Chapter 3 – Health Care Operations

Policy

• California Department of Corrections (CDCR), Division of Health Care Services (DHCS), Receiving and Release (R&R), nursing staff shall perform an initial health screening on each patient upon commitment to a CDCR institution to identify urgent/emergent dental needs.

Purpose

• To provide patients with continuity of health care and to identify urgent/emergent dental conditions requiring referral to a dentist for immediate care.

Procedure

• Each newly arriving patient, including new commitments and parole violators, shall receive an initial health screening including an assessment of their dental needs in R&R, prior to being housed, which shall be performed by nursing staff. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.1.8(c)).  This initial health screening shall not be considered as the Reception Center (RC) dental screening that is performed by a dentist and is an integral part of the RC classification process.

• Upon completing the initial health screening, the Registered Nurse (RN) or licensed health care provider, shall document the findings in the Electronic Health Record System (EHRS).

• The RN or licensed health care provider conducting the initial health screening shall be trained to perform assessments of dental needs prior to being assigned to work in R&R.  The Supervising RN, or designee, shall maintain all training records.

• Results of the initial health screening.

  • If the RN or licensed health care provider determines the dental issue to be urgent, the patient shall be referred to and evaluated by a dentist within one business day.

  • In the case of a dental emergency during dental clinic operating hours, health care staff performing the initial health screening shall follow the procedure outlined in the HCDOM, Section 3.3.5.9(c)(2).

  • In the case of a dental emergency outside dental clinic operating hours, health care staff performing the initial health screening shall follow the procedure outlined in the HCDOM, Section 3.3.5.9(c)(3).

  • Health care staff conducting the initial health screening shall follow the procedure outlined in the HCDOM, Section 3.3.2.3(c)(3) if the patient refuses the dental encounter.

• If any questions are answered “yes” by the patient during the initial health screening, the RN or licensed health care provider shall follow established protocol for referral of the patient to a dentist or physician for further evaluation or treatment.  Based upon the RN’s review of all relevant data, a disposition shall be recorded in the EHRS.

• The R&R nurse shall place the appropriate referral order in the EHRS for patients who need to be seen by a dentist on an urgent or emergent basis.

Policy

• All California Department of Corrections and Rehabilitation (CDCR), Reception Center (RC) patients who qualify, as defined in Sections (c)(1)(A) and (B) below, shall receive a dental screening by a dentist as part of the RC classification process.  A dentist shall assign a Dental Priority Classification (DPC) and identify urgent dental needs.  Timely treatment of Emergency and/or DPC 1 dental conditions shall be provided.

Purpose

• To provide patients with continuity of health care and to identify and provide timely treatment for those patients with Emergency and/or DPC 1 dental conditions.

Procedure

• Dental Screening in Reception Centers

  • Within 60 calendar days of a patient’s arrival at an RC:

    • A dentist shall perform a dental screening on each newly arriving patient, including new commitments and parole violators.

    • The patient shall receive education on oral hygiene which is included in the Patient Orientation to Health Care Services Handbook.

  • Patients who received a dental screening at an RC or a comprehensive dental examination at a Mainline Facility within the past six months need not receive a new RC dental screening except as determined by the attending dentist.  This includes patients who have paroled and are rearrested as well as those who transfer from one RC to another.

    • When, in the professional judgment of a CDCR dentist, a patient does not need to receive a new RC dental screening, the patient shall retain the most recently assigned DPC.

    • The dentist shall document the patient’s DPC in a clinical note in the Electronic Dental Record System (EDRS), in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid. The dentist shall select the “Skip DPC” option when signing the clinical note in accordance with EDRS Workflow 1-1.1 / 1-1.2 and associated Back Office Job Aid.

    • Patients who do not receive an RC dental screening according to the process described above do not need to complete and sign a CDCR 7423, Notification of Reception Center Dental Screening.

  • Dental screenings shall be documented on the EDRS odontogram, in accordance with EDRS Workflow 1-1.1/1-1.2 and associated Back Office Job Aid, and shall include, but not be limited to:

    • A panoramic radiograph unless one has been taken by CDCR within the past 12 months.

    • A screening of the head and neck as well as the hard and soft tissues of the oral cavity with a mouth mirror and adequate illumination, which includes at least:

      • A cancer screening.

      • Charting of a patient’s existing DPC 1 conditions (e.g., dental decay or other oral pathology) then treatment planning and assigning a DPC code to the most urgent condition, or multiple conditions of equal urgency, that the dentist determines are the most urgent, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

    • Documenting in a clinical note in the EDRS the presence of prosthetic appliance(s) (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.6.4(c)(1)(B), Dental Chronos, for requirements concerning documenting a prosthetic appliance).

  • The dentist performing the RC screening shall:

    • Review the screening findings with the patient and advise them of any Emergency and/or DPC 1 conditions.

    • Inform the patient of any DPC 2, 3, or 5 dental needs and provide them with a CDCR 7423 to complete and sign if they could benefit from dental care.

    • Document in a clinical note in the EDRS:

      • Any radiograph(s) taken during the RC dental screening.

      • That an RC dental screening was completed and the results reviewed with the patient who was then advised of, as well as offered treatment for, any Emergency and/or DPC 1 conditions.

      • Abnormal conditions noted from the head and neck screening and any required follow-up.

      • Whether the patient elected to receive or refused treatment of any existing Emergency and/or DPC 1 conditions. (Reference the HCDOM, Section 3.3.5.6, Patient’s Right to Refuse Treatment, for requirements concerning a refusal).

      • The purpose of the next encounter if one is scheduled or needs to be scheduled.

      • A brief entry indicating that the process described in Section (c)(1)(D)2 was followed if the patient has DPC 2, 3, or 5 dental needs.

    • Follow the procedure outlined in the HCDOM, Section 3.3.5.2(c)(3)(A) if the patient requires and has requested treatment of any Emergency and/or DPC 1 conditions.

    • Follow the procedure outlined in the HCDOM, Section 3.3.5.2(c)(3)(B) if the patient does not wish to receive treatment of their Emergency and/or DPC 1 conditions.

    • Indicate the patient’s DPC upon signing the EDRS clinical note, in accordance with EDRS Workflow 1-1.1/1-1.2 and associated Back Office Job Aid.

    • Set the EDRS RC dental screening procedure code to completed status in the Appointment Book.

    • Ensure the RC dental screening treatment request is set to completed status in the EDRS, and the corresponding Electronic Health Record System (EHRS) RC dental screening order is set to completed status.

  • Dental staff shall:

    • Only perform screening duties within their scope of licensure.

    • Follow the procedure outlined in the HCDOM, Section 3.3.2.3(c)(3) if the patient refuses the:

      • RC screening.

      • Panoramic radiograph.

    • Follow the procedure outlined in the HCDOM, Section 3.3.6.1(c)(2)(B) regarding scanning forms into the EDRS Document Center.

