1. Dental Readiness Inspection Pamela Alston, DDS, MPP Lead Oral Health Specialist Kevin T. Avery, DMD, MPH Oral Health Specialist

2. Webinar Objectives After this presentation, participants will be able to: –Describe the clinical technique for conducting the Dental Readiness Inspection. –Identify the signs and symptoms that should be documented in the student health record. –Share with students the results of the Dental Readiness Inspection in a motivating way.

3. Questions Why? What? Who? Where? When? How?

4. Why perform the dental readiness inspection?

5. PRH-Chapter 6 PRH-6.10(R2): A dental readiness inspection shall be completed within 14 days after arrival by the center dentist or designee as determined by the center dentist who authorizes the activity by a written personal authorization. The dental readiness inspection shall be documented in the appropriate section of the Job Corps Physical Examination Form. [revised April 18, 2013] responsibility timeframe Documentation requirements

6. Why? To identify urgent care needs To lower the broken appointment rate by letting students opt in or out of becoming a Job Corps “patient of record” To assist students in making an informed decision about becoming a “patient of record” To implement standards for oral inspections

7. “Before I forget, Derrick, here’s the dental plan.” I wish I had been ready to receive dental care when I was in Job Corps! From The New Yorker Magazine

8. What is the dental readiness inspection?

9. Clinical Oral Evaluations vs. Pre-Diagnostic Services “designated by the federal government as the national terminology for reporting dental services…”

10. Dental Procedure Definitions D0190 Screening: A screening, including state or federally mandated screenings, to determine an individual’s need to be seen by a dentist for diagnosis D0191 Assessment: A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment D0120-D0180 Evaluations Reference: CDT 2013 Dental Procedure Codes, Page 7,© 2012 American Dental Association

11. Who is responsible for performing the dental readiness inspection?

12. Sample Scope of Work Center Dentist

13. Sample Personal Authorization “Under authorization, [insert center nurse/dental hygienist/dental assistant name] may perform the dental readiness inspection.” [Center Dentist Signature] [Date]

14. Where is the dental readiness inspection performed?

15. When shall the dental readiness inspection be completed?

16. How is the dental readiness inspection performed?

17. Dental Readiness Inspection Armamentarium Personal Protective Equipment [PRH- 6.12, R13(d)] Light source Tongue depressor or mouth mirror Student health record [PRH-6.10, R2(b)]

18. Clinical Technique Retract the lip Look in the wide open mouth

19. JC Physical Exam Form, Section 15

20. Gaping Hole in Tooth UL LL LR UR Gaping hole in tooth

21. Severe Reported Pain

22. Severe Swelling in Mouth or Jaw

23. Bleeding in Mouth GingivaExtraction site

24. Painful Sore That Interferes With Eating

25. Decayed Tooth Gaping hole in tooth LR

26. Other Sores on both corners of lip Braces Sore on lip UR Sores all over tongue

27. Review the Oral Health Section of the Job Corps Health History Form From JC Health History form

28. No Obvious Serious Oral Health Problems

29. JC Physical Exam Form, Section 15 Findings Lack of findings Date Signature

30. Findings ≠ Diagnosis

31. What is next?

32. Immediate treatment Healthcare Guide- lines, PRH-6.12, R9 Emergency Care, PRH-6.10, R2(e)

33. Oral Examination Elective oral examination upon student request including x-rays to precede dental treatment [PRH-6, Exhibit 6-4, B.1.].

34. Laying Out the Options

35. Educate the Student

36. Use your resources!

37. Chronic Caries Disease

38. Recurrent Decay

39. “Please let me through, gentlemen. I’m a dental hygienist.” From The New Yorker

40. Bleeding in Mouth

41. Chronic Periodontal Disease

42. “I’ve always hated hospitals, dentists’ offices, and jails.” From The New Yorker But this is Job Corps. The dental folks don’t hurt and they are nice.

43. Gauge if the Student is Ready to be a Dental Patient

44. Criticism is Ineffective

45. Criticism Leads to Disgust Nonverbal expressions of disgust

46. Criticism Leads to Anger Nonverbal expressions of anger: b,d,e

47. What Does Work? Taking a motivational approach Discussing how oral health and oral health care fits with the student’s goals Explaining what the student can expect realistically

48. Motivational statement Difference Between DRI & OE Value of oral health services Conscious decision Procedure to make apt/ Receive basic oral care Can reverse refusal Signatures

49. “ You’re right, Jack, that does look like a cavity. Now on to other business…” from The New Yorker Did you educate him on how cavities can get worse and… Too bad he refused an oral exam to diagnose it. Yes, I did my best to educate and motivate him. …impact performance at JC or in the workplace? Well, we will be here for him if he changes his mind. He might qualify for basic oral care under our priority system.

50. Oral Exam Consent/Refusal for Minors Q. For minors, will we need to mail the refusal home for parents to sign? A. There is no PRH guidance for obtaining the parental/guardian refusal. The center can consult state law. It may be possible to obtain a telephone refusal with a witness. Be sure to document on the consent/refusal form.

51. Timeframe for Oral Exam Q. If the student requests an oral exam, can it be done immediately if you have the time to do it? A. The PRH does not specify a timeframe. The decision is left up to the center.

52. Refusing Students Q. Is the center dentist able to refuse to treat students who previously declined an oral exam? A. Students may reverse their previous decision to refuse an oral exam. Document the consent in the SHR. Follow your scheduling procedure.

53. Handling Walk-Ins Q. How should the Health and Wellness Center staff respond if a student presents with an oral health issue when the Center Dentist is not on center? A. Follow your SOP dealing with students who request a visit outside of open hours when the center dentist is not on center. Depending upon a nurse's assessment, healthcare guidelines may be followed and/or the student may receive a dental appointment with a timeframe commensurate with the urgency of need.

54. Legality of the Dental Assistant Performing the Dental Readiness Inspection Q. Where does the liability stop for the dentists? What if the Dental Assistant performs the dental readiness inspection and misses an interproximal lesion and the student has issues with an abscess? A. The inspector is not performing an assessment or evaluation. The Dental Assistant is performing the equivalent of a screening. The Center Dentist can check with the state dental board to ascertain the legality of a Dental Assistant performing the dental readiness inspection. Otherwise, the Center Dentist can make a different arrangement.

55. Minor Consent to Oral Examination Q. If the student is a minor, does the parent/guardian have to fill out a request for the exam? A. Parents sign a consent statement for the oral exam on the ETA 6-53 Job Corps Health Questionnaire. It suffices as a consent. When the student signs the consent, they are acknowledging their assent. Centers may want to contact parents/guardians of minors who refuse the oral exam and basic oral care.

56. Commendable Practice New Haven JCC Tips for a Healthy Mouth Oral Health kit --Martha Kurilec, DMD, Center Dentist

57. Commendable Practice A JCC Health and Wellness Center implemented a student pay grid with fake money to use to pay for Health and Wellness services. Students are educated on the importance of health insurance and the importance of making responsible and savvy decisions as it relates to health and wellness care.

58. Commendable Practice At Phoenix JCC Students with dental conditions who refuse the oral exam after seeing the RDH for the dental readiness inspection are counseled by the Center Dentist. They receive the oral exam right after counseling if they consent. Otherwise, they sign the refusal. Parents/guardians of minors notified by phone and the call is documented. Students who receive oral health in the community are assisted as needed with scheduling appointments.

59. Legality of Dental Assistant Performing the Dental Readiness Inspection Comment: I can see that my malpractice carrier may not like the current protocol because…having someone other than the dentist diagnose decay with the standard of care being breached, the lawyers are going to love this one. Response: There is an established Job Corps community standard for performing the inspection, documenting and communicating results. The Center Dentist is responsible for performing it or delegating it to a staff person who can legally and skillfully perform an inspection with a personal authorization.

60. Desire to Understand & Accomplish the Dental Readiness Inspection Comment: I was in the United States Air Force…I have never heard of this inspection. I know of the Type 1 Dental Readiness Exam (full x-ray series or panorex x-ray) or Type II exams for all. Be sure and explain what a dental readiness inspection is and how it is accomplished. Response: I hope that as a result of today’s webinar you know what a dental readiness inspection is and how it is accomplished.

61. Getting Education and Training to Become Employed “No Longer a Pipe Dream”

62. “Of course, with the position that has the benefits—medical, dental, et cetera— there is no salary.” From The New Yorker Thanks to Job Corps, I know the benefits are worth a lot!

63. There will be times particularly in the early stages of change when courageous acts, informed and skilled, will be absolutely essential to change health care as we know it.—Ed O’Neil, Influencing Change (2-01-11)