ASOD Clinic Manual 2022

ADAMS SCHOOL
First in care. For the people."

OF DENTISTRY
TABLE OF CONTENTS
Introduction .................................................................................................................................... 3
GAP Clinical Model .................................................................................................................................... 3
Defining Person-Centered Care ................................................................................................................. 3
GAP Clinical Team ...................................................................................................................................... 4
Standards of Care ............................................................................................................................ 7

Continuous Quality Improvement ............................................................................................................. 7
Standards for Patient Care and Outcome Indicators ................................................................................. 8
Patient Rights and Responsibilities .......................................................................................................... 10
Professionalism and Ethical Behavior ........................................................................................... 12
Clinical Safety ................................................................................................................................ 15
Adams School of Dentistry Clinical Guidelines ........................................................................................ 16
Patient and Provider Safety ..................................................................................................................... 29
Entrustable Professional Activities (EPAs) .................................................................................... 31

EPA 1: Assessment .................................................................................................................................. 31
EPA 2: Plan of Care .................................................................................................................................. 33
EPA 3: Team Care .................................................................................................................................... 34
EPA 4: Provision of Care .......................................................................................................................... 45
Patient Services and Operations ................................................................................................... 59
Start of Patient Service ............................................................................................................................ 64
During Patient Service ............................................................................................................................. 66
End of Patient Services ............................................................................................................................ 72
Special Circumstance Protocols ............................................................................................................... 74
Appendices.................................................................................................................................... 78
References............................................................................................................................................... 78
Appendix 1: Huddle Pre-Clinic Presentation............................................................................................ 78
Appendix 2: Medical Consultation Request............................................................................................. 79
Appendix 3: Pharmacy Consultation Decision Table ............................................................................... 80
Appendix 5: DXTX Checklist ..................................................................................................................... 82
Appendix 6: CDT Code Flowchart ............................................................................................................ 84
Appendix 7: Glossary for Assessment of the Clinical Encounter (ACE) Forms ......................................... 85
Appendix 8: Rubric .................................................................................................................................. 94
1
Purpose
The purpose of the Carolina Dentistry and Adams School of Dentistry Clinic Manual is to guide the clinic
teams to develop inter/intra professional collaborative practice to ensure safe, high quality, person-
centered care in a humanistic learning environment that supports the well-being and success of each
learner.
This manual is one of the tools used to achieve a high-quality education, enhance communication, and
obtain high levels of patient satisfaction. All members of the clinic teams will understand its content and
consult it when questions arise.
The manual should be followed to the extent that individual cases allow. Clinical faculty will learn from
each other and remain current with best practices.
Any new methods or procedures will be evaluated and discussed among clinical faculty and Adams School
of Dentistry administrators, and the manual will be updated with agreed upon revisions on a continual
basis.
2
Introduction
GAP Clinical Model
The general dentistry clinical experiences in the third and fourth year of the ACT curriculum are housed in
Guided and Advanced Practice (GAP). The UNC Adams School of Dentistry operates its clinics with the
focus on providing person-centered care to all patients regardless of race, ethnicity, gender, sexual
identity, national origin, religion, age, or disability status.
The faculty and staff are committed to creating a humanistic, inclusive learning environment for all
learners and for each other. All faculty, staff, and learners will abide by the school’s Code of Professional
Conduct that states that all dental professionals should possess not only knowledge, skill, and technical
competence, but also character traits that foster professionalism and adherence to ethical principles.
The objective of GAP is to provide comprehensive collaborative person-centered care using a vertically
and horizontally integrated learner-centered model with generalist and specialty areas and access to
other health professionals. This model will prepare learners with the knowledge, skills and attitudes to
provide comprehensive person-centered oral health care within an intra/inter-professional collaborative
team.
Defining Person-Centered Care

“Person-centered care” is approaching your patients (caregivers) as equal partners in planning,
developing and monitoring care to make sure it meets their needs, thereby making the patient an integral
component of the oral health team. This requires taking a holistic approach to care, considering the
patient’s preferences, values, cultural, religion, socioeconomic situation, and other health issues and
priorities. This may mean deviating from the established algorithm for/standards of treatment to meet a
patient’s specific needs and expectation. (Glick, 2019)
Some features of person-centered care are (based on Starfield, 2011):
 Focuses on the person and his/her relationship with the provider over time.
 Focuses on disease management in the context of the personal, social, religious, ethnic, and
other factors.
 Views patient in a holistic with all systems interrelated.
 Uses professionally defined conditions but allows modifications using people’s health concerns
and social determinants.
 Modifies diagnoses and treatment from large cohort studies, taking into consideration individual
information and desire for care.
 Bases outcomes on improvement of the person’s overall health and well-being, taking into
consideration multiple factors.
As an integral member of the oral health team, the patient must understand the necessary information to
make informed decisions (such as their diagnoses and the risks, benefits, costs, time course, and
expected outcomes of all treatment options). This places an emphasis on the patient’s rights and choices,
in addition to their responsibilities. Decisions will be made as a team and the provider maintains the
responsibility to follow the dental profession’s and the school’s standards of care and ethical behavior.
To achieve the goal of person-centered care requires continually refining your communication skills to
build a relationship with each unique individual that demonstrates respect and care, builds trust, and
ensures patient understanding of their dental care.
3
Goals
The Guided and Advanced Clinical Practice goals are to:
1. Apply the principles of person-centered care in clinical practice.
2. Refine the use of effective evident based clinical decision-making.
3. Develop advanced psychomotor skills and clinical techniques.
Values
The GAP Clinical Team commits to fostering a humanistic culture and learning environment, as
‘Humanism’ is the defining characteristic of the Adams School of Dentistry’s education model. We aim to
create a respectful and positive setting that is safe and inclusive, clearly communicating expectations, and
supporting each learner’s well-being and achievement, to provide a positive learning and working
healthcare environment for every member of our clinical team and our patients.
The success of this approach depends on clear, honest, open communication and members of the dental
school community meeting their responsibilities to themselves and each other. Giving feedback and
addressing issues are the most valued gifts that can be given each other, the team, and the school. It is
important to understand that giving feedback is sometimes as difficult as getting feedback, so viewing
feedback to support each other to individually grow and achieve our goals will contribute to creating a
humanistic education.
Faculty members’ responsibility is to model the profession’s and the Adams School of Dentistry’s highest
standards, and mentor learners in ways that support and motivate their learning. Learners, in turn, are
expected to set high standards, meet commitments to their clinic team and patients, seek support when
needed, and take personal responsibility to prepared for seminars and clinic, and for their own learning.
GAP Clinical Team

The goal of clinical team structure is to provide a consistent relationship among the faculty, care
coordinators, learners, and patients to deliver high-quality, comprehensive, and collaborative care with a
person-centered care approach. GAP aims to have teams of faculty working closely with students in each
practice (floor) that support and mimic all elements of a general dentistry practice. More complex
procedures would be referred to the specialty clinics, mirroring what happens in general dental practice.
Figure 1 delineates roles of each team member who collective support the learning experiences.
Preceptors work in tandem with predoctoral program directors to ensure practice readiness. Preceptors
are responsible for overseeing the comprehensive care (admissions, assessment, diagnosis, treatment
planning, provision of treatment, and general management) of patients assigned to their pre-doctoral
student groups and are responsible for supporting, directing, and evaluating the professional
development of the pre-doctoral students assigned to their groups.
4
Figure 1: Clinical Team
The team concepts are evident in shared learning opportunities within the teams and aim to fit learners
with the right faculty at the right time in all learning.
Read more: Curriculum Sakai Site
Team Structure
The third- and fourth-year DDS learners and first- and second-year Dental Hygiene (DH) in the GAP
curriculum are divided 2 practices, each containing 3 teams each, called Offices (Figure 2).
Figure 2: Schematic of Clinical Structure
Office members consist of DDS1-4, DH 1-2, 1 Lead preceptor, supporting clinical faculty, one care
coordinator, one patient navigator, and one dental assistant. DDS learners are assigned in alphabetical
order to an office in first year and remain with the office until graduation.
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DDS 1, DDS 2, DDS 3, and DH students work together in integrated teams with each student learner being
assigned patients with clinical needs and level of difficulty appropriate to their ability. DDS 1 students are
exposed to early clinical experiences and will engage in formal dental assistant training. DDS 1 and DDS 2
will work hand in hand with the DDS 3 and DDS 4 clinic when appropriate.
Dental Hygiene instructors will generally be supervising and instructing students performing at this
proficiency level. DDS4 students will provide routine hygiene care as quality patient care requires but will
generally be more focused on patients with more extensive periodontal needs and often will work under
the supervision of periodontal residents and faculty.
It is the responsibility of the learner in the GAP Clinical Team to deliver quality dental care in a courteous,
timely and professional manner as the primary care provider to the student’s family of patients.
Learners have the privilege of delivering care to their adult (generally 14 years or older) patients in the
areas listed below. Specialties are responsible for providing training materials and, if requested or
necessary, calibration training for faculty.
Read more: Adams School of Dentistry Policies
References
Starfield, B. Is patient-centered care the same as person-focused care? Perm J. 2011;15(2):63–69.
https://doi.org/10.7812/TPP/10-148
Glick, M. Precision-, patient-, person-centered care, oh my. JADA, 2019:15(3):161-162.

https://doi.org/10.1016/j.adaj.2019.01.008
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Standards of Care
The goal of the UNC Adams School of Dentistry and Carolina Dentistry is to promote access to care for the
population of North Carolina, within the scope of our educational programs and resources. These
standards are guidelines for patients accepted for care and not intended to be all inclusive or inflexible.
The standards are intended to provide overall direction for the core values that individuals should possess
in a dental care environment, but do not replace clinical evaluations established by individual educational
programs, e.g., Graduate, Predoctoral, Dental Hygiene, located within the school.
These standards are part of the regular Continuing Quality Improvement process with indicated
modifications and revisions operationalized as appropriate. These standards exist within the parameters
of applicable law and ethical principles. These standards do not constitute a guarantee of any particular
patient outcome.
Section 1: Patients will be informed of their rights and responsibilities. In addition,

Patient Rights patients will be treated in a professional manner.
Section 2: Patients accepted for care at the Adams School of Dentistry will receive the
Examination and appropriate examination designed to arrive at diagnosis.
Diagnosis
Section 3: Based upon the results of examination and diagnosis, a treatment plan will be
Treatment Plans formulated so that patients may receive treatment that is appropriate to meet
their needs.
Section 4: Based upon the results of the diagnoses, patients will receive quality care to
Quality of Care promote satisfaction, function, health, and esthetics, with such care rendered
in a safe and timely manner.
Continuous Quality Improvement

Quality of Patient Care Committee
The Quality of Patient Care Committee is responsible for regularly assessing the quality of care delivered
in the student patient clinics (i.e. Graduate, Predoctoral, and Undergraduate) by developing a quality
assurance plan to ensure continuous quality improvement of the patient care program.
This committee collaboratively defines the school’s Standards for Patient Care that are patient-centered,
focused on comprehensive care, and written in a format that facilitates assessment with measurable
criteria.
The committee determines the criteria upon which to evaluate all standards for patient care; sets
performance targets or benchmarks; and continuously reviews established standards for patient care and
revises as needed.
The designated leader designee collects, analyses, and submits the patient care data to the committee.
Additionally, the committee conducts an ongoing review of a representative sample of patients and
patient records to assess the appropriateness, necessity, and quality of the care provided.
7
The committee reviews all the outcomes data; assesses compliance with the defined standards of care
across Patient clinics; utilizes mechanisms to determine the cause(s) of treatment deficiencies; and
suggests corrective measures as appropriate.
The committee submits an Annual Quality of Patient Care Report of the outcomes for each standard and
the recommended corrective actions for those standards that did not meet the target outcomes.
The membership of the committee is representative of faculty and students throughout the school. The
committee meets monthly to monitor progress on data collection and analyses; reviews updated
outcomes data; updates quality assurance assessment tools; makes interim recommendations for quality
improvement and corrective actions; and monitors implementation of recommendations.
Continuous Quality Improvement Cyclical Process
ACT Plan
Describe the change,
Decide what's next.
predictions, and action
Make changes and start
steps. Plan to collect
another cycle.
data.
Study Do
Analyze data. Compare
outcomes to predictions. Run the test. Describe
Summarize what you what happens. Collect
learned. data.
We follow a plan, do, study, act (PDSA) cycle of quality improvement. This cycle continues until the
desired benchmark level is achieved for all standards. Indicators are continually monitored to ensure the
desired outcomes continue to meet or exceed the defined benchmarks.
Standards for Patient Care and Outcome Indicators

PATIENT RIGHTS
Patients will be informed of their rights and responsibilities. In addition, patients will be treated in a
humane and professional manner.
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# Outcomes Indicators
1.1 Receipt of Patient’s Bill of Rights document noted by patient (caregiver) signature
1.2 Students, faculty, and staff treat patients in a caring (humanistic) manner
1.3 Patients receive a Notice of Privacy Practices
EXAMINATION AND DIAGNOSIS

Patients accepted for care at the Adams School of Dentistry will receive the appropriate examination
designed to arrive at a diagnosis.
2.1 New patients (D0101/D0190) accepted for comprehensive care receive a clinical examination
and radiographic exam (D0150) within their first three visits
2.2 Patient protective equipment is utilized in the acquisition of dental radiographs
TREATMENT PLANS
Based upon the results of examination and diagnosis, a treatment plan will be formulated so that patients
may receive treatment which is appropriate to meet their needs.
3.1 Oral health providers explained the treatment options to the patient
3.2 The patient’s chief complaint was addressed
3.3 Comprehensive care patients, under active care, had a treatment plan in EPR that was signed
by the patient
QUALITY OF CARE
Based upon the results of the diagnoses, patients will receive quality care to promote satisfaction,
function, health, and esthetics, with such care rendered in a timely manner.
4.1 Care was provided in a timely manner
4.2 The annual procedure re-do rate is maintained below a reasonable percentage
4.3 Active patients are satisfied with their care
4.4 Patients in active treatment have had their medical history updated in last six months
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4.5 Patients with dental emergencies were able to promptly reach a member of the Adams
School of Dentistry regarding their concern
4.6 Infection control policies and procedures are followed
Patient Rights and Responsibilities

The employees and students at the UNC Adams School of Dentistry and its clinical practice, Carolina
Dentistry, are committed to providing the highest quality of dental care in a professional and
compassionate manner. We strive to develop a strong trusting relationship between the patient and/or
the patient’s parents or guardians and their oral health care provider. It is important that patients
understand the condition of their oral health and the treatment to be provided to address and/or
alleviate the condition.
Your Rights as a Patient
Treating the Carolina Dentistry recognizes and respects the dignity of each patient. Patients should expect
Person to be treated with consideration and respect regardless of age, color, disability, gender,
gender expression, gender identity, genetic information, national origin, race, religion, sexual
orientation, veteran status, or source of payment.
Appropriate Carolina Dentistry will provide services consistent with the patient’s needs. Patients will be
Services informed about what can and cannot be provided, and providers will make referrals for
treatment elsewhere when necessary. When the patient’s relationship with the school ends,
no matter the reason, the patient will be made aware of remaining treatment needs.
Understanding Patients are entitled to a clear explanation of their dental problems, recommended
the Plan of Care treatment, treatment alternatives, risks involved, estimated costs, who will provide care and
approximately how long it may take. When complications come up during treatment that
might change the plan of care or affect treatment results, patients will get a full explanation.
Consent and Patients have the right to participate in decisions about their dental treatment and have
Refusal of questions answered before making decisions. Patients may refuse treatment and should
Treatment expect to be informed of the possible consequences of such decisions.
Confidentiality Patient privacy rights are protected under the Health Insurance Portability and Accountability
Act (HIPAA), applicable state laws, and Adams School of Dentistry policies to which all
students, faculty and staff are bound. Communications about treatment will be made in
strict accordance with these laws and policies. Treatment records (including radiographs) will
not be released without written permission, except as required by insurance or by law.
Patients have the right to read and be informed about their dental record. Discussion of
treatment with friends or family members requires the patient’s verbal or written
permission, or a legal Power of Attorney document.
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Your Responsibilities as a Patient
As a patient or caregiver of a patient in our clinics, your responsibilities are to:
 Be considerate and respectful of other patients, students, and employees.

 Share honest and complete information about medical and dental history, previous illnesses,
hospitalizations, exposure to communicable diseases, allergies, medications, and current medical care.
 Let the provider know when there are changes in the patient’s general health condition, and when
patients experience unusual discomfort or complications following a treatment.
 Ask questions and understand the nature of dental conditions and treatments.
 Follow the instructions given to follow up on treatment.
 Be available to make appointments during the entire treatment phase; to keep scheduled
appointments; and to arrive for appointments on time.
 Consider that the school strongly encourages patients to have all dental treatment done in the student
clinic to which you are admitted, except in case of emergency or when referred for specific treatments
by an authorized Adams School of Dentistry provider.
 Pay for all services when received unless the Carolina Dentistry has approved other arrangements.
 Update all address and phone number changes directly with the main desk of the appropriate clinic as
soon as possible.
Not meeting these responsibilities can lead to patient dismissal.
Patient’s Representative
Once admitted as a patient in the Predoctoral Learner Dental Clinics, patients are assigned to a Care Coordinator
(CC), who is available during regular business hours to assist with any questions, concerns, or problems
concerning treatment.
Patients can reach their CC at (919) 537-3588.
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Professionalism and Ethical Behavior
Introduction
The faculty, staff and students at the UNC Adams School of Dentistry are expected to adhere to high
ethical and professional standards. In addition to applicable laws and regulations stipulating general
codes of conduct for UNC dental students (delineated in documents detailed below), there are a number
of established standards that guide our professional and ethical behavior in clinic settings.
CODA standard 2-21 reminds us that, “Graduates must be competent in the application of the principles
of ethical decision making and professional responsibility.” It is expected that Adams School of Dentistry
students have the capacity to learn, understand and apply these principles. It is expected that ethical
decision-making be guided in part by knowledge and practice of cultural humility and cultural
competence as well as principles of diversity and inclusion.
Additionally, CODA 2-17 articulates that, “Graduates must be competent in managing a diverse patient
population and have the interpersonal and communications skills to function successfully in a
multicultural work environment.”
All students are expected to demonstrate the principles, strategies and techniques to collaborate
successfully with diverse colleagues and patients. Embracing a person-centered approach to care,
students must be able to interact and communicate effectively and respectfully across diverse contexts
and diverse patient populations and demonstrate cultural humility.
Ethical behavior requires students to establish a partnership with the patient/caregiver that is physically
and psychologically safe for all parties, using person-centered and respectful verbal, non-verbal, language
and syntax in all exchanges.
With regard to professionalism with colleagues, the student’s verbal tone, language, non-verbal
interactions and actions must reflect respect for team members’ knowledge and experience (professional
and lived experience).
Student ethical behavior means the student is responsive to team members’ needs and reflects concern
for team members’ growth, success and overall well-being. The student recognizes and models the value
of the team approach in providing optimal patient treatment.
Informed by CODA, the school’s ACT curriculum specifies that students and program graduates must:
 Apply principles of professionalism and ethics

 Embrace diversity and inclusion
 Act compassionately
 Communicate in an effective and professional manner
 Prioritize patients’ values and preferences in providing person-centered care
At the Adams School of Dentistry, we are committed to a diverse and inclusive environment for faculty,
staff, students, residents, and patients. We are committed to creating and maintaining an environment
that welcomes, values, and supports the personal and professional development and care of all
individuals.
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More Information
 Adams School of Dentistry Diversity and Inclusion
o Internal School Resources (Onyen login required)
o Office of Inclusive Excellence Webpage
 UNC Campus Diversity
Professional Standards
 School Policies
 ADA Principles of Ethics and Code of Professional Behavior
 American Student Dental Association: Ethics
 American College of Dentists: Ethics Handbook for Dentists
 UNC Graduate School Handbook
Learner Professionalism
 UNC-Chapel Hill Student Conduct

 Adams School of Dentistry Technical Standards
 Adams School of Dentistry Sakai
Learner Code of Conduct
 Adams School of Dentistry Policy on Student Professionalism

