimum necessary to do your work. 

5. Mixing bowls, spatulas, and hoses for vacuum mixers are provided by the COD. They must be cleaned immediately after use. Failure to maintain equipment may result in loss of lab privileges. 

6. When working after hours, students are responsible for checking out any necessary equipment from Central Sterilization. 

7. Do not use these areas for social gatherings. Those activities should be confined to the student commons area, student lounge, or atrium. 

8. Please pick up after yourself. 

The College has an in-house dental laboratory to process crowns, fixed and removable partial dentures and complete dentures for student patients; they also use outside laboratory services for additional support as needed. These services are obtained via laboratory prescription through the axiUm system only.

Support laboratory services are critical to the timeliness of patient care and hence to your attainment of minimum clinical experiences. To better ensure that your cases are expedited, be sure your submitted work authorizations are filled out properly and completely, including a description of the required work, patient name, type of restoration and material required, case design, faculty, and all approved authorizations in the axiUm system.

If you need a case completed sooner than the published number of days normally required (refer to laboratory service schedule), you must obtain approval from the laboratory supervisor. Do not enter the laboratory area without permission; always check in at the receiving desk first.

To submit any case to the laboratory, the Central Business Office must certify via axiUm request that the patient has paid appropriately and must have been approved in the axiUm system.

Any gold crown that is found unacceptable for delivery must be returned to the support lab.

The protocols for the requisition of artificial teeth for Removable Prosthodontics may be found in their department manual. 

The Dental Support Lab schedule indicates the average time (in school days) necessary to complete the services listed.

The day the case is turned in and the day the case is picked up does not count toward production lead time. Weekends and holidays do not count.

Central Sterilization (CS) is on the first floor and is responsible for the sterilization of all items related to patient care in the College. The primary sterilization method is steam under vacuum pressure.

Routine sterilization of instruments, burs, and handpieces is mandatory for safe patient care in all clinic areas. Before using dental instruments or equipment for patient care, all students must confirm their equipment has been sterilized by evaluating the sterilization packaging. All patient-used instruments must be stored in Central Sterilization when not in use. Items used on patients can never be stored in your assigned clinic locker.

No outside equipment can be used in the clinic unless it has been reviewed and approved by the Clinic Materials Committee. Students may not check out any equipment, instruments, or handpieces for a classmate. If a student is picking up instruments for a classmate, the instruments will be checked out to the student at CS, and the student will be responsible for the return of the instruments. Students are responsible for all instruments or equipment checked out in their name. The student will be responsible for the replacement costs for any unreturned or broken items. Students may not keep any patient care items in their locker; all patient care items must be checked-in and stored in Central Sterilization or in the Clinic Dispensary.  

The instrument delivery/pickup system in Central Sterilization is designed to minimize cross-contamination. This process is as follows: 

1. Pick up sterilized burs, handpieces, cassettes, and other equipment from the Sterile Instrument Pickup window (Room 131A). 

2. Follow the process below for returning contaminated instruments to the dirty carts, found in each clinic.

3. DO NOT Bag:

   1. Operative instrument cassette

   2. Perio instrument cassette

   3. Handpiece cassette - Disinfect with a disinfectant wipe; then run the handpiece through the cleaner and lubricant machine located in the dry labs.

   4. Exam instrument cassette

4. Bag:

   1. Ultrasonic inserts

   2. All bur blocks into one bag

   3. Rubber dam kit including punch, forceps, frame, Paladent force, Paladent pin tweezers, Paladent Ring (1), and 3 rubber dam clamps.

   4. Bite fork

Central Sterilization has automated washers to clean, high-level disinfect, and dry instruments which are in cassettes. Cassettes are bagged and sterilized. The sterilization cycles are approximately 40-50 minutes. Sterilized instruments are stored in storage bins.

Students will acquire issued instrument kits from Central Sterilization on the day of their patient's appointment. Students may only check out sterilized instruments used for patient care on the day of the appointment and not before.

EACH STUDENT IS RESPONSIBLE FOR:

• Placing contaminated instruments into dirty bins within each clinic for the Central Sterilization staff to transport for sterilization.
• Students will be required to replace any lost instruments as soon as possible.
• Informing a staff member in Central Sterilization of a broken or defective instrument so it can be replaced.
• Making certain that any visible debris is removed from their instruments prior to packaging in the clinic.
• Ensuring all contaminated instruments are secure inside the cassettes to prevent bloodborne pathogen exposures or injuries to the Central Sterilization staff.  

Dental student kits/instruments are provided by The College of Dentistry for dental students.

1. Exam Kit
2. Operative Kits
3. Perio Cassettes
4. Electric Handpieces
5. Endodontic Kits
6. Rubber Dam Kits
7. Digital Studio Kits
8. Bur Blocks
9. Ultrasonic Tips
10. Impression Trays

Dental Hygiene students own their own instruments.

The Assistant Dean for Clinical Affairs has the ultimate responsibility for clinic administration; however, advice and input are received from many clinic-related committees. Student representation, on committees that help govern clinical affairs and set clinic policy, is necessary to ensure student interests and concerns are being addressed.

The function of the Clinic Operations Committee (COC) is to set procedures and policies for the operation of the student clinics. The areas of responsibility include Quality Assurance and Clinical Material and Instruments. Recommendations that have significant budgetary or personnel implications shall be forwarded to the Faculty Board and Dean’s Advisory Council for review.

The Assistant Dean for Clinical Affairs shall serve as chair. The committee shall consist of the following division heads and program directors (or their respective designees): Comprehensive Care, Dental Hygiene, Endodontics, Operative Dentistry, Orthodontics, Pediatric Dentistry, Periodontics, and Prosthodontics. The committee shall also include one junior and one senior dental student, and one senior dental hygiene student selected by the committee chair and approved by the committee membership, each of whom will serve one-year terms and may be re-selected. The Director of Compliance, the Director of Quality Assurance, the Clinic Manager, and the Senior Billing Manager are ex officio members. The COC shall meet three times per year – that is, once per academic term. The Office of the Assistant Dean of Clinical Affairs shall provide administrative support to the committee.

To facilitate the mission of the Clinic Operations Committee, two subcommittees will be established: Clinical Equipment and Materials and Continuous Quality Improvement.

The purpose of the Clinical Equipment and Materials Subcommittee is to address and track specialty equipment and materials used in the clinical and pre-clinical setting to achieve uniformity, contain costs, and maintain quality. The subcommittee shall forward its recommendations to the Clinic Operations Committee. The subcommittee must meet at least three times per year (i.e., once during each academic term) as set forth by the Clinic Operations Committee.

The Assistant Dean for Clinical Affairs will serve as chair. Membership of the subcommittee shall consist of two at-large members appointed by the Assistant Dean for Clinical Affairs who will serve one-year terms and may be reappointed, plus the heads of the divisions of Comprehensive Care, Dental Biomaterials, Operative Dentistry, Pediatric Dentistry, and Prosthodontics. The heads of these divisions may, with approval from the Assistant Dean for Clinical Affairs, select an alternate to serve as a member of this subcommittee. The Clinic Manager and Director of Compliance will serve as ex officio members. The Office of the Assistant Dean for Clinical Affairs shall provide administrative support to the subcommittee.

The Continuous Quality Improvement Subcommittee shall be responsible for establishing policies and procedures that assess the quality of patient care.  The subcommittee shall monitor and ensure compliance with the patient care standards of the College of Dentistry. The subcommittee will conduct a tri-annual review of the data collected and prepare reports with any necessary recommendations for presentation to the Assistant Dean of Clinical Affairs and the Dean.

The Director of Quality Assurance and Director of Patient Relations will serve as chair. Membership of the subcommittee will be composed of one faculty representative from each of the following: Comprehensive Care, Dental Hygiene, and Pediatric Dentistry. These positions are nominated by the subcommittee chair and approved by the respective department chairs. The subcommittee also includes one student nominated by the subcommittee chair and approved by the Clinic Operations Committee. Faculty members will serve three-year, staggered terms and may be reappointed. The student will serve a one-year term and may be reappointed. The subcommittee shall meet three times per year – that is, once at the end of each academic term. The Office of the Director of Quality Assurance shall provide administrative support to the subcommittee.

The Health and Safety Committee shall be responsible for establishing policies and procedures regarding infection control, hazardous waste management, and employee, student, and patient safety.  The committee shall ensure compliance with the various local, state, university, and federal policies that regulate these areas.  

The Health and Safety Committee will meet at least annually to review and revise sections of the Clinic Operations Manual that pertain to health and safety and make recommendations to the Dean to effect change and maintain compliance. 

The Director of Compliance (or his or her designee) will serve as chair. The Director of Compliance will nominate the committee members to be approved by their respective division heads/program directors. The committee shall be composed of the Director of Compliance, plus one representative each from the predoctoral program, dental hygiene program, post-graduate programs, and OU Dentistry Faculty Practice who will serve one-year terms and who may be reappointed.  In addition, student members on the committee will be nominated by the Director of Compliance and approved by the Assistant Dean for Clinical Affairs. The student membership will include one senior dental hygiene student to serve a one-year term and one junior dental student to serve a two-year term. The Office of the Director of Compliance shall supply administrative support to the committee.

All prospective patients are required to receive a screening assessment in Oral Diagnosis to determine their suitability as patients in the clinical program. After a preliminary evaluation of the medical/dental history and status, they will either be provisionally accepted, rejected, or referred based on an assessment of many factors, including potential value to the teaching program, ability to pay for treatment, availability for regular appointments, the ability of dental students to provide necessary care, etc. 

The purpose of the screening assessment is to select suitable patients for treatment and to provide the student with diagnostic experiences. The student dialogue with the patient during initial screening is critical to the patient’s understanding and acceptance of the program and its parameters. 

Accepted patients sign the Terms of Participation Form and are placed in the unassigned patient file to await future assignments and periodic review for appropriateness in meeting the clinical experiential needs of students. The assignments are made by the Assistant Dean of Clinical Affairs based on the requests of the Group Practice Directors and the Assistant Group Practice Directors. 

DS2 Faculty Advisor: Professor, Department of Diagnostic & Preventive Sciences

DS3 / DS4 Faculty Advisor: Group Practice Directors Division of Comprehensive Care

Shillingburg Clinic 1
Shillingburg Clinic 2
Shillingburg Clinic 3

Miranda Clinic 1
Miranda Clinic 2
Miranda Clinic 3

Robertson Clinic 1
Robertson Clinic 2
Robertson Clinic 3

The College of Dentistry, as a teaching institution, is strongly committed to providing its students with the best educational experience possible and as such, makes every effort to provide patients for students that offer a wide range of clinical experiences.  More importantly, the College is also committed to providing its patients with comprehensive care that is patient-centered and affordable.

Patients are accepted based on their educational value and assigned to students based on the student’s educational requirements.  There may be instances when an assigned patient does not exactly match the assignment request made by the student; this is unavoidable as treatment needs and the patient’s treatment expectations are subject to change with time.

Students are expected to act with professionalism, responsibility, and accountability in accepting patient assignments; repeated complications in the assignment process with a particular student will ultimately result in the student becoming responsible for procuring his/ her own patients for treatment.

Patients are screened in the Oral Diagnosis Clinic. This clinic is staffed by faculty and assigned students who are on an oral diagnosis rotation (see Section 5.1.2.4: Clinic Schedules). All patients, when completing the screening process, may be recommended for the student clinic, the Advanced Education in General Dentistry program, or may be rejected for our school programs. 

Common reasons for rejection from the student clinics are a case may be too complex for a student or other reasons that may make it difficult to deliver the dental care required.

During the assessment examination, key factors are entered into the axiUm record to categorize the patient’s dental needs. Once the examination is complete and the patient has been provisionally accepted into the program, the assessment information is provided to the Assistant Dean of Clinical Affairs.

On a bi-weekly basis, these patients are assigned to the Group Practice Directors. Senior patient assignments are made by the Group Practice Director to his/her students via the Communications Center. Junior patient assignments are made by faculty designated to either Miranda, Robertson, or Shillingburg Clinic. Sophomore patients are assigned by the Sophomore faculty designated for assignments.

While students are on scheduled rotation in the Oral Diagnosis clinic, they may screen a patient whose needs match their clinical requirements. A request for a specific assignment of a patient, who a student has personally screened, may be submitted to the Assistant Dean of Clinical Affairs; however, there is no agreement that the patient will be assigned to the requested student. Students are not to make promises to any patient regarding when or to whom the assignment will be made.

A student may personally screen and request assignments from family members, friends, or relatives of patients already in their patient family.  Such assignment requests will usually be honored, provided the patient’s dental needs meet the student’s level of ability.  

Once a patient assignment has been made by the Group Practice Director or DS2 Faculty Advisor, the patient’s information is referred to the Communications Center for entry of the assignment and scheduling of the initial workup appointment.

The Patient Services Coordinator (PSC) is responsible for running and maintaining the dental hygiene recall program. The PSC schedules recall patient appointments to available hygiene students' schedules.

All assigned dental hygiene patients (new patients or recall) will remain in the care of the assigned dental hygiene student until transferred to another student or released from the program.  The new patient assignment type DH to Comprehensive Care, requires the PSC to notify the Director of Comprehensive Care once the dental hygiene treatment has been completed for assignment to a dental student.

 A.    DH - Patients whose first experience in the College of Dentistry is in the Dental Hygiene student clinic. These patients will have a dental examination in conjunction with their first round of dental hygiene treatment. They are required to have an exam every 13 months with subsequent dental hygiene treatment. Upon examination, there are 3 possible outcomes:

         1.) No treatment is needed.
         2.) Limited treatment is needed.
         3.) Comprehensive care is needed.

 If limited treatment is needed, the examining dentist will complete a limited treatment form, which will be sent to the Quality Assurance Coordinator. If comprehensive care is needed, (4 or more procedures and comprehensive treatment planning) the examining dentist will send a limited treatment form to the Quality Assurance Coordinator that states full assignment is needed.

 B.     Recall – Patients who have completed their restorative treatment at the College of Dentistry and have been placed on recall or are in the Dental Hygiene Only recall system.

 C.     Comprehensive Care Clinic – Fourth-year dental students assigned to comprehensive care clinics will coordinate the periodontal recall needs of a limited number of their assigned patients with the GPD and the PSCs, for the DH collaboration. The patient is then assigned to a vertical team second-year dental hygiene student for periodontal treatment. The DH and DS student collaborate on the patient’s appointment needs and necessary radiographs.

 D.      Dental Students - Dental students may be seen as patients up to two times per semester. They may only be scheduled to fill in a last-minute cancellation or no-show unless the student has a dental emergency. Dental students may not be scheduled in advance and will not be added to your patient family.  Please see your clinical instructor if you have a no-show or last-minute cancellation and need a last-minute appointment with a dental student.

The DH Patient Services Coordinator (PSC) is responsible for scheduling dental hygiene appointments for their patients.  The PSC, in the clinic in which the patient is seen for treatment, will collect payment for services rendered and schedule subsequent appointments.

Should the patient call the student to reschedule an appointment, it will be managed by the student and communicated to the DH PSC. If a patient has already had two rescheduled appointments, the PSC will determine whether to send the patient a pending release letter or a release letter regarding scheduling difficulties.

Students, along with the PSC, should utilize their patient list to fill appointments that other patients have canceled.

The student is responsible for managing the need for antibiotic pre-medication for their patients. This will not be managed by the Patient Services Coordinator (PSC).

Dental Hygiene Students:

Family members and friends may be seen as personal patients. Contact Dental Hygiene PSC (via amail) to have a personal patient registered into axiUm.  Include the:

• Patient’s name
• Date of birth
• Address
• Email
• Best daytime contact number

Be sure to make it clear that you are a dental hygiene student by placing “DH1” or “DH2” after your name at the end of the message. The subject line should say “DH Personal Patient Request”. Personal patients should be utilized to fill open appointment times or cancellations.

If it is determined that a patient needs to be seen for urgent care (between appointments), the patient should be instructed to contact the DH Patient Services Coordinator.  The PSC will review the case and consult with the Director of Patient Relations on the best course of action for managing the patient’s dental situation. If a limited treatment assignment is deemed necessary, the Director of Patient Relations will complete a limited treatment form for dental student assignments. If a dentist has examined the area of dental concern, he/she should complete a limited treatment form and send it to the Quality Assurance Coordinator, via the axiUm “running man”, instead of having the patient contact the Communications Center.

During non-business hours, patients should be instructed to call 405-271-7744, where they will receive a recorded message with a phone number to contact the AEGD resident who is on call.

The management of pediatric/orthodontic patients is addressed through the Departments of Pediatric Dentistry and Orthodontics and is provided in their clinic manual.

Definitions:

Recruited patients: prospective patients recruited through social media whom students do not know personally.

Personal Patients: are family members, friends, or relatives of patients already in the student’s patient family.

The Director of Development and External Relations for the College of Dentistry will periodically create a patient recruitment message/advertisement for COD's social media accounts. Once this message is posted, students may share it only on their personal Facebook page, Twitter, and/or Instagram with a personalized message.

This recruitment message may NOT be posted to Oklahoma City (or any other city/town) Garage Sale, Facebook Marketplace, Craig’s List, Snapchat, or neighborhood pages.

It is a HIPPA violation to have the prospective patient give their contact information on social media in relation to becoming a patient at the COD. Recruited prospective patients should be directed to the COD website to complete the secure Prospective Patient form. The prospective patient can also be contacted by phone to gather their contact information. Do not ask the prospective patient to give you any information on social media.

Recruited prospective patients should be instructed to go to the COD website (dentistry.ouhsc.edu) to submit the Prospective Patient Form. Within the form, prospective patients can type the student’s name who has recruited them. This will be noted by the Communications Center in the axiUm record so the patient will be assigned to the student if the case difficulty is a match for that student’s academic level. Only prospective patients who meet the program requirements will be scheduled for a screening/assessment.

Students may request to screen people, which they know personally, as their personal patients, in the following manner:

·      DSs amail the Communications Center and DHs amail the DH PSC with the following information:

• My name is                                    and I am a DS     (or DH   ).
• I am requesting the following pt. be scheduled for a screening/assessment as my personal patient.
• Prospective Patient’s Name
• Prospective Patient’s phone number:
• Prospective Patient’s full address:
• Prospective Patient’s birthdate:

·      DH1 and DH2 students may screen/assess their personal patients in the DH Clinic
·      DS2 and DS3 students must have their personal patients screened/assessed in OD
·      DS4 students must screen/assess their personal patients in their Comp Care Clinic

Students must uphold the Student Professionalism Policy (3.14 in the Student Handbook) when managing their Facebook page.

