Attire
- Scrubs or business attire is required when you are on the clinic floor.
- Long hair must be pulled back and facial hair well-kept
- No open toe shoes, bare legs, tank-tops, jeans, or exposed mid-sections Patient Flow
When a patient calls HSDM for dental care they are given an appointment in Oral Diagnosis (OD) for a screening exam. When the patient arrives at OD, a brief exam is conducted and radiographs are taken. Based on this information, the patient is then referred to either the pre-doctoral, post-doctoral, or faculty clinics. If the patient is assigned to the pre-doctoral clinic, the front desk gives the patient a 2nd appointment on a new patient intake (NPI) day with a randomly assigned 3rd year student.
3rd year students can obtain new patients in the following ways:
- NPI – During third year, each student has an NPI day about once a month.
- Transfers from big sibs/ 4th year students/post-docs – transfers are more common at the beginning and end of 3rd year as the class above you either goes on externship or graduates.
- Senior Tutor – If you are short on a particular type of procedure (eg crowns, scaling and root planning, etc.), your senior tutor may give you a patient with that particular need.
Treatment Planning and Treatment Plans
After seeing a new patient for an initial exam, you take the information gathered during that exam and draw up a proposed treatment plan for that patient. At the beginning of 3rd year this can be overwhelming, but do your best to write it out. You then take your tentative treatment plan along with the chart, study models, and
photographs to your senior tutor. He/she will go over the proposed plan and help you fix any errors. Once the treatment plans are written properly, the senior tutor will swipe approval. If the patient is covered by
MassHealth, have the approved and signed treatment plan submitted by a PSL any necessary prior approvals.
Once you have the finances approved, you are ready to schedule your patient to discuss the treatment plans.
Once the patient has decided on a course of action the patient must sign and accept the treatment plan. You are now ready to begin treatment.
ADA codes
The ADA has created an official list of dental codes called the CDT to describe the various procedures performed in a dental practice. They did this to make communication between dental offices and insurance companies more universal. Our clinic also uses the CDT and the Harvard Dental Fee Schedule is based on these codes, with a few modifications. When treatment planning, you can use the search function to find these procedures in axium, and they can also be used to give your patients an idea of what certain treatments will cost. Below are the most commonly used codes during third year.
Discipline Procedure Code
Procedure Description Fee ($)
Diagnostic D0120 Periodic oral evaluation (recall) 24
Diagnostic D0150 Comprehensive oral evaluation (initial exam) 56
Diagnostic D0210 Intraoral-complete series (FMX) 80
Diagnostic D0220 Intraoral-periapical 1st film 19
Diagnostic D0270 Bitewing-single film 19
Diagnostic D0274 Bitewing-4 films 68
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Diagnostic D0330 Panoramic film 105
Preventive D1110 Prophy-adult 49
Preventive D1120 Prophy-child 40
Preventive D1203 Fluoride-child 24
Preventive D1204 Fluoride-adult 22
Preventive D1351 Sealant per tooth 22
Restorative D2140 Amalgam 1 surface 47
Restorative D2150 Amalgam 2 surfaces 60
Restorative D2160 Amalgam 3 surfaces 82
Restorative D2161 Amalgam 4 or more surfaces 91
Restorative D2330 Resin-based composite 1 surf anterior 45 Restorative D2331 Resin-based composite 2 surf anterior 62 Restorative D2332 Resin-based composite 3 surf anterior 75 Restorative D2335 Resin-based composite 4+ surf anterior 92 Restorative D2391 Resin-based composite 1 surf posterior 50 Restorative D2392 Resin-based composite 2 surf posterior 76 Restorative D2393 Resin-based composite 3 surf posterior 87 Restorative D2394 Resin-based composite 4+ surf posterior 93