 Code of Professional Conduct
Faculty and Staff Responsibilities
 Adams School of Dentistry Policies
Patient Confidentiality and Social Media
 Adams School of Dentistry Policy on Social Media
HIPAA Regulations
 UNC-Chapel HIPAA Information
Personal Appearance
 Code of Professional Conduct
Professional Dress Code
 Adams School of Dentistry Professional Dress Code Policy
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Clinic Privileges: Learner-Specific Criteria
 Learners must be currently enrolled and in good academic standing in the Adams School of Dentistry.
 A learner must possess the proper preclinical skills and a satisfactory level of professionalism as
evaluated by dental school faculty and administrators before progressing into the patient care
program.
 Once in the clinic, learners must strive towards competence in clinical skills and professional conduct
to retain clinical privileges.
If a student does not meet these standards, the leadership has the authority to suspend the learner’s clinical
privileges.
Read more: Reporting Code Violations
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Clinical Safety
Compliance Information
 Clinical Compliance Information
Radiation Safety
 NC Division of Radiation Protection
 The Use of Ionizing Radiation and Auxiliary Equipment
Unit Policies, Standards, and Procedures

 Adams School of Dentistry Infection Control Policy
 Violation of Compliance
 Emergency Response Manual
 Management of Medical Emergencies
Medical Emergency Team: (919) 537-

3911
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Adams School of Dentistry Clinical Guidelines
Hypertension
Questions to Ask/Necessary Information
1. Have there been any recent changes in your medications? What medicines are you currently taking? Did
you take your medication(s) today?
2. Do you take your blood pressure at home? If so, what is it usually?
Risk for Medical Emergency
 Acute elevation of a patients BP (headache, SOB, chest pain) with symptoms should be avoided.
 Stress management is important to lessen the changes of endogenous release of catecholamines,
therefore long or stressful appointments are best avoided for poorly controlled hypertensive patients.
Pertinent Laboratory Information: Management recommendations for BP (based on >3 BP readings)
☐ ≥130-59/85-99 Follow up with primary care provider within 60 days
☐ ≥160-179/100-109 Follow up with primary care provider within 30 days
☐ ≥180 SP or ≥110 DP Defer elective dental treatment. Follow up with primary care provider immediately.
☐ ≥181-210/111-119 with S&S Defer elective dental treatment. Refer to emergency department immediately.
For patients 65+ years, blood pressure control is considered 140-150/90+, depending on frailty.
Blood Pressure Categories
Normal: less than 120 and <80 High BP Stage 2: >140 or >90
Elevated: 120-129 and <80 Hypertensive Crisis: >180 and/or >120
Call doctor immediately
High BP Stage 1: 130-139 or 80-89
Considerations for Dental Treatment
Pre-operative
 Measure and record blood pressure, review health status to include all medications, and refer patient to
PCP prn (listed above).
 If blood pressure reading is above normal, two additional readings must be performed – with at least
one performed using a stethoscope and sphygmomanometer.
o For patients with a BP less than or equal to 180/110 and no evidence of target organ
involvement, any dental treatment may be provided.
o For patients with a BP greater than 180/11, defer elective dental care.
o Minimize stress; consider sedative premedication in excessively anxious patients.
Operative
 Provide local anesthesia of excellent quality.
 For cardiac patients, limit epinephrine to 2 cartridges of 1:100,00 epinephrine.
 For uncontrolled hyperthyroid patients or newly diagnosed (and not completely titrated) hypothyroid
patients, avoid epinephrine.
 Avoid epinephrine-containing gingival retraction cord.
 For patients with upper Stage 2 HTN, consider intraoperative monitoring of BP and terminate
appointment if BP reaches 180/110.
Post-Operative
 Make slow changes in chair position to avoid orthostatic hypotension.
Ensure patient’s vitals are stable prior to dismissal.
Little, Falace. The dental management of the medical compromised patient. 9th edition. Mosby, 2017.
JAMA, 2014 Feb 5;311 (5):507-20. doi: 10.1001/jama.2013.284427.2014 evidence-based guideline for the management of high blood pressure in adults:
report from the panel members appointed to the Eight Joint National Committee (JNC 8)
Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Paul K. Welton, Robert M. Carey, et al.
Journal of the American College of Cardiology Nov 2017
Benetos A, Pertrovic M; Hypertension management in older and frail older patients. Circulation Research 2019;124:1045-1060
16
The blood glucose target range for diabetics, according to the American Diabetes Association, should be
90-130 (mg/dL) before meals, and less than 180 mg/dL after meals (as measured by a blood glucose
monitor).
Glycemic Goals for Adults

The A1C goal for many non- Providers might reasonably suggest Less stringent A1C goals (such as
pregnant adults is <7%. more stringent A1C goals (such as <8%):
<6.5%) for selected individual  A history of severe
patients: hypoglycemia.
 Those with short duration of  Limited life expectancy.
diabetes, long life expectancy,  Advanced microvascular or
and no significant CVD. macrovascular complications.
 Extensive comorbid
conditions.
 Those with long-standing
diabetes in whom the general
goal is difficult to attain.
Reference link for ADA Guidelines for Diabetes
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Diabetes
1. What type of diabetes and when were you diagnosed?
2. What was your last A1C level and when was it taken?
3. Have you measured your blood glucose today? Most recent level? Normal range?
4. What medications are you taking? Dose, route, frequency and indication?
5. Have you eaten and taken your medications today?
6. Have you been hospitalized in the past year for problems related to your diabetes?
Risk for Medical Emergency: HYPOGLYCEMIA (rapid drop in blood pressure)
Signs/Symptoms
 Early: nausea, trembling, tachycardia, pallor, headache, sweating.
 Late: incoherent, uncooperative, diminished cerebral function, seizure activity, unconsciousness
Management:
 Responsive patient: provide source of glucose (glucose tablet, orange juice, regular soda, cake icing).
Arrange for escort home.
 Unresponsive patient: emergency protocol should be activated. Place nothing in the patient’s mouth.
An IV or IM dextrose may be administered by an experienced individual. Arrange for escort home.
Pertinent Laboratory Information
 Fasting blood sugar (reflects current control, that day). (>126 mg/dL = diabetes diagnosis)
 Random plasma glucose > 200 mg/dL with symptoms = diabetes diagnosis
 HbA1C (Glycosylated hemoglobin) (reflects average control over last 6-8 weeks)
o 4-6% - excellent control
o 7-8% - good control (≥6.5% = diabetes diagnosis)
o ≥9% - poor control
Pre-operative
 Determine glycemic control (HbA1C); note that although higher levels are associated with unfavorable
outcomes, no evidence shows that postponing elective surgery to improve glucose level control is
beneficial.
 Confirm patient has taken medications and eaten.
 Morning appointments are preferable, but not necessary: 1.5-3 hours after breakfast/insulin.
 Avoid elective dental treatment with blood glucose > 400 mg/dL.
 Have glucose source available (i.e., orange juice, cake icing, glucose tablets)
Operative
 Recognize signs and symptoms of hypoglycemia.
Post-Operative
 When appropriate, adjust insulin dose in coordination with physician according to patient’s ability to
maintain caloric intake.
 Avoid glucorticosteroids.
 Consider peri-operative or post-operative antibiotics for poorly controlled patients in invasive or
surgical procedures.
Oral Manifestations
Xerostomia, infections (including candidiasis), poor wound healing, increased incidence and severity of caries,
gingivitis and periodontal disease, periapical abscesses, burning mouth symptoms
Patton, Glick. The ADA Practical Guide to Patients with Medical Conditions, 2nd edition. Wiley, 2016.
Simha V, Shah P. Perioperative Glucose Control in Patients with Diabetes Undergoing Elective Surgery. JAMA. Published online January 7, 2019.
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Management of Patients with Prosthetic Joints
Undergoing Dental Procedures
Clinical Recommendation
In general for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior
to dental procedures to prevent prosthetic joint infection.
For patients with a history of complications associated with their joint replacement surgery who are
undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic
antibiotics should only be considered after consultation with the patient or orthopedic surgeon. To assess a
patient’s medical status, a complete health history is always recommended when making final decisions
regarding the need for antibiotic prophylaxis.
Clinical Reasoning for the Recommendation
 There is evidence that dental procedures are not associated with prosthetic joint implant infections.
 There is evidence that antibiotics provided before oral care do not prevent prosthetic joint implant
infections.
 There are potential harms of antibiotics including risk of anaphylaxis, antibiotic resistance, and
opportunistic infections like Clostridium difficile.
 The benefits of antibiotic prophylaxis may not exceed harms for most patients.
 The individual patient’s circumstances and preferences should be considered when deciding whether
to prescribe prophylactic antibiotics prior to dental procedures.
Copyright © 2015 American Dental Association. All rights reserved.
In cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and
when reasonable write the prescription.
Sollecito T, Abe E, Lockhart P, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical
practice for dental practitioners – a report of the American Dental Association Council on Scientific Affairs, JADA, 2015 146(1) 11-16.
The American Academy of Orthopedic Surgeons (AAOS) provides a report from an expert panel of
dentists, orthopedic surgeons, and infectious disease specialists, convened by the American Dental
Association (ADA) and the AAOS.
The report details the results of panel performed a thorough review of all available data to determine the
need for antibiotic prophylaxis to prevent hematogenous prosthetic joint infections in dental patients
who have undergone total joint arthroplasties.
The American Heart Association (AHA) provides information and resources to guide dentists on treating
patients with infective endocarditis (IE). Click here for information on IE in dental patients, and for links to
related resources.
If the patient has not had the prescription filled or needs an emergency procedure, antibiotics are available
on site and can be appropriated for immediate patient use by the following procedure:
 A completed prescription signed by the supervising faculty instructor to be taken to the Tarrson
Hall 3rd or 4th floor dispensary
 The medications will be tendered to the student dentist
 The prescribed appropriate medication (amoxicillin or clindamycin) will be dispensed
 Verification of the appropriate medication will be done by the faculty prescribing the medication
before administering to the patient.
 An appropriate note indicating this transaction will be recorded in the patient record for the day.
19
Cardiac Conditions Associated with the
Highest Risk of Adverse Outcomes from Endocarditis
for Which Prophylaxis with Dental Procedures is Recommended
 Prosthtic Cardiac Valve
 Previous IE
 Congenital Heart Disease (CHD)*
o Unrepaired cyanotic CHD, including palliative shunts and conduits
o Completely repaired congenital heart defect with prosthetic material or device, whether
placed by surgery or by catheter intervention, during the first 6 months after the
procedure**
o Repaired CHD with residual defects at site or adjacent to the site of a prosthetic patch or
prosthetic device (which inhibits endothelialization)
 Cardiac transplantation recipients who develop cardiac valvulopathy
*Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other forms of CHD.
**Prophylaxis is recommended because endothelialization of prosthetic materials occurs within 6 months after the procedure.
Dental Procedures for which

Endocarditis Prophylaxis is Recommended for Patients
All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or
perforation of the oral mucosa.*
*The following procedures do not need prophylaxis:
 Routine anesthetic injections through non-infected tissue
 Taking dental radiographs
 Placement of removable prosthodontic or orthodontic appliances
 Adjustment of orthodontic appliances
 Placement of orthodontic brackets
 Shedding of deciduous teeth
 Bleeding from trauma to the lips or oral mucosa
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other forms of CHD.
Prophylaxis is recommended because endothelialization of prosthetic materials occurs within 6 months after the procedure.
Timing: An antibiotic for prophylaxis should be taken in a single dose, 30-60 minutes before procedure. If
dosage is inadvertently missed before procedure, it may be taken up to 2 hours after procedure.
Patients Already Taking Antibiotics: If a patient is already receiving long-term antibiotic therapy with an
antibiotic that is also recommended for IE prophylaxis for a dental procedure, it is prudent to select an
antibiotic from a different class rather than to increase the dosage of the current antibiotic. It would also
be preferable to delay a dental procedure until at least 10 days after completion of the antibiotic therapy
to allow time for the usual oral flora to be re-established.
No Antibiotic Prophylaxis Needed: For patients with h/o coronary artery bypass graft surgery (CABG),
cardiac stents or pacemakers.
Clindamycin should no longer be used as first-line alternative to penicillin due to its high risk of C. Diff
infections.
Reference Material: ADA Antibiotic Prophylaxis Prior to Dental Procedures
20
Regimens for a Dental Procedure
Situation Agent Adults Children
Oral Amoxicilin 2g 50 mg/kg
Unableke oral Ampicilin OR 2 g IM or IV 50 mg/kg IM or IV
medicati Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
Allergicenicillins or Cephalexin*ꝉ OR 2g 50 mg/kg
ampicillin oral) Clindamycin OR 600 mg 20 mg/kg
Azithromycin or 500 mg 15 mg/kg
clarithromycin
Allergicenicillins or Cefazolin or ceftriaxone ꝉ 1 g IM or IV 50 mg/kg IM or IV
ampicillin nd unable to OR
take oraledication Clindamycin 600 mg IM oIV 20 mg/kg IM or IV
*Or other fist - or second-generation oral cephalosporin in equivalent adult or pediatric dosage.
ꝉCephalosporns should not be used in an individual with a history of anaphylaxis, angioedema or urticarial with pencillins or
ampicillin.
21
1. When is your expected due date?
2. Are your currently receiving prenatal care?
3. Are you currently taking any medications?
4. Have there been any changes in your oral health throughout your pregnancy?
In the late stages of pregnancy, if the patient is in the supine position, there is a risk of supine
hypotensive syndrome (rapid drop in BP, bradycardia, sweating, nausea, weakness, SOB). Have patient
roll to their left side so weight is taking off major vessels.
None, unless patient has gestational diabetes or anemia
Management for Dental Treatment
Oral health care, including radiographs, local anesthesia and pain medication is safe through pregnancy.
 Pre-operative: take blood pressure (elevated BP may be a sign of preeclampsia)
 Operative: avoid pacing patient in supine position during late stages of pregnancy
 Post-operative: minimize oral microbial load (consider chlorhexidine and/or fluoride)
Oral Manifestations
 Gingivitis and/or pyogenic granuloma due to hormonal changes
 Dental caries due to changes in diet (i.e., snacking, etc.)
 Erosion from vomiting (i.e., morning sickness)
o Inform patient to avoid brushing immediately after vomiting. Instead rinse with a
solution of 1 cup water and 1 tsp baking soda to neutralize the acid.
22
Pharmacological Considerations for Pregnant Women
The pharmacological agents listed below are to be used for indicated medical conditions and with
appropriate supervision.
Pharmaceutical Agent Indications, contraindications and special conditions
Analgesics
Acetaminophen May be used during pregnancy. Oral pain can often be managed
Acetaminophen with Codeine, with non-opioid medication. If opioids are used, prescribe the
Hydrocodone, or Oxycodone lowest dose for the shortest duration (usually less than 3 days),
Codeine and avoid issuing refills to reduce risk for dependency.
Meperidine
Morphine
Aspirin May be used in short duration during pregnancy; 48-72 hours.
Ibuprofen Avoid in 1st and 3rd trimesters.
Naproxen
Antibiotics
Amoxicillin May be used during pregnancy
Cephalosporins
Clindamycin
Metraonidazole
Penicillin
Ciproflaxacin Avoid during pregnancy
Clarithromycin
Levofloxacin
Moxifloxacin
Tetracycline Never use during pregnancy
Anesthetics Consult with a prenatal care health professional before using
intravenous sedation or general anesthesia. Limit duration of exposure
to less than 3 hours in pregnant women in the 3rd trimester.
Local anesthetics with epinephrine May be used during pregnancy
(e.g., Bupivacaine, Lidocaine,
Mepivacaine)
Nitrous Oxide (30%) May be used during pregnancy when topical or local anesthetics
are inadequate. Pregnant women require lower levels of nitrous
oxide to achieve sedation; consult with prenatal care health
professional.
Antimicrobials Use alcohol-free products during pregnancy.
Cetrylpyridinium chloride mouth May be used during pregnancy
rinse
Chlorhexidine mouth rinse
Xylitol
Additional Resources: ADA Pregnancy | Oral Health Pregnancy Consensus | Prenatal Oral Health
23
Heart Failure
1. When were you diagnosed with HF?
2. When was your last medical visit? Do you have new or worsening symptoms?
3. What are names, doses and schedule of your medications?
4. Are your treatments effective in controlling symptoms? (Are you compensated?)
5. What is your most recent ejection fraction?
6. ROS pertinent positives: SOB, orthopnea, fatigue, exercise intolerance, coughing or SOB at night
Classification of HF
 Class I: no limitation of physical activity; no dyspnea, fatigue, palpitations with ordinary activity
 Class II: slight limitation of activity; has fatigue, palpitations, dyspnea with ordinary activity,
comfortable at rest
 Class III: limitation of activity; less than ordinary activity results in symptoms but comfortable at rest
 Class IV: symptoms present at rest, any physical exertion exacerbates symptoms
Ejection Fraction (EF): measurement of the percentage Symptomatic Heart Failure (Uncompensated)
of blood leaving the heart each time it contracts.  Dental treatment should be limited to
EF Measurement What it Means urgent/emergency care.
55-70% Normal  The risk for medical emergency is high and routine
40-55% Below Normal dental care should be avoided until the patient is
Less than 40% May confirm diagnosis of deemed stable.
heart failure  Patients with CHF are at risk for acute failure, fatal
Less than 35% Patient may be at risk of life- arrhythmia, stoke or MI so the dentist should be
threatening irregular able to recognize and provide care for these
heartbeats possible symptoms.
Asymptomatic/Mild Heart Failure (Compensated)
 Any necessary dental treatment may be provided.
Pre-operative
 Thorough health history, including most recent EF
 Measure blood pressure and consider monitoring throughout appointment
 Short, low stress appointments to minimize stress
Operative
 Semi-supine or upright chair position, depending on patient’s comfort level
 Provide local anesthesia of excellent quality
 Limit use of epinephrine to 0.04 mg
 Avoid epinephrine impregnated retraction cord
 Patients in upper class II HF, consider intraoperative monitoring of BP and administration of
supplemental oxygen
 Nitrous oxide sedation can be used with a minimum of 30% oxygen
 If patient is on digitalis, be mindful of potentially increased gag reflex
Post-Operative
 Slow changes in chair position to avoid orthostatic hypotension
 Ensure stable vitals before dismissing the patient, recording pre- and post-op vitals in chart
 Achieve good hemostasis and analgesia before dismissing
Anticoagulated Patient
24
1. Why are you taking an anticoagulant (“blood thinner”)?
2. What is your current dose and has that dose changed recently?
3. (Only for patients on Coumadin (warfarin)) What is your most recent INR and when was it taken?
4. (Appropriate review of systems questions: easy bruising, epistaxis, bleeds excessively after injury)
Embolic risk far exceeds the risk of interrupting anticoagulation and the potential complications associated with
bleeding. Therefore, anticoagulant medications should not be stopped prior to dental treatment.
For patients on Coumadin (warfarin): If patient is not in therapeutic INR range, there is a high risk of bleeding from simple
oral procedures.
INR Target 2.5 (Range: 2.0-3.0) INR Target 3.0 (Range: 2.5-3.5)
 Atrial fibrillation  Thromboembolic complications at INR 2-3
 Aortic valve replacement (AVR) – mechanical  Mitral valve replacement (MVR) – mechanical
 VTE treatment and prophylaxis
Pre-Operative
Coumadin Direct Acting Oral Anticoagulants
 Obtain patient’s most recent INR and the date  No laboratory test currently available for
 For patients on short-term anticoagulation monitoring peri-operative risk of bleeding.
therapy, it might be appropriate to defer dental  Ensure patient is under regular care of PCP and is
treatment until after cessation of therapy. taking medication as prescribed.
ROUTINE DENTAL PROCEDURES:  Review pertinent ROS to help assess risk of
 All routine care may be safely performed without bleeding.
altering anticoagulation levels up to INR 3.5
 INR must be therapeutic <1 week of routine care
SURGICAL PROCEDURES:
 Confirm INR value <3.5 within 48 hours of surgery
 For extensive surgical procedures, individualize
treatment in consultation with PCP.
 Consider subdividing extensive procedures into
smaller surgeries to minimize risk of hemorrhage.
Operative
 Block anesthesia poses risk of excessive, difficult to control hemorrhage and needs to be done carefully or avoided.
 Infiltration and periodontal ligament injections are particularly well suited for patients with deficiencies of
coagulation.
Post-Operative
 Avoid ASA, NSAIDS for analgesia. Use acetaminophen for post-operative pain control.
 Ensure adequate hemostasis prior to dismissal.
 Give clear/complete post-operative instructions including afterhours contact information.
 Consider a follow up phone call to check on the patient.
Garcia D, Alexander JH, et al. Managemetn and clinical outcomesin pts treated with apixaben vs. warfarin undergoing procedures. Blood. 2014;
124(25):3692-2698
Wahl, Michael J. The mythology of anticoagulation therapy interruption for dental surgery. JADA, Volume 149, Issue 1, e1-e10. 2018
Chronic Obstructive Pulmonary Disease (COPD)