    • Monitor the EDRS QM Reception Center Length of Stay Report to ensure RC dental screenings are performed timely and the EHRS RC dental screening order is completed. The Health Program Manager III or designee at each institution shall be responsible for tracking RC dental screenings.

  • The Office Technician (OT) or designated dental staff shall schedule an encounter for patients that qualified for but did not have a panoramic radiograph taken for any reason other than a “Refusal.”  Efforts shall be made to schedule the encounter within ten business days of discovering that the patient did not have a panoramic radiograph taken.

• Dental Treatment in RCs

  • Dental treatment provided to RC patients shall be limited to the treatment of Emergency and DPC 1 dental conditions.

  • RC patients shall initiate access to dental services as outlined in the HCDOM, Sections 3.3.5.2(c)(3)(A); 3.3.5.13(c)(4)(A); and 3.3.5.13(d)(1)(C) and (D).

  • At the end of every treatment encounter for an RC patient, the dentist shall offer them a subsequent treatment encounter unless the patient’s DPC changes to a DPC 2, 3 or 4. (The procedure outlined in the HCDOM, Section 3.3.5.2(c)(2)(B) does not apply to most RC patients).

  • Patients who remain on RC status at an RC for 90 calendar days or longer may be eligible to receive DPC 2 care (excluding prosthetics) on a case by case basis.

  • Patients remaining on RC status at an RC for 180 calendar days or longer shall be notified within ten business days after completion of the 180 calendar days that they are eligible to receive an initial comprehensive dental examination performed by a dentist. (Reference the HCDOM, Section 3.3.2.3(c)(1)).

Policy

• All California Department of Corrections and Rehabilitation (CDCR) Mainline Facility patients shall be eligible to receive comprehensive dental examinations.

Purpose

• To ensure that CDCR patients are eligible to receive timely comprehensive dental examinations at a Mainline Facility. The purpose of the dental examinations shall be for the identification, diagnosis and treatment of dental pathology which impacts the health and welfare of patients.

Procedure

• Initial Comprehensive Dental Examination

  • Within ten business days of arrival at a Mainline Facility all patients shall be notified that they are eligible to receive an initial comprehensive dental examination performed by a dentist. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.2.2(c)(2)(E) for eligibility notification requirements concerning patients who remain on Reception Center (RC) status at an RC for 180 calendar days or longer).

    • The Office Technician (OT) or designated dental staff shall generate and send a notification slip informing patients:

      • Of their eligibility for the initial comprehensive dental examination.

      • They must submit a CDCR 7362, Health Care Services Request Form, to receive the examination.

    • The OT or designated dental staff shall schedule patients for an initial comprehensive dental examination within 90 calendar days of the dental clinic receiving a CDCR 7362 from the patient asking for the examination.  When this timeframe is not respected, the treating clinician shall document the reason in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

    • The notification slip shall be delivered to the patient through the Institution Interdepartmental Mail or the process used for priority ducat distribution.

  • The results of the Mainline Facility initial comprehensive dental examination and the patient’s Dental Priority Classification shall be recorded on the EDRS odontogram, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid, and in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.    The initial comprehensive dental examination shall include:

    • Clinically adequate radiographs of diagnostic quality.

    • The quantity and periodicity of radiographs shall be determined by a CDCR dentist based on current American Dental Association guidelines. An examination of the head and neck as well as the hard and soft tissues of the oral cavity with a mouth mirror, explorer and adequate illumination, which includes at least:

      • A cancer screening.

      • Charting of the patient’s missing teeth, existing teeth, restorations and dental decay.

    • Determination of the patient’s baseline plaque index (PI) score.

    • A Comprehensive Periodontal Examination.

    • A health history. (Reference the HCDOM, Section 3.3.6.1(c)(2)(E)).

    • Formulation and documentation of a dental treatment plan as well as sequencing treatment into numbered visits using the EDRS Treatment Planner, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

  • Patients transferring from one Mainline Facility to another and who have already received an initial comprehensive dental examination at a Mainline Facility, need not be re-examined upon transfer from one CDCR facility to another, except as determined by the attending dentist, or unless they meet the requirements for periodic comprehensive dental examinations as outlined in Section (c)(2)(A) through (C).

  • Patients who have paroled and are rearrested and who received a comprehensive dental examination at a Mainline Facility within the past six months, need not receive a new comprehensive dental examination, except as determined by the attending dentist.

  • Patients identified as needing and having requested an initial comprehensive dental examination shall be ducated by the OT or designated dental staff within the mandated timeframe for the procedure to be performed as outlined in Section (c)(1)(A)2.

• Periodic Comprehensive Dental Examination

  • After the initial comprehensive dental examination, all Mainline Facility patients shall be notified they are eligible to receive a periodic comprehensive dental examination by a dentist, every two years (biennially) until the patient reaches the age of 50.

  • After the initial comprehensive dental examination, all Mainline Facility patients 50 years of age or older shall be notified they are eligible to receive a periodic comprehensive dental examination by a dentist annually.

  • Patients with certain chronic systemic illnesses or medical conditions that could compromise their oral health shall be notified they are eligible to receive an annual comprehensive dental examination, regardless of their age. These include:

    • Diabetes

    • Human Immunodeficiency Virus (HIV)

    • Seizures

  • The results of the Mainline Facility periodic comprehensive dental examinations shall be documented as outlined in Section (c)(1)(B). The periodic comprehensive dental examination shall include:

    • Procedures listed in Section (c)(1)(B)1. through 2.

    • Updated charting of the patient’s periodontal status by completing a Comprehensive Periodontal Examination.

    • Re-evaluation of the patient’s PI score.

    • A health history. (Reference the HCDOM, Section 3.3.6.1(c)(2)(E)).

    • Updated charting of the patient’s existing dental restorations and decay.

    • Updated charting of a dental treatment plan as well as sequencing treatment into numbered visits using the EDRS Treatment Planner, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

  • The OT or designated dental staff shall:

    • Generate and send a notification slip informing patients:

      • Of their eligibility for the periodic comprehensive dental examination.

      • They must submit a CDCR 7362 to receive the examination.

    • Notify patients of their eligibility for an annual or biennial periodic comprehensive dental examination based on the date of the last comprehensive dental examination or the anniversary date of the patient’s last exam notification date as determined by the EDRS QM Report.

    • Send the notification slip no later than 60 calendar days before the anniversary date of the patient’s most recent comprehensive dental examination or the anniversary date of the patient’s last exam notification date as determined by the EDRS QM Report, whichever is more recent.

    • Ensure the notification slip is delivered to the patient through the Institution Interdepartmental Mail or the process used for priority ducat distribution.

  • The annual or biennial periodic comprehensive dental examinations shall be completed within 90 calendar days of the dental clinic receiving a CDCR 7362 from the patient asking for the examination.  When this timeframe is not respected, the treating clinician shall document the reason in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid. Patients shall be eligible to receive a periodic comprehensive dental examination regardless of Earliest Possible Release Date (EPRD) if the exam can be completed prior to their release date and performing the examination will not keep other patients from receiving care.

  • Patients may submit a CDCR 7362 requesting a periodic comprehensive dental examination no sooner than 60 calendar days before the date when they are eligible for the examination. If a patient submits a CDCR 7362 requesting a periodic comprehensive dental examination greater than 60 calendar days before the date when they are eligible, a CDCR dentist shall send a written response informing the patient when to submit a request.

• If a patient refuses the initial or periodic comprehensive dental examination, a CDCR 7225-D, Dental Refusal of Examination and/or Treatment, must be completed and signed by the provider and the patient. (Reference the HCDOM, Section 3.3.5.6(c)(6) for other requirements concerning a refusal).

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental facilities shall maintain a periodontal disease program for the diagnosis and treatment of periodontal disease that incorporates consideration of the most current version (MCV) of the Adult Correctional Dental Care (ACDC), Periodontal Treatment Guidelines (PTG).  Periodontal treatment shall be available to all patients based on completion of a comprehensive dental examination, the presence of a treatment plan, prior completion of Dental Priority Classification (DPC) 1 dental treatment and time remaining on their sentence. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.5.3, Appendix 1, Dental Priority Classification).

Purpose

• To establish guidelines and procedures for the treatment and management of periodontal disease in the patient population.

Procedure

• Diagnosis of Periodontal Disease

  • Mainline Facility Dental Clinics:

    • Comprehensive Periodontal Examination and Charting

      • Patients transferring to a Mainline Facility shall be eligible for a comprehensive periodontal examination.

      • The comprehensive periodontal examination shall be performed in conjunction with the comprehensive dental examination within the parameters outlined in the HCDOM, Section 3.3.2.3(c)(1)(B)4.

      • The comprehensive periodontal examination and charting shall be documented on and include conditions contained in the Electronic Dental Record System (EDRS) Perio Chart, in accordance with EDRS Workflow 1-3 as well as 1-4 and associated Back Office Job Aids.

    • Classification of Periodontal Disease

      • Periodontal Disease shall be classified according to the following categories from the American Academy of Periodontology (AAP) Position Paper “Diagnosis of Periodontal Disease” (J Periodontol. 74: 1237-1247).

        • Gingivitis

        • Chronic Periodontitis

        • Aggressive Periodontitis

        • Periodontitis as a manifestation of systemic disease

        • Necrotizing periodontal disease

        • Abscess of the periodontium

        • Periodontitis associated with an endodontic lesion

      • Descriptive modifiers shall be used to distinguish the extent and severity of the periodontal disease including, but not limited to:

        • Localized (<30% of sites involved)

        • Generalized (>30% of sites involved)

        • Slight

        • Moderate

        • Advanced

        • Case Type Indicators	Type II Slight Periodontitis	Type III Moderate Periodontitis	Type IV Advanced   Periodontitis
          Bleeding on probing	Yes	Yes	Yes
          Probing depth	< 4 mm	4 to 6 mm	> 6 mm
          Bone loss	≤ 10%	≤ 33%	> 33%
          Mobility	≤ 1	≤ 2	≤ 3
          Furcation grade	≤ 1	≤ 2	≤ 3
          Clinical attachment loss	< 2 mm	2 to 4 mm	> 4 mm
          Localized – < 30% of sites involved		Generalized – ≥ 30% of sites involved

      • The classification type and descriptive modifiers shall be documented in the EDRS Perio Chart, and in a clinical note in accordance with EDRS Workflow 1-4 and associated Back Office Job Aid.

  • RC Dental Clinics

    • Each parole violator or new commitment arriving at a Reception Center (RC) shall undergo a dental screening as outlined in the HCDOM, Section 3.3.2.2, Dental Care – Reception Center.

• Patient Education and Treatment of Periodontal Disease

  • The treatment of periodontal disease is a major part of dental practice and requires a coordinated effort between the patient and the dental team. The ultimate responsibility for controlling periodontal disease is that of the patient. 

  • Gross debridement may be performed for Mainline Facility or RC patients regardless of the Plaque Index (PI) score at the treating dentist’s discretion.

  • Mainline Facility Dental Clinic

    • Education

      • Methods and procedures to control periodontal disease shall be taught and demonstrated to patients by dental staff. These measures shall consist of individual instructions and training in oral hygiene and plaque control, which may include, but not be limited to:

        • The documenting of the PI score in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, as well as in the EDRS Periodontal Chart, in accordance with EDRS Workflow 1-4 and associated Back Office Job Aid.

        • Education on oral hygiene which is included in the Patient Orientation to Health Care Services Handbook.

        • Education on the signs and symptoms of periodontal disease.

        • Education on the effect of periodontal disease on oral and systemic health.

        • Education on the importance of controlling oral disease for female patients during and after pregnancy to reduce the potential for transmitting oral bacteria from mother to child.

        • Demonstration and training on the methods of preventing periodontal disease.

        • Education and training on proper oral hygiene techniques.

        • Availability of appropriate treatment modalities at the assigned facility.

      • The PI score is used to determine the percentage of teeth stained with plaque and is calculated as outlined in the HCDOM, Section 3.3.2.13(c)(2)(B). (Reference the HCDOM, Section 3.3.2.13(c)(2)(G) and (H) regarding documentation of the PI score).

    • Clinical Treatment

      • The treatment of moderate or advanced periodontitis shall be classified as DPC 2 care. Patients with aggressive periodontitis, periodontitis as a manifestation of systemic diseases, and necrotizing periodontal diseases may require consultation and coordinated case management with their primary care provider (PCP).

      • The treatment of gingivitis or slight periodontitis shall be classified as DPC 3 care. (Reference the HCDOM, Section 3.3.2.13(c)(2)(A) for treatment eligibility requirements).

      • The predominant mode of periodontal therapy within CDCR shall consist of periodontal scaling and root planing (SRP).  CDCR clinicians shall not provide periodontal therapy other than SRP without prior approval of the Dental Authorization Review (DAR) Committee and the Dental Program Health Care Review Committee (DPHCRC).  (Reference the HCDOM, Section 3.3.4.5(c)(3) and (4)).

        • Prior to SRP procedures, the attending dentist shall document a baseline charting of the periodontal status which shall include, but is not limited to, review of a radiographic survey.

        • Clinicians shall initiate treatment in a timely manner and minimize the number of encounters needed to complete SRP.  When this is not done, the treating clinician shall document the reason in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

        • It is recommended that patients who need two quadrants or less of SRP have it completed in a single encounter and those needing more than two quadrants have the treatment completed in two encounters that are at least two weeks apart.

        • Extreme care shall be exercised when providing scaling and/or root planing to patients with implants.  To prevent damage to the implant, the use of metal scalers and probes shall be avoided.

      • Patients shall receive a re-evaluation of their periodontal condition four to eight weeks following completion of treatment procedures associated with active therapy. When this is not done, the treating clinician shall document the reason in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

        • If a patient refuses a perio re-evaluation, the patient shall be advised to submit a CDCR 7362, Health Care Services Request Form, when they are ready to have the procedure performed. (Reference the HCDOM, Section 3.3.5.6, Patient’s Right to Refuse Treatment for requirements concerning a refusal).

        • When a patient submits a CDCR 7362 request for perio re-evaluation and it is determined that the patient previously refused the perio re-evaluation, at the discretion of the treating dentist, the Office Technician (OT) shall create a No Face-to-Face Treatment Request and schedule the patient. The appointment shall take place within 30 calendar days of the clinic’s receipt of the CDCR 7362. At the time of the appointment, the dentist shall treatment plan the perio re-evaluation in the EDRS Progress Note panel with the current date as the diagnosis date.

      • The re-evaluation shall include documenting of pocket depths, mobility, furcation involvement and bleeding on probing. These clinical observations may be performed and documented by a Registered Dental Hygienist (RDH) who shall forward the findings along with treatment recommendations to the treating dentist.

      • Patients who require continuing active therapy shall be assigned a DPC based on their periodontal disease condition at the time of the most recent re-evaluation.

        • For scheduling purposes, the “Date of Diagnosis” is the date that the re-evaluation is completed and the need for continuing active therapy is identified.

        • The patient may continue to receive non-periodontal procedures in accordance with and within the timeframes of their established treatment plan.

      • In order to assist in maintaining periodontal health and facilitate detecting active disease recurrence, CDCR clinicians may recommend periodontal maintenance for patients with a documented susceptibility to periodontal disease.

      • CDCR dentists shall document recommendations for periodontal maintenance on the EDRS odontogram Progress Note panel, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

      • Patients for whom the treating dentist recommends periodontal maintenance shall not be assigned a DPC for the periodontal maintenance when the patient has untreated, diagnosed dental conditions.  The patient’s DPC shall be based on the most urgent diagnosed, untreated condition.

      • When a patient no longer has any active periodontal disease sites; and all active and continuing active therapy has been completed; and the patient has reached a state of periodontal health; and the patient has no untreated, diagnosed dental conditions; and the dentist is recommending that the patient receive periodontal maintenance; or the dentist is not recommending periodontal maintenance, the patient shall be assigned a DPC 4.

      • When a CDCR dentist recommends periodontal maintenance for a patient, dental staff shall either assign a Continuing Care type of Perio in the EDRS Family File or update the Continuing Care as needed, in accordance with EDRS Workflow 1-4 and associated Back Office Job Aid. The patient shall be advised to submit a CDCR 7362 within a specified timeframe (e.g., 3, 4 or 6 months), based on the treating dentist’s professional judgment, to ask for periodontal maintenance.  The treating dentist shall inform the patient of the reason for the periodontal maintenance.

      • When a patient submits a request for periodontal maintenance, the dentist performing the paper review shall review the health record, or instruct a dental staff member to review the health record, to ensure that a CDCR dentist recommended periodontal maintenance and that the patient submitted the CDCR 7362 consistent with the recommended periodicity for the periodontal maintenance encounter.

      • When the health record review reveals that a CDCR dentist recommended periodontal maintenance and that the patient submitted the CDCR 7362 within the appropriate timeframe, the individual who conducted the health record review shall inform the dentist performing the paper review who shall indicate on the CDCR 7362 that the patient needs a periodontal maintenance appointment which the OT, or designated dental staff, shall enter in the EDRS Treatment Request Manager, in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.

      • When the health record review reveals that a CDCR dentist recommended periodontal maintenance and that the patient submitted the CDCR 7362 greater than 60 calendar days before the date when they are eligible, a CDCR dentist shall send a written response informing the patient when to submit a request.

      • When a patient submits a CDCR 7362 beyond the recommended timeframe, they shall be scheduled for a periodontal maintenance appointment as outlined in Section (c)(2)(C)2.m.

      • If a patient for whom a dentist has recommended periodontal maintenance fails to submit a CDCR 7362 to request the procedure, and the patient subsequently becomes eligible for and receives a periodic comprehensive dental examination, the treating dentist shall reject the unscheduled periodontal maintenance procedure at the time of the examination appointment in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

      • Provision of periodontal maintenance shall incorporate consideration of the most recent version of the ACDC, PTG.

  • RC Dental Clinics

    • Education

      • Patients diagnosed with periodontal disease shall be eligible to receive education on how to control the condition as outlined in Section (c)(2)(C)1.a.2) through 7).

    • Clinical Treatment

      • RC patients shall receive dental treatment as outlined in the HCDOM, Section 3.3.2.2, Dental Care – Reception Center.

Policy

• Within the second trimester of gestation, pregnant California Department of Corrections and Rehabilitation patients shall receive a comprehensive dental examination, periodontal examination and the necessary periodontal treatment in order to maintain periodontal health during the gestation period.

Purpose

• To establish protocols which prevent or treat gingivitis or periodontitis during pregnancy.

Procedure

• Pregnant patients shall benefit from the periodontal disease program as delineated here and in the Health Care Department Operations Manual (HCDOM), Section 3.3.2.4, Periodontal Disease Program.

• Diagnosis of Periodontal Disease

  • Pregnant patients shall receive a comprehensive periodontal examination, charting and classification to determine their periodontal condition and an appropriate treatment plan.

  • Pregnant patients shall have their plaque index (PI) score determined and recorded as outlined in the HCDOM, Section 3.3.2.13(c)(2).

• Treatment of Periodontal Disease

  • Education

    • Methods and procedures to control periodontal disease shall be taught and demonstrated to pregnant patients by dental staff as outlined in the HCDOM, Section 3.3.2.4(c)(2)(C)1.a.

  • Clinical Treatment

    • Pregnant patients shall receive a prophylaxis or scaling and/or root planing regardless of their ability to maintain an acceptable PI score. This treatment shall occur within their second trimester of gestation. A charting and re-evaluation of their periodontal condition shall be accomplished approximately 30 calendar days following completion of prophylaxis or scaling and/or root planing procedures with subsequent care planned as needed.

    • The attending dentist shall not utilize subgingival periodontal medications (e.g., Atridox, Periostat) that are contraindicated for use during pregnancy.

Policy

• The California Department of Corrections and Rehabilitation (CDCR) shall provide limited dental prosthodontic services to patients in its custody. Patients shall be eligible to receive a dental prosthetic appliance once every five years.

Purpose

• To establish standard guidelines and procedures for the fabrication, tracking, shipping, handling, storage and replacement of patient dental prosthetic appliances.

Procedure

• Dental Prosthodontic Services Guidelines

  • A patient’s need for a dental prosthesis shall be based on medical necessity as described in the California Code of Regulations (CCR), Title 15, Division 3, Chapter 2, Subchapter 2, Article 1, Section 3999.200 “Provisions of Care and Treatment Exclusions.”