After the patients have been assigned to the students, the protocol for scheduling an appointment is as follows:

DS2s and DS3s

1. The initial appointment is made by the Communication Center. 
2. The subsequent appointments are made by the Communication Center by utilizing the planner or by the PSC at the time of checkout.

DS4s

1. The initial appointment is made by the Communication Center. After the first attempt, the PSC follows up to make the initial appointment.
2. The subsequent appointments are made by the PSC at the time of checkout or by utilizing the DS4 planner.

DH1s and DH2s

1. The initial appointment is made by the DH PSC.
2. The subsequent appointments are made by the DH PSC at the time of checkout or by utilizing the DH planner.

Students are encouraged to be proactive in coordinating the scheduling of their patient family. Initial interactions with patients will determine the success or failure of all subsequent patient relations. Patient confidence and trust will be reflected in their first impressions of the student and the perception of the student’s interest in their needs.

1. Students are encouraged to call the patient as soon as possible (preferably within 24 to 48 hours of the assignment) from a phone within the COD.
   • When contacting a patient to confirm an appointment, the COD highly recommends that COD faculty, staff, and students use a COD telephone located on COD premises, instead of a personal telephone/mobile phone or electronic device. Telephones have been placed near workstations for COD faculty, staff, and students to have access to the COD electronic health record (EHR) for updating Medical Histories or entering notes into patient records. For students, see section 5.2.5.1: COD Phones for Student Use in COD Student Handbook for phone locations. See Contacting Patient by Phone HIPAA Policy. 
2. The student should call at reasonable hours. If the student needs to contact a patient in the evening, they should do so by 8:00 p.m.  Calling very late at night or early in the morning is discouraged. Elderly patients should be called relatively early in the evening.
3. Texting- Texting protected health information (PHI) is unacceptable. Texting a patient is not recommended. If the patient insists on receiving text messages, the student should always confirm the consent of the patient to receive text messages by reviewing the Request and Consent for Electronic Communication (ELCON). The patient may only receive text messages to the cell number indicated on the ELCON. If an ELCON is not on file or expired, a text message cannot be sent until the patient completes and signs a new ELCON for text messages at their next appointment.
4. If someone other than the patient answers the phone, the student should find out when the patient will be available and call again.  It is appropriate to leave a message to have the patient return the call by stating you are from the COD and leaving a return phone number. Do not divulge any information regarding the patient's past or upcoming treatment or appointment times to anyone not listed on the Authorization to Release PHI Verbally to Others form. Do not assume that the message will be forwarded to the patient.
5. The student should identify themselves once the patient is reached and state the reason for their call. The patient should be asked if they are still interested in being treated at the College of Dentistry.
6. The student should avoid identifying their class status and they should spell their name, if necessary. Patients often call the College of Dentistry and give a distorted or garbled version of a name which can make it difficult to identify the student.
7. Students should remind their patients to review the information in their copy of the “Terms of Participation” form (required availability for appointments, payment policies, etc.) and remind them that appointments will be 2-3 hours in length.
8. All scheduled patient appointments should be confirmed by the student the evening before. This is a helpful reminder to the patient and allows the student an opportunity to contact another patient if the original patient must reschedule.
9. At the end of the clinic appointment, the student should have a future planned procedure code and arrange their patient's next appointment, by checking the patient out with their PSC.
10. If a particularly involved or complex procedure was performed, the student should call their patient, before leaving the COD that day, to inquire about the patient's well-being. 

IMPORTANT! Record all phone contact attempts in the electronic record in the Patient Contact Notes section, including the number called.

The University of Oklahoma College of Dentistry will take all necessary steps to protect and safeguard patients’ Protected Health Information (PHI). Students should review the Contacting Patient by Phone or Electronic Devices Policy prior to calling, texting, or emailing patients. Failure to do so could result in HIPAA violations and sanctions.

The COD highly recommends using a phone located within the COD for calling patients instead of their personal phone. Phones have been intentionally placed near workstations, so students have access to axiUm for updating Health Histories or entering notes. Locations of phones available for student use are listed below:

Student Lounge

• Four (4) wall-mounted phones
• Always available

Radiology Viewing Room

• Four (4) wall-mounted phones
• Available Monday-Friday during normal business hours and after hours with card access.

Comprehensive Care Faculty Offices

• Available during non-clinic hours

Fourth Floor Faculty Offices

• Available during non-clinic hours

Phones can be used to make outside calls by dialing “9” plus the number. The caller ID will state “Health Care 405-271-8001”.  These phones can also be used to dial an extension on the OUHSC campus.

Note: voicemail is not activated on phones. 

Additional resources:

Contacting Patient by Phone or Electronic Devices Policy

Safeguards – Administrative and Physical

Emailing and Transmitting PHI

If a patient needs to be referred to the Graduate Periodontics Program to be seen by a resident, the examining dentist completes a referral form in axiUm and sends it to the Grad Perio staff (via axiUm running man).

Should you have a patient who needs to be referred to OMS/Oral Surgery Program to be seen by a resident,  the examining dentist completes an OMS Referral form in axiUm, and hand delivers it to the OMS resident clinic staff.

This electronic form provides the patient with information regarding patient acceptance, appointment availability, financial responsibility, follow-up care in dental hygiene recall, and eligibility for further treatment at the College of Dentistry. The consent form must be signed by the patient (or the patient's parent/guardian if a minor child) and a printed copy is given to the patient for their records. This confirms an understanding and acceptance of the responsibilities of participation in the student program at the College of Dentistry.

Informed consent is an important legal concept that protects the student and the College of Dentistry against any allegation that work was performed without permission. To ensure that informed consent is fully secure, the patient must be made aware of:

    1.  the nature of the existing medical/dental condition to be treated
    2.  prognosis of the condition, if left untreated
    3.  any or all risks involved with treatment
    4.  alternative methods of treatment
    5.  reasons for any subsequent changes in treatment.

The patient will also be required to sign the College of Dentistry’s Payment Policy which outlines the financial responsibilities of the patient and a statement regarding fee reductions for pediatric patients based on income level.  The patient may receive a printed copy of this form upon request for their records.

A patient accepted for emergency care or limited treatment is also required to sign a statement of understanding of the parameters under which care is being rendered.  It is the student's responsibility to ensure that all appropriate documents relating to informed consent are complete, signed, and made a permanent part of the patient's record.

These electronic documents are found within axiUm.

Provides the patient with information regarding the risks and benefits of Comprehensive Care, Local Anesthesia, Periodontal Treatment, and Restorative Treatment, in addition to the consequences of no treatment. This consent is to be signed before any treatment is provided.

The Master Treatment Plan (MTP) is the document, in the electronic record, of all planned treatments developed after departmental routing, specialty faculty consultation, or by other authorized individuals, such as Group Practice Directors.  This document, in addition to the signed predoc consent to treatment (PDPC), gives consent to the treatment listed. It is also a key element to utilize for providing a finance plan. The Master Treatment Plan and the Patient Consent to Treatment Form require the patient’s electronic signature.

Master Treatment Plans may be changed during treatment. Every time a change is made to the master treatment plan, the patient must sign a revised treatment plan. There are times when a master treatment plan may not be completed prior to the delivery of dental care to the patient. However, there must be a signed consent to treatment and a signed treatment plan for the procedures that will be completed prior to the completion of the master treatment plan.  Examples include delivering emergency care or starting periodontal treatment prior to the completion of the treatment plan.

Treating a patient without a signed PDPC and treatment plan is a serious recordkeeping omission. 

The Americans with Disabilities Act (ADA) provides for the protection of service animals for disabled people.  Service animals are working animals, not pets.  We welcome patients who require a service dog that is individually trained to do work or perform tasks for a person with a disability.  The task(s) performed by the dog must be related to the person’s disability.  If the patient has a service dog that falls under Titles II and III of the Americans with Disabilities Act (ADA), they can bring the dog with them to all areas of the clinic where the public is allowed to go.  It may be proper to exclude a service animal from surgical areas where the animal’s presence may compromise a sterile environment. 

The service animal must be harnessed, leashed, or tethered while in public places unless these devices interfere with the service animal's work or the person's disability prevents the use of these devices. A person may be asked to remove their service animal from the premises if: (1) the dog is out of control and the handler does not take effective action to control it or (2) the dog is not housebroken.  When there is a legitimate reason to ask that a service animal be removed, staff must offer the person with the disability the opportunity to obtain goods or services without the animal’s presence.  

Examples of service animals that must be allowed into public accommodations under the ADA include:

• Hearing dogs - alert their handlers to important sounds, such as alarms, doorbells, and other signals
• Guide dogs - help those who are blind or visually impaired navigate safely
• Psychiatric service animals - help their handlers manage mental and emotional disabilities by, for example, interrupting self-harming behaviors, reminding handlers to take medication, checking spaces for intruders, or supplying calming pressure during anxiety or panic attacks
• Seizure alert animals - alert their handlers of impending seizures, and may also guard their handlers during seizure activity
• Allergen alert animals - alert their handlers of foods or other substances that could be dangerous (such as peanuts).

If it is not apparent what the service animal does, we may ask only whether it is a service animal (we can ask if the dog is required because of a disability), and what tasks has the dog been trained to do. We may not ask what the person’s disability is and we may not request the provision of any service animal training certification or other proof of training.

If the animal does not perform a service but provides emotional support, therapy, comfort, or companionship, they are not allowed in the building. Dogs whose sole function is to provide comfort or emotional support do NOT qualify as service animals under the ADA.

Oklahoma City Clinics

During Clinic Sessions:

1.  The patient contacts either the Communication Center or the PSC and reports their dental concern.
2.  The dental concern is recorded in the contact notes of the patient’s electronic health record.
3.  The assigned student’s schedule is reviewed for open appointments.
4.  If the student is unavailable due to a rotation, the scheduler looks for another student in the same class and group practice who has an opening.
5.  If that is unsuccessful, the scheduler moves to the schedule of an adjacent group practice for an available student with whom to schedule the patient.
6.  If someone other than the assigned student sees the patient, an amail should be sent to the assigned student informing him/her of what transpired with the patient.

After Hours:

1.  The patient calls the main phone number 405-271-7744 and is given a number to call for the AEGD on-call resident.
2.  Upon receipt of being contacted, the resident contacts the patient to determine the nature of the dental concern and obtains the patient’s name, DOB, and assigned student’s name.
3.  The resident provides feedback to the patient regarding the dental concern and may determine that it is appropriate to call in a prescription for the patient.
4.  The resident amails the Director of Patient Relations, the Director of AEGD, and the student provider and records the following information in the patient EHR to report the management of the patient including:

• Patient instructions/information
• Follow-up care indicated
• Details of any prescriptions called in, including
  • Drug name
  • Dosage
  • Quantity
  • Pharmacy information including name, location, and phone number where the prescription was sent.

The student provider of the patient provides necessary follow-up.

During Academic Break:

1. The patient calls the Communications Center and reports their dental concern.
2. The Communications Center determines the urgency of the need by either referring the patient to AEGD to schedule an urgent appointment or scheduling the patient with the assigned student in the first available appointment session when the student returns. The Communications Center staff enters a contact note recording the patient’s dental concern.
3. If the choice is to schedule with AEGD, a referral is completed by Communications Center staff and forwarded to AEGD for scheduling.
4. The treating resident sends an amail to the assigned student, the Director of AEGD, and the Director of Patient Relations informing them of what transpired with the patient. 

Tulsa Clinic

During Clinic Session: Follow the same protocol as the OUHSC campus with the exception that the patient calls the Tulsa Clinic directly.

After Hours: 

1. The patient of record calls the Tulsa clinic and is directed to call AEGD for the on-call resident.
2. The resident triages the call and determines if the patient needs to be seen in the Tulsa Clinic. 
3. The resident contacts the on-call dentist regarding the emergency. 

During Academic Break: 

1. The patient of record calls the Tulsa clinic and the PSC or dental assistant will manage the emergency.  
2. The PSC or dental assistant will contact the Tulsa on-call dentist and an available dental student if the patient needs to be seen.  
3. The PSC or dental assistant will schedule the patient in the designated emergency chairs by utilizing axiUm.  
4. It is ideal that the patient be treated in the Tulsa clinic, but if no one is available, the patient will be directed to the AEGD clinic at the COD for care. 
5. If the patient needs to be seen at the COD, the treating resident will send an amail to the AEGD Director, the Tulsa Clinic Director, the assigned dental student, and the Director of Patient Relations informing them of what transpired with the patient.

1. The Communication Center will assign this patient to an available fourth-year student with an opening in their schedule.
2. After the emergency has been taken care of, the patient is scheduled for the appropriate completion of treatment.
3. Once the emergency treatment has been completed, the patient has the option to be screened for comprehensive care with the completion of the online Prospective Patient Form.

During Clinic Sessions

• The same protocol for the adult patient is followed with the exception that the student is responsible for contacting the parent to determine the nature and urgency of the emergency.  We consider this to be part of the teaching/learning experience -- discovering what is and what is not a true dental emergency. 
• If the situation is such that the patient needs to be seen before the assigned student can see the patient, then said patient will be scheduled either into the Pedo restorative rotation clinic or with another student. 
• If circumstances dictate, a prescription may be sent in.
• If the urgency/emergency can be managed without an immediate visit, the patient will be scheduled/added to the assigned student’s appointment list.  

After Hours

• The Pedo faculty should be contacted regarding how to address the particular patient's situation. 

During Academic Break

1. The patient’s parent or guardian contacts the Pedo PSC or PCM. They will determine the urgency of the need after consulting with the Pedo faculty. 
2. A referral is completed by Pedo PSC or PCM staff and forwarded to AEGD (or GPR program director if the patient is covered by SoonerCare).
   • If the referral is to the GPR program director, the Pedo PSC or PCM calls the GPR scheduler, ext. 14750, to alert that a referral has been sent through axiUm. 
3. The program, to which the patient was referred, will call the parent or guardian to schedule the patient.  
4. After treatment, the treating resident will send an amail to the AEGD Director or GPR Director (depending on which clinic treated the patient), the assigned dental student and the Director of Patient Relations informing them of what transpired with the patient.

In addition to completing minimum clinical experiences for graduation consideration, the student must also reconcile all assigned patients including all those initially assigned for complete treatment, patients accepted as a transfer, and patients provided limited care. Reconciliation involves planning the process for continued care (or removal from the program) prior to graduation and is expected of every student to complete the graduation sign-out process.

There are four methods for patient reconciliation:

1. Completion of Treatment
2. Transfer to Another Student
3. Patient Release
4. Completion of Limited Care

Completion of patient treatment is the most desirable method of patient reconciliation, and it is, therefore, highly recommended that students make patient assignment requests based on their ability to manage the patient’s care until completed. If a student requires counseling regarding their ability to manage their patient family, an appointment should be made with their faculty advisor.

Release involves the removal of a patient from the program and the discontinuation of treatment. This action will only be implemented for legitimate causes including (but not limited to):

• Inability to pay for treatment
• Lack of interest in the program
• Unwillingness to accept treatment recommendations
• Moving out of the area
• Three or more cancellations and/or failed appointments
• Severe behavioral management problems
• Unavailability for regular appointments
• Formal referral to a collection agency
• The patient requested to discontinue treatment
• Treatment not within the scope of the program – too complex

It is not acceptable to release a patient because of race, sex, age, or occupation.

It is also not acceptable to deliberately neglect a patient whose needs do not coincide with your expectations or academic requirements. Patient neglect is a punishable offense and will be discussed in the Patient Abandonment, section 5.2.10.3.

Never confront a patient with release without justifiable cause. To request release, see your Group Practice Director and PSC. A patient should never be confronted with dismissal unless the student has sufficient evidence that a valid reason exists. Always consult with the Director of Patient Relations before you consider these actions and certainly before the patient is informed.

The release of patients from the predoctoral program must be accompanied by proper documentation, which should include any information that may affect the future interactions of both the student and the College of Dentistry with the patient (financial difficulties, scheduling conflicts, unwillingness to accept planned treatment, mutual agreements to defer treatment, lengthy unavailability for treatment, etc.). Questionable patient releases require authorization from the Director of Patient Relations.

A single canceled or missed appointment is not reasonable grounds for release. While patients must be available at least two half-days per week, students will seldom see any patients more than once a week. If a patient is only available outside the normal clinical patient expectations, this may not be grounds for dismissal provided that their schedule coincides with the current available clinic time. The student should be reasonable and flexible with their expectations or the patient should be reassigned to a student who has clinic time available when the patient is available.

It is extremely important that the student establish authority regarding the College of Dentistry policies early in the relationship. Therefore, the student should be very familiar with the information in this manual and should be able to respond to questions regarding school policies. The student should tactfully dictate the frequency of appointments, determine treatment sequencing, and inform the patient when their actions may jeopardize their status in the program (frequent cancellations/no-shows, failure to pay account balance, etc.)

A patient referred to the College’s collection agency is automatically released even if you have not requested this action. You will not have access to any electronic record in collections without the permission of the Central Billing Office.

A patient may request reactivation if the reasons for the original release no longer apply. Reactivation of a patient referred to a collection agency will not be allowed. The Director of Patient Relations must approve all reactivation of released patients.

Infrequently, a patient may be notified through a letter of pending release regarding the nature of one of the above-listed problems that may be the cause for release if the circumstance does not change. Patients are given 2 weeks (10 business days) to appeal the release, if no response is received, the patient is processed for the final release.

Dental students may request an assignment of a Limited Care patient at any time by electronic submission. Limited Care Patient Requests are to be submitted electronically to the Director or Patient Relations. While assignment requests will be filled in the order they are received, there may be times when a request that is too specific will delay the process and other requests will be considered for assignment in the interim.

Additional considerations regarding the assignment:

• Students must have a Limited Treatment request on file for assignment.
• Students will be allowed 2 (two) Limited Treatment patients in their patient family.
• Students will not be assigned another patient until treatment is resolved on the previous patients assigned to them.
• Students must complete all Limited Treatment assignments. Patients will not be re-assigned.