25
Quesons to Ask/Necessary Information
1. When were you diagnosed with COPD?
2. When was your last medical visit? Do you have any new or worsening symptoms?
3. What are names, doses and schedule of medications?
4. Are your treatments effective in controlling symptoms?
5. Do you require supplemental oxygen? If so, when?
6. ROS pertinent positives: dyspnea, orthopnea, shortness of breath, wheezing, productive cough
7. Have you ever had difficulty breathing during dental treatment?
Risk fr Medical Emergency
 A patient with shortness of breath at rest, a productive cough, upper respiratory infection, or an O2 saturation of
< 91% is considered unstable for elective dental care.
 Routine care can be provided to patients with stages ! to III COPD but should be avoided in patients who have
stage IV COPD.
Pertinnt Laboratory Information
Stage Pulmonary Function Test Findings Symptoms
I: Mild Mild airflow limitations +/- chronic cough and sputum production;
FEV1/FVC <70% patient unaware of abnormal lung function
FEV1 ≥80% predicted
II: Mo Worsening airflow limitations Dyspnea on exertion, cough, and sputum
FEV1/FVC <70% production; patient usually seeks medical care
FEV1 between 50 and 80% predicted because of symptoms
III: Seve Further worsening airflow limitations Increased shortness of breath, reduced exercise
FEV1/FVC <70% capacity, repeated exacerbations impact quality
FEV1 between 30 and 50% predicted of life
IV: Ver Severe Severe airflow limitations Cor pulmonale (right heart failure), quality of life
FEV1/FVC <70% impaired, life-threatening exacerbations
FEV1 30% predicted or FEV1 <50% predicted
plus chronic respiratory failure
FEV1: Fed expiratory volume in 1 second; FVC: forced vital capacity; FEV: forced expiratory volume
Adoptom Global Strategy for the Diagnosis, Management and Prevention of COPD , Global Initiative for Chronic Obstructive Lung Disease
Consierations for Dental Treatment
Pre-Oerative
 Short morning appointments are preferable.
 Delay elective care if medically unstable (see above).
 Avoid elective care in hot, humid weather.
 In severely anxious patients, sedative premed with benzodiazepine can be used.
 For patients on bronchodilators, consider having them use prior to starting dental care.
Opertive
 If coexisting cardiovascular disease is present, stress reduction measures should be implemented, vital signs
monitored and supplemental oxygen provided pm.
 Cautious use of N2O and avoid completely in patients with severe COPD (stage III or worse).
 Avoid orthopnea with chair positioning (semi-supine or upright may be best).
 Avoid using a rubber dam in patients with severe COPD.
 Judicious use of local anesthetic with epinephrine (limit to 2 capsules 1:100K epi)
 Consider using pulse oximeter during appointment to monitor patient.
Post-Operative
 Avoid prescribing respiratory depressant drugs like barbiturates and narcotics.
 Avoid prescribing anticholinergic/antihistamine drugs that dry bronchial sections and increase risk of respiratory
infection.
th
Little, Fal. The dental management of the medical compromised patient. 9 edition. Mosby, 2017.
Patton,ck. The ADA Practical Guide to Patients with Medical Conditions, 2 nd edition. Wiley, 2016.
Asthma
Quesons to Ask/Necessary Information
26
1. When were you diagnosed with asthma?
2. When is the last time you had an asthma attack?
3. What typically precipitates an attack? What resolves it?
4. Have you ever been hospitalized due to asthma?
5. Have you had any recent changes in your medication?
6. Do you have your inhaler with you? (If so, make sure inhaler is easily accessible.)
7. Ascertain adherence to medication use (especially in the previous 4 weeks), the type of asthma (e.g.,
allergic vs. non-allergic), precipitating substances, frequency and severity of attacks, times of day when
attacks occur, whether asthma is a current or past problem, how attacks usually are managed, and
whether the patient has received emergency treatment for an acute attack.
Risk of an Acute Asthmatic Attack
Signs
 Inability to finish sentences with one breath, ineffectiveness of bronchodilator to relieve difficulty
breathing.
Management:
 Stop care, remove dental dam.
 Administer bronchodilator (Beta 2-agnoist).
 Administer oxygen (2-3L/min).
 If needed, administer subcutaneous epinephrine 1:100/0.3 to 0.5 cc subcutaneously.
 Activate EMS and repeat administration of bronchodilator every 20 minutes.
Pre-operative
 Remind patient to bring inhaler.
 Obtain medical consult if asthma is poorly controlled.
 For moderate to severe asthmatics, consider use of inhalers prophylactically prior to appointment.
Operative
 Provide stress-free environment through establishment of rapport and openness to reduce risk of
anxiety induced asthma attack. If sedation is required, use of nitrous oxide-oxygen inhalation sedation
or small doses of oral diazepam (or both) is recommended.
 Avoid asthma triggers.
 Monitor vitals and recognize signs of an attack (above).
Post-Operative
 Avoid erythromycin, macrolides, and ciprofloxacin in patients taking theophylline.
 Avoid aspirin and NSAIDS – may trigger an attack.
 Avoid barbiturates and narcotics.
Oral Manifestations
Bronchodilators and corticosteroids inhalers increase risk of caries, periodontal disease and candidiasis.
Simha V, Shah P. Perioperative Glucose Control in Patients with Diabetes Undergoing Elective Surgery. JAMA. Published online January 7, 2019.
27
Myocardial Infarction (MI)
1. When did you have an MI? How was it treated?
2. Are you currently under the care of a physician?
3. Do you have chest pain? How often? How do you treat it?
Cardiac Risk Stratification
 High Cardiac Risk: patients with symptoms of unstable angina or recent MI ≤30 days
 Intermediate Cardiac Risk: patients with a history of MI planned for extensive surgical procedures
 Low Cardiac Risk: patients with a history of MI planned for simple surgical or nonsurgical procedures
Patients with Chest Pain (acute angina) During a Procedure:

Signs/Symptoms:
 Early: heavy/pressure feeling in chest, sweating, trembling, nausea, jaw pain, feeling of impending
doom
 Late: vomiting, loss of consciousness
Management
 Responsive Patient: provide oxygen, take blood pressure, administer nitroglycerin, active EMS
 Unresponsive Patient: emergency protocol should be activated. Place nothing in patient’s mouth.
For patients with an unstable angina or recent MI (≤30 days)
 Avoid elective dental care.
 If care becomes necessary, STABLE ANGINA UNSTABLE ANGINA
consult with cardiologist to  Predictable  Recent onset chest pain
 Induced by exercise  Not readily relieved by nitroglycerin
develop a plan of care that is
or exertion  Precipitated by less effort than before and
safest for the patient.
 Lasts for <15 minutes that occurs at rest
Pre-Operative  Pain with increasing frequency and intensity
 Determine risk stratification.
 Take vital signs.
 Have nitroglycerin available.
 Patients on anticoagulant therapy or anti-platelet therapy: do not stop medications prior to procedure
Operative
 Short appointments, morning preferable.
 Comfortable chair position.
 Reduced stress environment possibly with oral sedation (short-acting benzodiazepine) 1 hour before
procedure or nitrous oxide.
 Have nitroglycerin and oxygen readily available.
 Achieve profound local anesthesia.
 Limit amount of vasoconstrictor to 2 capsules of 1:100 K epinephrine at a time (within 30-45 minutes).
 Avoid epinephrine-impregnated retraction cord
 For patients on platelet therapy, have additional hemostatic acids available for surgical procedures.
Post-Operative
 Achieve effective post-operative pain control.
Minassian C, et al: Invasive dental treatment and risk for vascular events: a self-controlled case series. Ann Intern Med 2010; 153: pp.499-506.
Skaar, D, et al: Dental procedures and risk of experiencing a second vascular event in a Medicare population. J Am Dent Assoc 2012; 143: 1190-1198.
Wahl, Michael J. The mythology of anticoagulation therapy interruption for dental surgery. JADA, Volume 149, Issue 1, e1-e10. 2018.
28
Patient and Provider Safety
 Blood and Body Fluid Exposure Protocol
 Procedure for Swallowed Foreign Objects
 AED and Oxygen Tank Locations
 Checking Oxygen Tank Pressure
 Protocol for Anxiety Management in the General Dental Clinics
Documentation of Medical Emergency

A Medical Emergency Record is generated each time the school’s Medical Emergency Team responds
to a call. The document is completed by a nurse or junior resident, signed by the school’s Medical
Emergency Team faculty member present at the patient emergency, and submitted to the Director of
Clinical Compliance within 48 hours. The original medical emergency record is to be included in the
patient record (chart) or, for non-patients, in the medical emergency file maintained by the Director of
Clinical Compliance.
Documentation of an Incident
For all injuries occurring in the school facilities, an Incident Report must be generated.
When the emergency involves a Carolina Dentistry patient of record, the faculty/healthcare provider
documents the emergency event in the patient's record.
Emergency Equipment
Automated External Defibrillators (AED) Oxygen Equipment
Defibrillation is a medically recognized method of Emergency oxygen tanks and related equipment
reversing certain potentially fatal arrhythmias. located in Brauer Hall, Tarrson Hall, First Dental
Successful resuscitation of a patient is related to Building, and Koury Oral Health Sciences Building
the length of time between the onset of an will be checked periodically by a designated
arrhythmia (ventricular fibrillation and/or pulse employee.
less ventricular tachycardia) and defibrillation.
Administration of supplemental oxygen is also
crucial to the resuscitation process.
29
Adams School of Dentistry Emergency Evacuation Plan
GAP Clinical Team members will assist in directing occupants and assist in relocating physically impaired
occupants to the closest staging area.
Occupants in the school’s facilities are to exit the building via the nearest exit and assemble at one of the
following designated staging areas and remain until instructed to disperse.
1. Burnett-Womack lawn (east)

2. Adams School of Dentistry Quad (north)
3. Manning Drive/ South Columbia Street (south/west)
Occupants must proceed to the designated staging area to ensure emergency response personnel and
vehicles have clear and immediate access to the site.
See the illustration below for staging areas:
3 1
30
Entrustable Professional Activities (EPAs)
Introduction
At the Adams School of Dentistry, we have defined four core Entrustable Professional Activities (EPAs).
EPAs comprise a series of tasks learners are expected to perform at a certain level of supervision by a
specified time point, offering a bridge between competency-based frameworks and clinical practice.1
The goal is to have multiple assessments to evaluate practice readiness based on a series of clinical
experiences, instead of a singular instance.2 The section below outlines these four core EPAs and their
subsections, defining the scope of services provided in the predoctoral clinic.
EPA 1: Assessment
Conduct a comprehensive patient assessment of oral and systemic conditions
1a) Obtain a health history
Graduates must be able to complete a thorough, accurate history (comprehensive or focused) in a

prioritized, organized, and systematic manner independently. The assessment should be tailored to the
clinical situation and specific encounter.
Resources
Comprehensive Health History Note Sheet Example (PDF)
Epic Tutorial for HHx Instructions (PDF)
Health History Faculty Calibration Presentation (PDF)
1b) Perform a clinical examination
Graduates must able to obtain a thorough, accurate examination (comprehensive or focused) in a

prioritized, organized, and systematic manner independently. The assessment should be tailored to the
clinical situation and specific encounter. The initial examination of a dentate patient must include, at a
minimum, documented clinical and radiographic findings of extraoral and intraoral soft tissues, occlusion,
periodontium, dentition, and restorations.
31
Click here for a DxT appointment checklist on Sakai under Diagnosis and Treatment Planning.
1c) Obtain diagnostic tests
Graduates must be able to select and accurately interpret common diagnostic and screening tests using
evidence-based, person-centered, and cost-effective principles in various settings.
Individuals should identify which diagnostic and screening tests are warranted as part of the information
gathering process—this includes being able to articulate the rationale for their selection and
communicate results to individuals within their care team or other healthcare providers.
This data gathering and interaction activity serves as the basis for clinical work and as the foundation for
evaluation and management. Learners need to integrate the scientific foundations of biomedical sciences
with clinical reasoning skills to guide their information gathering.
Individuals should be able to OBTAIN/ ORDER and INTERPRET the following:
 Radiographs (e.g. panoramic, periapical, bitewings, cephalometric, CBCT)

 Blood glucose
 Tooth Vitality
 Pathology studies (e.g. which tissue or cellular sample appropriate for mucosal and bone lesions)
 Salivary/oral fluids (e.g. culture and sensitivity, caries susceptibility tests)
Individuals are also expected to INTERPRET the following:
 Plasma/serum/blood studies (e.g. HgbA1c, CBC with differential, Liver Function Tests, Renal
Function Tests, coagulation/bleeding profiles including INR)
 Microbiology reports (e.g. aerobic/anaerobic bacteria, fungal, and viral cultures and sensitivity
results)
 Cardiac function tests including Ejection Fraction
Ordering Radiographs
Tip Sheet (Epic/UNC Health login required) | Video (Onyen login required)
Radiology Clinical Manual
The manual is on Sakai under Radiology.
32
Epic-MiPACS Instructions
Epic provides two ways to open your MIPACS images automatically. By using the local MIPACS desktop
client, or through the new MIPACS web viewer.
 MiPACS Desktop Client: Click on the MiPACS desktop icon.

 MiPACS Web Viewer: Click on the MIPACS Web Viewer button.
o The Web Viewer ONLY shows approved images. If there are any un-approved images, the
web viewer does not have any indication that the unapproved images exist.
o To have the images approved, you must secure the chart, and have a DA or clinical
instructor log in and approve images.
EPA 2: Plan of Care

Develop a comprehensive diagnosis, treatment plan, and obtain consent from a patient for their plan of
care.
2a) Form a comprehensive diagnosis and priority list
Graduates must be able to integrate patient data to formulate a risk assessment and develop a list of
diagnoses and concerns that can be prioritized. Graduates must be able to identify necessary
modifications and/or preparations required prior to care.
The list should include all general health, oral health, and behavioral/ psychosocial issues that may impact
on treatment planning and delivery of oral health care for that patient. The list should facilitate referral to
healthcare providers to address systemic health concerns, allied health providers to manage psychosocial
issues, and dental specialists to address specific oral health problems and treatment needs that are
beyond the scope or capability of the assigned learner.
View the Caries Diagnosis, Prevention and Management Manual on Sakai
2b) Develop comprehensive treatment plan
Graduates must have the ability to develop (construct and sequence) comprehensive treatment plans for
patients with simple, moderate, and complex needs using principles and information taught in didactic
courses.
These include, but are not limited to biomedical sciences, behavioral sciences; and specialty specific areas
such as, oral medicine, oral pathology, operative dentistry, fixed prosthodontics, removable
prosthodontics, endodontics, periodontics, oral and maxillofacial surgery, orthodontics, and pediatric
dentistry.
The plan must be person-centered and informed by patient concerns. This is a dynamic process that first
includes the ability to gather relevant information and answer key clinical questions often requiring
identifying information resources, retrieving information, and evaluating evidence used to address these
questions. Graduates should have basic skill in analyzing the quality of the evidence and assessing
applicability to their patients and the clinical context.
The second step of the process is integrating this information with patient findings to develop and
implement a treatment plan that addresses the diagnosed concerns. Graduates must be able to use
clinical reasoning to create a treatment plan that is founded in evidence.
33
List of CTD codes and step codes within a dental treatment plan (Epic/UNC Health login required)
Click here for more information on treatment planning.
2c) Obtaining informed consent
Graduates must be able to engage patients in an open, honest, and comprehensive discussion of
treatment options.
This conversation must be the basis for obtaining informed consent from patients, caregivers, and those
with special circumstances for all interventions, tests, or procedures that graduates perform in clinical
settings. This includes engaging in shared decision-making processes with the patient to optimize a
treatment plan that is inclusive and person-centered.
Graduates should NOT conduct informed consent for procedures or tests for which they do not know the
indications, contraindications, alternatives, risks, and benefits.
Click here for more information on signing treatment plans and consent in EPIC
EPA 3: Team Care

Conduct a transition of care by providing and receiving consults and referrals.
Requesting and receiving consult/referral
Graduates should be able to practice and function effectively in a care team environment. The practice of
dentistry is evolving into a group practice model with care teams built around person-centered care.
Conducting safe, timely- effective, efficient, person-centered, and equitable handoff communications
with other healthcare providers to optimize patient care as essential qualities of the graduate.
Handover communication through referrals and transitions of care ensures that patients continue to
receive high-quality and safe care from one healthcare team member or practitioner to another.
Handovers are also foundational to the success of many other types of interprofessional communication,
including discharge from one provider to another and from one practice setting to another.
Transitions can occur between other oral healthcare providers (e.g., dental specialties) and other
healthcare professionals (e.g., medicine, pharmacy, nursing, nutrition, social work).
 Values/Ethics (IPEC Competency 1): Work with individuals of other professions to maintain a
climate of mutual respect and shared values.
 Roles/Responsibilities (IPEC Competency 2): Use the knowledge of one’s own role and those of
other professions to appropriately assess and address the health care needs of patients and to
promote and advance the health of populations.
 Interprofessional Communication (IPEC Competency 3): Communicate with patients, families,
communities, and professionals in health and other fields in a responsive and responsible manner
that supports a team approach to the promotion and maintenance of health and the prevention
and treatment of disease.
 Teams and Teamwork (IPEC Competency 4): Apply relationship-building values and the principles
of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate
patient/population-centered care and population health programs and policies that are safe,
timely, efficient, effective, and equitable.
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All team care encounters should be entered under Adjunctive Services in the ACE form using the following
codes:
 D9310: Consultation (by dentist or physician other than practitioner providing treatment)
DDS student inputs this code. Include service provider as consulting specialist in Epic.
 D9311: Consultation with medical health care professional
Internal Referral/Consultation by Specialty
ENDODONTICS, PROSTHODONTICS, OPERATIVE DENTISTRY, AND PERIODONTICS

Consults Offered: Monday-Friday 8 a.m.-5 p.m.
Any issues in consult delays please reach out to the program’s Care Coordinator.
All referrals sent to our division will be reviewed by the Care Coordinator of that specialty and assigned to
the appropriate provider. Some clinics may have longer wait times than others – please allow 1-2 weeks
before follow up.
DO NOT promise a patient that they will begin treatment at their next appointment. The consult is meant
to determine if they patient has a need, but they will still undergo a full comprehensive exam if necessary
upon assignment in our clinic.
A referral should not be placed without a consult from that prospective specialty on the predoctoral clinic
floor in which they will discuss with the patient and DDS provider: estimated cost of treatment, time
commitment, and deem appropriateness of the specialty scope of practice as outlined below.
When calling for a consult, please use on-call phone number. If there is no response within 30 minutes-
contact front desk.
Consulting provider should assist predoctoral students in wording of the referral and put in a
documentation encounter of their own in Epic regarding the consult.
Referrals must be made in Epic:
1. Click add to order
2. Select SOD ENDODONTICS, SOD PERIODONTICS, SOD OPERATIVE, or SOD PROSTHODONTICS
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3. Fill out the referral form
Department should match where referral should go
Routine is default- should be left

unless it is determined urgent or
emergent by consulting provider
Do not click yes for either of these
4. Accept and sign the order – the authorizing provider should be the person who completed the
consult.
5. Finish note and sign encounter.
ENDODONTICS Consultation/On-call pager: 919-216-4450 Front Desk: 919-537-3993

All endodontises need to have a consult on the clinic floor and be approved by endodontic
faculty/residerior to scheduling or referral placement to determine appropriate level of provider.
The cases neeto be self -assessed (learner) using the AAE Difficulty Assessment Form guidelines, and if
appropriate fopredoctoral skill level, the student needs to present the case to the endodontic mentor
for approval.
Pulp and perial diagnosis and recent radiographs must be presented to the mentor. Once th e case
is discussed anverbally approved, a referral in Epic needs to be created to SOD Endodontic clinic and
submitted to thedodontic faculty/resident for official approval with the indication of the
appropriate levl of provider. Once approved in Epic, patient can be scheduled in pre-doctoral or
resident endodoc clinic.
All cases will beequired to have a restorative treatment planned prior to endodontic treatment.
Graduate Endotics Scope of Practice:

 Sedativ treatment of vital pulp
 Pulpotomy
 Pulpecty
 Root ca treatment
 Retreant of RCT
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 Periapical microsurgery
 Extraction
 Hemi section or root amputation
 Restorations for endodontically treated teeth
OPERATIVE Consultation/on-call phone number/front desk: 919-537-3832

The attending operative faculty on the clinic floor should be responsible for providing operative
dentistry consulting as needed.
If an operative faculty is not available in the DDS clinic, the operative consult may be initiated by the
student from the front desk in the reception areas on the third and fourth floors.
Graduate Operative Scope of Practice

 Direct restoration
 Tooth recontouring
 Vital tooth whitening
 Micro/macroabrasion
 Porcelain veneers
 Restoration of endodontically-treated teeth
 Ceramic and composite inlays/onlays and crowns)
 Crowns (≤3 unit FPD implants/natural teeth)
PERIODONTICS Consultation/On call phone number: 919-216-4928 Front Desk: 919-537-3936

Consults shoulbe completed on the clinic floor prior to referral to graduate peri odontology and/or
scheduled for mpletion in the predoctoral clinic. The periodontology attending faculty on the floor
should first requet consults. If the scheduled attending is unavailable, the on -call pager number can be
called to requet a consult.
Completed peontal charting and recent radiographs should be completed prior to requesting a
consult. Once t case is discussed the periodontal attending will make a determination if the case is
appropriate focompletion in the predoctoral clinic or if a referral is indicated to the graduate
periodontologynic. If indicated for the predoctoral clinic, the case can be scheduled and must be
discussed wi anticipated attending faculty at least 5 days in advance. If indicated for the graduate
periodontologynic, a referral in Epic needs to be created to SOD Graduate Periodontology clinic and
submitted to the riodontology faculty/resident for official approval.
Graduate Periodoogy Scope of Practice:

 Surgica therapy (flap/osseous, regenera tion)
 Laser Trapy
 Extractsite preservation
 Impla (single tooth up to full arch)
 Peri-impantitis
 Soft tisue grafting
 Guidebone regeneration (osteotome and lateral sinus lift)
 Crown lening
 Biopsy
 Canineposure
 Gingiveomy/ Frenectomy
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 Sedation (oral, nitrous and IV) can be offered for other specialties if coordinated for resident to
provide sedation while provider performs other procedural need, but must be coordinated
ahead of time through CC.
All implants must have a restorative plan BEFORE the implant will be placed. See predoctoral implants
section for more details.
PROSTHODONTICS Consultation/On-call phone number: 919-347-0260 Front Desk: 919-537-3947

The purpose of therosthodontics consult is primarily to determine if:
 A tooth is rstorable
 A case shoud be referred to the graduate prosthodontic clinic
Pros consults do nprovide treatment of any kind.
If time remains durng your DXT, obtain the diagnostic casts so that you have them for mounting at the
next visit. Clinical fculty at your initial DXT should be able to treatment plan most restorative
procedures.
If a prosthodonticsnsult is indicated, the following are required:

 DXT mus completed
 Diagnostists must be mounted
 Relevant rdiographs must be updated
Assuming all of thee have been completed, please ask for a prosthodontic consult from the
prosthodontic facy on the clinic floor. If they are unable to complete the consult in a timely manner,
or if there is not a osthodontic faculty member on the clinic floor, then ask the front desk to call for a
prosthodontic conult.
Patients may be refrred to the Graduate Prosthodontic Clin ic for various dental needs, and the
following list is inteed to serve as a guide when deciding if a patient’s needs are too complex and a
referral may be nessary.
 Severe dentl anxiety
 Vertical Diion of Occlusion (VDO) issues (not complete dentur es)
 More thaeight units of fixed prosthodontic units
 Complex cal history
 Ceramic onays and/or veneers except in certain situations approved by preceptor and clinical
faculty.
 Anterior ntal implants
 More thafive dental implants
 Occlusal pane discrepancy requiring extensive rehabilitation with fixed dental restorations.
 Severely rsorbed residual ridge
 Maxillary ilant retained overdenture
 Maxillary mandibular implant supported fixed dentures or bar supported overdentures
SAME DAY CROWN CLINIC

Prime scan technology from Dentsply Sirona allows the providers to be able to fabricate a final
restoration chairside that can be delivered same day. On a single appointment learners will be able to:
 Prepare a tooth for a full or partial coverage restoration
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 Scan- digital impression
 Design a restoration chairside
 Mill and characterize restoration
 Deliver- bond restoration same day.
The same day crown clinic is Tuesday and Thursday from 8 a.m. -5 p.m. in the Graduate Operative
Clinic (days and time subject to changer per semester).
To schedule predoctoral patients:

Complete an operative dentistry consult to deem if a case is appropriate for a same day crown. This will
allow for quicker scheduling.
The case will be reviewed with the preceptor and communication via email will be completed
with Anthony Gregory to schedule the appointment.
The day of the appointment, the patient will check-in and pay for the treatment, in the Operative
Dentistry suite on Brauer Hall, 4th floor.
The following is a description of the type of cases that are best suitable to be scheduled in this clinic:
 Single unit anterior and posterior restorations (Crowns, inlays, onlays)
 All restorations will be fabricated using lithium disilicate- Emax. This material requires 1.5 min
of occlusal reduction.
 No survey crowns or multi-unit FPDs
Pre-requisite:
 There are no prerequisites, but if a student has less than three crown experiences, they should
schedule the patient for the morning and afternoon session to allow for extra time.
PREDOCTORAL DENTAL IMPLANTS

The following describes the steps required to refer and assign cases for surgical implant placement. All
implant cases require to be approved by the implant team director or a member of the implant
assigning team.
The provider will contact Karen Grote directly by email to schedule a meeting with one of the members
of the team. The requirements for implant assignment are included in the UNC Predoc Dental Implant
Surgical assignment form.
The description of the workflow:

 Obtain diagnostic models and CBCT using radiographic guide, or a digital file of a diagnostic
wax up that can be merged with the DICOM file from the CBCT study.
 Treatment plan approved and signed in Epic by group preceptor or covering faculty.
 Complete the UNC Predoc Dental Implant Surgical assignment form and schedule meeting with
implant team.
 The implant team will refer the case to one of the graduate programs placing dental implants
(oral maxillofacial surgery, periodontics, and prosthodontics) and the CC or implant chief (oral
surgery) will assign the case to a resident.
 Resident will work with student and use the software of choice to plan the case digitally.
 Prior to scheduling surgery, the resident and patient will meet for a consult/exam.
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 The resident will do the surgical placement. The learner is encouraged to attend and assist
during the procedure. The Periodontics front desk will coordinate.
 Each learner is required to have certain number of implant surgical assisting experiences,
which will primarily take place during periodontics/prosthodontics rotations, but may be
required outside rotation if experience is not achieved during that time.
Full digital planning is no longer required as this step prior assignment. Digital planning will be done
once you are working one on one with the assigned resident.
 Once implant has been determined is ready for restoration by the resident who placed the
implant; impression parts will be ordered.
 Each clinic desktop has the icon "Implant Center Ordering." Click on the icon to submit your
order. At the end of the form, a faculty signature and submission click is required.
 The order will be sent directly to the implant center for dispensing followed by a copy of the
order in your email.
 The Implant Center Coordinator will coordinate with you to deliver the order.
GERIATRICS Consultation/On-call pager: 919-537-3866

A referral to the geriatric clinic can be completed through the Epic referral pathway. The reason for
referral may be an aged patient, patients with various cognitive/motor/psychological diagnoses and/or
those with compromised dentitions, polypharmacy, complex histories, medically compromised etc. In
addition, community dwelling older adults can be referred. Please communicate with the patient or
their representative and have them call our service for a new patient examination.
ORAL AND MAXILLOFACIAL For non-referral questions, contact the front desk at 919-537-3565 or the
SURGERY resident on call
Referrals to oral and maxillofacial surgery should be done via the Epic using the “UNC SOD Oral and
Maxillofacial Surgery” work queue.
The referral should be descriptive, concise, accurate, and explain why the treatment is beyond the
scope of the dental student provider. The acuity of the patient should be realistic.
Real emergencies such as difficulty swallowing, difficulty breathing, uncontrollable bleeding, infections
into fascial spaces, etc. should be referred person-to-person with one of the oral and maxillofacial
surgery faculty or residents.
ORAL MEDICINE Consultation/On-call pager: 984-215-6810 Fax: 984-974-0355

Refer a patient to al medicine clinic and enter order in Epic in the orders section lower left screen.
It will pull up asmbulatory Referral to Oral Medicine. Select “yes” or “no,” to answer whether it is a
referral for a clerance prior to bone marrow transplant, head and neck radiation, or some other
reason.
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If not for clearance, then a reason for referral section will appear.
Please select the reason that is most appropriate, or click other and add comments about why exactly
the patient is being referred.
Click accept and sign the order after associating it with the proper diagnosis for the day.
Once the referral goes through, the oral medicine coordinator will reach out to the patient and
schedule the appointment with an oral medicine provider.
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The oral medicine clinic accepts all of the most common medical insurance plans, so patient visits are
covered.
An oral medicine specialist routinely treats symptoms related to salivary gland dysfunction such as dry
mouth; viral, bacterial, and fungal infections of the oral cavity; soft and hard tissue lesions of the oral
cavity; oral mucosal diseases; oral changes related to systemic disease; headache disorders;
maxillofacial sensory or movement disorders; burning mouth disorders; orofacial pain disorders
including trigeminal and other neuralgias and temporomandibular disorders; and oral complications
from cancer and/or radiation therapy.
Oral Medicine Specialists very often perform excisional and incisional tissue biopsies of the oral cavity
and procedures such as trigger point injections and nerve blocks to treat TMD and facial pain
syndromes, as well as oral smears to confirm a diagnosis of candidiasis; however, the majority of the
oral medicine practice consists of non-surgical methods of treatment.
Other services performed by the Oral Medicine Specialist include fabricating occlusal splints to treat
TMD, soft medicine trays for application of topical steroids for conditions such as lichen planus and
mucous membrane pemphigoid, and fluoride trays.
Please see oral medicine website for additional details on conditions they manage.
ORAL AND MAXILLOFACIAL PATHOLOGY Consultation/On-call pager: 919-537-3162

To request a consult on the clinic floor, please call the consultation/on-call pager at (919) 537-3162. If
it is a radiograph, it needs to be a “radiology” consult which can be requested via Epic.
Oral pathology faculty asks learners to be ready to present the case and be present during the
consultation.
If there is a need for a referral for biopsy, the learner is responsible for coordinating that with the
faculty on the floor cosigning the referral (Epic).
OROFACIAL PAIN Consultation/On call phone number: 919-445-4143 [email protected]

Orofacial pain mana es chronic musculoskeletal pain, also known as Temporomandibular Disorders;
neuropathic pain, such as trigeminal neuralgia; neurovascular pain, such as migraine headaches; and
the managementf sleep apnea with oral appliances .
ORTHODONTICS Consultation/On-call pager: 919-537-3942

To request an orthodontic consultation, call the consultation/on-call pager at (919) 537-3942. This will
result in one of two possibilities:
1. The patient will be seen on site by the faculty on-call in the graduate orthodontic clinic or in the
student clinics.
2. The patient may be scheduled by the referring student reporting to the orthodontic clinic front desk
and providing demographic information so that a screening appointment will be scheduled exclusively
for the patient. Screening appointments are NOT scheduled in Epic.
To sign-up for a screening appointment in the graduate orthodontic clinic:
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 Contact both Mr. JC Underwood and Mr. John Whitley, and provide the patient name (and
demographic information) as well as the student name. The orthodontics team will contact the
patient for an initial appointment.
 If the patient is already in the building for another dental visit, you may initiate the screening
request in-person, subject to staff availability.
 If the patient is scheduled in advance (through Mr. Underwood and Whitley) for a screening,
they will also be informed of the option to have complete initial records for a fee that will be
disclosed during their initial health.
 The patient will be designated to an appropriate clinic according to the case difficulty for the
graduate or integrated clinic.
PEDIATRIC DENTISTRY Consultation/On call phone number: After Hours/Weekends: 1-984-974-

919-537-3956 1000 and ask to speak to the pediatric
dental resident on call
The purpose of the petric dentistry consult is primarily:
 To provide a coultation in management of child patient behaviors
 To determine a child patient should be referred to the graduate pediatric dentistry clinic,
hospital denta clinic of the UNCH operating room.
The initial consultation sually does not provide direct treatment at the time, but will assist in
determining the best stting for the child patient to access care. Referrals can be made in Epic:
1. Click “Add Order”
2. Select “SOD PediatriDentistry ”
3. Fill out referral form
4. Accept and order

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5. Finish note and sign encounter
RADIOLOGY Consultation/On-call pager: 919-537-3162

To request a radiology consult:
 Open Epic
o Find your recent encounter
o Open the encounter
 Go to the Wrap Up tab
 Go to Follow Up (click on expand)
o In “Send Chart Upon Closing Workspace,” under “Recipient”
 Type “P UNC SOD RAD” and hit tab or enter
 Select “UNC SOD RADIOLOGY CHAPEL HILL RESIDENT”
o In “Comments,” type:
 Image (pan, bw, pa)
 Image date (acquisition)
 Region of interest
 Your question
o Click “Send Now”
PHARMACY Consultation/On call Not on-call. Preferred method of referral

phone number: 919-843-5119 is via Epic, but learners may contact via
phone for availability.
Warm Handff Guidance for Pharmacy Consult
If a patient identifies a concern while completing the medication history section in Epic or screens
positive forollow -up consultation, prepare them for the pharmacy team by saying in a positive tone,
“Thank you or sharing that wi th me. We have a pharmacy team member who can help you with that.
Would youe interested in them reaching out to you by phone so you can discuss this further?”
If the patieeplies “yes,” follow the steps below to send a secure in-basket staff message to
the pharmacy am in the patient’s Epic chart. This can be used if the patient is interested in phone
follow-up wi a pharmacist , or if the student provider wants to send a referral at a later time for
provider coultation.
The Clinicalharm acist/Pharmacy Team aims to provide consultation regarding comprehensive

medication gement and assistance with referrals for primary care and medication access.
To request aatient or provider consult , send a secure in-basket staff message to the pharmacy team
in the paties Epic chart.
 In “To” box, type “P ASOD Clinical Pharmacy.” If you cannot find it, search for “ASOD
Clil Pharmacy” under “pools.”
o Subject Line: Pharmacy Consult Request #1-6 (see below, whichever number
corresponds to consult type)
o Patient: Tag designated patient so that chart is linked to message
In the messge, provide a brief description of the reason for the referral and the information the
patient spefically need s clarified.
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The Pharmacy Team Follow-up consults appropriate for our service include, but are not limited to:
1. Oral Health Impact Medication Review: provides student provider and/or patient with in-depth
review of patient’s medication list for impact on oral health and future oral care
2. Medication History Verification: patient is on complex regimen and/or patient has unknown
medication list and needs to be verified via retail pharmacy
3. High Risk Medication on Medication List: provides student provider with considerations for
treatment if patient is on an anticoagulant (Warfarin, Apixaban, Rivaroxaban, Dabigatran),
antiplatelet (Clopidogrel, Plavix), or insulin for diabetes
4. Chronic Disease State Management Patient Education: provides patient with review medical
condition education for conditions such as diabetes, hypertension, smoking cessation, asthma,
COPD, etc.
5. General Medication Education: patient has question regarding their medication regimen
6. Drug Information Request: provider/student provider has question regarding patient’s
medications
See Appendix 3 for a Pharmacy Consult Decision Table.
Most importantly, verify the patient’s contact information and any special needs or accommodations
(like interpretation services) prior to sending the referral.
What to Expect: Pharmacy Consult Response and Telephone Encounter

The Pharmacy Team will manage follow-up consults utilizing self-scheduling and will provide detailed
documentation following a visit. All patient consults will be primarily via telephone. All student
provider/faculty provider consults will be done primarily via in-basket messaging.
The pharmacy team will monitor their Epic in-basket and will attempt to contact patient within 48-72
business hours of referral. The pharmacy team will document any unsuccessful attempt to reach the
patient via telephone. After 2 attempts, the pharmacy team will send a secure in-basket message to
the consulting provider to inform of inability to reach the patient. The consulting provider will be
responsible for action items related to outreach.
SOCIAL WORK Consultation/On-call pager: 919-445-2748 (social worker is not on-

call, but learners may contact them for availability)
To request a patient or provider consult with Social Work, send a secure message to the social
work team in the patient’s Epic chart.
 Click the “open additional activity” icon in the patient’s chart
 At the end of the activity list, select “send message”, then “staff”
 In the “To” box, type “ASOD Social Work”. If you can’t find it, hit the “search” button (looks like
a magnifying glass) and search for “ASOD Social Work” under “pools”. Once you have selected
this, you should be able to type it in next time and it will populate for you.
In the message, please provide a brief description of the reason for referral.
EPA 4: Provision of Care

Provide dental care to prevent, establish, preserve, and restore oral health and function, including ancillary
therapy, preventive care, non-surgical and surgical care, and emergent care.
(4a) Ancillary Therapy
Anesthesia: Graduates should be able to deliver pain free dental care by effectively using materials and
skills in the proper administration of topical anesthetic and local anesthetic injections and nerve blocks.
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Prescription Writing: Graduates should be able to generate prescriptions for medications and lab orders
for therapies or interventions that are beneficial to patients (e.g. autoimmune, infection, pain,
prophylactic care prior to dental procedures, and post-operative medications).
Graduates must also recognize their limitations and seek review for any orders and prescriptions they are
expected to provide but for which they do not understand the rationale.
 Understand U.S. and North Carolina regulations governing prescription-writing practices and DEA
regulations regarding controlled substances prescriptions.
 Compose orders and prescriptions efficiently and effectively.
 Compose orders and prescriptions in verbal, written, and electronic formats that are compliant
with the scope of practice as well as state and federal laws and regulations.
 Recognize and avoid errors by using safety alerts (e.g., drug-drug interactions) and information
resources to place the correct order and prescriptions that maximize therapeutic benefit and
safety for patients.
 Consider and adjust for patient-specific factors such as age, weight, allergies, pharmacogenetics,
and co-morbid conditions when creating orders and prescriptions.
 Discuss the planned orders and prescriptions (e.g., indications, risks, administration, adverse side
effects) with others and use a nonjudgmental approach to elicit health beliefs that may influence
the patient’s comfort with orders and prescriptions.
(4b) Preventive Care
Graduates should be able to provide a continuum of care for patients and social systems that promotes
overall health. This includes an emphasis on prevention to minimize the development of disease and
maintenance care to minimize complications and reduce progression of disease. In addition, individuals
should be able to conduct appropriate follow-up to build a long-term relationship with patients and their
caregivers.
Oral Health Sustainability Program (OHSP)
The school has developed an Oral Health Sustainability Program (OHSP), which was previously known as
the Preventive Recall Program.
The goal of the OHSP is to provide an opportunity for DDS learners to work with dental hygiene learners
and simulate a clinical practice running multiple chairs. A few key points to keep in mind during this
experience:
 Learners (working with their CC) should schedule appropriate procedures as they are introduced
to managing "two columns" of patients. Guidance on this can be provided by your preceptor.
 Learners should come to clinic and cover HYG (if they are assigned) even if they have a
cancelation or no-show.
 Learners should NOT schedule procedures in other clinic areas (i.e. endo, oral surgery) if they are
assigned to OHSP to cover HYG.
 Learners are responsible to find a replacement in their office to cover HYG if they are going to be
absent on their scheduled day/time and to let their Preceptor, CC, and PN know so Epic can be
updated.
 HYG depends on DDS learners to be present to cover HYG exams, provide consults when needed,
review radiographs, and administer anesthesia, etc. If a learner is assigned to HYG, begin present
is imperative.
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 Learners assigned to HYG should complete a separate ACE form when they perform a periodic
exam, administer anesthesia, etc for a HYG learner.
 Note that despite the assignment, there will be times that there may be a patient cancellation or
no show, patient is present and does not require anesthesia for SRP, or an exams, consistent with
practice after graduation.
 We encourage learners to take responsibility for their education. There is a lot of value in learning
to work with HYG. All learners must be practice-ready general dentists before they can be
specialists and learning to cover HYG in addition to their own patients is part of this experience.
 Attending faculty will be responsible for covering OHSP (HYG Checks) when the learner is
assigned to the two columns.
Please refer to the Clinic Education Manual (pg. 45-50) for more information.
The program focuses on preventive oral health services for our patients and interprofessional care that
mimics the processes within clinical practice. The program’s rotation provides learners the opportunity to
experience collaboration of care between dental student and dental hygiene student to encourage
professional growth and practice-readiness.
By working together, learners will gain a better understanding of team-based, person-centered care, and
overall functionality of the periodic oral evaluation and co-discovery.
Once active treatment has been completed, all patients become part of the OHSP. Patients will remain
assigned to the same provider(s) for maintenance until graduation unless the patient has indicated they
do not want to participate.
Upon completion of the periodontal phase of therapy (perio re-evaluation), endodontic therapy, and/or
the last appointment in the restorative phase, the student dentist, in consultation with the supervising
faculty, will make recommendations for restorative and periodontal maintenance intervals. The
maintenance type and date will be entered in wrap-up section of Epic.
Providers are expected to check the Maintenance Report on a periodic basis and contact patients with
upcoming maintenance needs to schedule an appointment. The assigned Care Coordinator will discuss
overdue patients without proper documentation of the reason for maintenance delay with the learner.
Click here for more information in the Dental Hygiene Clinic Manual
*If there are no further treatment needs for up to 3 years, then the patient will be encouraged to seek care
in a private practice or community practice setting.
Scheduling
Scheduling of the OHSP program will be included as a function of the intramural rotations in the
curriculum.
Senior dental students will be assigned to OHSP rotation at various times throughout the year. Two D4
students will be assigned to OHSP rotation on half-day intervals throughout the year.
If an absence request is on file, it is the learner’s responsibility to find a replacement, and let their office
Preceptor and Care Coordinator know who will be covering their patient care. It will also be the learner’s
responsibility to coordinate making up missed OHSP sessions.
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The D4 learner’s clinic schedule should be planned out ahead of time individually and/or with the Care
Coordinator to keep patient care limited to exams, preventive care, direct restorative procedures,
delivery of appliances, and post-op visits.
This will provide opportunities for D4 learners to manage hygiene in their office, in addition to managing
their own patients for the day, much like practice after graduation. Hygiene management includes (but is
not limited to):
 Prescribing and reviewing radiographs alongside attending faculty