  • No patient shall be deprived of a prescribed dental prosthesis that was in their possession upon arrival into CDCR custody, or that was properly obtained while in CDCR custody, unless a CDCR dentist determines the appliance is no longer needed or its removal is indicated for reasons of safety or security. (Reference the CCR, Title 15, Division 3, Chapter 2, Subchapter 3, Article 9, Section 3999.395 “Artificial Appliances”).

  • If a patient’s dental prosthesis is confiscated for safety and security reasons, a dentist shall be notified by the next business day to determine whether the patient will require any accommodations due to the loss of the prosthesis.

  • A dental prosthesis shall be constructed only when:

    • The dentist believes the patient can tolerate it and can be expected to use it on a regular basis.

    • A patient is edentulous, is missing an anterior tooth, or has seven or fewer posterior teeth in occlusion.

    • All diagnosed preventive, restorative, endodontic and oral surgery procedures have been completed.

    • The active therapy phase of periodontal therapy has been completed and the patient is free of periodontal disease or is in periodontal maintenance.

    • Clinically adequate radiographs of diagnostic quality are present prior to initiating dental prosthodontic services. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.2.3(c)(1)(B)1.).

    • The patient has a Dental Priority Classification (DPC) 2 prosthetic need (e.g., complete denture) and a minimum of six months of verifiable, continuous incarceration remaining before release or parole; or the patient has a DPC 3 prosthetic need (e.g., partial denture) and a minimum of 12 months of verifiable, continuous incarceration remaining before release or parole, (Reference the HCDOM, Section 3.3.5.3, Dental Priority Classification).  Time requirements are calculated from the date final impressions are taken.

    • The patient, where applicable, has an acceptable Plaque Index (PI) score. (Reference the HCDOM, Section  3.3.2.13(c)(2)).

  • Medically necessary pre-prosthetic surgery (e.g., alveoloplasty without extractions, vestibuloplasty, torus removal) that cannot be accomplished by CDCR dentists at the local institution shall only be performed with prior approval of the Dental Authorization Review (DAR) Committee. (Reference the HCDOM, Section 3.3.4.5(c)(3) and (4)).  Pre-prosthetic surgery does not include any type of ridge augmentation.

  • When a patient’s treatment plan includes a dental prosthesis, the treating dentist shall inform them of the possibility that the prosthesis may not be completed prior to the patient’s parole date.

  • Any treatment plan that includes a removable partial denture shall also include consideration of a cast removable partial denture.

  • Complete dentures and/or removable partial dentures may be provided if the patient fulfills the requirements outlined in Section (c)(1)(D). These requirements may be modified at the discretion of the treating dentist based upon medical necessity and with prior approval by the DAR Committee. (Reference the HCDOM, Section 3.3.5.3(c)(3) and (4)).

  • A prescribed dental prosthesis, (including occlusal guards), shall be provided at state expense to all patients. Occlusal guards shall only be fabricated to minimize the effects of bruxism or clenching and not for treatment of sleep apnea, snoring or TMJ dysfunction. (Reference the HCDOM, Section 3.3.6.4(c)(1)(B), Dental Chronos, for requirements concerning documenting a prosthetic appliance).

  • Prescribed dental appliances made from precious metal shall not be ordered by CDCR dentists and repairs to existing dental prostheses made from precious metal shall not be performed by CDCR dentists or CDCR dental laboratories.  If a patient’s existing dental appliance made from precious metal needs repair, the dentist shall offer the patient the option of having a new prosthesis made. 

  • The treating dentist shall enter all necessary information on the appropriate dental lab prescription form, (e.g., CDCR 239, Prosthetic Prescription), when impressions for dental prostheses are taken, or when any intermediate step in the fabrication process is initiated. The treating dentist shall then follow the process outlined in the HCDOM, Section 3.3.6.1(c)(2)(B).

  • All dental prostheses which are fabricated for patients in the custody of the CDCR shall have the patient’s name and CDCR number embedded into the prosthesis for identification purposes. Laboratory stone models shall also have the patient’s last name and CDCR number inscribed on them.  The dentist shall not deliver any prosthesis before the proper identification, (i.e., patient’s last name and CDCR number) has been embedded in the resin of the denture or partial.

  • Dental prostheses without the proper identification on them shall be returned to the dental laboratory to have the patient’s last name and CDCR number placed on the prosthesis.

• Dental Prosthetic Monitoring

  • Dental staff shall use the Continuing Care function of the Electronic Dental Record System (EDRS) to monitor dental prosthetic cases, in accordance with EDRS Workflow 3-8 and associated Back Office Job Aid.

  • All prosthetic cases initiated for CDCR patients shall be documented in the EDRS Continuing Care. This is accomplished by setting the preliminary (for those cases where the preliminary is the final impression) or final impression code as complete in the EDRS appointment book in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid. The inclusion of a dental prosthesis in a treatment plan does not constitute initiation of a case. A case is not considered initiated until impressions have been taken.

• Dental Prosthetic Cases – Shipping and/or Storage Procedures

  • Patients who have been paroled or released from the CDCR

    • Completed dental prosthetic cases that cannot be delivered because the patient has been paroled or released shall be forwarded by mail to a dentist designated by the patient.

    • Completed prosthetic cases are to be shipped at state expense to the private dentist designated by the patient. Before the completed case can be shipped, the designated dentist shall request in writing that the completed dental prosthetic case be sent to their office. The charges incurred for the dentist’s services are to be borne by the patient.

    • The dental department shall store the prosthesis until contacted by the dentist designated by the patient, for a period of time not to exceed 12 months. If no activity has occurred, cases older than 12 months shall be destroyed.

  • Patients Transferred Between CDCR Institutions

    • When dental staff becomes aware that a patient for whom a prosthetic appliance is being made has transferred to a new institution, the Supervising Dental Assistant (SDA), or designee, shall contact the SDA, or designee, at the new institution to verify that the patient is there.

    • Upon verification that the patient is housed at the new institution, a completed prosthetic case or one that is in progress, regardless of the stage of completion, shall be forwarded directly by the SDA, or designee, to the patient’s new facility of assignment for completion or delivery.

    • This transfer shall be documented in the EDRS, in accordance with EDRS Workflow 3-8 and associated Back Office Job Aid.

  • General Information

    • A case may be forwarded only to a dentist for delivery or completion.

    • The sending clinic/dentist and the receiving clinic/dentist shall coordinate by telephone or e-mail the forwarding of a prosthetic case for completion or delivery.

• Replacement or Repair of Dental Prosthetic Appliances

  • A broken or damaged removable prosthetic dental appliance diagnosed as serviceable by the providing dentist shall be repaired as appropriate.

  • A removable prosthetic dental appliance diagnosed as unserviceable by the providing dentist shall be replaced as appropriate.

  • A removable dental appliance that has been lost or stolen shall be replaced as appropriate.

  • Dental prosthetic appliances shall be replaced according to the following criteria:

    • When evaluating a patient’s need for a replacement dental prosthetic appliance, the treating dentist shall consider the patient’s ability to masticate, as well as to maintain an appropriate level of health and weight for their height and frame.

    • All requirements as outlined in Section (c)(1)(D) are applicable for the replacement of a dental prosthetic appliance.

    • Replacement of a removable prosthetic dental appliance more often than once every five years shall be decided on a case-by-case basis and require Supervising Dentist (SD) and/or DAR Committee approval.

• Loose or Ill-fitting Dental Prosthetic Appliances

  • Patients who submit a CDCR 7362, Health Care Services Request Form, for denture related concerns such as loose or ill-fitting dentures shall be afforded all eligible CDCR Dental Prosthodontic Service options.

  • A CDCR dentist shall evaluate a patient’s removable dental prosthetic appliance when the patient indicates that the appliance:

    • Is not staying in properly.

    • Does not allow the patient to chew properly because the appliance is unstable or is not fitting properly.

  • If the CDCR dentist diagnoses the current appliance as serviceable, then consideration shall be given to chairside or lab reline procedures.

  • If the current appliance is diagnosed as not serviceable, then consideration shall be given to replacement as outlined in Section (c)(4).

  • Should all CDCR Dental Prosthodontic Service options be exhausted, then consideration shall be given to the use of a denture adhesive. The treating dentist shall advise the patient to purchase denture adhesive from the Canteen or order denture adhesive from the Canteen Over-the-Counter (OTC) Products List (Reference the HCDOM, Section 2.1.3, Over-the-Counter Products).

  • CDCR dentists shall not recommend denture adhesive for patients with:

    • A documented allergy to denture adhesives or their ingredients.

    • An appliance that is grossly inadequate in fit and/or function.

    • An appliance that demonstrates excessive loss of vertical dimension.

    • An appliance that is broken or missing any flange.

    • Mucosal conditions indicative of pathology, e.g., Candidiasis.

• Patients with Special Prosthetic Needs

  • A dentist who diagnoses that a special dental prosthetic need exists for any patient may request an exemption by submitting a request to the DAR Committee for review and approval.  The request must include the items listed in the HCDOM, Section 3.3.4.5(c)(4)(A) and (C) as well as the following:

  • Patient history of prior prosthetic needs and replacements.

  • Providing dentist’s recommendations concerning the fabrication or replacement of a removable prosthetic appliance.

  • Special circumstances that warrant the fabrication or replacement of a removable prosthetic appliance.

Policy

• The California Department of Corrections and Rehabilitation (CDCR) shall provide patients with dental restorative services utilizing CDCR approved dental restorative materials.  Dental restorative services shall be limited to the restoration of carious teeth with enough structural integrity to provide long-term stability.

Purpose

• To establish guidelines and parameters for the delivery of dental restorative services to patients incarcerated within CDCR.

Procedure

• Appropriate and current radiographs shall be reviewed before initiating restorative procedures.

• All CDCR approved restorative materials utilized in the dental clinics shall have the approval of the American Dental Association.

• CDCR dental staff shall verify that every patient has received a copy of the Dental Materials Fact Sheet prior to restorations being initiated.

• Permanent Restorations

  • Amalgam is the only material approved by the CDCR for restoration of Class I and II lesions of posterior teeth. CDCR dentists shall not place composite restorations on occlusal or interproximal surfaces of posterior teeth.

  • Amalgam, light cured composite and glass ionomer shall be considered acceptable materials for buccal pit restorations of posterior teeth.

  • Amalgam and glass ionomer shall be considered acceptable materials for Class V restorations of posterior teeth.

  • Light cured composite shall be the material of choice for anterior restorations.  When indicated, glass ionomer may be utilized.

• Temporary or Sedative Restorations

  • Temporary or sedative restorations shall be placed when indicated.

  • Temporary polycarbonate crowns shall be utilized on anterior teeth that have been previously prepared for crowns or that require a crown. For posterior teeth that have been previously prepared for crowns or that require a crown, stainless steel crowns shall be utilized.

  • Remineralization temporaries, such as glass ionomer that release fluoride into the tooth structure and promote remineralization of tooth structure, shall be placed as early as possible in the treatment sequence to provide holding care for patients with extensive caries. These sedative restorations may be placed before establishment of a treatment plan or shortly after completion of a comprehensive dental examination on patients who exhibit extensive dental caries.

• Teeth diagnosed with advanced periodontitis shall not be eligible for restorative dental treatment.

• Although every effort shall be made when restoring anterior teeth to achieve a reasonable esthetic result, cosmetic dentistry shall not be provided.

• Routine dental care shall be discontinued if, in the judgment of the providing dentist:

  • The patient is not maintaining an acceptable level of oral hygiene necessary to preserve the health of their oral cavity.  (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.2.13(c)(2)).

  • The patient has a record of intentionally failing to keep appointments. Such patients shall be eligible to receive Emergency and DPC 1 dental treatment only. (Reference the HCDOM, Section 3.3.5.1(c)(4)(C)).

• Reference the HCDOM, Section 3.3.4.5(c)(3) and (4) for referral requirements.

Policy

• Dental clinics within the California Department of Corrections and Rehabilitation (CDCR) shall provide necessary oral surgery services to all patients.

Purpose

• To establish guidelines and parameters whereby patients in the custody of CDCR receive necessary oral surgery services in a timely manner.

Procedure

• A full range of necessary oral surgery procedures including biopsies shall be available to all CDCR patients regardless of incarceration time.

• Any medically necessary oral surgery procedure that cannot be accomplished by CDCR dentists at the local institution shall be made available by referring the patient to contracted Oral Surgeons, or to outside facilities. (Reference the Health Care Department Operations Manual, Section 3.3.4.5(c)(3) and (4).

• Routine extraction of asymptomatic third molars is an excluded service.

• A CDCR 7425, Consent for Extraction(s), or for all other surgical procedures, a CDCR 7342, Informed Consent to Surgical, Special Diagnostic, or Therapeutic Procedures, must be completed and signed by the patient prior to provision of the services.

• At the discretion of the treating dentist, patients shall have a post-op follow-up oral surgery appointment after each surgical procedure.

• The Supervising Dentist (SD) or designee shall make arrangements to receive timely notification from the Triage and Treatment Area (TTA) or Utilization Management (UM) Nurse regarding patients that return to the institution after having surgical procedures provided at an outside facility. The SD or designee shall establish a Local Operating Procedure (LOP) for scheduling post-op oral surgery appointments for these patients.

Policy

• All California Department of Corrections and Rehabilitation (CDCR) patients shall be eligible to receive limited endodontic (root canal therapy) services at CDCR dental clinics.  Endodontic services within the CDCR shall be performed in accordance with established criteria and within the specific guidelines of this chapter.

Purpose

• To establish dental treatment parameters for providing patients with endodontic services in CDCR dental facilities.

Procedure

• Endodontic procedures shall not be performed when extraction of the tooth is appropriate due to non-restorability, periodontal involvement or when the tooth can easily be replaced by an addition to an existing or proposed prosthesis in the same arch.

• Endodontics, or root canal therapy, shall only be performed for a patient on the upper and lower six anterior teeth when all of the following conditions are met.

  • The retention of the tooth is necessary to maintain the integrity of the dentition.

  • The tooth has adequate periodontal support and a good prognosis for long-term retention and restorability.

  • The tooth is restorable using CDCR approved methods and materials and does not require extensive restoration including either a pin or post retained core build up.

  • There is adequate posterior occlusion, either from natural dentition or a dental prosthesis, to provide protection against traumatic occlusal forces.

• A CDCR 7424, Consent for Root Canal Treatment, must be completed and signed by the patient prior to the initiation of treatment.

• Apicoectomies, retrograde fillings, posterior root canal therapies, hemi-sections, root amputations and re-treatment of root canal therapies are excluded procedures and as such require prior approval of the Dental Authorization Review Committee. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.4.5(c)(3) and (4)).

• Posterior root canal therapy may be considered if all of the following conditions are met:

  • Conditions listed in Section (c)(2)(A) through (D).

  • The tooth in question is vital to the patient’s masticatory ability.

  • The tooth in question is essential as an abutment for an existing removable cast partial denture or is necessary as an abutment on a proposed removable cast partial denture for that arch.

• Palliative endodontic therapy (Dental Priority Classification [DPC] 1) shall be available, on an emergency basis only, for patients with less than six months of verifiable, continuous incarceration time remaining on their sentence (i.e., only emergency pulpal debridement for the relief of acute pain shall be provided).

• Root canal therapy (DPC 3) shall be available to all patients within the guidelines of this chapter, according to their dental treatment plan, PI score and with the approval of the treating dentist.

• All root canal therapy shall be completed at the dental facility where the procedure was initiated.  A hold shall be placed on all patients whose root canal therapy cannot be completed in one appointment.  The hold shall remain in effect until the root canal therapy is completed. (Reference the HCDOM, Section 3.3.6.6(c)(2) regarding placing a hold).  Patients undergoing palliative endodontic therapy are excluded from this “hold” process.

Policy

• Fixed prosthetic services, (i.e., lab processed crowns and bridges), shall be considered an excluded service and shall not be routinely provided to patients by dentists employed by the California Department of Corrections and Rehabilitation (CDCR).

Purpose

• To define fixed prosthetics as an excluded service and to establish guidelines for the provision of such treatment procedures when no other treatment modalities can provide the desired outcome.

Procedure

• Fixed prosthetics shall not be routinely provided to patients.  CDCR dentists who wish to provide fixed prosthetics for a patient must receive prior authorization from the Dental Authorization Review (DAR) Committee.  (Reference the Health Care Department Operations Manual, Section 3.3.4.5(c)(3) and (4)).

• Fixed prosthetics:

  • Shall not be utilized to restore missing or defective teeth if an adequate restoration can be placed, (e.g., a stainless steel crown or an amalgam with cuspal coverage), or if a removable partial denture can be fabricated to replace the missing teeth.

  • May be provided if all of the following criteria are met:

    • All the teeth involved in fixed prosthetic therapy have adequate periodontal support, with no mobility other than normally occurring physiologic movement.

    • All the teeth involved have a good prognosis of restorability and long term retention.

    • All Dental Priority Classification (DPC) 1, 2 and 3 dental care has been completed prior to commencing fixed prosthetic treatment.

    • The patient has demonstrated a Plaque Index score of 20% or less for two consecutive months after the completion of all DPC 3 dental care.  At the end of this two-month period a request for fixed prosthetics may be submitted to the DAR Committee.

    • The patient has a minimum of six months of verifiable, continuous incarceration time remaining on their sentence, after approval by the DAR Committee.

  • The above criteria shall apply for all instances in which fixed prosthetics are requested including DPC 5 Special Dental Needs Care.

• Laboratory processed crowns shall be utilized only for teeth that a CDCR dentist determines are critical for maintaining the integrity of the patient’s arch and only when a stainless steel crown or bonded amalgam/composite restoration has failed or is contraindicated.

• Non-precious metals shall be utilized for fixed prosthetics unless the patient has a documented allergy to those commonly used for crown and bridgework.

• Bonded bridges, (i.e., Maryland Bridges), shall not be utilized.

• Patients undergoing fixed prosthetics that are in progress but not completed at the time of their incarceration, shall have their dental needs met with CDCR authorized restorative materials and procedures only, (e.g., removable prosthetics, stainless steel crowns).

Policy

• California Department of Corrections and Rehabilitation (CDCR) dentists shall not initiate the placement, completion, or repair of dental implants for patients.

Purpose

• To establish that dental implants are not a dental service provided for patients by the CDCR and to provide guidelines for the treatment of patients with existing dental implants.

Procedure

• A patient with dental implants begun but not completed at the time of their incarceration shall not have their dental implants completed by CDCR.

• Patients shall be referred to an Oral Surgeon to have a failing dental implant evaluated for possible removal.  (Reference the Health Care Department Operations Manual, Section 3.3.4.5(c)(3) and (4) for referral requirements).

Policy

• California Department of Corrections and Rehabilitation (CDCR) dental departments shall not initiate orthodontic procedures, (i.e., braces), or continue orthodontic treatment for patients incarcerated while in active orthodontic treatment.

Purpose

• To establish guidelines for managing patients incarcerated while in active orthodontic treatment.

Procedure

• Orthodontics is not a dental service provided by CDCR dental departments.

• Patients may request to have orthodontic bands/brackets removed by the CDCR dental department. The CDCR shall not be held liable for changes to the patients’ dentition once the orthodontic bands/brackets are removed and shall obtain informed consent from all patients who request removal of orthodontic bands/brackets.

• Every attempt shall be made to contact the treating orthodontist prior to removal of orthodontic bands or brackets.

• Removal of orthodontic bands/brackets and/or arch wires shall be at the discretion of the treating dentist and does not require approval by the Dental Authorization Review Committee.

• The CDCR shall not be held liable for the replacement of orthodontic bands that are damaged or removed in the process of providing dental procedures on banded teeth.

• Reference the Health Care Department Operations Manual, Section 3.3.4.5(c)(3) and (4) for referral requirements.

Policy

• Within 14 business days of arrival at an institution, all California Department of Corrections and Rehabilitation (CDCR) patients shall receive the Patient Orientation to Health Care Services Handbook containing information regarding dental health care services.  CDCR Mainline Facility patients shall also receive a baseline Plaque Index (PI) score as well as oral hygiene instruction (OHI) at the time of their comprehensive dental examination and treatment plan formulation.

Purpose

• To ensure that patients are aware of the dental services provided for them at a Mainline Facility and are educated about the importance of proper oral hygiene.

Procedure

• General Requirements

  • The Health Program Manager (HPM) III at each institution shall ensure that all patients receive the Patient Orientation to Health Care Services Handbook within 14 business days of arrival at an institution that describes the process used for obtaining dental services.

  • The Supervising Dentist (SD) at each Mainline Facility shall ensure that all patients receive a baseline PI score (Reference the Health Care Operations Manual [HCDOM], Section 3.3.2.3(c)(1)(B)) as well as OHI at the time of their initial comprehensive dental examination and treatment plan formulation.

  • For each patient that refuses OHI, the dentist or designee shall complete a CDCR 7225-D, Dental Refusal of Examination and/or Treatment.  (Reference the HCDOM, Section 3.3.5.6(c)(6) for other requirements concerning a patient refusal).

  • Toothbrushing for all CDCR Incarcerated persons: Incarcerated persons shall be allowed to brush their teeth at least once a day, within the facility’s security guidelines and encouraged to brush after meals.

  • Dental Floss for all CDCR Incarcerated persons: Incarcerated persons shall be allowed to use dental floss or flossers once a day, within the facility’s security guidelines.

• PI Score

  • In order to qualify for Dental Priority Classification (DPC) 3 Routine Rehabilitative care (with the exception of periodontal treatment), a patient must maintain an acceptable level of oral hygiene which shall be measured and evaluated by the use of the PI score.

  • A patient’s PI score shall be calculated using the CDCR 237-E, Plaque Index Scoring Record, or by utilizing the following formula:

    • 

  • A PI score of 20% or less represents an acceptable level of oral hygiene.

  • When a patient’s PI score is unacceptable, every effort shall be made to help them improve the PI score by cleaning their teeth and by giving OHI.  The PI score is designed to assist dental staff in educating patients on the importance of proper oral hygiene.

  • Patients with a PI score above 20% or who refuse OHI shall receive only Emergency, DPC 1, 2 (subject to the requirements for time remaining on their sentence [Reference the HCDOM, Section 3.3.5.3, Appendix 1, Dental Priority Classification]), and 5 dental care.

  • The dentist or designee shall determine a patient’s baseline PI score at the time of the comprehensive dental examination and treatment plan encounter.  At the treating dentist’s discretion, a patient’s PI score may be re-evaluated during any subsequent encounter. 

  • For patients administered a PI score at the comprehensive dental examination and treatment plan encounter, the dentist shall document the patient’s PI score in the Electronic Dental Record System (EDRS) Perio Chart under Diagnostics in accordance with EDRS Workflow 1-4 and associated Back Office Job Aid as well as in a clinical note in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid. 

  • During subsequent dental encounters, the dentist shall document a patient’s PI score as described in Section (c)(2)(G).

  • If a dentist determines that a patient who is requesting DPC 3 treatment has a PI score of greater than 20%, the dentist shall refer the patient to the Institution Dental Health and Self-Care Educator (IDHSCE) or designated Dental Assistant (DA) to receive additional OHI.  In these situations, the provider or dental assistant shall set an in-house procedure code C1020 as complete in the patient’s EDRS Appointment Book in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid. The EDRS automatically creates a Continuing Care type of PI>20 in the EDRS Family File for patients with a PI score above 20% when the procedure code C1020 is set complete.

    • After the patient has received additional OHI and practiced the skills for 30 calendar days, they may request to have their PI score evaluated by submitting a CDCR 7362, Health Care Services Request Form.

    • If the patient’s PI score remains greater than 20% after receiving additional OHI and practicing the skills for 30 calendar days, designated dental staff shall provide further OHI to the patient who shall follow the procedure outlined in Section (c)(2)(I)1. 

    • After each session of OHI and practicing the skills, patients are expected to submit a CDCR 7362 if they wish to have their PI score re-evaluated.

  • If a patient requests to have their PI score re-evaluated, the dentist performing the paper review shall assign the CDCR 7362 a Paper Review Code (PRC) of “Other” (or “Routine”) and have the patient scheduled for a PI score re-evaluation encounter within the appropriate timeframe.  (Reference the HCDOM, Section 3.3.5.13(d)(2)(B)5. through 7.).

    • During the encounter, the dentist or designee shall perform a PI score re-evaluation.

    • Based on the results of the PI score re-evaluation, the dentist or designee shall have the patient scheduled for treatment as outlined in Section (c)(2)(A) through (E) or shall follow the procedure outlined in Section (c)(2)(I).

• IDHSCE Training Program

  • The Chief Dentist (CD), Training, Division of Health Care Services (DHCS), Adult Correctional Dental Care (ACDC), shall coordinate development of the IDHSCE Training Program, referred to in this chapter as the training program, used to train DAs as IDHSCEs.  The CD, Training, DHCS, ACDC shall review and modify the training program as needed.

    • The HPM III shall implement the training program at their institution.

    • The Supervising Dental Assistant (SDA) shall ensure that:

      • One or more DAs at their institution are trained as IDHSCEs.

      • Only DAs that have successfully passed the training program provide OHI to patients.

    • The SDA shall document the completion of the training program along with any subsequent oral hygiene instructor training provided to the IDHSCEs.

    • Documentation shall include at a minimum the following:  the name of the lesson plan used to train the IDHSCEs, the name of the trainer, the names and signatures of the IDHSCEs trained, the duration of the training, and the date of the training.

    • The SDA shall maintain this documentation, along with a copy of the lesson plan and handouts, for a period of three years.

  • The IDHSCEs shall provide OHI to the following:

    • Each patient at the time of the initial comprehensive dental examination and treatment plan formulation.

    • Patients with a PI score greater than 20% who are referred by a dentist for the purpose of improving the patient’s PI score.

    • Other patients referred by the dentist, or SD.

  • OHI for CDCR patients shall consist of, but not be limited to, an oral hygiene/dental health education demonstration presented by a dental clinical staff member.

  • Patients who do not speak or understand English, or who are hearing impaired, shall be provided OHI, where resources are available, by utilizing contract interpreting services, or staff who can translate for them.  (Reference the HCDOM, Section 3.3.5.5, Interpreter Services).

  • All instructional materials shall be communicated in alternative equally effective means as needed.

  • OHI shall include, but not be limited to, the following topics:

    • Causes of dental disease.

    • Toothbrushing techniques.

    • Dental flossing techniques.

    • Responsibility of the patient for their oral hygiene.

    • Proper nutrition for dental health.

    • Access to dental care.

    • Dental clinic hours of operation.

    • Eligibility for care.

    • Dental Priority Classification system.

    • Types of dental care provided.

    • The effects of certain systemic illnesses on dental health.

    • Oral hygiene aids.

    • Preventive dentistry education.

    • The role of fluoride in dental health.

    • Specialized OHI for developmentally disabled patients.

    • Need for periodic comprehensive dental examinations.

    • The effects of pregnancy on dental health. (Women’s Institutions).

  • The dental clinical staff member providing the OHI shall document the completion of OHI in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.  Documentation must include the date of instruction, type of instruction given, and name of the dental clinical staff member providing the instruction.