Once the student has accepted a Limited Care patient, they are responsible for every procedure specified on the form including any required follow-up care.  Limited Care patients may be taken directly to the proper clinic(s) for treatment or consultation as necessary; a work-up and treatment planning is not needed unless requested by consulting faculty. The Workflow for Limited Treatment Patients can be found in the Clinic Binder in each clinic faculty office. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder.

Abandonment - a unilateral termination of the patient-physician relationship by the physician without notice to the patient.

The relationship between physician and patient generally continues until it is terminated by mutual consent of both parties.  However, a relationship can be discontinued through the dismissal of the physician by the patient, the physician's withdrawal from the case, or the physician’s services are no longer required.  Failure to follow up on patient care after the acute stage of illness has subsided or neglect to give patient warnings of necessary instructions may involve the physician in serious legal difficulties.  Premature termination of treatment is quite often the subject of legal action.

Closely related to this type of problem is one which occurs when the physician, though not intending to end the relationship with the patient, fails to ensure the patient’s understanding that further treatment of the complaint is necessary.

The following elements must be present for a patient to recover damages for abandonment:

1. Unreasonable discontinuance of medical care.
2. Discontinuance of medical care against the patient’s will: termination of the physician-patient relationship must have been brought about by a unilateral act of the physician. There can be no abandonment if the relationship is terminated by mutual consent or dismissal of the physician by the patient.
3. A physician’s failure to arrange for care by another physician or refusal by a physician to enter a physician-patient relationship by refusing to respond to a call or render treatment is not considered abandonment. A plaintiff will not recover damages unless it can be established that a physician-patient relationship has been established. (i.e., Buttersworth v. Swint, 186 E.E. 770 (Ga. 1936)
4. Foresight that discontinuance may result in physical harm to the patient.
5. Actual harm suffered by the patient.

The relationship between a physician and patient, once established, continues until it is ended by mutual consent of the parties, revoked by the patient’s dismissal of the physician, by the physician’s withdrawal from the case, or until the physician’s services are no longer needed. A physician who decides to withdraw his services must provide the patient with reasonable notice so that the services of another physician can be obtained.

The Director for Quality Assurance and Director for Patient Relations will not tolerate willful abandonment, and has joined the Department of Pediatric Dentistry in establishing the following guidelines to aid in determining if abandonment has occurred:

1. Willful or undocumented failure to see patients with treatment needs within the semester assigned.
2. Failure to see any patient for two consecutive semesters without sufficient documentation in the record to justify such failure to see the patient.

In cases where abandonment has occurred, a grade of “F” will be given for the Clinical Record-Keeping and Patient Management course for the semester during which the incident occurred.

Students may provide dental care to other students under the following conditions:

1. In the event of a cancellation or no-show by a COD patient.  Student-on-student appointments should not be pre-scheduled preventing a COD patient from being scheduled.
2. There is a specified dental need (usually identified by symptoms or examination by a private dentist).
3. Any lab costs incurred are the financial responsibility of the student patient.
4. An appointment must be scheduled in axiUm and all clinic protocols must be followed.
5. Not as comprehensive care with a full workup, but as limited treatment.

Workflow for student-on-student treatment can be found in the Clinic Binder in each clinic faculty office. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder.

Referrals between the predoctoral program and post-graduate programs occur to enhance the continuity of care in situations where the treatment needs of the patient are beyond the limitations of the predoctoral program. This referral process involves the various post-graduate clinics: AEGD, Grad Ortho, Grad Perio, and Oral Surgery as well as the Adult predoctoral program and must be started through consultation by full-time faculty from the referring department. The workflow for the COD Referral process can be found in the Clinic Binder in each clinic faculty office. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder. 

Dental practitioners must complete the Patient Referral for Limited Treatment in Students Clinics form and submit appropriate x-rays to the Quality Assurance Coordinator via email located on the form. This information is reviewed and the patient is assigned to the appropriate student. In the case of endodontic treatment, the assignment is coordinated with the Chair of Endodontics. When patients needing endodontic treatment are assigned to a student, the student will review the case with the Chair of Endodontics before scheduling the patient in the clinic.

If a patient reports a concern they want addressed by the administration, the Director of Patient Relations should be contacted to help reconcile the patient’s concern. 

The student is granted access to only those patients to which they are assigned. When a patient no longer participates in the program, the student will no longer be provided access to the electronic record.

There are several different record assignments used at the College of Dentistry:  

• Emergency
• Limited Treatment
• Screening
• Dental Hygiene
• Comprehensive Care which includes all assignments for the following clinical courses:  
  • Adult Preventive
  • Patient Contact
  • Clinical Department Care
  • Comprehensive Care

Other areas of record assignments are:

• Faculty Practice
• Advanced Education in General Dentistry
• Graduate Orthodontics Program
• Graduate Periodontics Program

Any student given this type of assignment is granted limited time access only to the record to complete the treatment. 

Treatment History Notes make up the major portion of your required record entries. While documentation of actual clinical interactions with patients is mandatory, all interactions should be recorded. Clinical interactions are actual appointments during which treatment is planned and/or rendered. Non-clinical interactions include all other activities relevant to your patient (telephone conversations, consultations with faculty, appointment arrangements, cancellations or failed appointments, personal observations, etc.).

Treatment history notes should contain facts and avoid the use of statements that convey judgment of the patient or their behavior. When appropriate you may quote the patient in the progress note to be certain that you have accurately conveyed their sentiment.

A template note is utilized by each student who enters the factors of the treatment delivered for each of the appropriate sections. Any contact with the patient that involves dental care decisions or scheduling appointments must be entered into the record within Contact Notes.

Decisions regarding releases, transfers, referrals, etc. are often based on non-clinical activities such as cancellations, failed appointments, and telephone conversations. The assigned Patient Services Coordinator (PSC) is mostly responsible for these entries into the patient record, but you may be asked to enter any supporting information into the record to assist the PSC in addressing these non-clinical entries into the record. 

Start Check / PTP: This step is critical to the delivery of care for your patient. This acknowledges that you have received authorization to begin treatment on the patient. This authorization is time-coded and must be authorized by the supervising faculty. Any student who begins treatment without this authorization will be subject to a minimum of one-week suspension from the clinic.

       Start: Check Notes/Items:

1. Patient presents for: (planned or proposed treatment)
2. Review of medical status
3. Vitals: current blood pressure, pulse, and respiration reading, temperature, and Covid questions
4. Chief concern
5. Contraindications to treatment
6. Request for permission to proceed (PTP)
7. Additional comments

Treatment Note: Upon completion of treatment, the appropriate template note must be completed.

Treatment Conclusion:  Always escort your patient to meet with the Patient Services Coordinator (PSC). Before checkout, students must have all records completed and authorized by the supervising faculty. The next planned appointment must be in the chart to schedule the patient for the next appointment. If the patient does not have any remaining treatment, then a prophylaxis or maintenance appointment must be planned.

Students are required to enter treatment codes and notes into every patient’s electronic health record after the patient’s appointment has been checked out. The Office of Quality Assurance and Compliance will conduct a daily audit of the previous business day’s charts to identify any missing treatment codes and notes. To guarantee students are correctly reconciling patient charts with missing treatment codes and notes, the following corrective actions will be implemented until rectified:

• Instrument holds – students will be prevented from receiving any instruments from Central Sterilization
• Chart locks – will be applied to any charts on the student’s current schedule to prevent the student from beginning treatment

Missing/Unapproved Treatment Codes

1. An autogenerated amail notification, from axiUm, will be sent to each student provider when a code is missing from a checked-out patient’s chart.
2. If the code is not entered and approved by the faculty for that appointment date, an email from the Office of Quality Assurance and Compliance will be sent to the student provider with a deadline for reconciliation.
3. The student should email the Office of Quality Assurance and Compliance once the codes have been correctly entered and approved by the faculty to prevent the implementation of the corrective actions.
4. Instrument holds and chart locks will be released once the student provider has notified the Office of Quality Assurance and Compliance that the patient’s chart has been correctly reconciled.
5. Student providers must enter missing codes and have faculty approve the codes within one (1) business day. It is the student’s responsibility to contact faculty, either in person (physically locating faculty within the building) or via email and amail to have codes approved.

Missing/Unapproved Notes

1. The Office of Quality Assurance and Compliance will email the student providers directly when any notes are missing from a checked-out patient’s chart.
2. The email will contain instructions for correcting the patient’s chart and a deadline for reconciliation. Missing notes must be entered on the same day as receipt of the email; however, notes are not required to be approved by faculty on the same day.
3. The student provider should email the Office of Quality Assurance and Compliance once the notes have been correctly entered and approved by faculty to prevent the implementation of the corrective actions.
4. Instrument holds and chart locks will be released once the student provider has notified the Office of Quality Assurance and Compliance that the patient’s chart has been correctly reconciled.
5. Student providers must enter missing notes within the same day and faculty must approve the notes within five (5) business days. It is the student’s responsibility to contact faculty, either in person (physically locating faculty within the building) or via email and amail to have notes approved.

Sanctions

Student providers who use another student provider's instruments while theirs are on hold will be subject to:

• First offense- Formal write-up for both students
• Second offense – Formal write-up and possible one-week removal from the clinic for both students
• Third offense - Removal from the clinic for a minimum of two weeks for both students

Instruments must be turned in to Central Sterilization at the end of each clinic day and may not be stored in lockers or clinic bags. Students who use instruments that were not turned in to Central Sterilization because their instruments were on hold will be subject to:

• First offense – Professionalism Concerns Report written and filed in student's record
• Second offense – Professionalism Concerns Report written and two-week removal from the clinic
• Third offense – Recommendation to the Dean and Vice Provost for dismissal from the professional program

An integral part of the student’s education in delivering patient care is learning to document all interactions properly and completely while demonstrating consistent continual dental care for all your assigned patients. Proper record management is important for several reasons. The patient record is a legal document; it affords liability protection to the patient, the student delivering the care, the faculty supervising the care, and the College of Dentistry should any questions arise about the treatment rendered. 

The patient record also contains all pertinent information regarding the patient’s medical, dental, emotional, and behavioral background which may have an impact on the type and extent of treatment provided to the patient. Providing dental care without this essential information increases the likelihood of errors and inefficiency in treatment. The patient record is also the primary source of information for institutional decisions about the patient’s treatment status within the teaching program. Issues regarding the transfer, reassignment, division of care, or referral cannot be defended without proper documentation in the patient record. 

The accuracy and completeness of patient records are also important aspects of the College of Dentistry’s accreditation process through the Commission on Dental Accreditation and the American Dental Association. 

Evaluating the student’s capabilities in these areas is accomplished through participation in an auditing process of their patient records. 

Dental Students: 

Beginning in the fall semester of the junior year, each student will be evaluated during audits of all assigned patient records once each semester. The audit includes a review of all records, an identification of deficiencies as per criteria published in the syllabus, and the assignment of a grade in the fall and spring semesters. 

The Group Practice Director performs the audits on the patient records of their respective DS4 students. The Director of Compliance, Director of Quality Assurance and Patient Relations, Clinical Assistant Professor, and the Assistant Dean of Clinical Affairs perform the audits on the patient records of all DS3 students. 

The Patient Records Audits comprise the basis of Clinical Recordkeeping and Patient Management Courses I-IV, 8105, 8505, 9105, and 9505, respectively. The Director of Compliance is the course director.

Dental Hygiene Students: 

Starting in the spring semester of the first year, each dental hygiene student will be evaluated during an audit of patient records. The student will participate in one audit during the first-year spring semester and two audits per semester during the third and fourth semesters. A grade is awarded in their Clinical Dental Hygiene Course for the accuracy of the records audit.  

TAR Form instructions can be found in the Clinic Binder located in the faculty offices within each clinic. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder.

The workflow for Endodontic Approval Protocol for Emergency Patients can be found in the Clinic Binder located in the faculty offices within each clinic. The “official” Clinic Binder is also available in axiUm. The location is axiUm/Links/Clinic Binder.

The workflow for Endo Approval Protocol for Comp Care Patients can be found in the Clinic Binder located in the faculty offices within each clinic. The “official” Clinic Binder is also available in axiUm. The location is axiUm/Links/Clinic Binder.

The workflow for Completing the Graduate Periodontics Referral form can be found in the Clinic Binder located in the faculty offices within each clinic. The “official” Clinic Binder is also available in axiUm. The location is axiUm/Links/Clinic Binder.

The workflow for Limited Treatment Patients can be found in the Clinic Binder located in the faculty offices within each clinic. The “official” Clinic Binder is also available in axiUm. The location is axiUm/Links/Clinic Binder.

The workflow for Oral Surgery Protocol for Consultations, Treatment Planning, and Referrals can be found in the Clinic Binder located in the faculty offices within each clinic. The “official” Clinic Binder is also available in axiUm. The location is axiUm/Links/Clinic Binder.

The workflow for Completing the Oral Surgery Referral Form can be found in the Clinic Binder located in the faculty offices within each clinic. The “official” Clinic Binder is also available in axiUm. The location is axiUm/Links/Clinic Binder.

The Protocol for Coding/Charging for Dispensing of Antibiotics can be found in the Clinic Binder located in the faculty offices within each clinic. The “official” Clinic Binder is also available in axiUm. The location is axiUm/Links/Clinic Binder.

Relative Value Units (RVU) are a set of values assigned as a way of standardizing and comparing service volumes across all disciplines. They reflect the relative level of time, skill, training, and intensity required of a provider to provide a given service. Each student is required to achieve a minimum number of RVUs in each of the following disciplines:

• Fixed Prosthodontics
• Removable Prosthodontics
• Operative
• Periodontics

Specific RVU amounts accumulated for Occlusion, Oral Diagnosis, and Oral Surgery are counted toward the total count necessary for graduation.

An RVU is one (1) hour of clinical time expected for the dental procedure. Although a baseline RVU amount has been assigned to each procedure, the supervising faculty may adjust for the degree of difficulty and for the quality of performance. RVUs earned as DS2 and DS3 students will be included in the requirements for the Comprehensive Care course.

Externship RVUs:

During Externships, students will record all procedures completed using the eCLAS software system. Procedures completed will be added to the final RVU amounts during the Fall and Spring semesters, after receiving Community Dentistry approval.

RVU Amounts:

The Director of Comprehensive Care will provide a current report on the associated RVU for each procedure. The current list of procedure codes with the appropriate RVU amounts can be found within the class D2L site and links. Additional global changes in RVUs may occur during the Comprehensive Care course; a notification will be provided on a timely basis, if applicable. 

There is a fee charged for all dental treatment provided at the OU College of Dentistry. The clinic fee schedule lists the fees charged for dental procedures provided by students in the predoctoral program and the dental hygiene baccalaureate program.  It is reviewed and revised periodically. A copy of the current fee schedule is available in axiUm Links, and a laminated copy can be found in every clinic faculty office area.

Fees charged are approximately 1/3 the cost of those in private practice.  Since clinic fees provide a substantial part of our operating funds, the faculty, staff, and students should pay close attention to and adhere to the strict application of published fees. Deviation from the clinic fee schedule requires authorization from faculty and is entered into the axiUm system via a TAR (Treatment Adjustment Request) form adjustment.  The TAR Form workflow can be found in the Clinic Binder in each clinic faculty office. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder.

A 5-digit procedure code number identifies each procedure in the fee schedule and within the axiUm system.  This code is important to identify the diagnosis and nature of the treatment, determine the appropriate fee to charge and facilitate the insurance filing process.

The first digit identifies the health profession - dentistry is designated "D".  The second digit identifies the discipline (restorative dentistry codes begin with "2", endodontic codes begin with "3" and periodontics codes begin with "4", etc.).  The last three digits identify the specific procedure.  Each major code section ends with a "999" code to be used for any procedure that cannot be identified by a specific descriptive code.  The “999” codes are not to be used for no charge or follow-up visit codes and must have a narrative. All codes coincide with the CDT current approved codes booklet, normally updated, and published each year.

Some codes in the axiUm schedule are presented in slightly different formats.  Codes with the letter “D” are ADA- recognized codes.  Codes that contain a “.1, .2”, etc., or any other numerical code or letter after the period, are to differentiate the steps within our process to complete a procedure at the college. These codes will identify, for example, impression steps or other procedural steps for the fabrication of a restoration. 

Only the ADA codes with no additions to the end of the code are used to create a charged procedure, file insurance claims, or any other method of reporting a procedure for which a charge is made.

The fees listed are based on the nature and complexity of the procedure.  The schedule also contains explanatory notes under some code descriptions to help determine when the use of a particular code is appropriate. If unsure which code to use or what fee to assess, consult with your Group Practice Director, assigned faculty, Patient Services Coordinator, or Clinic Manager.

Although published fees are standard for a given procedure, a fee reduction, waiver, or refund may be warranted on occasion. Only authorized faculty or a designated administrative staff member appointed by the Assistant Dean of Clinical Affairs can approve these reductions or refunds.

The amount of the reduction, waiver, or refund must be entered via a TAR form in axiUm (Treatment Adjustment Request; see section 5.4, “Reporting Protocols for Treatment Delivery”) and approved by the attending faculty. 

Unless circumstances warrant otherwise, partial, or full refunds on Prosthodontics or other work involving laboratory charges will not be allowed. The Director of Quality Assurance or assigned administrative staff must approve all fee reductions, waivers, and refunds.

Patients are expected to pay for services when rendered unless financial arrangements have been made with the Patient Services Coordinator and the Central Business Office. All services that are rendered are charged to the patient's account at the start of the procedure. 

For general information, all payments, except as noted below, may be made by cash, personal check, or approved credit card/debit card. Payments can be made to the assigned Patient Services Coordinator in each clinic or the Patient Account Representative in the south hall near the main service elevators on the third floor. Screening fees must be paid in cash or by credit/ debit card. Patients who are not patients of record but who present for treatment (walk-in emergencies, extractions, etc.) are also required to pay in cash or by credit/debit card for services rendered for the procedure to be performed. 

Patients who have delinquent financial plan payments or a delinquent account balance will be suspended from further treatment (and subject to release from the predoctoral program) until their account balance is satisfied. New services will not be scheduled until the outstanding account balance is satisfied. When the financial plan is current, or the account balance is $0.00, treatment can be continued.

If there is no payment activity on an account, a 30-day balance reminder letter of delinquency is sent to the patient.  If payment is still not received, a 60-day balance reminder is sent to the patient.  The patient will be given 15 days to respond, and if no payment is received within the next 15 days, the account is turned over to collections, and the patient is automatically released from the program.  Reinstatement is considered only if the patient agrees to [1] pay the total amount outstanding on the account and [2] maintains a zero balance during the remainder of treatment. Only the Director of Patient Relations can approve reinstatement. If there is a planned appointment, the PSC will be notified via the axiUm mail system when a delinquency letter is sent to one of that group practice’s patients.

Discounts are not available to student family members, College of Dentistry staff, and staff family members screened for patient care in the predoctoral program.

Many of the patients seen at the college have dental insurance. The Patient Services Coordinator assigned to each clinic receives the necessary information to file claims on the patient's behalf. 

A general note on insurance: pre-authorization is required for many large claims.  Your Patient Services Coordinator can provide you with additional information in these situations. 

A proposed treatment plan (with estimated costs) must be provided to the patient via the axiUm system. While the college files the necessary insurance claims, the patient is still responsible for the payment of the account.  As a note of interest for the insured patient, very few procedures are paid-in-full, with many insurance companies limiting the number of procedures during a specific period. Most insurance carriers have deductibles ranging from $25-$100 and maximum reimbursements ranging from $1000-$1500 per calendar year. 

Patients are expected to pay for treatment when rendered. If a patient has insurance, their co-payment is expected at the time of service. Your Patient Services Coordinator will provide any additional information as needed.

Many insurance carriers, for which the College of Dentistry is a non-participating provider, pay the patient directly.  In many cases, even though the patient has dental insurance coverage, the patient may not have any benefits if a non-participating provider provides services.  Clarification can be requested from your Patient Services Coordinator.

Complete information must be in the axiUm record for proper filing of the insurance claim. The Patient Services Coordinator will request any further information that is required for the claim to be filed. Please keep in mind insurance carriers may need some additional information, such as the initial placement of full coronal restorations or a filling. If dentures or partials are replaced, insurance carriers require the original date they were placed and the date and tooth numbers originally extracted. All insurance claims are filed automatically once the procedure has been completed via the axiUm system. 

Program Overview

Delta Dental of Oklahoma’s Charitable Foundation (DDOK) sponsors funding for our indigent care patients. Funding is available for the spring and fall semesters to those patients who have incomes 100%, 150%, and 200% above the federal poverty level until the funds are depleted for each semester. An income matrix is used to determine the maximum funding amounts of $375, $750, or $1500 to be applied toward the patient’s comprehensive treatment plan based on the current poverty levels. An assigned patient will be provided with the required application to begin the process. Detailed criteria for covered and non-covered services can be obtained from your Patient Services Coordinator. In general, any esthetic treatment is not covered by charitable funds.

The college from time to time will engage in other charitable funds programs. You will receive information at the appropriate time if these programs are in place.

As mentioned, patients are expected to pay in full for services when rendered (initial appointment).

• For fixed prosthodontic treatment, 50% of the fee must be paid when the procedure is initiated and the other half before delivery or cementation.
• For single crowns and bridges, the business office must give approval, via axiUm, before the Support Laboratory can issue any gold for procedures.
• Complete and partial dentures must be paid in full prior to sending the case to the lab for processing.

Note: the metal issued to students for preclinical usage is not acceptable metal for intra-oral use. This metal is for teaching purposes only.

• For dental services that span multiple appointments such as fixed/removable prostheses, scaling/root planing, complex endodontics, etc., the total fee will be charged at the initial appointment.

If a patient terminates their association with the College, a refund for the credit balance (if applicable) will be issued.

When the creation of the Master Treatment Plan is complete, the patient will sign the treatment plan, which becomes an estimate of the total costs involved in performing the recommended treatment, and a copy will be provided, if requested, to the patient. This is a treatment plan estimate only; quoted fees may change if treatment is modified during care. 

Fee increases that occur during a patient’s treatment plan are normally honored for the initial treatment plan fees if treatment on the patient is currently in process. For any patient that has not had continual treatment for 90 days, the treatment plan will be charged at the new fee schedule. 

The Division Head of Oral Diagnosis and Radiology must have advanced training in radiation physics, radiation biology, radiation protection, radiographic techniques, and radiographic interpretation appropriate for the group being instructed.  All dental faculty and teaching staff that supervise student clinical radiology activities must have credentials signifying their qualifications and good standing within their disciplines.  Students must be supervised by the teaching staff and faculty during all radiographic procedures.

The College's ionizing radiation guidelines comply with the Radiation Control for Health and Safety Act authorized by FDA, the Consumer-Patient Radiation Health and Safety Act, the Oklahoma Department of Health Rules and Regulations, the Oklahoma State Dental Practice Act, and the recommendations of the American Dental Association and the American Academy of Oral and Maxillofacial Radiology.

The Division Head of Oral Diagnosis and Radiology shall serve as the College's Radiation Protection Representative (RPR) with advice and input from the Clinic Operations Committee. 

1. The RPR is responsible for establishing, implementing, and monitoring policies on radiographic practices for all diagnostic radiation sources in the College. They will also work in cooperation with established university radiation standards and radiation protection programs to coordinate, monitor, and control the use of x-ray and other imaging equipment.
2. RPR will work in cooperation with the Director of Compliance and the Health and Safety Committee at the College of Dentistry.
3. Only faculty, students, and staff certified by training will acquire radiographic images. Students will perform the radiographic procedures under the supervision of dental faculty and trained staff.
4. The dental faculty and the student will establish a need for diagnostic radiographic images by tentative diagnoses by evaluation of patient history and clinical examination. Faculty will prescribe the appropriate radiographic procedures in electronic health record system before exposure.
5. The RPR will conduct periodic continuing education programs for all staff operating x-ray generating and processing equipment. All such staff must be thoroughly conversant with all materials regarding radiation hazards, safety practices, and state and federal radiation rules and regulations.
6. Radiographic images made as part of a diagnostic workup should be confined to the Oral Radiology clinic whenever possible. Reasonable exceptions are radiographic images made as part of treatment in other clinics, off-site training programs, and student externships and unavailability of radiology clinic.
7. The RPR is responsible for implementing and monitoring a facility-wide radiographic quality assurance program. The RPR and the Clinic Policies Committee are responsible for controlling the use of ionizing radiation and for ensuring the consistent application of this policy by all clinical departments and programs. Every entity with radiographic capacities is expected to monitor daily compliance with this policy. All actions taken to maintain safety and quality must be documented with quality assurance activities in each department. Applicable portions of this policy must be posted or otherwise available in each satellite area.

Introduction: The appropriateness of dental care is intimately related to the accuracy of diagnosis. Dental radiographic images constitute a vital diagnostic tool in dental practice. While the risks of ionizing radiation to patients and operators are not fully understood, statistical risk estimations must be weighed against specific benefits. Risk analysis is usually based on the biological effects seen in laboratory studies and at higher doses. These data are then extrapolated, and inferences are made about the hazards to human beings exposed to x-radiation. It is accepted that diagnostic levels of x-radiation can potentially cause harmful effects. This concern alone demands that professional judgment always be used when handling radiation. 

Purpose: The purpose of this document is to establish guidelines that will govern the use of ionizing radiation within the College of Dentistry. The intent is for patients to receive minimal radiation necessary for diagnosis and treatment. The decision to expose any patient to radiation for diagnostic purposes should consider that any exposure to ionizing radiation is potentially harmful. The policy statements in this document apply to all patients treated or evaluated within the College of Dentistry. The only exceptions are consenting patients participating in research protocols approved by the Radiation Safety Committee and the Office of Research Administration / Institutional Review Board of the University of Oklahoma Health Sciences Center (OUHSC). 

The ionizing radiation guidelines in this section are reviewed annually and revised, as necessary. They incorporate those procedures and protocols that improve the risk-benefit ratio by maximizing the diagnostic yield from radiography and minimizing exposure to unnecessary radiation. Staff, faculty, and students are expected to be thoroughly familiar with these guidelines and to apply them in every instance of radiation use.

Policy Statement: To minimize radiation exposure to faculty, staff, students, and patients, the making of all radiographic images must be strictly governed according to the following protocols:

1. Follows the published Food and Drug Administration, American Dental Association, and the American Academy of Oral and Maxillofacial Radiology guidelines, standards, and regulations pertaining to use of dental radiation and prescribing dental radiographs.
2. The prescription for all radiographic images must be added to the patient's record and authorized by the licensed attending dental faculty member. Prior radiographic images, if available, should be evaluated before new radiographic images are ordered. Only those additional views needed for complete diagnosis/treatment planning will be exposed. This does not preclude making a new intraoral full mouth survey if it is appropriate to the diagnosis.
3. The need for all radiographic images, as established through history and clinical examination, is based on the professional judgment of dental faculty and licensed dentists.
4. Radiographic images ordered on a routine basis, without patient’s need, are prohibited. Screening radiographic images will be kept to the number needed to determine the acceptance of a patient for treatment and will become part of any subsequent diagnostic radiograph series in the patient’s record.
5. When a need for radiographic images is established, students will be required to produce a minimum number of radiographic images consistent with an adequate diagnosis of disease.
6. Radiographic images should only be made on patients capable of compliance. Non-compliant patients may be referred for the procedure to be done under appropriate sedation.
7. The need for radiographic images during and/or after treatment, and the frequency of recall radiographs, will be based on the patient's needs and the professional judgment of the attending dental faculty.
8. Retakes/remakes should be approved by a faculty supervisor or radiology staff before retaking any images. The student must identify the faulty image, cause of error and correction method. Faculty or trained staff must provide input and assist students during retakes. Students may retake an image once after consulting with faculty or trained staff. If additional retakes/remakes are needed, they must be done under the direct supervision of the faculty or trained staff. Retakes should be taken only for a valid clinical or diagnostic reason, not the purpose of improving the esthetics of the radiograph.
9. If a student is judged to lack the required technical skills, they will be required to complete a competency review in technique and knowledge of radiation protection principles with the Division Head of Oral Radiology.
10. Radiographic surveys shall show appropriate region of interest including crown of teeth, root apex, surrounding periapical bone, and each crown with minimum overlapping.
11. The policy for exposing radiographic images for staff, faculty, students and patients is the same.  Radiographic exposures will only be made when there is a potential benefit by the discovery of useful information on the radiograph.
12. Radiographs for teaching purposes only are not allowed. 
13. Radiographic images will not be made only for administrative or research purposes (including insurance claims or legal proceedings). However, diagnostic radiographic images may be used for administrative purposes. Radiographic images of patients will also not be made only for training or demonstration.
14. Professional judgment and selection criteria must be used to determine the frequency and extent of each radiographic exposure.  Every effort must be made to limit radiation exposure to the patient and the operator.  
15. Imaging For Research: Any research related radiographic imaging activity must be approved prior to start of a project by the Institutional Review Board (IRB) at the University of Oklahoma Health Sciences Center. Activity must stop at the end of approval period from IRB.
16.  ALARA principle applies to all types of imaging. All the radiographs must be prescribed by a licensed faculty member.  Appropriate codes should be entered and completed in the patient’s electronic health record.

All exposed radiographic images must be made according to the following guidelines. Any technical deviations must be approved by the attending dental faculty or trained staff. 

1. A clinical examination must be performed first to determine if radiographs are needed or not. Based on clinical judgment and the patient’s history, the provider decides what radiographs (type and number) are needed.
2. Providers must ask the patient if any radiographs were taken outside OUCOD. If yes, ask the patient to provide any details they can remember such as the date taken, what type, and how many. 
3. For pre-doc clinics, radiographs from outside practices can be emailed to radiology at CODRADIOLOGY@OUHSC.EDU.
4. Patients can request an outside practice to email the radiographs to OUCOD on this email. Radiology staff cannot make this request. Radiology staff can only upload images that are digitally received on this email. It would be best if radiographs were received before the day of the appointment.
5. If any radiographs are found to be undiagnostic, retakes can be done based on the clinical judgment of the provider/faculty.
6. To minimize risks associated with radiation exposure, use the fastest imaging system appropriate for the diagnostic need. At OUCOD, digital image receptors of varied sizes are used. 
7. Periapical and bitewing radiographic images are acquired with circular or rectangular collimation that limits the beam to a diameter of 2.75 inches or less at the patient's face. Use open-ended, shielded beam-indicating devices (BID) only. 
8. Ensure that the target-to-skin distance for intraoral radiography is no less than 8 inches. Long BID length is preferred. 
9. Use image receptor holding devices during standard intraoral techniques. Digital retention of intraoral image receptors is not recommended. 
10. Protective body aprons and thyroid shields are currently optional for all intraoral radiographic imaging.
11. Operators using hand-held devices must wear protective aprons.
12. Operators should not hold patients or image receptors during the radiograph exposures. If assistance is required for children or disabled patients, an adult member of the patient's family or other non-radiation staff may help. If the need arises, the operator must wear a protective apron when stabilizing the patient or image receptor and stay out of the primary X-ray beam. 
13. The operator should not stabilize or hold the tube head of a wall-mounted or mobile x-ray unit on wheels by hand during exposures. During each exposure, the operator should stand out of the primary beam and stand behind an adequate protective barrier that permits patient observation and communication. The tube head must not vibrate or drift during exposure. 
14. For fixed wall-mounted tube heads, the exposure button must be located behind the barrier or at a safe distance. Operators must apply continuous pressure on the exposure button throughout the exposure time until the exposure cycle has been completed. 
15. Portable mobile X-ray generators and hand-held devices such as Nomad must be used with proper precautions.
16. Fixed wall-mounted X-ray generators shall have a posted list of “average” exposure factors that are appropriate for the views taken with that machine. Professional judgment must be used if an adjustment is needed.
17. All x-ray generators must meet federal requirements for collimation and filtration: Total filtration of x-ray machines should not be less than 1.5 mm aluminum equivalent at 70 kVp or less and not less than 2.5 mm on machines operating above 70 kVp.  Collimation: beam diameter of 2.75 inches or less at the patient's face.
18. If a malfunction is detected in an x-ray generating unit, do not use the unit unless the necessary corrections have been made and the equipment recalibrated. Report the malfunction to the Division Head of Oral Diagnosis and Radiology. 
19. For extraoral radiography, restrict radiographic images to the area in question and with the beam collimated equal to or smaller than the size of the image receptor. Use the fastest extraoral digital image receptors appropriate for the diagnostic need.
20. The number of radiographs needed for a patient will vary depending on the type of encounter, various clinical situations, history, risk factors, available radiographs, etc. Please review the ADA/FDA guidelines for prescribing dental radiographs.  
21. There is no such practice as taking radiograph(s) every 6 months or every year on a patient. This is incorrect practice. Taking radiographs before any clinical examination is also an incorrect practice.
22. All radiation exposures for each patient must be included in the patient's record.
23. Current ADA / FDA guidelines for prescribing dental radiographs can found at: https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations
24. Evidence for discontinuing radiographic shielding: https://jada.ada.org/article/S0002-8177(23)00391-4/fulltext
    As you will note, the Position Statement makes two recommendations:
    1. Discontinuing shielding of the gonads, pelvic structures, and fetuses during all dentomaxillofacial radiographic imaging procedures
    2. Thyroid shielding not be used during intraoral, panoramic, cephalometric, and cone-beam computed tomographic imaging

The College of Dentistry will follow standard/universal precautions during all patient care. The operator is required to adhere to the following infection control practices before, during, and after all radiographic exposures:

RADIOLOGY ROOM SET-UP AND INFECTION CONTROL PROCEDURES

***NOTE TO Student: Please read before you start.

Before retrieving your patient:

• Your room will be assigned by one of the staff in Radiology.
• Each room will only have a Dexis sensor on the wall holders next to the monitor.
• All other clean supplies will be on the table inside the room except cotton rolls, edge ease, tube cover, and rubber bands.
• Be sure to wash (sanitize) your hands before setting up your room.
• Chair: Place a clean big (opaque colored) plastic bag on the chair's back.
• BID: Secure a plastic bag on the tube head.
• Place a rubber band on the BID to keep the plastic bag tight.
• Put blue sticky barrier tape on three (3) items: the timer button inside the room, the mouse, and the exposure button outside the room.
• Place a blue napkin on one side of the keyboard tray, inside the room. This is for your sensor and XCP’s as you use them in the patient’s mouth. Since the items will become contaminated, this napkin will keep them isolated in one place.
• Cover the keyboard with a plastic bag in the room called a “Keyboard Cover”.
• Cover the sensors with a plastic sleeve first, then place a finger cot over the plastic sleeve. Lay the covered sensor on top of the blue napkin.

***Put on your gown, mask, and protective eyewear: DO NOT WEAR GLOVES TO GET THE PATIENT. Your gloves will be placed when starting images.

Bringing the patient back to the room:

• At the patient's request, place the protective shielding on the patient.
• Remove the patient’s eyeglasses and any removable dentures.
• Discuss exposure time with the assigned staff member before taking images.
• Be sure to wash your hands, put on clean gloves, then start your images.
• When you have completed your images, they will be evaluated and approved before you dismiss the patient and begin room clean-up.
• Once approved, remove your gloves, then take off the lead apron and collar from the patient, hang them up, and dismiss the patient to the waiting room, escorting them if necessary.

ROOM CLEAN-UP PROCEDURES

After dismissing the patient:

• Put on a new pair of gloves.
• Remove all barriers placed: chair, tube head, timer button, mouse, exposure button, tray, and sensor.
• Take all contaminated instruments (XCPs, etc.) and borrowed eyewear to the sterilization room marked “Darkroom”.
• Disassemble the instruments, then place the items in the container of soapy water specifically marked for each item.
• Return to the room used for images, put on a new pair of gloves, and begin clean-up with “PDI Wipes”.
• Disinfect the chair and the tube head arms, not the tube head.
• Remove barriers from the sensor, wipe the cord, and then hang it up in the slot provided on the wall. If a breach (saliva contamination) occurs during images, wipe the sensor with PDI wipes (gently and not over-saturated) before hanging the sensor in the slot provided on the wall.
• Disinfect the black tray that holds the keyboard and mouse.
• Disinfect the protective shielding, if used.
• Remove your gown; however, remain in your mask until exiting the clinic.

1.  While wearing clean gloves, place a transparent plastic sleeve over the sensor using the outer sleeve to cover the activation switch.

2. Next, slide the finger cot (nitrile barrier) over the transparent sleeve and sensor.

3. Take the images with XCP and the sensor.

4. Remove contaminated gloves. While wearing clean gloves, remove all barriers from the sensor.

5. Disinfect the cord only with PDI wipes.

6. DO NOT DISINFECT THE SENSOR. Only if a breach has occurred (saliva contamination), disinfect the sensor with a PDI wipe. 
7. Hang the sensor on the wall or place it into the sensor case.

Portable or mobile X-ray equipment is defined as an X-ray machine mounted on a permanent base with wheels and/or casters for moving while completely assembled. Below are additional requirements for portable X-ray equipment (in addition to the requirements for wall-mounted X-ray units):

1. Before using a new machine, approval from the Division Head Oral Diagnosis and Radiology will be obtained for a specific location(s) and procedures to ensure compliance with x-ray permits. The machine will be tested by the Radiology staff before use.
2. During the exposure, the operator: 
   a. Must be positioned so that their exposure is as low as reasonably achievable (ALARA). 
   b. Should never be in line with the direct/primary x-ray beam. 
3. Operators and bystanders (other than the patient) should be at least 6 feet away from the x-ray machine when energized or have suitable shielding utilized.
4. The tube housing should not be held by the operator during exposure.
5. Infection control guidelines must be followed.

NOMAD is a Food and Drug Administration (FDA) 510(k) approved hand-held x-ray unit that has demonstrated substantial equivalence to a portable intraoral x-ray system designed for field use. The patients scheduled for routine intraoral radiographs at the College of Dentistry will continue to be imaged using fixed wall-mounted or mobile X-ray machines. The radiology division will provide training for the safe use of NOMAD to the staff, faculty, and students. Dental and hygiene students will be introduced to the fundamentals of using the NOMAD X-ray device during the pre-clinical radiology courses. Training sessions will be offered periodically for the staff and faculty. Daily, attending clinical faculty or the clinic dispensary staff should be familiar with safe handling of the hand-held. Help and training should be sought from Radiology as needed. 

Below is a summary of guidelines for NOMAD (hand-held X-ray generator):

1. The NOMAD must be checked out by the operator from the clinic dispensary or staff office.
2. Students using the NOMAD will be under the supervision of the attending faculty. Standard radiation protection procedures must be followed; the only exception is that the operator of the NOMAD is physically present in the operatory with the patient during the x-ray procedure.
3. The NOMAD’s circular protective shield must always be in place, at the recommended position (on the outer edge of BID towards the patient).
4. Operator must try to stay behind the Nomad during exposure and try to hold it as close to the patient’s face / target as possible.
5. Image receptor holding devices (XCP or tabs) should be used with the Nomad.
6. Shorter XCP rods are available in clinics for using with NOMAD.
7. Operator must use both hands to hold the Nomad unit to ensure steady support during the procedure.
8. Nomad must be returned to dispensary personnel upon completion of the x-ray procedures.
9. According to the recommendation by the medical physicist, the operator must use a protective body apron during the imaging.
10. Operator must make sure that the Nomad and the patient will not move during the procedure.
11.  Operators must keep all others at least 6 feet away from the primary source of radiation.
12. Nomad can only be used in approved locations. For example, general waiting areas are not approved locations.
13. To prevent the spread of infections, the Nomad should be disinfected after every patient using wipe-discard-wipe technique with approved wipes.
14. Persons (students, staff, and faculty) using the Nomad machine will be responsible for controlling the immediate area in which the device is used.
15. In situations such as research studies, where one operator may be taking extreme numbers of images, a radiation-monitoring device may be required.

The staff in the main radiology clinic will be responsible for the quality control checks in the clinics and implementing whatever corrective measures are necessary to maintain the quality of the radiographic images.

1. All machines capable of producing ionizing radiation and processing units are under the auspices of the Division Head Oral Diagnosis and Radiology. An annual inspection of all X-ray equipment will be done to maintain performance standards by a qualified radiation physicist. Inspection reports will be kept in a logbook in radiology.
2. Any irregularity or malfunction in an X-ray generator will necessitate that it be turned off until a determination has been made, by a qualified radiation expert, that it is safe to operate. 
3. An X-ray generator should not be operated by any student or staff in such a fashion that it would endanger either the operator or the patient. Failure to observe this will result in the discontinuation of radiology privileges.

All radiation workers should receive as little radiation as reasonably achievable (ALARA). Personal radiation monitoring devices (Thermoluminescent personnel monitoring devices) or dosimeters can be worn during working hours by all faculty and staff who regularly use the X-ray equipment. Request to wear a badge must be made via email to the Division Head Oral Diagnosis and Radiology.

Radiation workers: No employee (radiation worker/occupationally exposed worker) should receive more than 5 rems (5,000 mrem or 0.05 sievert) whole-body radiation exposure each year. This is the radiation protection guide value. For an added precaution, quarterly readings above 10 percent of the radiation protection guide (0.5 mSv, or 50 mrem) should be investigated. Dosimetry reports must be kept as a permanent record for each employee and be made available for inspection by the employee.

Declared pregnant radiation worker: The worker's dose limit remains at 5000 mrem per year regardless of her declaration of pregnancy. The Declaration of Pregnancy initiates the dose limit for the fetus. The dose limit for the fetus is 500 mrem for the entire pregnancy. If, upon declaration of her pregnancy, the fetal dose is determined to already be 450 mrem or more, the worker's dose limit for the remainder of her pregnancy is 50 rem.

The Radiation Safety Officer (RSO) of the University of Oklahoma College of Dentistry must receive written notification of pregnancy from the pregnant individual. It is recommended that a pregnant radiation worker declare her pregnancy so that her occupational radiation exposure potential can be evaluated to ensure that the dose to the unborn child does not exceed 500 mrem (0.5 rem) over the duration of the pregnancy. Please consult with RSO and / or Division Head of Oral Diagnosis and Radiology for further assistance.

Radiation safety manual of the University of Oklahoma Health Sciences Center can be found at:

Radiation Safety Office Documents (ouhsc.edu)

General public: The limit to members of the public (including employees not involved in working with sources of ionizing radiation) is 100 mrem (1 mSv) per year resulting from licensed or registered activities at this institution.

All radiation exposures for each patient must be included in the patient's record.

This form letter is provided for convenience. To make a written declaration of pregnancy, fill in the blanks in this form letter, use a form letter the licensee has provided, or compose your own letter. Submit this to the Director of Compliance at OUCOD.

DECLARATION OF PREGNANCY 

To: ________________________________________________ 

            In accordance with the NRC’s regulations at 10 CFR 20.1208, “Dose to an Embryo/Fetus,” I am declaring that I am pregnant. I became pregnant in ____________________ (only the month and year need to be provided). 

            I understand the radiation dose to my embryo/fetus during my entire pregnancy will not be allowed to exceed 0.5 rem (5 millisieverts) (unless that dose has already been exceeded between the time of conception and submitting this letter). I also understand that meeting the lower dose limit may require a change in job or job responsibilities during my pregnancy. 

________________________________ 

(Your signature)

________________________________ 

(Your name printed) 

________________________________ 

(Date) 

8.13-8.13-11

Please contact Director of Compliance at the University of Oklahoma College of Dentistry for further guidance.

Further information about radiation safety can be found at the main office of University of Oklahoma Health Sciences Center, Office of Compliance:  http://compliance.ouhsc.edu.

There is always the possibility, however slight, that a medical emergency may arise. The following constitutes a standard protocol for the initial management of all medical emergencies:

1. Position the patient properly (varies with the type of emergency) and make sure they are breathing. Ensure that airway and circulation are adequate. Be prepared to administer basic life support and cardiopulmonary resuscitation (CPR) as necessary.
2. Dial 911, monitor vital signs (pulse, respiratory rate, and blood pressure), and assess the level of consciousness.
3. Notify both the attending faculty and the Director of Compliance by calling 1-3083 or 405.473.6064. The supervising clinic faculty must remain with the person needing emergency treatment, as they are responsible for the life support of the person until appropriate help arrives.
4. Obtain a medical emergency cart.
5. Complete an Emergency Treatment Record form located in the emergency cart.

1. If you suspect the visitor/patient is having a cardiac arrest (not breathing and/or no pulse), CPR should be instituted immediately and a bystander should retrieve the Automatic External Defibrillator (AED) from the nearest location (South hallway on 1^st floor and north hallway on floors 2-5).  Notify the clinic faculty.
2. The student/resident will Call 911, Campus Police will ask the following questions: 
   a.  Nature of emergency
   b.  Identify the College
   c.  The floor 
   d.  The room/clinic number
3. Remain on the telephone until the EMS arrives.
4. Send someone to the 1st-floor main entrance to meet the EMS.
5. Inform the Director of Compliance by calling 1-3083 or 405-473-6064 as soon as possible.
6. Document the specifics of the emergency and the actions taken in the patient’s electronic health record (EHR). Document all medications dispensed, dosage, route, and time on the Emergency Treatment Record (see Section 5.2.12) located in the medical emergency cart. Give a copy to EMS when they arrive and keep a copy for our records. This will be scanned into the EHR.
7. Following proper disposition of the emergency, the healthcare provider (student, staff, resident, or faculty), and the attending faculty member must prepare a detailed report of the incident including names, dates, times, circumstances of occurrence, treatment rendered, condition of the patient, and final disposition of the case on a Clinical Incident Reporting Form (see Section 5.2.12). Provide this report to the Director of Patient Relations and Director of Compliance. A copy of the report will be forwarded to the Dean’s Office.
8. Suppose a patient reports an adverse incident to the healthcare provider or the patient service coordinator (PSC) by telephone during off-hours. In that case, the incident needs to be documented in the patient’s EHR and reported to the Director of Compliance the following business day. 
9. Neither the healthcare provider nor the faculty involved should make any statements to the patient regarding the final disposition of any medical, ambulance, and treatment fees. All documentation will be forwarded to the OUHSC Office of Risk Management, which will assist the visitor with additional questions.

Report all accidents or medical events, whether emergency or non-emergency in nature. Call 911, if necessary, and report the incident to the Director of Compliance (DOC) in Room 234, by calling 405-271-3083.

If an accident (for example; falling down the stairs or falling in or around the building) occurs to a visitor or patient not involved in dental treatment, contact the DOC and/or the Campus Police at 405-271-4911 to investigate.

Examples of an accident or incidents while providing treatment are:
a.  Cutting patient lip/tongue
b.  Wrong site surgery/procedure

1. Procedures to follow are:
   a.  Alert your supervising faculty
   b.  Call the Office of Compliance for assistance at ext. 1-3083 or 46876. If unavailable, call the Director of Patient Relations at 34031.
2. Document on Clinical Incident Reporting Form.
3. The form goes to the Office of Quality Assurance and Compliance, Room 238.
4. The Director of Compliance will assist in providing appropriate emergency care if the patient needs it.

The Director of Quality Assurance and Patient Relations will help provide an appropriate administrative response to the incident. 

This report is confidential, protected by the work product and peer review privilege, and intended to record an incident that may expose the OU College of Dentistry to liability.  The Clinical Incident Reporting Form is prepared in anticipation of litigation and may be discoverable in any future litigation. To protect this privilege, please:

1.   Disclose this report only to the following persons authorized to review it:

Director of Compliance
Director of Patient Relations
Assistant Dean of Clinical Affairs

2.   Do not disclose this document to unauthorized persons (including patients).

3.   Do not mention or place it in the dental record.

4.   Do not photocopy, fax, or duplicate in any form the completed report.

This document will be kept on file in the Office of Quality Assurance and Compliance, Room 238.

The Clinical Incident Reporting Form should be completed in situations where clinic outcomes of treatment are less than desirable. Supervising faculty should assist students in completing this form and signing it prior to submission.  The Office of Quality Assurance and Compliance will keep this document on file at the College of Dentistry.

The Clinical Incident Reporting form is available in all clinics in the Clinic Binder. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder.

INSTRUCTIONS FOR COMPLETING THE CLINICAL INCIDENT REPORTING FORM

A student, practitioner, or faculty member shall complete this report when an incident that causes a negative response by a patient or family member occurs or is suspected to occur.  All sections should be completed as applicable.  

Demographic information:  Please include ALL information regarding the patient record, those people involved, and the clinic in which the incident took place.  Indicate if informed consent was obtained in written or verbal form.

I.   Occurrence: Include a concise description of the incident and the names of any other individuals who witnessed the incident; if additional space is needed, the back of the form may be used.  All written reports should only contain facts and should not include opinions, conclusions, or judgments.

II.  Discovery: Indicate all individuals that acknowledged the incident, including the patient, family members of the patient, or a person escorting the patient.  Provide a description of the information given to this person(s) and indicate whether a prognosis and any follow-up care were discussed.  Be certain to indicate the patient’s understanding of the explanation for the cause of the incident and their satisfaction with that explanation.  If a resolution was proposed to the patient include a description of the terms discussed.

III. Resolution: Indicate who INITIALLY offered reimbursement to the patient. Supervising clinic faculty should indicate who requests reimbursement for approval by Clinic Operations (either Supervising Faculty or the Department Chair). Be certain to indicate in the “Patient’s Comments” any questions or remarks made by the patient in response to the terms of reimbursement. Additionally, a description of any arrangements such as remakes, special arrangements for treatment in other clinics, etc. should be included in the section on “Arrangements Made…”.  “Additional Comments” should include a brief discussion of the patient's concerns regarding how the situation was managed and any remarks that may be the result of a conversation with a family member or person escorting the patient.   

BOTH FACULTY AND STUDENT OR PRACTITIONER MUST SIGN THE REPORT AND DATE OF COMPLETION

A copy of the treatment progress notes from the patient’s dental chart must be attached to the form and returned in an envelope marked CONFIDENTIAL to the Office of Quality Assurance and Compliance, in Room 238.

This form will be available in all clinic faculty offices and should be completed immediately following the incident. 

Upon receipt, the Office of Quality Assurance and Compliance will review this form with the appropriate departmental faculty to determine a course of action and prevent future incident recurrence. Students and faculty should refer any further communication from the patient regarding the incident to the Director of Patient Relations. This report shall be shared with the OUHSC Office of Legal Counsel and the OUHSC Campus Risk Management Office.

1. The College of Dentistry has a Cardiac Science Model G-5 automatic external defibrillator (AED) on each floor.
2. All AEDs contain both adult and pediatric defibrillator pad sensors.
3. The AED on the first floor is found on the southwest brick wall next to the Commons. The AEDs on floors 2, 3, 4, and 5 are found in the north hallway.
4. The Office of Compliance is responsible for testing and maintenance of the AEDs.
5. The Office of Compliance is responsible for sending annual reports to the OUHSC Office of Risk Management.

In addition, all AED compartments contain Blood Clot kits. The contents of the kit are as follows:

• Bag (TORK) 
• Bear Claw Nitrile Glove, Large 
• Nasopharyngeal Airway 28F with Lubricant 
• HyFin Vent Chest Seal Twin Pack 
• ARS Needle Decompression Kit (14g x 3.25") 
• C-A-T (Combat Application Tourniquet) Blk 
• Z-Fold Combat Gauze 
• S-Rolled Gauze (4.5" x 4.1yard) 
• ETD 6" Emergency Trauma Dressing 
• Trauma Shears (7.25") 
• Polycarbonate Eye Shield 

Red Emergency Carts are available in every student clinic. The Inventory Associates and/or Clinic Assistants complete a Monthly Emergency Cart Checklist (the form is available from the Department of Compliance). The purpose is to identify expired or missing medications and supplies and to replenish oxygen tanks. Each clinic’s checklist is turned in to the Director of Compliance (DOC) for record keeping. The DOC maintains all emergency cart contents for replacement when expired. All expired medications are disposed of according to OUHSC hazardous waste disposal protocol. The emergency carts are equipped with the following items:

Emergency Cart Contents

Albuterol Inhaler
Aspirin 81mg
Diphenhydramine 25mg tablets
Diphenhydramine – 1mL vile IM injectable
Epi-Pen Adult and/or Child
Epinephrine 1:1,000
Insta-Glucose
Naloxone Hydrochloride 2mg
Nitro-lingual tablet 1mg/mL

Glucometer, test strips, and lancets
Oxygen tank
Positive and passive pressure O₂ mask

Airway - adult and child
Alcohol prep pads
2 x 2s in a pouch
Blood Pressure Cuff/Stethoscope
Coban Wrap
Flashlight
Latex free tourniquet
Microshield
Notepad/Pencil
23-gauge needle
5cc syringe
Pocket mask
Scissors
Thermometer - infrared
Tongue blades
Tonsil Suction
Treatment Record

The Emergency Evacuation Plan for the OU College of Dentistry is located on the College of Dentistry website. The Emergency Evacuation Plan provides details on:

• How to exit the building in an emergency.
• Where your muster point is located - 300 feet away from the COD.
• Who to check in with.
• Active Shooter/Threat or Lockdown information.
• Severe weather locations.

Note: The COD does not have fire drills; if you hear an alarm sounding, exit the building and proceed to your muster point. 

This document outlines the parameters that guide decisions relative to the care of patients who present with elevated blood pressure. The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines for blood pressure targets and treatment recommendations were updated as of November 2017:

*Non-compliant w/ therapy or intensify anti-HTN Rx therapy; treat anxiety prn.

GUIDELINES:

All BP measurements and vital signs taken must be recorded in the patient’s electronic health record (EHR) immediately Students are required to measure vital signs at each appointment. 

•    Blood pressure should be measured using a sphygmomanometer and stethoscope or calibrated stand (oscillometric) monitor. Other calibrated oscillometric (electronic) BP measuring devices may be used except for wrist cuffs.
•    Support the arm and make sure the BP cuff is at heart level and the patient is sitting upright with both feet on the floor.
•    If elevated, have patient sit quietly for 5 minutes then remeasure. Consider measuring in both arms and record the higher reading.

• Utilize appropriate stress management protocols. In patients with hypertension who are anxious or fearful, consider use of intraoperative inhalation sedation with nitrous oxide / oxygen.
• Additional appointment management protocols. Avoid rapid position changes to minimize the risk of orthostatic hypotension. For patients with BP measurements greater than 140 / 90, periodic monitoring of BP during treatment, and at the conclusion of the appointment, is advisable.
• Capacity to tolerate care; Hypotensive. Patients with BP measurements below 90/60 should be questioned to determine if treatment may continue. Have or do they:  
• Do you faint, have vertigo, or have blurry vision?
• Do you fall? 
• Have you started a new blood pressure medication or any new medication?
• Have you taken any non-prescribed medications or street drugs?
• Have you been diagnosed with renal disease?
• Have you been diagnosed with congestive heart failure or irregular heartbeat?
• Do you have a well-balanced diet including water intake?
• Is this a normal blood pressure reading for you? 

• Capacity to tolerate care; Hypertensive. Patients with BP measurements 160 / 100 may receive any necessary dental treatment. For those presenting with BP > 160 / 100, elective dental treatment may be deferred until the BP is brought under better control as confirmed by receipt of a medical clearance from the patient’s primary care physician, internist, or cardiologist. If urgent or emergency dental treatment is determined to be required, proceed with limited and conservative treatment procedures as possible to address the chief complaint and/or relieve acute pain unless the BP is confirmed to be > 180 / 110. At this point, no treatment of any type should be performed without a physician consultation.

NOTE: Superficial surgical procedures, including minor oral and periodontal surgery and non-surgical dental procedures, are classified as low risk. Therefore, it appears that the risk associated with most general, outpatient dental procedures is very low.

TREATMENT CONSIDERATIONS:
Table 2                        CURRENT Values [mm Hg]              Dental Management

*Abnormal pressures should be confirmed by the attending faculty before termination of the appointment. Document in the patient’s chart the cuff placement (ex: right arm), patient position (ex: sitting), interval between readings, and method/s of measurement (ex: stand monitor).
*For borderline values, use professional judgment while taking into consideration patient specific factors such as age and co-morbidities as well as the planned treatment procedures.

• Follow-up considerations: Encourage healthy lifestyle changes, Rx compliance, and self-monitoring when discussing a patient’s level of BP control. Physician follow-up intervals will vary based on the stage of HTN, type of medication(s), level of BP control, and 10-year cardiovascular disease risk assessment.

REFERENCES:

1.    Little, JW, Miller, C, Rhodus, NL. Little & Falace’s Dental Management of the Medically Compromised Patient, 9th Edition, 2018

The following is a summary of the 2007 American Heart Association revision for recommendations for endocarditis antibiotic prophylaxis.

Endocarditis Antibiotic Prophylaxis IS indicated for the following Cardiac Conditions:

• Prosthetic cardiac valves or material+ 
• Previous, relapse, or recurrent infective endocarditis
• Congenital heart disease (CHD)*
  • Unprepared cyanotic CHD, including palliative shunts and conduits.
  • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure.**
  • Repaired CHD with residual effects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization).
• Cardiac transplantation recipients who develop cardiac valvulopathy.

+For patients who have a left ventricular assist device (LVAD): a medical consultation is required.
*Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
**Prophylaxis is recommended because endothelialization of prosthetic material occurs within six months after the procedure.

Dental Procedures Where Endocarditis Prophylaxis IS indicated:

All dental procedures which involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa*.

(See Table below)

Dental Procedures That Do Not Require Endocarditis Prophylaxis:

*The following procedures and events do not need prophylaxis:

• Routine anesthetic injections through non-infected tissue
• Taking dental radiography
• Placement of removable prosthodontics or orthodontic appliances
• Adjustment of orthodontic appliances
• Placement of orthodontic brackets
• Shedding of primary teeth
• Bleeding from trauma to the lips or oral mucosa.

The College of Dentistry’s policy regarding antibiotic prophylaxis for patients with prosthetic joints acknowledges the evidence-based clinical practice guideline (CPG) published in the Journal of the American Dental Association in January, 2015.¹ This CPG is intended to clarify the joint guideline published in December, 2012 by the American Academy of Orthopedic Surgeons (AAOS) and the American Dental Association (ADA).² The policy will be reviewed annually or on an as-needed basis to reflect changes in evidence levels for the practice of antibiotic prophylaxis for patients with prosthetic joints.

Recommendation 1: There is no need for dental practitioners to routinely administer prophylactic antibiotics prior to dental procedures to prevent infection in patients with orthopedic implants. This recommendation is based on the most current evidence-based science.

Recommendation 2: Dental practitioners should consider premedication under the following circumstances where the patients may be at increased risk for joint infection:

• Previous prosthetic joint infections
• Immunocompromised/immunosuppressed patients:
  • inflammatory arthropathies such as rheumatoid arthritis, systemic lupus erythematosus, etc.
  • Chemotherapy or radiation-induced immunosuppression secondary to malignancies
• AIDS
• Type I or poorly controlled Type II diabetes
• Hemophilia

For patients referred to in Recommendation 2, the patient’s physician (preferably an orthopedic surgeon) should provide input regarding patient management. If the physician desires the patient to receive prophylactic antibiotics the physician should provide the patient with a prescription for the antibiotic of the physician’s choice.

The dental practitioner should not write the prescription.

References:

¹   Sollecito T, Abt E, Lockhart P, et al. "The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients with Prosthetic Joints". JADA 2015;146(1):11-16.

²   American Academy of Orthopaedic Surgeons; American Dental Association. "Prevention of Orthopedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report". Rosemont, IL: American Academy of Orthopedic Surgeons;2012.

When a patient presents for an appointment with an indication for antibiotic premedication and the patient has not taken the antibiotic as prescribed, there is the option of dispensing the antibiotic on-site through the Oral Diagnosis (OD) Division rather than rescheduling the patient. 

• Any antibiotic dispensation must be authorized by supervising faculty. 
• The student will add a new prescription into the eRx module in axiUm containing the drug name, dosage, number of pills/caps, and instructions such as "take all four capsules immediately”.
  • Select the supervising faculty’s name as the provider and select the COD as the pharmacy. 
  • Supervising faculty will log in as eRx user and sign the prescription by choosing “sign don’t send”. 
  • Dental hygiene patients will be entered by OD dental faculty.  
• The student must chart add the appropriate code for the antibiotic they are dispensing and have supervising faculty approve the planned and completed code. There is a fee for on-site dispensing in the student clinics.
  • R9600 Amoxicillin 500 mg x 4 ($6.00) 
  • R9601 Azithromycin 500 mg x 1 ($10.00) 
• The student will go to the OD Clinic to request the antibiotic from OD faculty.
  • You must comply with the recommended waiting period of 30-60 minutes before initiating invasive procedures 
• Students will document in the PTP note the medication, amount, and time the premed was taken by the patient. 
• If the patient is unable to take amoxicillin or azithromycin, the patient will need to be rescheduled and the appointment aborted. 

Things to Know and Remember:

• If premedication is required, there must be a minimum of 10 days between appointments. 
• If a procedure must be scheduled within the 10-day interval, an antibiotic of another class on the regimen should be selected. 
• Repeated treatment sessions require alternative antibiotic regimens at each appointment or at least 4 weeks between treatment sessions. 
• If premedication is indicated and the patient and student doctor/faculty forget or unanticipated bleeding occurs, the antibiotic may be given up to 2 hours following the completion of the procedure. 
• On-site dispensing of antibiotic premedication is not a replacement for providing the patient with a prescription that they should fill at their pharmacy. 
• On-site dispensing is for those times when a patient forgot to take the antibiotic before coming or they did not take the full dosage. 
• There are also instances in which the patient presents for urgent care and is unaware that they need to be premedicated. Ideally, pre-planning should occur and a prescription written or called in for the patient in advance of the appointment. 

The Health and Safety Committee develops guidelines that provide the criteria for the treatment of immune-suppressed patients.  These guidelines as well as clinic workflows can be found in axiUm Links in the Clinic Binder section. 

CRITICAL LAB TEST VALUES - Results are only valid for 6 months from the lab result date. The patient will need to have new labs completed once the results are > 6 months old.

Complete Blood Count W or W/O Differential:

• White Blood Cell: count <2000 consider premedication with an AHA regimen for invasive procedures or delay elective procedures
• Absolute Neutrophil: (ANC) ≥750 - <1,000/cc-consider premed for invasive procedures to prevent any infection with the regimen.
• Platelets:
  • ≥50,000: no contraindications
  • >20,000 - <50,000: minor treatment including endodontic and restorative treatment
  • ≤20,000: NO TREATMENT!
• Hemoglobin: ≥ 8 g/dL
• Blood Glucose: ≤ 200 mg/dL

CD4 Count – Considerations:

• A normal CD4 count ranges from 500–1,500 cells/mm³.
• Conventional wisdom says there is no level at which dental care cannot be done.

HIV-1 RNA Viral Load - Considerations:

• Does not have an impact on dental treatment planning, modifications would be based on the critical lab values.
• The viral load trends and is usually checked at 3- to 6-month intervals unless the patient is introduced to a new medication and then 2- to 8-weeks post-initial therapy.
• Viral load and CD4 count have a strong association, as one goes up the other goes down.

INR- International Normalized Ratio (prothrombin time):

• As with any patient taking blood thinners, an INR of 2.5-3.5 is ideal for most dental treatments. Full mouth extractions, periodontal surgery, etc. ~ 3.0 or physician consult.
• If planning an invasive procedure, INR should be checked within 24 hours prior to the procedure.

Dental Device Considerations:

• HIV/AIDS: ultrasonic scalers that generate aerosols are okay to use excluding no other respiratory complications i.e., COPD, TB, uncontrolled asthma. Evidence shows a reduced risk of potential exposure to the health care worker with an ultrasonic scaler VS traditional hand instruments that have blades. HIV/AIDS must have blood components for transmission.
• Lasers and electro surge: Contraindicated with patients who present with herpes simplex virus in vesicular stage (HSV) and human papillomavirus (HPV). No evidence exists of aerosolization or inhalation with HIV or HBV. Follow all recommended precautions with lasers. 

Follow Standard Precautions:

• Use standard precautions when working with any patient; everyone is treated the same.
• PPE: All required PPE used with blood and OPIMs for treatment, gown, mask, eyewear, and gloves

Good Clinical Judgment:

Use the above recommendations as general guidelines. This will ensure their safest and most efficient dental care.

References:

Maria Flores, DDS and Peter L. Jacobsen, Ph.D., DDS; Pacific Protocols for the Dental Management of Patients with HIV Disease, 2007

Little, James W, Falace, Donald A.; Dental Management of the Medically Compromised Patient 8^th edition

www.hivdent.org

www.cdc.org

Ryan White (RW) patients receive comprehensive dental care at COD. This program is funded by Federal and State governments through grants. Every RW patient is allotted $2000 for dental treatment. All the patient’s needs are taken care of with the exception of the following:

1. Cosmetic Dentistry
2. Orthodontic Treatment
3. Implant Dentistry

New RW Patient Protocol:

OU Health Infectious Disease Institute (IDI) refers potential RW patients to be screened at the COD. The COD will adhere to the following protocol:

1. IDI will send the patient’s information and initial bloodwork to the QA staff.
2. The QA staff will create a patient chart in axiUm and upload the initial lab results.
3. The Communications Center schedules the initial screening appointment with the Oral Diagnosis clinic.
4. If the patient is accepted into the predoctoral program, they will be assigned to a student.
5. The Communications Center will schedule the initial workup appointment.
6. Students (DS and DH) will work closely with faculty to complete comprehensive dental treatment.

Existing RW Patient Protocol:

All RW patients are required to have updated labs within their axiUm chart prior to receiving treatment. The lab results must be dated within six months of each treatment appointment. If labs are older than six months, they are considered expired and the patient should be contacted, by the student, to have new labs drawn.

1. For ongoing treatment, the COD Grant Coordinator will generate an axiUm report for all upcoming appointments scheduled for RW patients.
   • The report is generated each Friday for the upcoming week.
2. The Grant Coordinator will search OU Health's EMR to retrieve current lab results to upload in the RW patient's axiUm chart.
3. If the labs are expired, the assigned student should contact the patient at least five days prior to the appointment to instruct the patient to have new labs drawn.
4. It is the patient's responsibility to contact the IDI clinic, by calling 405-271-6434, to request that a lab script be sent to the OU Health lab so that necessary labs can be drawn. 
   • The COD does not submit lab scripts to the lab for RW patients.
   • The COD does not call the RW patient's physician to request lab scripts for our patients.
5. The COD requires the following lab results:
   1. Complete Blood Count With (or without) Differential
   2. HIV-1 RNA Viral Load
   3. CD4 Count
6. If there are fewer than three required lab results in the OU Health EMR, the COD Grant Coordinator will upload the remaining labs in the patient's axiUm chart.
7. The student should discuss with the faculty to determine if treatment can continue or if all labs are required depending on the procedure to be performed.

Short Notice Appointments Scheduled:

If an RW patient is being seen for an emergency or short notice appointment (placed on the schedule and being seen for treatment in less than five days),  and the RW labs are expired in the patient's axiUm chart, the student will need to contact the Grant Coordinator to search for current labs prior to contacting the patient.

1. The student should send an email, from their OUHSC email account (to prevent a HIPAA violation), to andrea-adams@ouhsc.edu or call extension 45444 (if calling from a COD phone) to request a search of the patient's OU Health EMR for current labs to upload into axiUm. The information needed in the email or via phone call is: 
   • RW Patient’s Name
   • Patient’s DOB
   • Patient’s axiUm chart number
   • Date of the short notice appointment
2. If current labs are available within the patient’s OU Health EMR, they will be uploaded into the patient's axiUm chart.
3. If current labs are not available (expired), the student will then need to contact the patient to have labs drawn or reschedule the appointment until current labs are available in the patient's OU Health EMR.
4. The Grant Coordinator will contact the student with information regarding the status of the labs via email or phone.

• The COD faculty should assist students with interpreting lab results and determining if a patient can be treated for an emergency if current RW labs are not available. 

Diabetes mellitus is a group of metabolic diseases that lead to high levels of blood glucose (hyperglycemia), which occur when the body does not produce any or enough insulin or does not use insulin well. Because diabetes is a relatively common condition, dental providers are likely to encounter it frequently. Oral manifestations of uncontrolled diabetes can include xerostomia; burning sensation in the mouth; impaired/delayed wound healing; increased incidence and severity of infections; secondary infection with candidiasis; parotid salivary gland enlargement; gingivitis; and/or periodontitis.

Types of Diabetes:

Type 1 Diabetes: a chronic autoimmune disease in which the beta cells in the pancreas create little to no insulin, and accounts for 5% to 10% of all diabetes cases.

Type 2 Diabetes: accounts for 85% to 90% or more of diabetes cases and is one of the most common chronic diseases, characterized by decreased response of target tissues to normal levels of insulin, dysregulation of insulin production, or a combination of both.

Prediabetes: when blood glucose levels are higher than normal, but not high enough for a formal diagnosis of diabetes. The person is at increased risk for developing type 2 diabetes, as well as at increased risk for heart disease and stroke. It is estimated that as many as 90% of those with prediabetes are unaware that they have prediabetes.

Gestational diabetes: a state of glucose intolerance that occurs in pregnant women who do not otherwise have diabetes. Occurring in the second half of pregnancy, gestational diabetes is caused by placental hormones and results in insulin resistance and relative insulin deficiency. Although true gestational diabetes resolves during the postpartum period, those who have had gestational diabetes are at increased risk of developing type 2 diabetes later in life.

Common Complications:

Three common complications that can occur when glucose levels are not well controlled are hypoglycemia, hyperglycemia, and diabetic ketoacidosis.

Hypoglycemia: a condition in which blood glucose levels drop below normal. For many people with diabetes, this means a blood glucose level of 70 milligrams/deciliter (mg/dL) or less. Although patients with diabetes often recognize signs and symptoms of hypoglycemia and self-intervene before changes in or loss of consciousness occur, staff should be trained to recognize the signs and treat patients accordingly.

Hyperglycemia: occurs when blood glucose levels are abnormally high. This can occur anytime there is not enough insulin in the bloodstream or the body is not using insulin properly.

Diabetic Ketoacidosis: Diabetic ketoacidosis is a serious condition that can develop when there is not enough insulin to help the body adequately use glucose.

(Refer to Table: Symptoms and Treatment for Patients with Diabetes Mellitus)

*NOTE: People who have concomitant kidney disease should not drink orange juice for their 15 grams of carbohydrates because of the high potassium content. Apple, grape, or cranberry juice cocktail are good alternatives.

Monitoring Glucose Levels

Blood-glucose levels can be checked chairside using a drop of blood and a glucometer. Since they are intended for use by multiple individuals, glucometers are designed to facilitate thorough cleaning and disinfection between uses to help prevent the spread of bloodborne pathogens. After each use, the device must be cleaned and disinfected according to the manufacturer’s instructions. After blood is tested, refer to the chart below to determine the correct Treatment Considerations.

HbA1C and Estimated Average Glucose (eAG)

(28.7 x A1C) – 46.7 = eAG mg/dl

A dental provider may want to ask a patient with diabetes questions such as:

• How old were you when you were diagnosed with diabetes and what type of diabetes do you have?
• What medications do you take?
• How do you monitor your blood sugar levels?
• How often do you see your doctor about your diabetes? When was your last visit to the doctor?
• What was your most recent HbA1c (A1C) result?
• Do you ever have episodes of very low (hypoglycemia) or very high blood sugar (hyperglycemia)?
• Do you ever find yourself disoriented, agitated, and anxious for no apparent reason?
• Do you have any mouth sores or discomfort?
• Does your mouth feel dry?
• Do you have any other medical conditions related to your diabetes, such as heart disease, high blood pressure, history of stroke, eye problems, limb numbness, kidney problems, delays in wound healing, or a history of gum disease? Please describe.