 Performing periodic oral evaluations
 Administering anesthesia for scaling and root planning
 Consulting with dental hygiene students regarding health history and medications
 Participating in the co-discovery process alongside dental hygiene students
The D4 learners assigned to OHSP rotation will also be responsible for facilitating the morning and
afternoon pre-clinic huddles for their office. This will provide opportunities for learners to develop
leadership skills that are vital to their success after graduation, whether as an associate dentist or practice
owner.
At the conclusion of each clinic session, the D4 learner will also be responsible for completing a daily ACE
assessment for their participation in the OHSP rotation.
It will be the responsibility of the D4 learners to meet with the dental hygiene learners prior to the clinic
session to discuss the appointments for these patients. Some items that may be discussed in these
meetings or “mini-huddles” include radiographs, anesthesia needs, pending treatment, and prescription
products.
The dental hygiene patients should also be assigned in Epic to the learners participating in the OHSP
rotation for the week to facilitate seamless integration of treatment plans, clinical notes, documentation,
and scheduling treatment.
The Periodic Oral Evaluation (D0120)
The periodic oral evaluation code is a frequently used examination code in dental practice. This code
applies and should only be used to report a diagnostic treatment plan and evaluation assessment
performed on a patient to gather any new changes since the patient’s last visit. This code is to be billed
only for established patients.
The vertical integration model provides an opportunity for dental and dental hygiene student providers to
learn and work collaboratively as a team to promote improved oral health care for our patients. This
model mimics various practice environments learners may experience upon graduation. The periodic oral
evaluation is an opportunity for student providers to continue developing their communication skills with
patients, each other, and attending faculty. This patient visit also allows learners to build rapport with
their patients and provide continuity of care to increase the likelihood of continued care for the patient.
What components of the appointment must already be completed prior to the periodic oral evaluation?
1. Updated health history

2. Identify chief complaint (if there is one)
a. Retrieve appropriate instruments and supplies for student dentist to address chief
complaint during periodic oral evaluation. Take appropriate PA radiographs as indicated.
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Examples include un-cemented crowns, occlusal adjustments, partial denture
adjustments, etc.
3. Complete head and neck evaluation, oral cancer screening, and other assessments
4. Complete periodontal charting at appropriate intervals
a. Once every 12 months for D1110
b. Every visit for D4910
5. Obtain radiographs at start of appointment. This allows the DDS student to come at any time to
perform exam.
6. Obtain intraoral photographs with intraoral camera, when indicated
7. Tour of the mouth
a. Intraoral photographs of pertinent findings (completed by DH student)
b. Discussion of pertinent findings and patient education with intraoral photographs
(completed by DH student)
i. Important to note that DH student is not making a diagnosis, but is pointing out
areas of concern that the DDS student will confirm and recommend any
treatment if indicated
What are the components of the periodic oral evaluation?
Dental Hygiene to Dental:
1. Identify the chief concern (if there is one)

2. Review patient’s health history
3. Review recent dental work completed, pending referrals, outstanding treatment needs, etc.
4. Provide overview of periodontal health
5. Discuss pertinent findings and patient education with intraoral photographs
6. Take notes while DDS student is performing examination
Dental:
1. Review radiographs
2. Complete thorough head and neck evaluation and oral cancer screening (completed by both DDS
and DH student providers)
3. Answer any questions the patient may have regarding areas of concern, recommended
treatment, outstanding treatment, etc.
4. Discuss pertinent findings and patient education with intraoral photographs
5. Obtain referrals or consults, when indicated
6. Re-appoint for D0150 PLAN if treatment needs are extensive and additional time is needed to
discuss treatment options, obtain consults, and/or answer questions
Following the completion of the periodic oral evaluation, the DH student should continue the prophylaxis,
periodontal maintenance, or nonsurgical periodontal therapy.
The DH student will provide oral hygiene education, place in Epic the patient’s next recall visit and
treatment with the DDS student and continue to discuss with patient next steps.
Hygiene Handoff (Dental Hygienist – Dentist)

1. Patient Intro
a. Name
b. Pertinent MHx
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c. Visit type – prophy, perio maintenance, SRP
d. Chief complaint (if applicable)
2. Radiographs obtained today (if applicable)
a. If no radiographs taken, mention why
3. Intraoral photos obtained today (if applicable)
4. Perio charting
a. Probing depths
b. BOP/Exudate
c. Recession
d. Furcation
e. Mobility
f. Plaque/Calculus
5. Home care
a. Excellent, good, fair, poor
b. Manual/electric toothbrush
c. Flossing, threaders, Waterpik
6. Pertinent findings today w/ intraoral photos
a. Caries, fractured teeth or fillings, pain
b. Are sealants needed?
c. Opportunity to discuss treatment needs and educate patient
d. Discuss whitening, occlusal guards, orthodontics, etc. if no other treatment needs
Workflow of OHSP Rotation Schedule

1. Huddle: The D4 student assigned to OHSP rotation conducts the clinic huddle. Exam,
radiographic, and anesthesia needs are reviewed at this time. Each D4 learner identifies which
hygiene patients they will be responsible for during the clinic session.
2. At start of the appointment, have DDS attending faculty approve any radiographs to be taken for
dental hygiene. Radiographic needs should be reviewed during the clinic huddle and should be
consistent with ADA Guidelines. Use this as a learning opportunity for DDS faculty and DDS
students to teach DH students what radiographs are prescribed and when. If radiographs are to
be taken in the radiology clinic, DH students are to generate the order to be sign by DDS faculty
and DDS faculty are to place radiographs needed in the treatment plan. It is important to make
every attempt to take necessary radiographs on the clinic floor to mimic private practice as much
as possible.
3. Have hygiene take necessary radiographs at the beginning of the appointment. Patient health
history, periodontal assessment and charting, and intraoral photos should all be completed prior
to the exam.
4. Once the above items are completed, the DDS attending faculty and DDS student provider
complete the periodic exam when they are available to do so. Have the DH student alert the DDS
attending faculty and DDS student they are ready for the exam whenever is convenient.
5. The DH student should take down notes to discuss for the hygiene handoff when the DDS faculty
and DDS student come in the operatory to complete the exam. The hygiene faculty should
approve the note, ensuring the DDS billing provider for the exam is correct, and that the note
reflects the DDS student provider and DDS attending faculty who completed the exam.
6. Any treatment diagnosed during the periodic exam should be scheduled with a DDS student
provider in the office unless the patient is already assigned to a student provider. The DH student
should generate a referral to assign the patient to the office if the patient is not already assigned
to the office. The DH student needs to send an in-basket message to the office’s scheduler and
DH PCC, so the patient can be assigned to a dental student provider in the office for treatment.
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7. DH student should obtain necessary signatures for prescription products and items from
dispensary requiring DDS approval.
8. Dental faculty should be using the time for the periodic exam to teach our DH student learners
about the information we want ready and presented to us when we come into the operatory for
the exam, and as a time to teach co-diagnosis/co-discovery.
9. It is imperative the DH student learner is inquisitive, asking the patient about any concerns, and
being investigative, even if the patient is not ‘due’ for an exam. If the DH student identifies any
areas of concern that need addressed, they should be asking for a D4 learner and their attending
to take a look.
10. When possible, offer same-day treatment opportunities, such as sealants, bleach tray
impressions, occlusal guard impressions, and direct restorations. When applicable, these
procedures may be performed by the dental hygiene student provider or delegated to another
appropriate provider who is available.
Epic Note Templates and Documentation

Periodic exam completed by [insert DDS student name] and supervised by [attending faculty name].
Chief Complaint:
Oral cancer screening:
Clinical findings include:
Radiographs ordered:
Radiographic findings include:
Recommended treatment:
Alternative treatment options and discussion:
Referrals:
Next appointment:
*For scaling and root planing, indicate who administered anesthesia, what type, and how much.
Learning Opportunities
 Dental hygienist  dentist handoff
 Intraoral photos and co-discovery
o Always look for areas of concern and treatment opportunities
o Obtain updated intraoral photos for areas of concern and pending treatment needs
 Team-based, person-centered care
Additional preventive areas include the following:
(4c) Preventive Care
Procedure Check: Prophylaxis (Adult and Child)
 Isolation and tissue management

 Plaque and calculus removal
 Stain removal
 Local medication delivery (if applicable)
Adult Prophylaxis (D1110/ Child Prophylaxis (D1120): Prophylaxis is the removal of plaque, calculus, and
stains from the tooth structures in the permanent and transitional dentition. It is performed in the
absence of bone loss.
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Procedure Check: Fluoride and Interim Caries Medication
*Note this includes fluorides (D1206 [varnish]/1208); and interim caries medication application per tooth
(D1354)
Procedure Check: Sealant

 Preparation
 Restoration
Faculty Calibration: Pit and Fissure Sealants
Other Codes
 Nutritional counseling for control of disease (D1310)

 Tobacco counseling for the control and prevention of oral disease (D1320)
 Oral Hygiene (D1330)
Non-Surgical and Surgical Care
Graduates should be able to perform core non-surgical and surgical procedures of an oral healthcare
provider for essential patient care. These procedures include those within the scope of a general
dentistry practice, which attends to patients in all stages of life and diverse backgrounds, including those
with special health care needs. The goal is for these procedures preserve and restore the oral complex as
a necessary feature to support overall health.
This section outlines the EPA categories covered as non-surgical and surgical care. Please refer to
specialty handbooks for details. Appendix 8 will link you to detailed rubrics for various procedures.
RESTORATIVE: DENTATE DIRECT
Procedure Check Steps: Restorations
 Isolation and tissue management  Restoration

 Preparation Initial  Local Medication (if applicable)
 Preparation Final
Video Content: Operative Procedures
Operative Guidelines for Posterior Composite Restorations
Posterior Composite Restorations Calibration Presentation
Operative Clinical Manual
Direct Dentate Preparation and Restoration Rubric
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RESTORATIVE: DENTATE INDIRECT
Procedure Check Steps: Fixed Prosthetics
 Isolation and Tissue Management  Restoration: Definitive

 Preparation  Cementation
 Impression  Local Medication (if applicable)
 Restoration: Provisional  Communication/ management with lab
Fixed Prosthetics Clinical Manual
Faculty Calibration: Fixed Prosthodontics
Indirect Dentate Crown Preparation and Restoration Rubric
Indirect Dentate Pediatric Dentistry Stainless Steel Crown
Procedure Check: Fixed Bridge and Implant Restorations
 Impression
 Restoration: Provisional
 Restoration: Definitive
 Cementation
 Local Medication (if applicable)
 Communication/ management with lab
Implant Assignment Protocol:
 Obtain diagnostic models and CBCT using radiographic guide.

 Treatment plan approved and signed in EPIC by group preceptor or covering faculty.
 Fill out UNC Pre-Doc Dental Implant Surgical assignment form and schedule meeting with
implant team.
 The implant team will refer the case to one of the graduate programs and PCC’s or
implant chief (Oral surgery) will assign the case to a resident.
 Resident will work with student and use the software of choice to digitally plan the
case.
 A consult will be scheduled with the resident and patient prior scheduling surgery.
 Surgical placement will be done by resident and student should attend and assist during
the procedure.
Note: Full digital planning is no longer required as this step prior assignment. Digital planning will be done
once you are working one on one with the assigned resident.
Implant Restoration Workflow:
 Each clinic desktop has the icon "Implant Center Ordering."

 Click on the icon to submit the implant parts needed for treatment.
 At the end of the form, it will require the faculty to sign the order.
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 Once the order is signed, learner can proceed to click submit.
 The order will then be sent directly to the implant center for dispensing.
 Learner will receive a copy of the order in your email.
 The Implant Center Coordinator will coordinate with the learner to deliver the order.
Click here for more information
Indirect Partial Edentulous Implant Fixed Preparation and Restoration Rubric
ENDODONTICS
Procedure Check: Endodontics

 Access Preparation
 Work Length Determination
 Root Canal Instrumentation
 Root Canal Obturation
 Restoration
 Post Treatment Assessment
Endodontics Clinical Manual
Endodontics Case Difficulty Assessment Form
VIDEO: Pulp and Periapical Test Instruction
Faculty Calibration: Endodontic Diagnosis
Endodontics Rubric
PERIODONTICS
Procedure Check: Perio Scaling and Root Planning
 Isolation and Tissue Management

 Calculus identification
 Calculus removal
 Stain removal
Scaling and Root Planning (D4341, D4342): Involves instrumentation of the crown and root surfaces of the
teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal
disease and is therapeutic, not prophylactic, in nature. Root planning is the definitive procedure designed
for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated
with toxins or microorganisms.
Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral
evaluation (D4346): The removal of plaque, calculus and stains from supra- and sub-gingival tooth
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surfaces when there is generalized moderate or severe gingival inflammation in the absence of
periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony
pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with
prophylaxis, scaling and root planning, or debridement procedures.
Full mouth debridement to enable a comprehensive evaluation and diagnosis on a subsequent visit
(D4355): Full mouth debridement involves the preliminary removal of plaque and calculus that interferes
with the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on the
same day as D0150, D0160 or D0170.
Chairside Guide to Periodontitis Staging and Grading (AAP)
CDT Code Flowchart
CDT and ICD Codes
Faculty Calibration: Peri-Implant Diseases
Periodontics Clinical Manual
Non-Surgical Periodontics Rubric
Periodontics During Diagnosis and Treatment Planning
Procedure Check: Perio Maintenance (D4910)

 Plaque and calculus removal
 Stain removal
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Periodontal Maintenance (D4910): Periodontal Maintenance is started after completion of active

periodontal therapy and continues at varying intervals for the life of the dentition or its implant
replacements. The goal is to minimize the recurrence and progression of periodontal disease. Periodontal
maintenance is not synonymous with a dental prophylaxis.
Protocol for Periodontal Charting
Every new patient must receive a full periodontal chart as part of the comprehensive oral evaluation if
the patient is being seen in the third and fourth floor student clinics.
A patient who presents with a healthy periodontium or gingivitis, does not have periodontitis:
 Receives full charting once a year

 Spot probing should occur at each visit.
o *If concerns or changes noted, it should be brought to the attention of attending faculty
to review need for perio consult, change in treatment, if existing dental work is
contributing to issue, etc.
Patient with periodontitis (e.g. D4910):
 Must receive full charting at each visit

o Charting completed at each periodontal maintenance visit provides a way to
longitudinally collect data to track the progression of disease deterioration,
improvement, or stabilization. This then helps focus the efforts of the clinician, educates
the patients, and make decisions on referrals and appropriate care for the patient.
Full charting includes: periodontal probing, recession measurements, mobility, furcation involvement
Procedure Check: Post Treatment Assessment
 Evaluation of therapy
 Prognosis and risk assessment
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 Plan of advanced care (if applicable)
 Oral health sustainability interval
D0170 (Re-eval for limited or problem focused); D0180 (perio re-evaluation)
Post Treatment Assessment Clinical Manual
PROSTHODONTICS: PARTIAL EDENTULOUS
Procedure Check: Removable Pros
 Impressions
 Maxillo-mandibular relations (MMR)
 Try In
 Insertion
 Follow Up
Guidelines for RPD Design
RPD Helpful Hints PDF
Removable Prosthodontics Clinical Manual
Edentulous Removable Impression Rubric
Edentulous Removable Maxillo Mandibular Record Rubric
Partial Edentulous Removable Prosthesis Insertion Rubric
Partial Edentulous Fixed Prosthodontics Bridge
Partial Edentulous Implant Fixed
PROSTHODONTICS: EDENTULOUS
Procedure Check: Removable Pros
 Impressions
 Maxillo-mandibular relations (MMR)
 Try In
 Insertion
 Follow Up
Complete Denture Step-by-Step Checklists
Complete Denture Calibration Review
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Click here for Digital Dentures in DDS Clinics
Click here for Removable Clinical Manual
Edentulous Removable Impression Rubric
Edentulous Removable Maxillo Mandibular Record Rubric
Partial Edentulous Removable Prosthesis Insertion Rubric
Partial Edentulous Fixed Prosthodontics Bridge
Partial Edentulous Implant Fixed
ORAL MAXILLOFACIAL SURGERY
Procedure Checklist: OMFS
 Sterile Field
 Patient Position
 Proper Instrument Use and Handling
 Bleeding Control
 Suturing
 Post Op Instructions
Oral and Maxillofacial Surgery Rubric
Click here for Oral Maxillofacial Surgery Clinic Manual
Emergent Care
Graduates should be able to promptly recognize a patient who requires emergent care, perform
evaluation, initiate management, and seek help, if necessary. Early recognition and intervention provide
the greatest chance for optimal outcomes in patient care. This often calls for simultaneously recognizing
need and initiating a call for assistance. Graduates need to be able to manage medical emergencies
within the realm of general dental practice.
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Patient Services and Operations
Patient Care Operations
GAP Clinic Hours
Weeks 1-5
Office BC Monday Tuesday Wednesday Thursday Friday

Huddle 9 a.m. 8 a.m. Seminars 8 a.m. 9 a.m.
PatienCare 9:15 a.m. 8:15 8:15 9:15
Starts
Huddle 1:30 p.m. 1:30 p.m. 1:30 p.m. 1:30 p.m. 1:30 p.m.
PatienCare 1:45 p.m. 1:45 p.m. 1:45 p.m. 1:45 p.m. 1:45 p.m.
Starts
Note, lunch is from 12-12:45 p.m. and meetings from 12:45-1:30 p.m. Clinics will end at 11:30 a.m. and
4:30 p.m. to allow time for chart writing and assessment completion.
Office DEF Monday Tuesday Wednesday Thursday Friday

Huddle 9 a.m. 8 a.m. 9 a.m. 8 a.m. Seminars
Patient Care 9:15 a.m. 8:15 a.m. 9:15 a.m. 8:15 a.m.
Starts
Huddle 1:30 p.m. 1:30 p.m. 1:30 p.m. 1:30 p.m. 1:30 p.m.
Patient Care 1:45 p.m. 1:45 p.m. 1:45 p.m. 1:45 p.m. 1:45 p.m.
Starts
Week 6 is variable depending on the block. When not in seminars, all morning clinic huddles will begin at
8 a.m. and afternoon clinics at 1:30 p.m. The exception will be when completing your Practice Reviews.
Huddles will begin at 2:15.
GAP Clinic Overview

