Comprehensive and Limited Patient Care

Subject: Comprehensive and Limited Patient Care
Effective Date: June 1991
Review Dates: February 2002, September 2016

Purpose

To establish guidelines for managing patients’ oral health needs who are accepted for care at the University of Washington, School of Dentistry.

General Policy

Comprehensive dental care consists of an in-depth evaluation of the patient, including the diagnosis of dental needs and desires which shall be addressed in a timely, appropriately sequenced, caring, and professionally responsible manner. This policy applies to all patients who are assigned to students and/or a department.

Patients who seek limited care at the School of Dentistry for specific services such as oral surgery, endodontics, restorative, prosthodontic, implant and emergency care may be accommodated as outlined in this policy.

Implementation

I. Patient Acceptance

Patient acceptance decisions are based on the oral health needs of the patient in relationship to the scope of the educational programs of the school.

Patients interested in becoming a patient of the Predoctoral Student Clinic are required to attend a screening appointment before being accepted for treatment. Initial screenings are completed at the Dental Admissions Clinic (DAC). The screening appointment includes a screening examination, identifying patient’s chief dental complaints/needs, panoramic radiograph and completing a health history form. At the end of the screening examination, each patient is informed of their dental needs. Patients are accepted based on the complexity of the patient’s needs in conjunction with the student’s educational needs.

Patients accepted to the Predoctoral Student Clinics are assigned to a dental student for comprehensive dental care in the Clerkship or General Practice (GP) program. The accepted patient is required to take additional radiographs prior to the treatment planning appointment.

Patients who register but fail to initiate care or delay their care for 2 years are no longer considered comprehensive patients of record. Should they choose to be reinstated, they must follow the usual admission and acceptance protocols and go through the usual intake process to ensure complete diagnostics are taken and recorded.

Patients who are not accepted to the Predoctoral Student Clinic are referred to one of the following clinics for limited or comprehensive care: Graduate clinic, Advanced General Dentistry (AGD) or the Faculty Practice clinic (UW Dentists).

The patient is scheduled for a consecutive appointment in the respective clinic for one of two exams: Exam Limited Problem Focused (ADA Code D0140) appointment or Exam Comprehensive New/Established (ADA Code D0150).

During this appointment for comprehensive patients, the dental student conducts a detailed examination to evaluate the patient’s needs and develop a comprehensive treatment plan before beginning treatment. Additionally, consultations will be completed; urgent and preventive services (OHI, prophylaxes, caries control, temporary restorations) are initiated; and the comprehensive treatment plan is presented to the patient for signed approval.

Patients accepted for limited care will receive a limited problem focused/limited care exam. This exam is an evaluation that is limited to a specific oral health problem, complaint or procedure. Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergency, trauma, acute infection or singular procedure.

The protocol for taking radiographs is outlined in Appendix A, Guidelines for Prescribing Dental Radiographs.

II. Assignment

Patients who are accepted for comprehensive care are assigned to predoctoral students.

III. Formulation of the Treatment Plan

A. Diagnosis and the Treatment Planning Process

The formulation of a treatment plan must take into account the present complaint, personal and family history, past medical and dental history, physical examination, and appropriate diagnostic tests and procedures. Vital signs shall be taken and recorded annually on all active patients and the Medical History Update Form (See Section 3F) must be completed as outlined in Appendix B.

B. Consults for the Comprehensive Care Treatment Plan

The treatment plan is to be developed from the supporting consultations, which must be signed by either a full- or half-time faculty member in the Departments of Restorative and Periodontic Dentistry, and the assigned faculty advisor in the Department of Prosthodontics (if applicable) as well as a faculty member from the respective departments in which other consultations occur.

C. Treatment Plan Approval for Comprehensive Care Patients

Once the consultations have been completed, the treatment plan is approved by faculty.

D. Treatment Plans for Limited Care Patients

Limited care patients may be referred to the School for a specific procedure by an outside agency or practitioner. Limited care includes amalgam, composite, veneers, single crowns, a bridge or periodontal care.

Limited care patients must complete a comprehensive oral examination under faculty supervision to determine whether to proceed with a diagnosed limited care, to reject, or to refer the patient for comprehensive care. Respective clinic directors determine acceptance of patients for limited care.

Family members of students may self-refer for evaluation of a specific procedure.