Scheduling Considerations

In general, morning appointments are advisable for patients with diabetes since endogenous cortisol levels are typically higher at this time; because cortisol increases blood sugar levels, the risk of hypoglycemia is less. For patients using short- and/or long-acting insulin therapy, appointments should be scheduled so they do not coincide with peak insulin activity, which increases the risk of hypoglycemia. It is important to confirm that the patient has eaten normally prior to the appointment and has taken all scheduled medications. If a procedure is planned with the expectation that the patient will alter normal eating habits ahead of time (e.g., conscious sedation), diabetes medication dosing may need to be modified in consultation with the patient’s physician. Patients with well-controlled diabetes can usually be managed conventionally for most surgical procedures. If the patient’s food consumption will be affected after oral or dental surgery, a plan to balance the patient’s diabetes medications and food intake should be established in advance.

Coordination with the patient’s physician may be necessary to determine the patient’s health status and whether planned dental treatment can be safely and effectively accomplished. Physicians should make laboratory test results available to the dentist upon request, and inform the dentist of any diabetic complications of relevance to the individual patient prior to dental procedures. The physician may need to adjust the patient’s diabetes medication to help ensure sustained metabolic control, before, during, and after surgical procedures. Patients with diabetes should obtain regular medical and dental care, including regular dental visits for a full evaluation of their dental and periodontal condition.

References:

1. American Dental Association, January 2022, Diabetes, ADA.org [online], Available from: https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/diabetes .

Amalgam waste generated in the clinics is to be disposed of in a container labeled “amalgam waste”. All unused, scrap, and empty amalgam capsules are to be placed in a properly labeled container provided in the amalgam procedure tub. Specifically:

1. Extracted teeth with amalgam are to be placed in a container labeled amalgam waste for hazardous waste disposal.
2. Using the HVE to suction waste amalgam from equipment, floors or counters is prohibited.
3. Amalgam waste generated during pre-clinical laboratory exercises must be disposed of in provided containers labeled “amalgam waste”.
4. All hazardous waste is logged, labeled, and packaged by the Director of Compliance. The OUHSC EHSO hazardous materials staff is responsible for the disposal of the hazardous material following federal and state laws.

OUHSC Plumbing will inspect the boxes when they do their PM in the equipment room every 6 months.

1. The plumbing shop will notify the Facilities Coordinator as to how many boxes are full and need to be changed out.  

2. Call Rebec at 1-800-569-1088, and ask for Christi Gochanour. Inform Christi of how many boxes need to be replaced. 

3. Rebec will send empty boxes. KEEP THE CARDBOARD BOXES THEY COME IN!  

4. Put in SUR to have the new boxes switched out with the full ones. 

   • Every time you need the boxes changed out, you must put in a new SUR. 

5. The plumbing shop will put the full ones in the cardboard boxes used to ship the new ones. Then tape up the boxes and secure them to empty pallets with clear plastic wrap.  

6. Call Rebec again and set up a pick-up by UPS freight. 

7. UPS will pick up the pallet. 

1. All workforce members at the College of Dentistry must participate in the TB surveillance program during onboarding, regardless of their participation in patient care. Employees involved in patient care will complete an annual TB screening questionnaire after their first year of service. Employee immunization records are maintained by the OU Health Employee Health Clinic. The Director of Compliance has access to the COD database.
2. Respiratory Protection Program is available for workforce members who have the potential of exposure to TB or any other respiratory pathogens that require an N95 respirator for treatment. The EHSO will fit-test students who want to be fit-tested. The OU Health Employee Health Clinic will fit-test any employee who wants to be fit-tested.

In addition to the above engineering controls, the following work practice controls will be used:

1. Disposable barriers will be placed whenever possible to cover contact surfaces. This will include light handles, light switches, chair controls, chair handles, patient chairs, slow-speed suction, air/water syringes, HVE, keyboards, mice, and x-ray equipment. Barriers include plastic wrap, bags, adhesive wrap, and other moisture-impervious materials. Use personal protective equipment (PPE) when disposing of contaminated barriers. Refer to the Proper Dental Unit Set-up with Barriers poster found in all clinical faculty offices.
2. A debris bag should be available at each dental unit to discard all medical waste. Waste that was generated that has significant amounts of blood or saliva (drips when squeezed) must be disposed of in the waste receptacle labeled with a RED biohazard sticker, provided in each clinic.
3. Contaminated needles and sharps will never be sheared off or purposely broken. Needles must be recapped after each use. Workforce members are to use the one-handed scoop technique or a protector card for recapping used dental needles. Sharps are to be placed into RED sharps containers located at each dental unit. 
4. Disinfect using the wipe-discard-wipe technique using the Environmental Protection Agency (EPA) registered intermediate-level hospital disinfectant on all patient contact surfaces that do not have a barrier in place. If the barrier becomes compromised, then use the wipe-discard-wipe technique. Allow the disinfectant to sit on the surfaces for the manufacturer’s recommended time, usually 3 minutes. Non-sterilizable equipment used during procedures (e.g. amalgamators, torches,) must be disinfected between patients. Curing lights need to be disinfected or have a barrier put in place.
5. Flush air/water lines, ultrasonic scaler lines, and handpiece lines for 30 seconds at the beginning of each appointment. Wear PPE during the flushing procedure.
6. Dental unit waterlines are treated to control biofilm and reduce micro-bacterial count in operatory aerosol and spatter. All dental units have self-contained water systems. When refilling the unit water bottle, clean gloves must be worn. Use ICX® treated water from the designated water sources. The ICX® tablet maintains water quality for up to two weeks.
7. Disinfect removable appliances, alginate impressions, blue bite impressions, and PVS impressions with the Clorox Healthcare Fuzion disinfectant located at each dental unit for the recommended contact time of 3 minutes. Rinse with water prior to transporting or working in the clinical laboratory.
8. Extracted teeth without amalgam are considered biohazardous and are placed into the biohazard trash. Extracted teeth with amalgam are to be placed into the amalgam waste container for proper disposal.
9. For clinical lab safety, wear proper PPE when performing laboratory procedures. Hair and loose clothing need to be secured to minimize the potential for cross-contamination and injury. Always use fresh pumice, a clean disposable tray, and a sterile rag wheel when using the polishing lathe.
10. Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in areas where there is a reasonable likelihood of exposure to blood or OPIMs. Food and beverages are not to be kept in refrigerators or freezers where patient products, blood, or OPIMs are stored.
11. Hair should be secured off the face so that it does not interfere with or become contaminated during procedures. 
12. Workforce members must adhere to good hand hygiene practices following CDC recommendations. Hand washing with soap and water for 40-60 seconds must occur prior to donning gloves at the beginning of the day. Workforce members must wash their hands (if visibly soiled) or use hand sanitizers immediately after removing contaminated gloves and prior to donning another pair of gloves.
13. Use over-gloves or remove gloves when leaving the operatory to prevent cross-contamination.
14. All instruments must be sterilized between patients including high-speed handpieces, slow-speed attachments, dental hygiene prophy angles, ultrasonic tips, and ultrasonic handpieces. Each morning Central Sterilization (CS) performs a Bowie Dick test on the autoclaves. Every load from CS utilizes a challenge pack and is checked prior to releasing the load for patient use. The CS autoclaves undergo biological monitoring once weekly. Each clinic's autoclave undergoes weekly biological monitoring.
15. All contaminated, reusable instruments or equipment must be turned in to the dirty instrument tubs in each clinic. The CS staff will retrieve the tubs in a closed-case cart preventing cross-contamination. Uncovered contaminated equipment is not allowed outside of clinical areas. 
16. All checked out student instrument kits must be turned in to Central Sterilization at the end of each day. You may not store any sterilized items in your clinic locker.

Each clinic’s tabletop (Prevacuum) sterilizer (Statum) undergoes a weekly spore test inoculated with Geobacillus using the following procedure:

1. The spore tests are brought to CS for processing.
2. The results are kept on each sterilizer in a logbook maintained by the CS staff.
3. If results are positive, repeat the spore test and examine the procedure to ensure the sterilizer is loaded correctly (not overfilled), the pack is not too large, and the manufacturer’s instructions have been followed.
4. If the results are positive again, do not use the sterilizer until it has been inspected or repaired. Using another sterilizer, reprocess any items sterilized since the last negative spore test.

The College of Dentistry uses ADEC®¹ closed water system dental unit.

1. Each day before use, flush the dental unit water lines for 30 seconds.
2. Flush the ultrasonic scaler unit water line for 30 seconds prior to placing the insert.
3. Refill water bottles with deionized water treated with ICX® tablets to prevent biofilm in the lines. Treated water can be found in each clinic in 20 L bottles labeled “ ICX® Treated Water”.
4. When refilling water bottles on the units, do not touch the inner tubing with your hands or gloves.

The College of Dentistry follows the Centers for Disease Control and Prevention (CDC), Organization for Safety and Asepsis Procedures (OSAP), Occupational Safety and Health Administration (OSHA), and the University of Oklahoma Health Science Center (OUHSC) Infectious Disease Policy (https://compliance.ouhsc.edu/ehso/Home/Forms-Resources/Links) recommendations and guidelines for infection control to ensure patient and workforce member safety. 

The infection control guidelines are intended to foster an awareness of concepts and methods when performing required patient care procedures. For your safety and the safety of others, the general principles of cleanliness in the workplace, the use of protective attire, the separation of uncontaminated and contaminated items and work areas, and constant consideration of the potential for cross-contamination should be observed. 

For all dental procedures, students will be observed and graded accordingly for compliance with infection control and patient safety. 

The Office of Compliance performs routine monitoring of infection control compliance to ensure adherence to the guidelines and recommendations. 

Gross negligence in infection control standards may result in the generation of a Professionalism Concerns Report and up to a two-week suspension from the clinic.

All personal protective equipment will be the correct size, clean and in good repair, and fit properly. PPE is designed to protect the skin and mucous membranes of the eyes, nose, and mouth from blood or other potentially infectious material (OPIM). Spray and aerosol from hand pieces and air-water syringes, patient coughs, and other activities in the operatory are possible sources of pathogens. PPE required includes:

1. Eye protection devices, such as goggles or glasses with solid side shields or chin-length face shields, are required to be worn whenever splashes, sprays, splatter, or droplets of blood or OPIM may be generated, and eye contamination can be reasonably anticipated. Eyewear must be cleaned and disinfected between patients. Protective eyewear is required for the patient to protect their eyes from debris.
2. ASTM Level III surgical masks that cover both nose and mouth are required to be worn whenever reasonable anticipation of the production of aerosols or splatter of microorganisms exists. Masks are to be changed if wet or visibly soiled and between patients. Do not wear masks under the chin or dangling around the neck.
3. N95 respirators are optional. Respirator fit-testing must be completed before wearing and annually, thereafter, if an N95 respirator is to be worn for your protection. 
4. Long-sleeve disposable over-gowns will be worn for all aerosol-generating clinical procedures. Gowns should be changed if torn or visibly soiled. Gowns should be removed before leaving the treatment areas and under no circumstances should they be worn outside of the clinic area, including the waiting room, patient checkout offices, or restrooms. Street clothes, work clothes, or scrubs worn under over-gowns are not considered personal protective equipment.
5. Single-use disposable, non-latex gloves will be worn for all clinical procedures where there is reasonable anticipation to encounter mucus membranes or OPIMs. Patient exam gloves are worn for non-surgical procedures. Sterile surgical gloves will be worn for all surgical procedures, e.g., periodontal surgery, oral surgery, and implant placement. If you leave the operatory during patient care, gloves must be removed and discarded (or protected with over gloves).
6. Head covers are optional. If they are worn, they must cover the entire head and all hair must be covered. Fabric must be washable. Material cannot have inappropriate content. Head covers can only be worn for one day.
7. Face shields are worn if eyewear does not have appropriate side shields. 
8. PPE that is soaked with blood or OPIMs should be placed in a designated container labeled biohazard trash.

UNIT SETUP

PRECLEAN

1. Wash hands for 40 - 60 seconds and gather PPE (surgical mask, eyewear, face shield (optional), head covering (optional), and over-gown) and the pitcher to flush the evacuation system.

2. Put on surgical mask and eyewear. Perform thorough hand hygiene for 40 – 60 seconds. Don new gloves

3. Position patient, operator and assistant chairs, bracket table, light (position light pole to opposite side of operator), assistant’s cart, swivel arm & rheostat.

4. Fill the water bottle with properly treated water (DO NOT touch the tubing when reattaching the water bottle to the unit).

5. Flush the evacuation system for 2 minutes.

6. Flush the water lines for 30 seconds and place the pitcher back in the cabinet. The unit is ready for patient care.

DISINFECT

1. Clean dental chair, operator's and assistant's stools utilizing soap* and water. *If blood is present, use a disinfectant towelette.

Use disinfectant towelettes (using “Wipe Discard Wipe Technique”) on:

2. Operator’s and assistant’s levers and assistant’s cart

3. Dental light switch, handles, and arm

4. Bracket table, bracket table accessories (A/W syringe, connectors, holders, and hoses), bracket table arm, and water bottle

5. Swivel arm and accessories (A/W syringe, connectors, holders, and hoses)

6. Paper towel dispenser, soap dispenser, faucet handle, all objects on countertop, countertops, cabinet facings, cabinet handles, & sink rim

7. Rheostat and rheostat cord

8. Remove gloves, dispose of into trash, and perform hand hygiene. Don new gloves.

9. Cover chair back and place barrier film on switches, controls/levers, and arm rests—includes the hydraulic lever.

10. Cover bracket table and assistant’s cart with dental bibs; place instrument cassette on bracket table.

11. Insert saliva ejector, HVE, and A/W syringe tip; cover with plastic sleeves

12. Hang white bag from unit; throw all items used during treatment into white bag then place into trash

13. Barrier keyboard/mouse (Rule of thumb: keyboard cover on – gloves on; keyboard cover off – gloves off

UNIT BREAKDOWN

DISINFECT

1. While wearing PPE used during treatment, disinfect the unit.

2. Remove contaminated gloves used for treatment, perform hand hygiene, dismiss patient, and don new gloves.

3. Safely and securely place instruments in the cassette before transporting to designated bin.

4. Place contaminated disposables in the white bag and place the bag into the trash. Remove contaminated gloves and dispose of into trash. Perform hand hygiene and don new gloves.

5. Repeat steps 1-7 for unit disinfection above. Afterwards, remove contaminated gloves, dispose of into trash, perform hand hygiene, and don new gloves.

6. Flush water and evacuation lines for 30 seconds.

7. Return equipment to its original position. Place the rheostat on the dental chair on a paper towel.

8. Remove over gown and contaminated gloves, dispose of into trash, perform hand hygiene, and don new gloves.

9. Remove face shield and protective eyewear (operator and patient)and disinfect using soap and water. Remove contaminated gloves, dispose of into trash, perform hand hygiene, and don new gloves.

10. Remove surgical mask and disposable head cover (if used) to dispose of into trash. Remove contaminated gloves, dispose of into trash, perform hand hygiene, and don new gloves.

11. Retrieve mop from dispensary and mop with floor cleaner around treatment area.

12. Remove contaminated gloves, dispose of into trash, and perform hand hygiene.

The following includes the policy document containing expected infection control practices and procedures for the Labs. These policies are to be followed at all times. Student failure to do so will result in a grade reduction in the Professionalism category, see course syllabus,  and students will be subject to the relevant warnings.

Student/Resident/Faculty Hygiene Policies Prior to Lab Use:

• Users are required to perform the appropriate hand hygiene procedures upon entering the Wet Labs and prior to utilizing any lab equipment
  • If the user has not been actively engaged in patient care immediately prior to entry, they may opt to utilize hand sanitizer only
  • If the user has been actively engaged in patient care immediately prior to entry, they must wash their hands  
• Users are required to obtain and use the appropriate PPE upon entering the Wet Labs and prior to utilizing any lab equipment
  • At a minimum the correct PPE for use in the wet lab should include:
    • Gloves
    • Safety Goggles
    • Mask
    • Gown (optional)

Disinfection and/or Sterilization of Items Transported Into the Lab:

• Any impressions brought into lab must undergo the following procedure prior to entry:
  • Impressions must first be washed with water (and gently cleaned if necessary) to remove any blood, saliva, or bioburden that would impede decontamination
  • Next, impressions should be sprayed thoroughly with Clorox for Healthcare and allowed to sit for the necessary 3 minute contact time
  • Finally, any remaining or pooled disinfectant or cleaning agents should be rinsed and the impression should be dried to prevent any deleterious effects on materials cast in the impression
• Any dental prostheses or indirect restorations brought into the Lab must undergo the following procedure prior to entry:
  • Provisional and permanent indirect restorations:
    • Restorations brought from a laboratory setting directly to the Lab do not require any additional disinfection
    • Restorations brought directly from patient care must first be washed with water and cleaned to remove any blood, saliva, plaque, calculus, or any other bioburden that would impede decontamination
    • Next, restorations should be sprayed thoroughly with Clorox for Heathcare and allowed to sit for the necessary 3 minute contact time
    • Finally, the restoration should be rinsed of any remaining disinfectant and dried
• • Removeable prostheses
    • Prostheses brought from a laboratory setting directly to the Lab do not require any additional disinfection
    • Prostheses brought directly from patient care must first be washed with water and cleaned to remove any blood, saliva, plaque, calculus, or any other bioburden that would impede decontamination
      • If bioburden persists and attempts to remove are unsuccessful, place the prosthesis in a sealable bag, put your name and chair number on the bag. Ask the clinic Inventory Assoicate to have access to the ultrasonic inside the dispensary. Pour enough tarter and stain remover to cover the appliance; initiate the ultrasonic cycle for 15 minutes and re-examine prosthesis to ensure bioburden has been completely removed. Repeat cycle as needed.
    • Next, prostheses should be sprayed thoroughly with Clorox for Healthcare and allowed to sit for the necessary 3 minute contact time
    • Finally, the prostheses should be rinsed of any remaining disinfectant and dried

Materials/Equipment

• Stone Use: After any and all impressions brought into the wet lab are appropriately disinfected and labelled, various stone substances may be mixed (according to manufacturer prescribed water/stone mixture ratio).
  • Available stone:
    • Found in the drawers under the stone grinders
    • Die Stone–
    • Mounting Stone –
      • Pink
      • Green
    • White Stone –
  • After pouring the appropriate stone mixture into any impression, the cast may be allowed to rest on Styrofoam trays with your name and date or in holders or on the counter surface of the Stone casts are allowed to remain in this area no more than 24 hours
    • Any impressions left without being appropriately labelled will be thrown out.
    • Any stone casts left in the designated cast setting area for more than 24 hours will be thrown out
  • Any stone spilled on the floor must be swept up and thrown away to prevent a fall risk in the t Labs (a dustpan and hand-broom are available in the clinic)
• Mixing Bowls/Spatulas
  • Prior to disinfecting, clean any bioburden from mixing bowl and spatula
  • Disinfect with PDI disinfecting wipes, using wipe discard wipe technique or sprayed thoroughly with Clorox for Healthcare using spray wipe spray technique.
  • Allow to sit for the necessary 3 minute contact time
  • It is recommended that you remove the stone from any bowls or spatulas prior to allowing stone to set by rinsing with cold water
  • If stone is allowed to set, it will be required to remove any and all set stone from the bowl and/or spatula by any means necessary
• Table Vibrators
  • Prior to use for pouring stone into any impression, must ensure that the table and motor box are clean and free from stone (to the best of your ability). Then utilize the clear cover-bags (provided in the drawer near the vibrator) to cover the table.
  • If, during the course of use for the day, the clear cover-bag becomes excessively dirty or torn, you must replace the cover-bag
  • The last person of the day to use the, after use for pouring stone into any impression, must remove and discard the clear cover-bag and ensure the table and motor box are clean and free from stone (to the best of your ability).
• Combination Unit
  • When using the Whip Mix Vacuum Stone Mixer, inspect the device first to make sure the vacuum hose is intact and unobstructed
  • After using the unit, you must ensure there is no stone left on the unit to set up, and you must clear or clean any remaining stone from the appliance
  • Clean mixing bowl and tubing immediately after use
• Designated Stone Setting Areas
  • After pouring the appropriate stone mixture into any impression, the cast may placed to set in the stand holders provided or on Styrofoam trays on the counter surface in the wet lab
  • How they are to be placed:
    • Ensure the stone cast has your name and date on the tray
    • At the end of each day, any setting casts and impression trays that are not appropriately labeled will be disposed of in the appropriate manner. In addition, any setting casts or impression trays that are labeled with the previous date will also be disposed of.
  • After you reclaim any set stone casts and trays, ensure the area is completely free of stone and the counter is clean

Ultrasonic Cleaning Bath

• • Setting up the Ultrasonic Bath for use:
    • The clinic Inventory Associate is responsible for the maintanence and cleaning of the ultrasonic baths
  • Cleaning Intraoral Prostheses:
    • Obtain a sealable plastic bag from the cart next to the dispensary and place your prostheses in the bag
    • Put your name and chair number on the outside of the bag with a Sharpie
    • Ask the clinic Inventory Assoicate to have access to the ultrasonic inside the dispensary.
    • Pour enough tarter and stain remover to cover the appliance; Place plastic bag into a beaker filled with water
    • Place beaker into ultrasonic and initiate the ultrasonic cycle for 15 minutes. Re-examine prosthesis to ensure bioburden has been completely removed. Repeat cycle as needed.
    • After the prostheses is cleaned, remove it from the Tartar and Stain solution and thoroughly rinse to ensure no solution is transferred back to the patient
    • Empty the beaker of any remaining solution and rinse it thoroughly with water from the sink. Leave next to ultrasonic

• Wet Model Trimmer
  • You must wear safety glasses to use model trimmer.
  • When using the wet model trimmer, ensure there is adequate water flow to the internal grinding wheel; immediately after using the appliance, and prior to turning it off, use the attached water-sprayer to clean the wheel (while in motion), as well as the trimming table and the recess underneath the trimming table
  • After trimming your model, check the sink for any large, set pieces of stone and throw them into the trash to prevent clogging the sink. If the sink appears backed up or the trap under the sink appears to be mostly full of stone, please notify the Inventory Assoicate.
  • After Using the Trimmer and turning it off, inspect the Clear Plastic Safety Shield once again and clean as needed
• Polishing Lathe/Buffer
  • Inspect the Lathe to ensure the appliance is undamaged.
  • Remove any residual pumice/residue, wipe thoroughly with PDI, and allow to sit for the necessary 3 minute contact time.
  •  Place clean Styrofoam tray in the tray area. Do not reuse tray or lathe attachments that are left on from the previous person.
  • Place IN USE magnet on the lathe you are using
  • Prior to using the Lathe for polishing, obtain new pumice (located next to the Sand blaster); the pumice should be damp, but not runny). Utilize this pumice paste to polish your prostheses
  • After Polishing and prior to Buffing any prostheses, Obtain a new Styrofoam tray, rag wheel, and buffing compound block (all separate from the equipment utilized in polishing). Secure the rag wheel to the Lathe and apply the Buffing compound directly to the dry rag wheel (while the wheel is moving; no solution is necessary)
  • Once finished with the Polishing Lathe, remove the catch tray and discard, Remove the rag wheel and place into “dirty rag wheel tub” located behind the lathe. Finally, wipe the Lathe down with a damp paper towel to ensure no pumice paste residue is left on the appliance
• Abrasive Blaster
  • The Abrasive Blaster does not require any additional sterilization methods if the prosthesis being cleaned has been adequately disinfected (see above).

1. Prior to Using a Lab Station, ensure the station and associated Electric Handpiece are clean and free from obstruction. If using the Electric Handpiece, ensure the table vacuum motor is turned on (operating switch is located on the front of the motor box), and that the intake is unobstructed, while also ensuring the plastic safety shield is fastened in place (in front of the vacuum intake).
2. If using/working with flame and wax, please place white butcher paper over the entirety of the workspace table to prevent wax from melting/adhering to/damaging the table surface. Butcher paper is on a roll mounted on the wall.
3. Upon completion of using the Lab Station, remove and dispose of any paper, clean off any stone residue, disinfect the surface with PDI wipes and allow to sit for the necessary 3 minute contact time, and ensure the table vacuum motor is turned off. If any tools/burs are left unsupervised, they will be disposed of (or may be confiscated and sterilized for use by the dispensary).

• Pressure Pot for Curing
  • NOTE: The Great Lakes Pressure Pot has the potential to be the most dangerous piece of equipment in the Wet Lab, as improper use and failure can result in EXPLOSION! Please ensure you are using the pot correctly for your safety as well as the safety of any other lab occupiers
  • The pressure pot should be cleaned daily to prevent residue buildup. If you are the first person to use the pot, use a wet paper towel to wipe the inside clean, followed by a dry paper towel to dry the internal surfaces. If the pot has large amounts of residue on the inside, or the water appears excessively dirty, contact clinic Inventory Assoicate. After this, add approximately ½ inch of water.
  • When using the Pressure Pot, place your prosthesis inside the pot on the tray and secure the lid by ensuring both handles align and the lock switch is moved into the locked position.
  • To pressurize the pot, flip the toggle lever on the right side until the pressure reaches between 15-20 PSI. If the pressure exceeds 20 PSI, depressurize the pot, discontinue use, and immediately conatact the clinic Inventory Associate to inform them that the appliance is over pressurizing and needs to be repaired.
  • To release pressure and open the Pressure Pot, first, ensure the pressure line is closed by moving the toggle switch to the closed position. Then, press the pressure release button above the lock switch on the handle (pressure release will make a loud hissing sound). Finally, move the switch to the unlocked position, rotate the upper handle and open.

After use of any lab equipment for the fabrication of dental casts or any dental prosthesis, it is necessary to disinfect the item prior to removing it from the lab (for transport to chairside or non-chairside location) to prevent any unforeseen cross-contamination

• First, casts/prostheses/restorations should be sprayed thoroughly with Cavicide and allowed to sit for the necessary 3 minute contact time
• Finally, the item should be rinsed of any remaining disinfectant and dried

Any sharp tool or instrument used in the Wet Labs must utilize the same policy implemented throughout the entirety of the COD

• Sharps must be disposed of in a sharps container located at every dental unit
• Any Sharp or Lab Equipment related injuries must be reported

During business hours:

• If the injury results in minor trauma and requires little to know first-aid with no serious risk to life or limb, first focus on the appropriate first aid treatment of the injury. Once the injury is treated, immediately (so as to not forget any relevant information) report it to the COD Office of Compliance
• If the injury results in moderate trauma, requiring more attention than basic first aid (ex. sutures), but posing no serious risk to life or limb, stabilize the wound, then immediately report to the supervising faculty and the COD Office of Compliance (Rm. 232).
• If the injury results in major trauma that poses serious risk to life or limb, STOP, perform immediate first aid and contact 911, requesting Emergency Medical Services(EMS) to your location. Immediately after that, contact COD Office of Compliance (13083 or 405-473-6064) to inform them of your situation so they can direct EMS to your location.

After business hours:

• If the injury results in minor trauma and requires little to know first-aid with no serious risk to life or limb, first focus on the appropriate first aid treatment of the injury. Notify COD Office of Compliance about injury.
• If the injury results in moderate trauma, requiring more attention than basic first aid (ex. sutures), but posing no serious risk to life or limb, stabilize the wound, then transport yourself to the nearest Emergency Room for treatment.
• If the injury results in major trauma that poses serious risk to life or limb, STOP, perform immediate first aid and contact 911, requesting Emergency Medical Services to your immediate location.

Adherence to the above polices is considered Mandatory, and any observed deviation from the above written protocol should be immediately corrected by any on looking observers. If the offending party fails to correct their mistake, it should be documented and reported to the Director of Compliance and the Assistant Dean for Clinical Affairs.

All alginate, polyvinyl siloxane, and polysulfide impression material should be handled in the following manner after removal from the mouth: 

1. Rinse the impression by filling it with water and dumping the water.
2. Spray liberally with the disinfectant solution presently in use (Clorox for Healthcare) and place in a sealed baggie for recommended contact time (3 minutes).
3. Rinse the impression again.
4. Alginate should be gently dried, and the casts poured as soon as possible. 
5. Polyvinyl siloxane and polysulfide impressions should be gently dried, and the casts poured according to the manufacturer’s directions. 

1. Wear proper PPE when performing laboratory procedures. Eyewear is a MUST when using any rotating equipment.
2. Hair and loose clothing need to be secured to minimize the potential for cross-contamination and injury.
3. Always use fresh pumice, a clean disposable tray, and a sterile rag wheel when using the polishing lathe.

1. Wipe instruments carefully with a damp gauze during treatment to eliminate debris from drying.
2. Make sure all instruments are secure inside the cassette.
3. Place instrument cassettes in tubs provided in each clinic.
4. All contaminated equipment must be turned into the dirty tubs provided for disinfection or sterilization.
5. Central Sterilization staff will transport all cassettes to Central Sterilization in a closed instrument case cart.
6. The transportation of open, contaminated cassettes to Central Sterilization is prohibited.

1. Contaminated sharps must be discarded immediately in containers that are puncture-resistant, sealable, leakproof, and adequately labeled as SHARPS.
2. Each dental unit is supplied with a sharps container. They should be kept in an upright position and checked periodically to prevent overfill.
3. Contaminated needles and sharps shall not be sheared or purposely broken. Needles must be recapped after each use. Recapping needles is allowed for procedures requiring more than one administration of anesthesia. In such cases, a one-handed scoop technique or protector card is required.
   Sharps include the following:
   1. Dental needles
   2. Anesthetic carpules
   3. Broken glass
   4. Lab blades
   5. Surgical blades
   6. Endodontic files
   7. Burs
   8. Gates-Glidden or any other endodontic preparatory instruments

1. All components of the electric handpieces must be sterilized between uses.
2. Wipe the attachments that were used for patient care with disinfectant wipes. Let stand for appropriate contact time.
3. While wearing clean gloves, take the attachments to the dry lab for cleaning and lubrication at the designated station.
4. Dental hygiene cordless handpieces require the sleeve to be sterilized between uses. The motor has a barrier placed between the sleeve and the motor. 

The following engineering controls will be used to eliminate or minimize workforce member exposure to bloodborne pathogens or OPIMs:

1. Autoclaves will be used to sterilize reusable sharp instruments in clinical settings.
2. Dental dams or Isovacs will be used in patient procedures when necessary to reduce aerosolization to workforce members.
3. Hand washing and hand sanitizing facilities will be available to all workforce members who have the potential for bloodborne pathogen exposures. Facilities are available at each operatory, in all clinics, dispensaries, and laboratories.
4. High-volume evacuation (HVE), dental dam or Isovac utilization, and proper patient positioning will be used to reduce exposure to blood or OPIM droplets.
5. Instrument cassettes are completely enclosed, thereby reducing the handling of reusable contaminated sharps. Workforce members are responsible for securing instruments inside the cassettes before turning them in to Central Sterilization for decontamination.
6. Sharps containers are available at each operatory and are to be used for all disposable sharps which include, but are not limited to, needles, scalpels, files, and anesthetic carpules.
7. Instrument washers/disinfectors and ultrasonic cleaners will be used to reduce workforce members from handling contaminated sharp instruments. Dispensary and Central Sterilization personnel are responsible for monitoring the effectiveness of the equipment and reporting problems as needed.

All reusable critical and semi-critical items that are heat tolerant undergo heat sterilization.   Semi-critical items that are not heat tolerant will undergo high-level disinfection or are disposed of.  If a high-level disinfectant is used, it will be tested for efficacy prior to placing items. Currently, we use a hydrogen peroxide high-level disinfectant (Resert XL® by Steris).  It is a solution of a concentration of hydrogen peroxide (2.0%) and a blend of inert ingredients that help achieve rapid microbial efficacy (8-minute contact time).  Prior to use, the solution must be checked with monitoring strips for efficacy.

Single-use items will never be re-used.

All cassettes that are not prepackaged or water-resistant go through the washers prior to sterilization. Each washer is tested daily for chemical effectiveness. The test strips are kept in a logbook maintained by CS staff.

Methods of Heat Sterilization:

Central Sterilization uses pre-vacuum sterilization. Each sterilizer undergoes a weekly spore test inoculated with Geobacillus.

1. The results are kept for each sterilizer in a logbook maintained by the Central Sterilization staff. 
2. If results are positive, repeat the spore test and examine the procedure to ensure that the sterilizer is loaded properly (not overfilled), the pack is not too large, and the manufacturer’s instructions have been followed.
3. If the results are positive again, do not use the sterilizer until it has been inspected or repaired. Using another sterilizer, reprocess any items sterilized since the last negative spore test.
4. A challenge pack is placed in every load before sterilization.
5. The load cannot be released for use until the challenge pack has been verified for all parameters of sterilization have been met.
6. The challenge packs are kept in a logbook for reference.
7. Class V indicators are placed inside sterilization bags that have been packaged in CS.

Disposable Sharps 

1. Contaminated sharps shall be immediately discarded in containers that are puncture-resistant, sealable, leakproof, and adequately labeled as SHARPS.
2. Each dental unit is supplied with a sharps container. They should be kept in an upright position and checked periodically to prevent overfill. 
3. Once full, clinic staff are responsible for securing the lid, transporting it to Central Sterilization, and placing it into a shipping container for weekly biohazard pick up.

Non-Sharps Regulated Waste

1. Other regulated waste (saturated gauze, extracted teeth) should be placed in a biohazard container located in each clinic. The containers are labeled Biohazard Trash Only, are closable, and are constructed to contain all contents.
2. Do not place red bags in the regular trash.
3. Red bag trash is removed, sealed, transported to the biohazard room found on the first floor, and placed in a shipping container for weekly biohazard pick up.
4. Surgical suction, containing liquid biohazardous waste, is disposed of in a container that is labeled Biohazard Trash Only.

Waste generated during the procedure that is not regulated (e.g., air/water syringe, patient napkins) is placed in plastic bags, sealed, and disposed of in regular trash.

Workforce members should ensure clinical areas are maintained in a clean and sanitary manner.  All equipment and patient contact surfaces shall be decontaminated as soon as possible after contact with blood or OPIMs.

The following procedures should be taken in the event of spills:

1. Standard/Universal precautions must be observed. Cleaning of spills must be limited to those persons who are trained for the task.
2. Only disposable towels should be used to avoid difficulties involved with laundering.
3. Blood or OPIM spills:
    
   1. Alert people in the immediate area of the spill
   2. Put on PPE – mask, eyewear, gloves, and over-gown
   3. Cover the spill with paper towels or absorbent materials
   4. Carefully pour EPA-registered disinfectant on the surface and begin to clean up the spill
   5. Allow the disinfectant to be in contact with the surface for the manufacturer’s recommended contact time
   6. Discard all materials into a biohazard red bag for disposal

For additional information, click the link:

https://compliance.ouhsc.edu/Portals/1061a/Assets/EHSO/Policies%20and%20Programs/hazwastedisposalspill.pdf?ver=2019-09-11-035137-387 

Eyewash stations are available in every clinic and laboratory following ANSI and OSHA standards for workplace exposures.

Extracted teeth used for the education of Dental Health Care Workers (DHCW) should be considered infective and classified as clinical specimens because they contain blood. All persons who collect, transport, or manipulate extracted teeth should handle them with the same precautions as for biopsy specimens.

1. Ask your local dentists or oral surgeons if you can have their extracted teeth.
2. Standard precautions should be adhered to whenever handling extracted teeth.
3. Since pre-clinical educational exercises simulate clinical experiences, students should adhere to standard precautions in both settings.
4. All persons who handle extracted teeth in educational settings should receive the Hepatitis B vaccine. 

Before extracted teeth are manipulated, the teeth first should be cleaned of adherent material by scrubbing with detergent and water or by using an ultrasonic cleaner.

If possible, separate the collected teeth into two separate containers.

• One for teeth without any silver (amalgam) fillings.
• One for teeth with silver (amalgam) fillings.
• If you are unsure if they contain silver or are unable to separate, place them all into one container. 

1. Cover teeth with water to keep them moist.
2. Acceptable containers are plastic or glass wide-mouth jars with a lid that will close securely (mayonnaise jar).
3. Do not use plastic water bottles.
4. Print your full name and graduation year on your container; for example, Joe Student 2027.
5. You may now begin to turn your teeth into Central Sterilization on the first floor. 
6. Sterilization times may vary.
7. Teeth without amalgam will be heat sterilized using a liquid autoclave cycle for 40 minutes. 
8. Teeth with amalgam will be immersed in a 10% formalin solution for 14 days.