The learners of GAP Clinical Team provide their patients with person-centered care while being mentored
to ensure the procedures are accomplished correctly and efficiently.
Patients in the learner clinics are a critical part of the school’s education process, but they are also
patients who deserve–and receive–the highest level of care.
Registration:
Individuals interested in becoming patients of Carolina Dentistry go to www.carolinadentistry.org to
complete a new patient registration.
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Friends and Family Admission Protocol
The learner will contact the Patient Admissions Coordinator or the Administrative Support Supervisor to
schedule for a D0150 in any available (green) slot.
The appointment notes will indicate "family/friends" and the patient will be expected to pay a fee of
$110.
Upon arrival, the patient must check in with the front desk on the ground floor and proceed to radiology
for x-rays before heading to the third or fourth floor for their appointment.
Patient Assignment and Transfer Protocol

Care Coordinators (CC) make all patient assignments. Patients are assigned to learners based upon the
dental needs of the patient and educational experiences needed of the learner.
Learners may request additional patients or types of cases from the Care Coordinators. Patients that will
not be assigned to an undergraduate learner will be notified and referred to a specialty clinic or to private
practice.
All patient transfers from a learner to another learner or co-assignment to two dental learners will be with
the approval of the Care Coordinator and preceptor.
Assigned patients are generally not transferred between learners except when the learner providing care
graduates.
However, learners are allowed to share or transfer patients to other providers to complete their clinical
experiences. This is usually done on a case-by-case basis, primarily in the spring semester, and only on
approval of the Preceptor and CC.
Patient Communication
Patient Introduction: When introducing the attending faculty member and the patient during each clinical
experience, the student’s verbal tone, language, non-verbal interactions and actions reflect respect for
the knowledge and experience all team-members (provider and patient) bring to the encounter.
Practicing cultural humility, the student introduces the faculty and patient using each one’s preferred
name and, as necessary, preferred pronoun. Tone, demeanor and manner are consistent during the
encounter, reflecting equal respect for all parties.
Patient Discussions: Discussion between student provider and patient is a back-and-forth exchange. In
discussion of treatment options, reasonable expected outcomes, risks, benefits and costs, the student
actively and authentically engages the patient in shared decision making.
As such, the student’s communication with the patient reflects respect for the patient’s intelligence and
lived experience. Interactions such as these require the student to establish a partnership with the
patient that is physically and psychologically safe for all parties, using person-centered and respectful
verbal and non-verbal language and syntax in all exchanges.
In addition, it is the responsibility of the student to support the patient’s language and literacy needs to
enhance communication and understanding. Patient providers are expected to maintain confidentiality
of patient information.
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Appointment Reminders
Patients receive appointment reminders via Epic three (3) days in advance, using the contact phone
number in the patient's registration record. Patients with a cell phone number receive a text message
notification, and patients with a landline number receive a voice message.
Appointment reminders are also sent via MyChart fourteen (14) days before the appointment.
Late Arrival/No Show Patients

A learner should call a patient who has not arrived within 15 minutes of the scheduled start time of the
appointment and determine the status of the appointment. The Patient Navigator will contact the GAP
Clinic when patients arrive more than 30 minutes late.
In such cases, depending on the circumstances and on factors in the clinic, the learner might not be able
to see the patient.
Late arrivals can lead to a patient being dismissed.
Learners who have no show/cancellation patients should report to their preceptor who will assign further
duties to the learner.
Professional Patient Interaction

The GAP Clinic is a dental treatment area. The dental treatment operatories and the immediate
surrounding clinical areas are restricted to clinical team members and patient being treated ONLY. No
other person should be in the dental treatment area. If for some reason an exception is required (e.g. a
legal guardian is required), permission must be granted by the Preceptor or another supervisor.
Adult patients who are accompanied by children under 14 years of age must bring a responsible adult to
care for the children in the waiting area during the dental visit. Children are not permitted to accompany
the patient to the dental operatory. Legally children cannot perform the role of the primary interpreter
between the patient and the provider.
All members of the GAP clinical team must wear name badges in clinic.
Daily Dental Treatment Assignment

The daily assignment is created a week in advance by the Clinic Manager. Changes are made throughout
the week to reflect cancellations or rescheduling. Operatory assignments are accessible here.
Preceptors can work directly with the Clinical Manager if there are specific changes they would like to see
within their Office.
Personal Items in Dental Treatment Areas

Dental treatment areas must not contain personal items. Personal items can interfere with the flow of
patient, provider and attending faculty access and egress, thus creating a safety concern for tripping or
falls as well as potential contamination of personal effects.
Personal items also collect dust and spatter, creating surfaces that cannot be appropriately disinfected.
This includes backpacks, purses, pictures (except for the display of current dental or dental hygiene
license), or other items that are not related to treatment.
Except for language interpretation, meditation apps or music to calm a patient, or medical emergencies,
learners and educators must not answer cell phones.
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Personal calls or texts are prohibited. Using a cell phone for personal business can lead to potential
contamination.
Cell phones must be out of the spatter zone (three feet) or in a drawer. Before touching a phone, you
must remove gloves, and wash your hands or use hand sanitizer.
Periodic disinfection of cells phones is recommended.
Interpretation Services
A tablet is assigned to each Office for virtual language interpretation. The tablet must be requested at the
dispensary.
The protocol to contact Spanish Interpreter, Natalie Cruz, is on

the back of the tablet. For other languages, use the OPI system.
The use of personal phones for interpretation is not appropriate.
American Sign Language (ASL) and Interpretation Protocol

Free aids and services are provided to patients needing
American Sign Language (ASL) interpretation.
For patients who are hearing-impaired, a certified American Sign

Language (ASL) interpreter can be requested in advance by
emailing the school’s Spanish Interpreter at
[email protected] with at least 48 hours’ notice. When
possible, requests should be made as soon as the appointment is
scheduled.
Protocol:
1. ASL patient appointment scheduled with the school.

2. Appointment details sent to the school’s interpreter,
Natalie Cruz ().
3. Check out the laptop located in room 1007A Tarrson
Hall.
4. Take brief overview lesson on how to request the VRI on
the application.
5. Use VRI at the throughout the appointment as needed.
6. Log-in information:
a. Username: LibertyLanguage
b. Password: ccgvri
7. Click on “Settings” in the lower left of the screen.
8. Select audio and then run the tests for speakers and
ringing. Ensure “Logitech USB Headset” is selected
where indicated.
9. Call by hovering over “Dispatch” and clicking “Call.”
10. Note the use of VRI in the patient’s record, including the name and ID if available.
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GAP Clinic Structure
General Dentistry Clinic: Learner-led clinic organized by practices under the supervision of the office and
deputy preceptors assigned to the office. This includes the Oral Health Sustainability Program (OHSP) and
the Mountain Area Health Education Center (MAHEC); the latter considered a core school site.
Intramural Rotations: Internal clinics under the supervision of specialty faculty and staff.
Extramural Rotations: Please refer to the Dentistry in Service to Communities (DISC) section on the clinical
Sakai site. Additional extramural rotations can be requested as part of Individualization and in
coordination with Extramural Site Coordinator.
Comprehensive Care Service

Patients accepted for general admission to the predoctoral clinics at Carolina Dentistry will be given the
opportunity to receive a full range of dental services (i.e., comprehensive dental care).
All comprehensive care patients will be assigned to a dental learner and to one of six offices in the DDS
predoctoral clinical program.
If any portion of the patient’s plan of care is deemed inappropriate for the assigned learner to perform at
that stage of their education, the patient may be referred to another learner within the same office, or a
resident, for that portion of the treatment.
Patients who cannot be accepted for general care in the pre-doctoral clinics are referred to an
appropriate intramural residency or faculty program, or to an extramural private practitioner.
Each of these individuals is informed of the referral and is given appropriate information relative to the
service or practitioner to whom the referral was made.
Limited Care Service

Limited care patients come from several sources. Those who:
 Present for urgent care

 Have been referred to the school by an external dentist or health care provider for attention to a
specific dental problem only
 Are referred from Oral Health Sustainability Program (OHSP)
Although a treatment plan must be formulated for these patients, it will be limited to a specific problem,
e.g., extraction for relief of pain or root canal therapy only per prescription of referring dentist.
Patients who are referred for a specific dental problem, a notation must be made in the record to
document the referral, treatment to be performed, and plans for follow-up.
If there are further needs that exceed the limited care that they were originally referred for, Clinical
Operations should be notified by submitting a referral to the Learner Clinics and communicating via in-
basket with the Care Coordinator. Referral codes should be entered as part of your ACE form.
If the patient originated from OHSP Program:

Any treatment diagnosed during the periodic exam should be scheduled with a DDS learner provider in
the office unless the patient is already assigned to a learner provider. The DH learner should generate a
referral to assign the patient to the office if the patient is not already assigned to the office. The DH
learner needs to send an in-basket message to the office’s scheduler and DH CC, so the patient can be
assigned to a dental learner provider in the office for treatment.
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Patients remain within their respective offices throughout their treatment for continuity of care.
Scope of Service
Learners complete a broad variety of services of varying complexities within the scope of the general
dentist. All experiences are under direct supervision of the faculty of the ASOD. Learners in the general
dentistry office are expected to deliver care in the following areas that fall within the Entrustable
Professional Activities (EPAs).
1. Diagnosis and treatment planning including referral and follow-up of patients.
2. Preventive procedures
3. Periodontal procedures: conservative, surgical treatment of disease and procedures to facilitate

completion of dental procedures.
4. All direct operative procedures
5. Endodontic procedures to include vital pulp therapy, indirect pulp caps.
6. All indirect restorative dental procedures to include veneers, crowns, fixed partial dentures and
implant restorations where the vertical dimension of the patient’s dentition is not altered.
7. All removable prosthodontic procedures
8. All emergency/urgent care dental procedures that can be safely diagnosed and treated within the
scope of the general dentist.
9. Soft tissue biopsies where the procedure does not potentially impair the functional or esthetic
structure of the oral cavity.
Start of Patient Service

Expectations from Learners
 Be consistent: start and finish a case with the same faculty
 Be on time
 Be compliant with infection control and dress code policy.
 Be prepared: Be knowledgeable about procedures performed, review patient chart before arrival,
address questions about case in huddle
 Engage in person-centered care: Consider patient's dental needs and treatment options in the
wider context of patient's life and preferences and embrace cultural humility.
 Complete on time.
Pre-Clinic Huddle
To organize and streamline person-centered clinical care, a Pre-Clinic Huddle will take place at the start of
each clinic session. Each huddle will consist of two teams (approx. 10 providers including Dental Hygiene)
and last ~ 15 -20 minutes.
Preceptors may designate a huddle leader from DDS4 learner and have them rotate weekly.
The learning objectives are.

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1. Provide an overview of the patient with attention to the multiple factors (e.g..physical, social,
psychological) that impact diagnosis, care plan and outcome; person centered care for the clinical
session.
2. Ascertain learner preparedness to provide patient person-centered, culturally responsive care.
3. Align and motivate the team to provide optimum person-centered care.
Current Definitions and ASA-Approved Examples

ASA PS Definition Adult Examples, including Pediatric Examples, Obstetric Examples,
Classification by not limited to including but not limited to including but not limited to
ASA I A normal healthy Healthy, non-smoking, no or Healthy (no acute or chronic
patient minimal alcohol use disease), normal BMI
percentile for age
ASA II A patient with mild Mild diseases only without Asymptomatic congenital Normal pregnancy*, well
systemic disease substantive functional cardiac disease, well controlled gestational HTN,
limitations. Current smoker, controlled dysrhythmias, controlled preeclampsia
social alcohol drinker, asthma without without severe features, diet-
pregnancy, obesity exacerbation, well controlled controlled gestational DM.
(30<BMI<40), well-controlled epilepsy, non-insulin
DM/HTN, mild lung disease dependent diabetes mellitus,
abnormal BMI percentile for
age, mild/moderate OSA,
oncologic state in remission,
autism with mild limitations
ASA III A patient with Substantive functional Uncorrected stable Preeclampsia with severe
severe systemic limitations; One or more congenital cardiac features, gestational DM with
disease moderate to severe diseases. abnormality, asthma with complications or high insulin
Poorly controlled DM or HTN, exacerbation, poorly requirements, a
COPD, morbid obesity (BMI controlled epilepsy, insulin thrombophilic disease
≥40), active hepatitis, alcohol dependent diabetes mellitus, requiring anticoagulation.
dependence or abuse, morbid obesity, malnutrition,
implanted pacemaker, severe OSA, oncologic state,
moderate reduction of renal failure, muscular
ejection fraction, ESRD dystrophy, cystic fibrosis,
undergoing regularly history of organ
scheduled dialysis, history (>3 transplantation, brain/spinal
months) of MI, CVA, TIA, or cord malformation,
CAD/stents. symptomatic hydrocephalus,
premature infant PCA <60
weeks, autism with severe
limitations, metabolic
disease, difficult airway, long
term parenteral nutrition.
Full term infants <6 weeks of
age.
ASA IV A patient with Recent (<3 months) MI, CVA, Symptomatic congenital Preeclampsia with severe
severe systemic TIA or CAD/stents, ongoing cardiac abnormality, features complicated by
disease that is a cardiac ischemia or severe congestive heart failure, HELLP or other adverse
constant threat to valve dysfunction, severe active sequelae of event, peripartum
life reduction of ejection prematurity, acute hypoxic- cardiomyopathy with EF <40,
fraction, shock, sepsis, DIC, ischemic encephalopathy, uncorrected/decompensated
ARD or ESRD not undergoing shock, sepsis, disseminated heart disease, acquired or
regularly scheduled dialysis intravascular coagulation, congenital.
automatic implantable
cardioverter-defibrillator,
ventilator dependence,
endocrinopathy, severe
trauma, severe respiratory
distress, advanced oncologic
state.
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ASA V A moribund patient Ruptured abdominal/thoracic Massive trauma, intracranial Uterine rupture.
who is not expected aneurysm, massive trauma, hemorrhage with mass
to survive without intracranial bleed with mass effect, patient requiring
the operation effect, ischemic bowel in the ECMO, respiratory failure or
face of significant cardiac arrest, malignant
pathology or multiple hypertension,
organ/system dysfunction decompensated congestive
heart failure, hepatic
encephalopathy, ischemic
bowel or multiple
organ/system dysfunction.
ASA VI A declared brain-
dead patient whose
organs are being
removed for donor
purposes
* Although pregnancy is not a disease, the parturient’s physiologic state is significantly altered from when
the woman is not pregnant, hence the assignment of ASA 2 for a woman with uncomplicated pregnancy.
**The addition of “E” denotes Emergency surgery: (An emergency is defined as existing when delay in
treatment of the patient would lead to a significant increase in the threat to life or body part).
INITIATE THE ASSESSMENT OF CLINICAL ENCOUNTER (ACE) FORM UPON PATIENT ARRIVAL AND BEFORE
PROCEDURE BEGINS.
As you begin your clinic, keep in mind that procedures are to be completed by 11:30 a.m. for morning
clinic, and by 4:30 p.m. for afternoon clinic to give the remaining 30 minutes for checking the patient out,
entering notes in Epic, and completing the indicated assessment (ACE).
During Patient Service

Before Patient Leaves
The patient must not be dismissed until a final faculty check.
Learner provider must make proper entries in the Progress and Treatment Notes before attending faculty
will sign Epic progress notes.
Information should include type and amount of anesthetic used, including vasoconstrictors, bases and/or
liners used, and brand of restorative material, information relating to patient relations and reactions,
follow-up instructions for the patient, plan for the next visit and any other information pertinent to
treatment of the patient.
Whenever possible, students must use Epic progress note templates note templates.
Providers must close the encounter promptly and associate a clinical diagnosis for the charges to
completely drop in the patient's account.
Learner-providers must enter faculty name covering the clinic session as billing provider.
For fee discrepancies, learner–provider should communicate with Patient Business Services Manager by
in basket message.
Fee Adjustment Requests

Enter the ADJ modifier in charge capture next to the charge (s) you are requesting for the fee to be
adjusted. Enter a justification in comment box every time the modifier is used.
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The Fee Adjustment Review Board will review requests for final decisions, and the Care Coordinator will
communicate a final decision to the requester.
Dental Codes
Multi-steps procedures require step-codes to be entered in Epic.
The D code is only entered when the procedure is complete. After this is done, the charge will drop in the
patient accounts and will be processed by Patient Business Services (PBS).
List of approved step codes for the Student Clinics is located here.
Billing Modifiers
The preceptor or deputy preceptor is the only authorized personnel to enter the 20 percent discount
(D020) and Do Not Bill (DNB) modifiers.
For dental implant codes and implant package for removable overdenture codes an (IMP) billing modifier
should be entered when the procedure is completed for the fee adjustment to be approved by Patient
Business Services (PBS).
Students are not authorized to enter this specific modifier without approval.
When entering the modifier, learner-provider must add a justification. PBS will not process modifiers
without a justification.
Learners should add the faculty name in the justification in the event that PBS has any questions.
The workflow for Initial Placement/Replacement modifiers will change (on August 17th). Instead of
entering the modifier in the charge capture section, there is a requirement on the D-code for a Procedure
Note be completed when treatment is marked as complete.
The initial (INIT) and replacement (REPL) modifiers must be entered for the following dental codes.
Modifier Name Description

DNB Do Not Bill Used when charge should be $0 for any reason (courtesy,
remake/correction, etc.). All DNB/fee adjustments will go to the work
queue for the billing office to review and approve/deny.
MAT Precious Metal Used with D-codes where the standard metal is typical to increase the
price to cover the cost of more expensive/precious metal.
OVR Overdenture Applied to all charges as part of the overdenture package to ensure each
is adjusted to the package fee.
DO20 20 Percent Discount A maximum of 20% discount will be allowed for any services. All D020/fee
adjustments will go to the work queue for the billing office to review and
approve/deny.
INIT Initial Placement Due to billing, some codes require it to be submitted that this is an initial
placement.
REPL Replacement Due to billing, some codes require it to be submitted that this is a
replacement.
IMP Implant Package Applied to all charges as part of the implant package to ensure each is
adjusted to the package fee.
ADJ Fee Adjustment Applied to one or more charges where the provider is requesting a fee
adjustment for the patient. The providers must enter a comment with the
justification. The Fee Adjustment Review Board will review the request for
a final decision.
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Appointment Scheduling
Learners should schedule the next appointment(s) for their patients in Epic before
the patient leaves the appointment as often as possible.
It is the learner's responsibility to arrange a date and time for their patient’s appointments, and
communicate that information to the Patient Navigator for scheduling in Epic.
The learner’s schedule of appointments will be monitored by the Care Coordinator and it is their
responsibility to assure that the learner is exercising efficient scheduling and maintaining full schedule of
appointments.
Student Dos and Don’ts When Communicating with Patients
Do Don’t
Discuss Discuss scheduling appointment – Give medical/dental advice without a known
identify date/time diagnosis
Provide Provide post-appointment Promise fee waivers
instructions already shared during last Quote a fee without a diagnosis or treatment plan
appointment
Discuss personal health information (PHI) via non-
secure email
Receiv Receive concerns and forward them Do not subject yourself to harassing language
to your Care Coordinator (profanity, yelling, etc.)
Best Modes for Student Communication
In-Person  Demonstrate confidence and commitment by preparing for the appointment and
knowing the plan for the current and next appointment.
By Phone  Minimize confusion. Be clear and succinct.
 Acknowledge any concerns shared with intent to address at next appointment or to
MyChart share with appropriate faculty or staff.
 Document in the chart what was shared/discussed.
Below are guides to scheduling the next patient visit and checkout.
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Below is a diagram of scheduling outside of the patient visit.
Payment Collections
For self-pay patients (those without Medicaid coverage), payment is due at the time of service for most
procedures.
Procedures that require outside lab work, such as crowns and dentures, payment is due at the time of
final impressions. Nothing should be sent to the lab without this prepayment, and likewise nothing should
be delivered without the payment.
We accept cash, check, Visa, MasterCard, and American Express. Payment can be made in person, by
mail, over the phone, or through MyChart.
Front desk staff should collect any previous balance when checking-in a patient as well as expected
charges for the day. Service should not be rendered on patients who do not pay at check-in unless the
procedure is deemed medically necessary. Medically necessary procedures are generally limited to
emergency extractions or root canals.
Payment plans on procedures done in the pre-doctoral clinics are not allowed at this time. The graduate
student/resident clinics will allow six-month payment plans for procedures or treatment plans over $500.
Those payment plans require a down payment of 50 percent of the expected treatment cost that
collected at the start of treatment. The payment plans are set up with the clinic’s care coordinator.
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Providers should discuss treatment plan costs with their patients and explain that payment is due at the time
of service (with the noted exception for required pre-payments). However, providers should not discuss
payment options or make any financial agreements with the patient. Providers should direct patients to the
Patient Business Services (PBS) office for those discussions.
The PBS office does not file claims on behalf of patients of the Student Dental Clinics at this time. We can
and do provide paperwork to the patient in order for the patient to file for reimbursement. We also assist
patients with questions about their insurance and provide additional information to the carrier as
requested.
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End of Patient Services
Patient care must be completed by 11:30 a.m. for morning clinics and by 4:30 p.m. for afternoon clinics.
Progress Notes Protocol