Treatment plans for new limited care patients will be developed to list the specific procedure(s) to be performed in the department in which the plan originates. Services to be rendered shall be limited to those consistent with the educational programs of the department(s) involved. Treatment plans for limited care patients shall include either a Patient Acceptance Agreement or list the exclusions of care in the treatment plan. The exclusions / limitations may be described in categories of needs via custom school codes rather than on a procedure basis (e.g., deep caries, abscess, missing teeth, etc.). Authorization for care and the limitations must be obtained by patient signature. (See Appendix C).

E. Periodic Oral Evaluations

Upon completion of all active care, patients receive a final treatment assessment and are invited to participate in the schools’ hygiene recall program. The recall examination should be performed every 12 months on patients whose care is in progress or has been completed. Patients in current treatment have at least one annual recall preventive maintenance visit. A patient who develops new treatment needs is assigned to a dental student for care.

During the recall preventive maintenance visit, a periodic oral examination (ADA Code D0120) is conducted. A treatment plan is then formulated and is authorized by a designated faculty member from the department in which the majority of care will be provided if the periodontal status is acceptable. Acceptable periodontal status is defined as no pockets greater than 4 mm in depth and no gingival inflammation. Patients who do not meet these criteria may be assigned to a student or to an alternate care provider.

The periodic recall examination (ADA Code #0120) shall include the following:

• Update of the medical history
• Assessment and recording of vital signs
• Extraoral evaluation
• Assessment of the head and neck areas
• Assessment of the oral mucosa
• Periodontal screening examination
• Examination of existing teeth
• Evaluation of existing appliances and prostheses
• Assess need for radiographs

A complete health history is to be taken on all patients every three years. Patients returned to active status after three years of inactivity are to complete a new health history before initiating treatment.

IV. Care Delivery

A. Consent

The treatment proposed and rendered must take into account the general health, availability, financial resources, and desires of the individual patient. Patients are to be informed about the oral health needs, treatment alternatives, expected outcomes, and significant risks and consequences of the proposed treatment. Patients shall also be informed of risks and consequences associated with not having treatment of their existing conditions.

Consent for either comprehensive or limited care must be obtained prior to the onset of treatment and granted by patients via their signature on the treatment plan, or on a separate consent form.

B. Timeliness of Care

The predoctoral student who is assigned a given patient will design a comprehensive treatment plan and make every attempt to complete the identified treatment. The exception to this is when a patient is assigned for limited care such as an Endodontic therapy assignment or limited Restorative treatment.

Treatment needs of patients that exceed the student’s training, or that fall outside departmental requirements may be managed by graduate students; intramural faculty practitioners; and/or by referral to the private dental community.

No patient will be treated without a current and signed treatment plan with the exception of emergent and diagnostic care or in the case of a departmental or private limited care referral. Treatment plans must be updated, approved and signed by the patient, and approved in axiUm by a faculty member in whose department the majority of care will be provided. Treatment plans must be updated within 12 months from the original/previous treatment plan.

C. Delay of Care

If the patient is unable to comply with the stated guidelines a delay of care status must be approved and documented by the Patient Services office. This grants the patient and student an extension of the deadlines for treatment planning and care delivery.

IV. Care Sequencing

Treatment will be rendered in an appropriately sequenced manner reflecting the phasing detailed in the treatment plan.

A. Phase Descriptions

1. Phase 1: Diagnostic services as well as urgent care that is related to threatening oral conditions, discomfort, or impacting on the social needs of the individual patient.
Examples:
a) exams, radiographs, models
b) gross caries
c) acute pulpal disease
d) acute periodontal disease
e) fractured teeth

2. Phase 2: Non-urgent care that is related to the elimination of oral conditions which may ultimately impact on the patient’s health and well being.
Examples:
a) routine restorative and periodontal treatment
b) essential prosthodontics
c) preventative services
d) elective extractions
e) symptomatic endodontic therapy independent of other services

3. Phase 3: Elective treatment that can be delayed more that six months without negative consequences for the patient.
Examples:
a) nonessential prosthodontics
b) orthodontics
c) composite veneering

4. Phase 4: Maintenance care which follows the completion of all planned primary therapy. This does not include maintenance care which may occur along with primary care services.