Restorative D2750 Crown-PFM high noble metal 529
Restorative D2790 Crown-Full cast high noble metal 575
Restorative D2930 Prefab SS crown-primary tooth 76
Restorative D2950 Core buildup 74
Restorative D2952 Cast post and core 102
Restorative D2954 Prefab post and core 96
Endo D3310 Endo therapy (root canal)- anterior 221
Endo D3320 Endo therapy (root canal)- bicuspid 240
Endo D3330 Endo therapy (root canal)- molar 280-pre-doc price
Endo D3330 Endo therapy (root canal)- molar 600-post-doc price
Perio D4210 Gingivectomy/plasty- 4 or more 258
Perio D4211 Gingivectomy/plasty- 1-3 teeth 56
Perio D4249 Crown lengthening 176
Perio D4260 Osseous surgery-4 or more/quadrant 211
Perio D4261 Osseous surgery-1-3 teeth/quadrant 160
Perio D4271 Free gingival graft 211
Perio D4274 Distal or proximal wedge 112
Perio D4341 Scaling/root planing 4 or more/quadrant 49
Perio D4342 Scaling/root planing 1-3 teeth/quadrant 24
Perio D4910 Periodontal maintenance 49
RemovProsth D5110 Complete denture-maxillary 386
RemovProsth D5120 Complete denture-mandibular 386
RemovProsth D5130 Immediate denture- maxillary 552
RemovProsth D5140 Immediate denture-mandibular 552
RemovProsth D5213 Maxillary partial denture- cast metal frame 494 RemovProsth D5214 Mandibular partial denture- cast metal frame 494
RemovProsth D5410 Adjust complete denture- max 22
RemovProsth D5411 Adjust complete denture- mand 22
RemovProsth D5421 Adjust partial denture- max 19
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RemovProsth D5422 Adjust partial denture- mand 19
RemovProsth D5820 Interim partial denture-max 150
RemovProsth D5821 Interim partial denture- mand 150
FixedProsth D6010 Implant 942
FixedProsth D6056 Implant prefabricated abutment 240
FixedProsth D6059 Implant abutment PFM crown 457
FixedProsth D6750 Bridge-crown 529
FixedProsth D6240 Bridge-pontic 529
FixedProsth D6801 Bridge drawing bar 0
OralSurgery D7140 Extraction of erupted teeth 44
OralSurgery D7210 Surgical removal of erupted tooth 80
D9940 Occlusal guard 163
D9972 External bleaching per arch 130
D9972A Bleaching refill kit 62
D9999 Unspecified adjunctive procedure 0
Charts / Charting
Document every encounter with patients. If you call a patient, write it in the chart. If you see a patient, write the progress notes in the chart. If you are scheduled to see a patient, and he/she fails to show, write it in the chart.
Sample treatment notes:
Comprehensive exam (initial)
Comprehensive oral exam, study models
CC: Need a lot of work and dentures, probably have cavities, don't want more infections.
HPI: Pt had cleaning and dental exam 2 years ago at BU teaching practice. Recently had abscess and infection relating to impacted #17 and #25 and had those teeth extracted 1/10 at BIDMC by Dr. Flynn.
PMH: Pt has hx of hyponatremia, HTN, mild Diabetes-II, GERD, scoliosis, hypercholesterolemia.
Allergies: NKDA
Meds: atenolol, omeprazole, norvasc, simvastatin, and hx 3 once yearly IV infusions of Zometa.
SH: Lives with daughter in coolidge corner, works part time at CVS, has no dental insurance FH: Hx breast cancer and diabetes.
PDH: Pt brushes 1-2x/day with manual toothbrush and infrequently flosses. Has hx of posterior teeth extractions in Mexico and #26 came out when chewing candy last year. Recommended twice daily brushing and flossing. Pt used to wear U/L partial dentures, but has not worn since January extractions. Pt states her mouth is dry.
Exam: Extra-oral shows basal cell carcinoma removal scars and L sided TMJ click at maximal opening. Intra-oral soft tissue findings include hyperplastic retromolar pad. Hard tissue findings include multiple missing teeth, #12 carious crown loss and residual root tip. Multiple cervical carious lesions and severe xerostomia noted.