Learner-provider must make proper entries in the Progress and Treatment Notes before attending faculty
will sign the Epic progress notes.
Information should include type and amount of anesthetic used, including vasoconstrictors, bases and/or
liners used, and brand of restorative material, information relating to patient relations and reactions,
follow-up instructions for the patient, plan for the next visit and any other information pertinent to
treatment of the patient.
Whenever possible, learners must use progress note templates found in the Epic system.
Assessment of Clinical Encounter (ACE)

Learner progression towards practice-readiness is assessed in multiple ways, though frequent and
meaningful assessments. Assessment modes are varied, occur in multiple settings, and are observed by
multiple faculty members. Further, both formative and summative assessment occur at regular intervals
throughout the clinical years to provide meaningful data on progression. Each learner’s level of
independence is monitored through this trajectory with the goal of increasing autonomy and competency
over time. This structure allows faculty to identify learners requiring additional support as early as
possible to maximize their success through the program.
Domains Description
Case Description Patient demographics, visit difficulty, patient circumstances, etc.
Quality of Care Entrustable Professional Activities (EPA) and CODA Standards
Critical Error Under the domains of Advocate (e.g., professionalism), Clinician (e.g., technical,
safety, privacy), and Thinker (e.g., critical thinking).
Independence Supervision Scale “O” Score: a five-item scale ranging from “I had to do it,” to “I did
not need to be there.”
Reflection Comments describing what went well and areas for improvement
(start/stop/continue).
GAP Clinic:
Assessed using the ACE at the end of each patient encounter.
If engaged in the care, you are the secondary provider. Complete the ACE and use the assisting/secondary
provider code.
Intramural and Extramural Rotations:
Weekly assessments will be used for intramural rotations, and one assessment will be conducted at the
end of each five-week DISC rotation.
The ACE should be used in intramural rotations where direct patient care occurs (primary provider), and
during your radiology/orthodontic rotations that will take place in half day sessions.
Learners will receive summary data periodically to assess whether their metrics meet specific targets for
progression. These data will inform the learner self-assessment.
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On week five of each block, the learner will receive a report of their performance from the care
coordinator that includes clinic encounter data, practice management metrics, case exposure
(type)/diversity. The learner completes a self-assessment to evaluate their performance and reflect on
their ability related to designated professional activities specific to the ACT framework and CODA
Standards. Learners set goals for their following block and/or semester.
The learner’s office preceptor and/or deputy preceptor evaluate and confirm that the learner meets all
targets. If targets are not met, the faculty completes a performance Improvement Plan identifying desired
outcomes, necessary support, and a specific action plan to address specific changes expected within the
coming block or semester. This information is sent to the GAP Phase Team, which approves and provides
additional support as needed. This team is comprised of the individual who manages the phase, deans
associated with education/curriculum, specific individuals who teach within the seminar, the office
preceptor and pre-doctoral directors who are responsible for specific specialty areas.
DDS4 Learners: Independent Assessment forms and Protocols Links

To maximize ease of transition in the ACT curriculum, DDS4 learners will complete the independent
assessments for graduation. The incoming third year class will be part of the new ongoing assessment
framework and will not be asked to complete the independent assessments, as every day will be an
assessment and the collection of this, and other data will determine practice readiness.
The following independent assessments are needed for graduation for the DDS4 learners:
COMPETENCY ASSESSMENT INFORMATION

(See document in file name “2022 Number of Procedures to challenge independent assessment”)
The above link provides who to contact about the assessment, what forms are required, when is the
assessment or competency due.
Diagnosis and Operative Periodontology Prosthodontics - Prosthodontics -

Treatment Fixed Removable
Planning
Evaluation Critia Daily ACE form Perio Exam FPD Simulation Impression Tray
for Year 2-3 Diagnosis Referral assessment (Mock Final Impression
Class II Independent Tx Planning Board)
Adult Patient Ex Assessment Maxillomandibular
and Diagnosi Periodontal Implant Simulation Relations
2-3 Class III-IV Examination, assessment
Independent Diagnosis, Referral, RP Insertion
Evaluation Critia Assessment and Tx Planning Natural Crown
for Year 3-4 Form Preparation (STAR) RP Post-Insertion
Adult Patient Ex Perio Scaling Root Natural Tooth

and Diagnosi Planing Crown Restoration-
3-4 (STAR)
Periodontal Scaling
and Root Planning Implant Restoration
Assessment Form (experience)
Periodontal
Maintenance
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Periodontal
Maintenance
Assessment Form
Reevaluation Initial
Periodontal Therapy
Reevaluation of
Initial Periodontal
Therapy Assessment
Form
Special Circumstance Protocols

Special Cost Packages
Single Unit Implant Package
Implant packages are comprised of the first two procedures (D0367 and D6010), AND one of the
abutment procedures (D6056 or D6057), AND one of the crowns or one of the retainer procedures.
When used with the IMP modifier, any combination of the four procedures will total $1,200 when priced
from the PB ASOD STUDENT UNDERGRAD DEFAULT fee schedule.
Billing Modifiers
CDT Procedure Description Original Fee Reduced Fee

D037 CBCT $218 $218
D600 SURG PLCMT IMPL BODY:ENDOSTEAL $935 $530
D606 PREFAB ABUTMENT-INCL MOD AND PLCMNT $198 $200
D607 CUSTOM FAB ABUTMENT-INCL PLCMNT $570 $200
D608 ABUT SUPP PROCLN/CERAMIC CROWN $570 $350
D601 ABUT PORCLN TO MTL CROWN NOBLE MTL $627 $350
D608 ABUT SUPP RETAIN PORCLN/CERAMIC FPD $548 $350
D601 ABUT SUPP RETAIN PORCLN FUSD MTL FPD $627 $350
DO NOT PRINT OR SHARE THIS TABLE WITH PATIENTS.
This package does not include bone grafting, sinus lifting, temporization; additional CBCT; tooth
extraction; and occlusal splint.
Overdenture Package
The implant overdenture package (Package Total = $2500) includes upper and lower final dentures, the
surgical stent, surgical placement of two implants, second stage uncovering of the implants, the two
implant abutments, and pickup of the attachments into the lower denture. It does not include the
extractions, alveoloplasties, tori removal, or any additional surgical procedures other than placement of
the two implants and second stage surgery for uncovering of the implants. These non-included surgical
codes may change due to degree of difficulty. It does not include any interim dentures, nor does it include
a laboratory hard reline if needed. Use with the OVR modifier.
CDT Procedure Description Tooth Original Fee Reduced Fee

D0367 CBCT-CAPTURE AND INTERP. $218 $218
D6190 RADIOGR/SURG IMPLANT INDEX $144 $57
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D5110 COMPLETE DENTURE – MAXILLARY $375 $375
D5865 OVERDENTURE – COMPLETE MAND $825 $400
D6010 SURG PLACE IMPLANT: ENDOSTEAL 22 $935 $600
D6010 SURG PLACE IMPLANT: ENDOSTEAL 27 $935 $600
D6052 SEMI-PRECISION ABUTMENT 22 $297 $125
D6052 SEMI-PRECISION ABUTMENT 27 $297 $125
Estimate Total $4026 $2500
DO NOT PRINT OR SHARE THIS TABLE WITH PATIENTS.
Medicaid
Learner will use the Medicaid References to assist during treatment planning. If a recommended
treatment needs prior approval, providers must contact Elizabeth Rocafuerte via Epic In-basket to initiate
the process. Make sure to include the subject line: “MEDICAID APPROVAL REQUEST.” If the learner needs
additional assistance, they should contact Ms. Rocafuerte at 919-537-3940.
Patient Navigators must enter and verify Medicaid insurance. Also, we must review the response in EPIC
to determine the category of coverage and if the patient has another primary dental above Medicaid. If
they have a primary dental, then that insurance information needs to be entered into EPIC as well.
More information on Medicaid is available on the Clinical Operations SharePoint (Onyen required)
Contract Vendor Lab (CVL)

CVL is a secure location where student dental lab cases are processed, and implant parts are retrieved.
(Only authorized or escorted personnel/vendors may be allowed to enter the CVL.) The CVL is committed
to assisting School of Dentistry students in obtaining the highest standard of laboratory services for our
patients.
Contract Vendor Lab Contact Information

Location: Tarrson Hall
Hours of Operation:
Monday-Friday: 8 a.m. – 5:15 p.m.
Phone Number: (919) 537-3836
Lab Scripts
Scripts MUST include the following information for the CVL to accept the case:
 Provider’s name and number

 Patient’s name and chart number
 Provider’s signature
 Instructor’s signature
 Rx instructions
 Materials included in the scripts (examples: articulator or case) optional
Payment Verification
The CVL staff is prohibited to accept lab cases in the following situations:
 If the patient payment cannot be verified in Epic

 If a Medicaid patient’s approval documentation cannot be verified
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 If a fee adjustment does not equal the script request
 If the fee adjustment has not been approved and received at the CVL
 If clerk in Patient Accounts has not given clearance for Medicaid cases
Dental Tracking System (DTS)
Once the patient finances have been verified and approved the patient lab case will be entered into the
DTS (Dental Tracking System). The DTS will be queried for past work performance for the patient. If prior
work was completed, use of the prior lab is recommended.
The DTS will maintain record of:
 Provider name and number

 Instructor name and number
 Patient name and chart number
 The expected return dates.
 The pan number assigned to the case
The type of work to be completed and the process:

Crowns Complete Denture Partial Denture RPD-Acrylic Crowns-Implants
Metal, PFM, (Acrylic) (Metal, Acrylic) Acrylic RPD with Metal, PFM,
Porcelain (Noble) Conventional or Framework clasps Porcelain
Die, Framework Digital Bite Rims/ Acrylic RPD Die, Framework
(for Bridges), Bite-rims/ Occlusal rims without clasps (for Bridges),
Complete Occlusal rims Tooth set-up or Night Complete
Tooth set-up or try-in guard/Occlusal Abutments
try-in Complete/Process guard Standard or
Complete/Process Custom
Reline Repairs – Notation
in Remake Section
and Note Section
Lab Selection for Case Processing
Choose the lab to which the case will be sent. CVL staff uses a rotation method to send lab work out if the
patient has not already utilized a lab.
CVL staff will record the lab name on the top left section of the script and record the assigned pan
number on the top right section of the script.
The case will be set aside for packaging. Models are bubble wrapped and sealed.
The wrapped models along with all items from the student/provider will be put into a “Lab-loc Specimen”
bag.
Top white copy of the script is put in the outside pocket of the “Lab-loc Specimen” bag.
Once packaged, it will be placed in the vendor lab bucket located in the vendor lab corner awaiting lab
pickup.
Click here for lab work authorization information
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Clinic Wet Lab: Learner Use and Responsibilities
Learners are responsible for cleaning the lab after each use. The lab area should be left clean of extra
stone, counters cleaned, used supplies discarded. Failure to do this can result in suspension of privileges
to use the lab.
Learner Responsibilities:
 Only the wet labs behind the front desk may be used at this time.
 Anything that is taken into the lab should be disinfected and bagged.
 Keep your gown, mask, and hat but remove your gloves and perform hand hygiene prior to
heading to the lab.
 Don a new pair of gloves before starting any work in the lab.
 Disinfect everything that you have touched/used
 Discard your gloves and perform hand hygiene prior to exiting the space.
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Appendices
References
1. ten Cate O. A primer on entrustable professional activities. Korean J Med Educ 2018;30(1):1-10.
2. ten Cate O. Entrustability of professional activities and competency-based training. Med Educ
2005;39(12):1176-7.
Appendix 1: Huddle Pre-Clinic Presentation
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Appendix 2: Medical Consultation Request
Date:
Patient’s Name: Chart #:
DOB: Address:
City: State: Zi Code:
To: Physician Fax: Phne:
From: Dr.
Student: SID:
The above mutual patient presents to Carolina Dentistry for:
BP: HR: Glucose: O2 Sat:

PMH:
Meds:
In order to be fully aware of the patient’s medical history and rovide safe treatment, we require
additional information as follows:
Please fax encounter notes and specialty notes: ☐ PCP ☐ Cardiac ☐ Neurology
☐ Endocrine ☐ Pulmonary ☐ Heme/Onc ☐ Gastroenterology
☐ Transplant team/surgeon ☐
Please include:
☐ Active Problems ☐ PMH ☐ Surgical History ☐ Allergies
☐ Meds/Dosages ☐ CBC w/diff ☐ CMP ☐ LFT
☐ HgbA1c ☐ INR ☐ Coags ☐ Thyroid Panel
☐ PFTs ☐ CD4 ☐ CD8 ☐ ANC
☐ HIV load ☐ ANA ☐ SSAB
☐
☐ EKG ☐ ECHO ☐ EF % ☐ Stress Test
☐
☐ CXR ☐ DXA ☐ CT ☐ MRI
☐
Dr. Faculty ID: Date:
I, hereby consent to the release of my

medical/dental records to Carolina Dentistry and the Adams School of Dentistry.
Signature of Patient, Parent or Guardian Date
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Appendix 3: Pharmacy Consultation Decision Table
TYPE DESCRIPTION WHAT QUESTIONS DO I NEED TO PHARMACY TEAM ACTIVITIES
ASK?
1 Oral Health Impact Provides in-depth review of patient  Am I aware of the  Full medication review
and Medication medication list for impact on oral health medication-specific effects and/or thorough assessment
Review and future oral care. for the medications the of medications and oral
 Antichloinergic, Anti-depressants patient is taking? health implications prior to
 Bisphosphates (e.g., alendronate,  Is patient currently taking follow up
risedronate, ibandronate) one of these types of  May include impact on oral
 GERD/GI Meds (e.g., omeprazole, therapy? (Antidepressants, health including xerostomia,
esomeprazole, pantoprazole) bisphosphates, GERD bleeding risk, side effects
 Anti-infectives (e.g., amoxicillin, medications, anti-infectives, that may influence
cephalexin, clindamycin) antipsychotics, anti- treatment, and co-
 Neurological/antipsychotic (e.g., neoplastics, and radiation) morbidities
diazepam, triazolam, lorazepam)  How are they taking them?  Provide patient
education/counseling on
diet/lifestyle and medication
 Indicate referral to
PCP/specialist if needed
2 Medication History Patient is on complex regimen and/or  Did patient bring complete  Full medication review
Verification has unknown medication list, and needs medication list? and/or thorough assessment
to be verified via retail pharmacy after  Who is patient’s PCP? of medications and oral
attempt by provider.  Does patient take any herbal health implications prior to
supplements or OTC follow up
products? What kind?  Patient
 Are there medications I do education/counseling
not recognize?  Determine PCP info for
follow up if possible
3 High Risk Provides considerations for treatment if  Is patient on anticoagulant  Anticoagulants: discuss
Medications patient is on anticoagulant (Warfarin, therapy? indication, last dose taken**
Apixaban, Rivaroxaban, Dabigatran),  How are they taking them?  Discuss implications on
antiplatelet (Clopidogrel, Plavix) or  Patients on warfarin: when planned treatment with
insulin for diabetes. was last INR? INR value? patient and provider
4 Chronic Disease Review medical condition education for  Has patient taken their  Educate patient/learner on
States and Patient conditions such as diabetes, medications prior to this monitoring and medication
Medication hypertension, smoking cessation, appointment (esp. HTN and information (e.g., managing
asthma, COPD, etc. diabetes)? hypoglycemia)
Hypertension  If a patient has diabetes,  Handouts provided if
 >140 systolic and/or >90 diastolic have they eaten before their applicable (e.g., tobacco
 Patient taking ≥2 BP medications appointment? cessation products, drug
Diabetes  What did they eat? information, etc.)
 Pre-op blood glucose>180 or <80  Have they taken their BG  Discuss inhaler regimen and
OR HA1c >8 recently? control; provide inhaler
Respiratory (asthma/COPD)  If not, what was their pre-op technique education for
 Patient using ≥2 inhalers BG? uncontrolled patients
Smoking Cessation  Indicate referral to
PCP/specialist if needed
5 Prescribing New Patient has a question regarding their  Has patient tried this therapy  Medication education
Meds/Medication medication regimen. May include: before? counseling (e.g., adverse side
Education antibiotics, analgesics, anesthetics,  Reason for prescribing this effects, dosing instructions,
saliva modifiers, anxiolytics drug? Diagnosis? drug interactions)
 Barriers to affording this  Evaluates how new
medication (insurance medication could impact
coverage)? current treatment
6 Drug Information Provider has question about patient Provide verbal/written resource to
(DI) Request medications patient or learner. Indicate referral
to PCP/specialist if necessary.
**Anticoagulants: generally not recommended to hold anticoagulants even for more invasive dental procedures. Extractions are usually OK as
long as INR is <3.0. Discussion regarding anticoagulants should include patient and learner with emphasis on procedures planned and how this
may be affected by anticoagulant therapy. Particularly with newer class of anticoagulants and even dual anticoagulation therapies.
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Appendix 4: Patient Relations Complaint Routing
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Appendix 5: DXTX Checklist
PRE-CLINIC PREP AND HUDDLE:
In Chart Review, assess the available patient history, radiographs, and existing data base for your assigned
patient. Prepare for your presentation of the patient at the Pre-Clinic Huddle.
AT THE DXT VISIT:
1. LOG IN to Sakai/ STAR Student Assessment (ACE form) using D0150 (or D0150PLAN for a reassigned
patient) procedure code. Sign on to Epic at ASOD Group Practice Third or Fourth Floor to access your
scheduled patient. Seat the patient in your assigned operatory, Room the patient, and begin the exam.
2. PATIENT HISTORY and (if warranted) additional radiographs: Review Medical History taken from patients
Telehealth visit, and enter any missing responses, findings, and conditions including medications,
allergies, psychosocial history, family history, RoS, oral health history -- be prepared to discuss with your
attending faculty the patient’s ASA designation, medical risk, and any dental treatment modifications
based on the patient’s health.***
 In consultation with your attending faculty determine if additional radiographs are needed. *** If
additional radiographic images are to be obtained do so now – if the images (pa’s or bw’s) are to
be obtained in the Office no ORDER is needed. If radiographs (CMS or Panoramic) are to be
obtained in the OMFR Clinic, ORDER the images, close ROOMing and escort the patient to
Radiology Clinic
 Add D0150 [comprehensive oral evaluation] code and the code(s) for any radiographs obtained on
this date [CMS D0210, BWs D0274; Pan D0330] to PLAN.
3. CLINICAL EXAM: EO/ IO, Occlusal Exam, Tooth Chart, Perio Classification
 Adult Extraoral/Intraoral Exam; if the patient has noteworthy intraoral lesions, document on
Specialty Exam/ Soft Tissue
 Occlusal Exam [Notes/ Create Note/ Create New Note/ Occlusal Exam/ My Note DENTAL EXAM]
 Dental and restorative exam and charting [Tooth Chart: Hard Tissue]
 Periodontal charting (probe and record 6 sites on each tooth) [Tooth Chart: Periodontal Chart]
 Periodontal findings, classification, diagnosis & prognosis [document on Specialty Exam/Perio
Classification and Diagnosis] ***
4. TX PLAN: If the patient needs a Simple or CONTROL PHASE plan of care