B. Exceptions in Sequencing

If the decision is made to alter the above sequence (e.g., construct a fixed partial denture without uprighting a molar, or fabricate a removable partial denture without first performing indicated periodontal surgery), then an appropriate entry should be made in the progress notes, approved by the patient, initialed on the visit slip, and signed by the student and instructor(s) of the appropriate department(s).

VI. Case Completion

At the completion of care, a final oral evaluation is done and the code UW 100 or UW106 is used in axiUm in conjunction with the Completed Treatment Review (CTR). Patients will be assigned for preventive maintenance following the completion of their primary care. Students are responsible for managing the completion of the treatment plan for their assigned patients.

Patient disposition must be indicated in the progress notes.

The guidelines listed in the Clinic Procedures Manual must be followed for referring patients to students, intramural faculty practices, and/or the private sector.

Appendices:
Appendix A, Guidelines for Prescribing Dental Radiographs
Appendix B, Policy Statement Regarding the Updating of Medical Histories and Vital Signs
Appendix C, University of Washington School of Dentistry Limited Care Agreement

Dean of UW SOD:

Joel Berg, Dean of the UW School of Dentistry
October 24, 2016

 

Appendix A

GUIDELINES FOR PRESCRIBING DENTAL RADIOGRAPHS

Modified after recommendations issued by the U.S. Department of Health and Human Services, Public Health Service, and the Food & Drug Administration.  The recommendations in this chart are subject to clinical judgment and may not apply to every patient.  They are to be used by dentists only after reviewing the patient’s health history and completing a clinical examination.  The recommendations do not need to be altered because of pregnancy.

Clinical Situations for which Radiographs may by indicated include:

Positive Historical Findings

1. Previous periodontal or endodontics therapy.
2. History of pain or trauma.
3. Familial history of dental anomalies.
4. Post-operative evaluation of healing.
5. Presence of Implants.

Positive Clinical Signs/Symptoms

1. Clinical evidence of periodontal disease.
2. Large or deep restorations.
3. Deep carious lesions.
4. Malposed or clinically impacted teeth.
5. Swelling.
6. Evidence of facial trauma.
7. Mobility of teeth.
8. Fistula or sinus tract infection.
9. Clinically suspected sinus pathology.
10. Growth anomalies.
11. Unexplained bleeding.
12. Positive neurologic findings in the head and neck.
13. Evidence of foreign objects.
14. Unexplained sensitivity of teeth.
15. Facial asymmetry.
16. Abutment teeth for fixed or removable partial prosthesis.
17. Oral involvement in known or suspected systemic disease.
18. Pain and/or dysfunction of the temporomandibular joint.
19. Unusual eruption, spacing, or migration of teeth.
20. Unusual tooth morphology, calcification, or color.
21. Missing teeth with unknown reason.

Patients at high risk for caries may demonstrate the following:

1. High level of caries experience.
2. History of recurrent caries.
3. Existing restoration of poor quality.
4. Poor oral hygiene.
5. Inadequate fluoride exposure.
6. Prolonged nursing (bottle or breast).
7. Diet with high sucrose frequency.
8. Poor family dental health.
9. Developmental enamel defects.
10. Developmental disability.
11. Xerostomia.
12. Genetic abnormality of teeth
13. Many multi-surface restorations
14. Chemo/radiation therapy

Appendix B

Policy Statement Regarding the Updating of Medical Histories and Vital Signs

On entry to the School of Dentistry patient care system, each patient will have completed the Medical and Dental health history questionnaire; and the responsible student will have investigated items of concern — if necessary, with guidance from a faculty member and, where appropriate, by means of consultation with the patient’s physician. At this initial stage, the patient’s vital signs will have been recorded as part of the basic assessment. The following policy statement provides guidelines for the updating of the health history, and for the repeat recording of the vital signs at intervals, both for patients on the recall system and for those who — for whatever reasons — have not been seen on a frequent and regular basis.

On every visit for active treatment, it is important that the student should begin the clinical appointment by asking the patient if there is any change at all in the patient’s medical status. This applies to all visits for all patients under active treatment. This question should be a routine matter. If the patient indicates any change, then the student will need to pursue the matter with additional questions and update the medical history form. It is the duty of the patient to be truthful about their medical history and to report changes in their history to their provider.

Patient’s vital signs must be recorded at the initial visit, then at recall visits. Patients of high risk shall be monitored at each visit.

Appendix C

University of Washington School of Dentistry Limited Care Agreement