Radiographic exam reveals impacted #32 and multiple recurrent carious lesions around existing restorations.
34 Perio exam shows generalized mild-moderate plaque accumulation and gingivitis, generalized recession, class II mobility on #24.
Tx plan: extract #12 and #32, caries control, U/L RPDs NV: adult prophylaxis and review and accept tx plan Operative
Pt arrived on time.
RMH, no changes.
Tx: #15 DO composite, primary caries in the distal groove
Anesthesia achieved by PSA and palatal block with 2x1.7ml 2% lidocaine with 1:100k epi.
Isolation achieved by rubber dam and 12A clamp.
Prepped DO prep in #15 to remove caries, checked with caries indicator. Placed tofflemire matrix and wedge. Vitrebond placed, etched, OptiBond solo, filled Vit-L-Essense hybrid shade A2, adjusted occlusion, polished using PrismaGloss. Occlusion, margins, contact checked.
Procedure supervised by Drs. Kapos and Chang.
NV: 6 mo recall.
Surgical treatment note
Pt arrived on time. Consent signed.
Anesthesia achieved by 5x 1.7mL 3% polocaine by left PSA, MSA, and ASA, right MSA and ASA, and bilateral GP and NP blocks. During procedure anesthesia wore off, 2x1.7 0.5%
bupivacaine w/ 1:200k epi admin by infiltrate.
Nitrous given at 35-65% throughout.
Flap raised from #11-14. All maxillary teeth extracted: #6-14. #13 required surgical extraction.
Continuous sutures placed bilaterally with 3-O plain gut. Hemostasis achieved.
Alveoloplasty performed, bilateral canine areas and left posterior.
BP: Initial- 143/86, 68 pulse, 97% O2 Highest- 249/135, 75 pulse, 99% O2 Final- 177/108, 64 pulse, 99% O2
Rx given: 5/500 Vicodin, disp 20, sig 1-2 tablets PO q4-6h PRN pain, max 8 tablets/day.
Post-op instructions provided.
Patient Management
As your patient base grows, it is important to carefully track which of your patients have particular needs and to communicate that information to the senior tutor‘s office.
Once you begin seeing patients, you may soon realize that the patient population at HSDM is not always the easiest with which to work. Patients have scheduling issues, financial constraints, and diverse personalities.
Here is a list of tips to help you manage your patients:
- Ask/note the best days/times for the patient to come in and if they are able to come on short notice - Call patients 1-2 days before scheduled appointments. axiUm automatically calls each patient, but it‘s
good to confirm yourself.
- Call patients the night after a big procedure (eg endo, perio surgery, oral surgery) - Schedule subsequent appointments before patients leave
- When you start a removable case, schedule all appointments necessary for that case when the case starts. If you choose not to do this, make sure that the patient is aware of the approximate number of appointments required to complete the case (overestimate).
35 - Stay on top of your patient‘s financial issues. HSDM accepts Mass Health, Delta Dental Premier, and
BlueCross BlueShield Dental Blue. Each plan is different and Mass Health requires approval of the treatment plan prior to treatment. Talk to your PSL if you have questions.
Sterile Technique in the Operatory:
Considering that many procedures at HSDM are done without an assistant, the suggestion is to use the tray and table for placement of dirty instruments and materials, and to use the shelves/counters for storage of clean instruments/materials. If you need something from the clean area, remove your gloves and drop the selected instrument/materials on the tray or table. Then re-glove and continue with your procedure. If you have an assistant, they can get you the needed supplies and place them on your tray, eliminating the need to change gloves. Note: the sterile technique for perio and oral surgery is much more rigorous; see these specific sections for more information. The teaching clinic does not operate under, ―sterile,‖ techniques, but the above methods are OSHA approved and consistent with standard of care.
Emergency Management:
HSDM Protocol for Patient Emergencies:
- Stay with your patient and tell someone to go to the front desk and make an announcement calling for Dr. Harvard to report to the appropriate bay (signals to the faculty that there is an emergency) - Have someone grab the oxygen and crash cart - located in sterilization
Blood Bourne Pathogen Exposure
- You must begin treatment within 1 hr. of exposure.
- Report incident to the Clinic Floor Manager (Pam Simmons) IMMEDIATELY.
- The Office of Clinical Affairs will arrange for you to be seen at UHS at Vanderbilt Hall.
- If there is no one in the Office of Clinical Affairs, call UHS-Vanderbilt Hall (432-1370) to be seen IMMEDIATELY.
- If there is no one at UHS- Vanderbilt Hall, go to the 24-hr. Clinic (495-5711) at UHS-Holyoke Center in Cambridge IMMEDIATELY or to BWH.
- Regardless of where you are sent to be treated, the patient should be questioned about their medical history. The Office of Clinical Affairs/ Pam Simmons usually asks the patient if they would be willing to be tested at UHS as well.
- If your eyes are exposed to spray or blood, there are eye-wash stations located between chairs 3 & 4 of each bay and there is a shower to wash your eyes near the sterilization counter.
36 Common Medical Emergencies
All of the following necessitate that a ―Dr. Harvard‖ call be made, and the faculty member in charge will decide if the patient‘s condition warrants advanced emergency care and if 911 should be called. Oxygen tank is located in sterilization.
Symptoms Management
Syncope (90% of all emergencies)
pallor, nausea, diaphoresis, dizziness, faint feeling, loss of consciousness
- Trendelenburg position
- Ensure patent airway (head tilt-chin lift) - Give oxygen or ammonia (smelling salts) - Monitor vital signs
- Postpone further dental care. Patient must leave w/ escort
Hyperventilation (9% of all
emergencies)
tachypnea, prolonged may lead to syncope; ‗tight‘ chest pain, stomach ache, leg cramp, arm numbness
- Calm patient and seat upright
- Apply rebreathing (plastic head-rest cover or ambu bag with O2 but no ventilation) - Monitor vital signs.
Anaphylactic Shock
hives, rash, pruritus, erythema, angioedema, tongue swells, dyspnea, wheezing
- Identify allergen and discontinue - Mild: give Benadryl
- Severe: give EpiPen (1:1000,0.3-0.5 cc IM) - Maintain airway and give oxygen.
- Monitor vital signs Asthma gagging, dyspnea, wheezing,
stridor, cyanosis, unresponsive
- Calm patient
- 2-3 puffs of Albuterol and monitor vitals Aspiration gagging, dyspnea, wheezing,
stridor, cyanosis, unresponsive
- If good air exchange, encourage patient to breathe and cough.
- If poor air exchange, do Heimlich
maneuver and/or CPR, and monitor vitals - Take patient to Hospital to x-ray/ surgery MI SOB, angina, anxiety, diaphoresis,
hypotension
- Position patient upright.
- Give Nitroglycerin and monitor vitals.
- If pain persists: assume MI. Give oxygen and/or do CPR until EMS arrives
- If Arrhythmia - use Defibrillator (3x) and continue CPR until EMS arrives
Hypoglycemia combative, dizziness, weakness, confusion, intense hunger, sudden collapse, unresponsive, diaphoretic
- If conscious: give PO sugar
- If unconscious: start IV with dextrose 50%
- Maintain airway and give O2 - Monitor vital signs.
Seizure sudden collapse, unresponsive, diaphoretic, eyes roll back under lids, seizure, patient may vomit, twitch
- Protect patient: move instruments, try to control patient head
- Maintain airway and give O2.
- Many need to start IV, give valium 1mg/min until seizure stops
Local Anesthesia Overdose
biphasic response: drowsy, visual disturbances, circum-oral
numbness, increased talkativeness, apprehension, slurred speech, muscular twitching, convulsions, seizure, loss of consciousness
- Position patient supine.
- Maintain airway and give 02
- Monitor vital signs and wait for EMS - Discontinue treatment for this appointment.
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