 Engage the patient in a consent discussion addressing all reasonable options including risks,
benefits, and costs for each
 Construct DRAFT simple or Disease Control Phase plan of care
 Upon patient approval of the concept, list all D-codes on the plan and sequence in order of
treatment; if all parties agree, move the plan from DRAFT to PLAN ***
 Have the patient e-sign the treatment plan [WRAP UP/ AVS/ DOCUMENT LIST/Treatment Plan]
 Have the patient e-sign the Consent form [DOCUMENT LIST/ SOD PROCEDURE CONSENT] ***
 Print a hard copy of the treatment plan and/ or consent if the patient would like it
NOTE: If the patient does not need control phase treatment, but does need complex prosthodontic
treatment, you will need to meet with your preceptor to determine the Definitive Phase Plan of Care prior
to the next patient visit. Regardless, be sure to create – at a minimum – a PLAN for the procedure you
anticipate doing at the next patient visit.
82
5. ADDITIONAL PROCEDURES
 Extraoral and/ or Intraoral photographs
 Impressions/ facebow/ bite registration (not necessary for Control Phase but required for
definitive prosthodontic treatment planning)
 Oral prophylaxis (time permitting) on transfer or pOHP patients ***
6. WRAP UP
 Move D0150 and the D-code(s) for any radiographs taken on this date from PLAN to TODAY.
Digital Impressions will not be an extra cost
 If a scheduler is available, they schedule the next appointment for the patient with you. If a
scheduler is not available, send an In-Basket message to your Patient Navigator
 Check with attending that patient is okay for dismissal ***
7. AFTER DISMISSAL
 Complete the progress note: Carolina Dentistry General Dentistry Clinic - New Patient Exam
 Complete the Assessment of Clinical Encounter for the Comprehensive Oral Evaluation and
discuss with your attending faculty
You will be evaluated via the school’s CLINICAL ASSESSMENT; semester and year end grades per DENT
241/ 341 Clinical Diagnosis and Treatment Planning Syllabus
*** = faculty check steps
83
Appendix 6: CDT Code Flowchart
84
Appendix 7: Glossary for Assessment of the Clinical Encounter (ACE) Forms
The following section aims to provide criteria, definitions, and examples to calibrate learner evaluation
using the Adams School of Dentistry clinical assessment forms. The clinical assessment process is based
upon the Entrustable Professional Activity (EPA) and Capacities framework.
I. CORE INFORMATION
Encounter Data
Begin the form by selecting the faculty attending you in clinic on the day of the encounter and encounter
date using the calendar provided.
Completion of Data
All forms must be completed by midnight the day of patient encounter.
II. EXPOSURE
Patient Background
Criteria Definition Criteria Definition
- Epic 12-digit medical record - < 5 years

number
PatienMRN Patient Age - 6-12 years
and Nae - If patient name is associated
- 13-17 years
with an MRN in Epic, the name
will automatically populate. - 18-64 years
- > 65 years
- Average: well controlled Patient - Complex medical history (ASA >2)

systemic disease, no significant
Visit Dificulty Circumstances - Cognitive impairment
management challenges, access
in care delivery - Developmental disability
- High: Poorly controlled systemic (Follows - Significant physical limitation

disease; management challenge CODA
- Visual or speech impairment
(e.g., behavioral); difficulty in Standard 2-
care delivery; advanced clinical 25) - Interpretations services (in person or
presentation of dental disease via phone)
- None of the above
Procedure Code(s)
85
Procedural Skill Procedural Code Procedural Skill Procedural Code
- D0120, D0140, D0145,

D0150, D0160, D0170,
D0180, D0190, D0191,
D0415, D0417, D0417,
D0419, D0425, D0431,
D0460, D0470, D05002,
D0601, D0602, D0603,
D0999, D0210 Acq/Int,
D0220 Acq/Int, D022A
Acq/Int, D0230 Acq/Int,
Diagnostics * D0240 Acq/Int, D0250 Periodontics - D4341, D4342, D4346, D4910
D0270 Acq/Int, D0272
Acq/Int, D027A Acq/Int,
D027B Acq/Int, D0330
Acq/Int, D033A Acq/Int,
D0391
- D5211, D5212, D5213, D5214,

D5221, D5222, D5820, D5821,
- D1110, D1120, D1206, D6051, D6056, D6057, D6058,
D1208, D1310, D1320, Prosthodontics: D6059, D6061, D6062, D6065,
Prevention
D1330, D1351, D1353, Partial Edentulous D6066, D6067, D6068, D6069,
D1354 D6071, D6072, D6075, D6076,
D6077, D6112, D6113, D6740,
D6750, D6752, D6790, D6792
- D2140 Perm/Prim, D2150

Restorative: Perm/Prim, D2160 - D5110, D5120, D5130, D5140,
Prosthodontics:
Dentate Direct Perm/Prim, D2161 D5810, D5811, D5863, D5865,
Edentulous
** Perm/Prim, D2330 D6110, D6111, D6114, D6115
Perm/Prim, D2331
86
Perm/Prim, D2332
Perm/Prim, D2335
Perm/Prim, D2391
Perm/Prim, D2392
Perm/Prim, D2393
Perm/Prim, D2394
Perm/Prim, D2940, D260,
D2961, D2962
- D2510, D2520, D2530,

D2540, D2542, D2543,
D2544, D2610, D2612,
- D7111, D7140, D7210, D7220,
Restorative: D2614, D2620, D2630, Oral Maxillofacial
D7250, D7286, D7310, D7311,
Dentate Indirect D2642, D2643, D2644, Surgery
D7320, D7321, D7953
D2645, D2740, D2750,
D2751, D2752, D2790,
D2930, D2931
- D3110, D3120, D3220,

- D9230, D9310, D9311, D9450,
Endodontics D3221, D3310, D3320, Adjunctive Services
D9950, D9944, D9995, D9996
D3330
Note:
* Radiology has been separated into acquisition and interpretation.
** Pediatric teeth can be identified as primary (Prim) versus permanent (Perm).
*** Fixed Prosthodontics Code are under Restorative Dentate Indirect and Prosthodontics Partial
Edentulous. Step codes used in Epic are available for selection in the ACE form.
III. QUALITY
Ratings to assess quality as defined by the Adams School of Dentistry:
 Meets expectations of the graduate: Has met standards for practice readiness.
 Progressing: Developing skills appropriate for learners’ level (e.g., DDS2/DDS3/DDS4).
 Below expectations: Performing at a substandard level that may or may not include a critical
error.
Encounter Management
- Present, on time, engaged Safety & - Follows infection control standards

Infection Control
Prepardness - Knowledgeable about - Complies with safety regulations
procedures to be performed
e.g., mask, eye protection, gown, etc.
- Reviews patient chart before
arrival
87
- Addresses questions about
case in huddle
- Practices efficiently to achieve - Obtains necessary information &

outcomes safely data
Time Documentation/
Management - Limits procrastination & Completeness & - Asks appropriate follow-up
distractions Accuracy questions
- Accurately interprets findings
- Submits documentation in a timely

manner that is succinct, complete,
and accurate, and in compliance
with laws and regulations
Capacities
Criticalinking - Interpretation of data Team - Considers multiple perspectives and

& Decison - following systematic process Communication viewpoints
Making & Collaboration
- Evidence & rationale to - Interactions are respectful and
support decision (applies demonstrate cultural competence
evidence-based care)
- Engages as a collaborative partner
- Prioritization consistent with
patient needs, values &
preferences
Person- - Engages in person-centered Biomedical - Accurate application of biomedical

Centerd Care care: Science science knowledge to patient care
(commnication Application
*Shows respect for patients'
, patien
values, preferences and
awarenss &
expressed needs
sensitivty)
*Provides patient with
information and education on
clinical status, progress,
prognosis, and processes of care
*Actively engages
patient/caregiver as a partner in
decision-making
*Attends to patient’s physical

comfort, manages pain
88
*Provides emotional support
and alleviates fear and anxiety
*Involves family and friends in

patient experience as
appropriate (needs, decision-
making)
*Provides post-appointment
information regarding
medications, plan of care, and
available resources/support
- Employs verbal tone, syntax,

language, and non-verbal
interactions that demonstrate
cultural competence
- Supports patient/caregiver
language and literacy needs to
enhance communication
Heath - Provide patient with

Promotion information to facilitate self-
care and health promotion
Entrustable Professional Activities (EPAs)
Procedural Skills
Procedural Skill Definition Procedural Skill Definition
- Removable Partial Denture,

- Evaluation/Re-Evaluation, Implant prosthesis , Fixed
Tests, Radiology partial denture
Prosthodontics:
Diagnostics - Isolation &Tissue Management,
Partial Edentulous
Preparation, Impression,
- EPAs, Equipment use, Image
Restoration: Provisional,
Quality
Restoration: Definitive,
Cementation,
89
Communication/management
with lab
- Impressions, MMR, Try-in,

Insertion, Follow-up,
Communication/management
with lab
- Prophylaxis, Fluoride, - Complete denture/Implant

Sealants, Counseling, Oral overdenture
Hygiene Instructions - Impressions, MMR, Try-in,
- Prophylaxis: Isolation & Tissue Insertion, Follow-up,
Management, Plaque and Communication/ Management
calculus removal, Stain with lab
Prevention Removal, Local Medication (if Prosthodontics: - Impression, Restoration:
applicable) Edentulous
Provisional, Restoration:
- Fluoride: Isolation & Tissue Definitive, Cementation;
management Prosthesis insertion &
management,
- Sealant: Isolation & Tissue Communication/management
Management, preparation, with lab, Local medication
restoration delivery (if applicable)
- Amalgam, Composite, - Pulp cap (indirect, direct),

Protective Restoration, Therapeutic pulpotomy, Pulpal
Direct Veneers debridement, Root Canal
(Anterior, Bicuspid, Molar)
Restorativ: - Isolation & Tissue
Management, Initial Endodontics - Isolation & Tissue Management,
Dentate Diect
Preparation, Final Access Preparation, Work
Preparation, Restoration, Length Determination, Root
Local Medication (if Canal Instrumentation, Root
applicable) Canal Obturation, Restoration
- Inlay, Onlay (Cast, Ceramic)

and Composite), Indirect - Extractions
Veneers, Pontic, Crowns - Case Presentation, Sterile Field,

(Ceramic, Cast, PFM, SSC) Patient Positioning, Throat
Restorativ: Oral Maxillofacial Screen, Adequate Anesthesia,
- Isolation & Tissue
Dentate Inirect Surgery Proper use and handling of
Management, Preparation,
Impression, Restoration: instrumentation, Control
Provisional, Restoration: Bleeding, Suturing, Post op
Definitive, Cementation, Instructions
Local Medication (if
90
applicable), Communication/
management with lab
- Nitrous, Consultation, Case

presentation, Occlusion
analysis, Occlusal Guard,
- Periodontal scaling and root Teledentistry
planning, Periodontal
Maintenance - Teledentistry: Data Collection,
Problem Solving, Referral,
- Isolation & Tissue Technology Management
Non-Surgical Management, Calculus
Adjunctive Services - Occlusal Analysis: Impressions,
Periodontics identification, Calculus
removal, Stain removal, Facebow Transfer Record,
Local medication delivery (if Mounted Casts, Occlusal
applicable) Analysis
- Occlusal Guard: impressions,

maxilla-mandibular relation,
Record, Definitive Appliance,
Communication/mgmt with lab
Critical Errors
Definition: An event or unprofessional behavior that disrupts safe, legal, and ethical person-centered care.
A critical error includes events or behaviors- whether evident or harmful to the patient- that could lead
to, but not limited to, disciplinary action by an employer or Board of Dentistry. In an academic setting,
repeat critical errors may prompt discussions for dismissal from the program.
Domain Revised Critical Errors
- Fails to act for the benefit of the patient
Advocate - Reports or documents false or intentional inaccurate information
- Practices under the influence of drugs/alcohol
- Exhibits inappropriate conduct with patients, faculty, staff, and/or peers
- Inaccurate patient assessment and/or diagnosis that could cause harm
- Irreversible technical procedure error
- Excessive and/or irreversible damage during a procedure
Clinician - Incorrect procedure, tissue, location, or patient for any clinic activity
- Inappropriate medication dosing, administration, and/or prescription
- Infection control breach
- Radiology procedure breach
91
- HIPAA violations or breaches of confidentiality
- Unable to solve a problem that can cause patient harm
Thinker - Unprepared to the extent that can cause harm
- Disregards faculty instruction or no faculty consent
IV. INDEPENDENCE
Independence ratings are based on the Ottawa Surgical Competency Operating Room Evaluation (O-
SCORE), designed to assess a learner’s level of independence using behavioral anchors.
Retrospective O-SCORE: How much supervision did the learner need during the entire encounter?
 Faculty had to do it for the learner (hands-on intervention)

 Faculty had to talk the learner through it (consistent verbal guidance
 Faculty had to prompt the learner from time to time (intermittent verbal guidance)
 Faculty had to be in the room, just in case (limited indirect supervision)
 Faculty did not need to be there (independence)
Prospective O-SCORE: How much supervision should the learner have on a future encounter that is
similar?
 Faculty would have to do it for the learner (hands-on intervention)

 Faculty would have to talk the learner through it (consistent verbal guidance
 Faculty would have to prompt the learner from time to time (intermittent verbal guidance)
 Faculty would have to be in the room, just in case (limited indirect supervision)
 Faculty would not need to be there (independence)
Patient Awareness and Sensitivity: Engages in person-centered care; considers patient’s dental needs and
treatment options in the wider context of the patient’s life and preferences; embraces cultural competence
The learner engages in person-centered care and considers the patient’s oral health and the multiple and
inter-related factors that affect the patient: factors at the policy and societal level (including everything
from systemic racism to Medicare and Medicaid policies), at the community level (including what access
to healthy food and water looks like in the community to available public transportation) and at the family
and individual level (including genetic and biological factors as well as mental health factors and family
make up). Patient awareness requires that the provider gathers both holistic and specific knowledge of
the patient and then considers and attends to the multiple factors that may influence patient overall
experience, from intake to treatment and recovery. Guided by cultural competence, this approach
requires the provider to assume a learner stance and set aside their own prior assumptions in
interactions with patients to learn from and with the patient. The learner then uses their understanding
92
of patient’s lived experience to guide shared decision-making and treatment planning alongside the
patient.
Team Communication and Collaboration: Considers multiple perspectives and viewpoints; interactions are
respectful and reflect cultural competence; engages as a collaborative partner; seeks opportunities for
learning and personal growth
The learner values all members of the team, evidenced in respectful verbal and non-verbal interactions,
active listening, and collaborative decision-making. Practicing cultural competence, the learner seeks out
and values team members’ multiple perspectives and viewpoints. The learner assumes a self-reflective
and flexible stance, seeking opportunities for learning and growth as evidenced by asking authentic
questions, actively listening during interactions and seeking input from colleagues. The verbal tone,
language, non-verbal interactions and actions reflect respect for team members’ knowledge and
experience (professional and lived experience). Learners are responsive to team members’ needs and
reflects concern for team members’ growth, success and overall well-being. The learner recognizes the
value of the team approach in providing optimal patient treatment.
Patient/Caregiver Communication: Employs verbal tone, syntax, language, non-verbal interactions and
actions that reflect cultural competence; actively engages patient/caregiver as a partner in decision-making;
supports patient/caregiver language and literacy needs to enhance communication.
The learner seeks to establish a partnership with the patient/caregiver that is physically and
psychologically safe for all parties. The learner considers the patient and caregiver as equal partners in
care. To that end, the learner seeks out and provides the best approach to support patient/caregiver
communication that considers, among other things, the patient’s language and literacy needs. The
learner actively and authentically engages the patient/caregiver in shared decision making, using person-
centered and respectful verbal, non-verbal, language and syntax in all exchanges. Recognizing that the
patient is the only one who deeply knows his/her/their life experience, learner’s communication with the
patient and caregiver reflects respect for the patient’s and caregiver’s intelligence and lived experience.
Throughout the exchange, the learner is self-reflective about their engagement to ensure they are
creating a comfortable space for patient/caregiver participation, seeking verbal and non-verbal cues from
the patient/caregiver and pivoting as necessary.
93
Appendix 8: Rubrics
DENTATE: DIRECT OPERATIVE
94
DENTATE: DIRECT OPERATIVE PEDIATRIC DENTISTRY
95
DENTATE: INDIRECT CROWN
96
DENTATE: INDIRECT PEDIATRIC STAINLESS STEEL CROWN (SSC)
97
DIAGNOSIS AND TREATMENT PLANNING (DXTX)
98
EDENTULOUS RECORD BASE OCCLUSAL RIM
99
EDENTULOUS REMOVABLE
100
ENDODONTICS
101
LOCAL ANESTHETIC
102
NON-SURGICAL PERIODONTOLOGY
103
ORAL HEALTH RISK ASSESSMENT
104
ORAL HEALTH RISK MANAGEMENT
105
ORAL AND MAXILLOFACIAL SURGERY
106
PARTIAL EDENTULOUS FIXED PROSTHODONTICS BRIDGE
107
PARTIAL EDENTULOUS IMPLANT FIXED
108
PARTIAL EDENTULOUS REMOVABLE PARTIAL DENTURE (RPD) DESIGN
109
PERIODONTOLOGY DURING DIAGNOSIS AND TREATMENT PLANNING (DXTX)
110
PRECLINICAL REMOVABLE PARTIAL DENTURE (RPD) DESIGN
111
PREVENTIVE FLOURIDE
112
PREVENTIVE MAINTENANCE
113
PREVENTIVE SEALANT
114
RADIOLOGY ACQUISITION
115
RADIOLOGY INTERPRETATION
116
REEVALUATION
117
REMOVABLE PROSTHODONTICS CUSTOM TRAY
118

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ADAMS SCHOOL

First in care. For the people."

Standards of Care ............................................................................................................................ 7

Entrustable Professional Activities (EPAs) .................................................................................... 31

Defining Person-Centered Care

Some features of person-centered care are (based on Starfield, 2011):

1. Apply the principles of person-centered care in clinical practice.

2. Refine the use of effective evident based clinical decision-making.

3. Develop advanced psychomotor skills and clinical techniques.

GAP Clinical Team

Read more: Curriculum Sakai Site

Figure 2: Schematic of Clinical Structure

Read more: Adams School of Dentistry Policies

Glick, M. Precision-, patient-, person-centered care, oh my. JADA, 2019:15(3):161-162.

Section 1: Patients will be informed of their rights and responsibilities. In addition,

Continuous Quality Improvement

Continuous Quality Improvement Cyclical Process

Standards for Patient Care and Outcome Indicators

1.3 Patients receive a Notice of Privacy Practices

EXAMINATION AND DIAGNOSIS

2.2 Patient protective equipment is utilized in the acquisition of dental radiographs

3.2 The patient’s chief complaint was addressed

4.1 Care was provided in a timely manner

4.3 Active patients are satisfied with their care

4.6 Infection control policies and procedures are followed

Patient Rights and Responsibilities

Your Rights as a Patient

As a patient or caregiver of a patient in our clinics, your responsibilities are to:

 Be considerate and respectful of other patients, students, and employees.

Not meeting these responsibilities can lead to patient dismissal.

Patients can reach their CC at (919) 537-3588.

 Apply principles of professionalism and ethics

 UNC-Chapel Hill Student Conduct

Learner Code of Conduct

 Adams School of Dentistry Policy on Student Professionalism

Faculty and Staff Responsibilities

 Adams School of Dentistry Policies

Patient Confidentiality and Social Media

 Adams School of Dentistry Policy on Social Media

 UNC-Chapel HIPAA Information

 Code of Professional Conduct

Professional Dress Code

 Adams School of Dentistry Professional Dress Code Policy

Read more: Reporting Code Violations

Unit Policies, Standards, and Procedures

Medical Emergency Team: (919) 537-

Glycemic Goals for Adults

Dental Procedures for which

Reference Material: ADA Antibiotic Prophylaxis Prior to Dental Procedures

Chronic Obstructive Pulmonary Disease (COPD)

Patients with Chest Pain (acute angina) During a Procedure:

Documentation of Medical Emergency

1. Burnett-Womack lawn (east)

See the illustration below for staging areas:

1a) Obtain a health history

Graduates must be able to complete a thorough, accurate history (comprehensive or focused) in a

1b) Perform a clinical examination

Graduates must able to obtain a thorough, accurate examination (comprehensive or focused) in a

1c) Obtain diagnostic tests

Individuals should be able to OBTAIN/ ORDER and INTERPRET the following: