Public Health Dental Hygienist (PHDH) Toolkit
Procedures, Equipment, and Supplies
Office of Oral Health
Massachusetts Department of Public Health

Differences Between Private Practice vs. Public Health Dental Hygiene Care

This is a table describing the differences between private practice and public health dental hygiene care.  

Risk Management for Dental Public Health Programs: Things to Consider

•	Higher degree of responsibility in a public program
•	Patient Abandonment- ensure adequate referral and tracking system
•	Record Keeping, Privacy, HIPAA
•	OSHA/Infection Control
•	Liability/Malpractice Insurance
•	Comply with Evidence-based Guidelines for community /school-based programs
•	Special Permitting for Mobile Dental Facilities or Portable Dental Operation (effective February 16, 2011)

Documentation

•	A PDHD must have documentation of the following:
•	Compliance with educational requirements for PHDH practice 
•	A written collaborative agreement with a licensed dentist 
   (234 CMR 5.08(3))
•	Signed, informed consent of the patient or legal guardian
•	Patient’s written ‘Information Sheet’ (234 CMR 5.08(1)(F))
•	Data for required reporting to the Massachusetts Department of Public Health Office of Oral Health (234 CMR 5.08(7))
•	Permit for operation of a Mobile Dental Facility (MDF) or Portable Dental Operation (PDO)  (effective February 16, 2011

Documentation- The Collaborative Agreement

•	A PDHD must enter into a collaborative agreement with a licensed dentist before rendering treatment, advertising, or soliciting patients to provide any dental hygiene services in a public health setting
•	A PDHD must maintain contact and document communication with the dentist with whom the PDHD has entered into the collaborative agreement
•	The collaborative agreement between a dentist and PHDH should explain how and on what conditions referrals to the dentist should be made; how the PHDH will follow-up with the referral; how records will be stored; etc.
•	For specific details for developing a  collaborative agreement, 234 CMR 5.08(3)

According to 234CMR 5.08(3)(f-k), The Collaborative Agreement Must :
•	Specify dental hygiene procedures to be provided and the populations to be served pursuant to the collaborative agreement;
•	Specify and describe responsibilities for creating, maintaining, storing, retrieving and providing for the confidentiality of patient records;
•	Specify and describe responsibilities for establishing systems, policies and procedures to ensure compliance with board regulations, including, but not limited to requirements of 234 CMR 5.00 and 7.00 as may be applicable; 
According to 234CMR 5.08(3)(f-k), The Collaborative Agreement Must :
•	Specify and describe responsibilities for developing, implementing, and maintaining emergency medical protocols and for the provision of periodic review and training on same; 
•	Include any considerations for age- or procedure- specific protocols as may be deemed necessary by the dentist or public health dental hygienist;
•	 Include any considerations for medically-compromised patients as may be deemed necessary by the dentist or public health dental hygienist… 
•	Go to the PHDH Documents and Resources Page for a sample collaborative agreement

Informed Consent	

•	It is imperative to obtain informed consent prior to completing any dental hygiene services. 
•	A PHDH is required to: “Obtain written, signed informed consent of the patient or legal guardian which complies with board regulations contained herein and informs the patient or legal guardian that the services provided by the public health dental hygienist are not a substitute for a dental examination by a dentist and informs the patient that the patient or legal guardian that the patient should obtain a dental examination by a dentist within 90 days…”
•	Go to the PHDH Documents and Resources Page for a sample informed consent form.

Additional Requirements 234 CMR 5.15(3)(f)(3)

A signed written consent must also include the following…
•	An explanation of the scope of services that may be rendered:
•	Notice that the patient may continue to obtain dental care through any other provider;
•	Notice that the treatment of the patient may affect the future rights and benefits due the patient under private insurance, Medicaid, or the children’s health insurance program;
•	Information on how the patient or legal representative can contact the mobile or portable dental operation or public health dental services program; and IF APPLICABLE…
•	A request for permission to allow the patient’s dental insurance carrier to be billed for treatment provided to the patient; and
•	A request for permission to provide the official designated by the school,  nursing home, residential facility or institution with a written summary of the examination.

Portable Dental Equipment

•	Portable Dental Equipment:
•	Patient chair and hygienist’s chair
•	Unit/Operatory (suction, water/air syringe, handpiece)
•	Light
•	Supply cases 
•	Curing light/battery (sealants)
•	Privacy screen
•	Transport cart
•	Sterilization Equipment

The PHDH must follow the rules and regulations for the use of mobile and portable dental equipment (234 CMR 7.00) and effective February 16, 2011, obtain a permit from the Board for the use of that equipment.

Picture- Portable dental equipment.

Portable Dental Programs- Other Requirements

•	The PHDH must maintain a log that includes the dates, locations where services were provided, and names of all individuals providing services on behalf of the PHDH.
•	The PHDH using portable dental equipment must wear a name tag that states his/her name, professional title, and function.
•	Portable Dental Programs must have:
•	Handicap access;
•	Equipment and sterilization system compliant with CDC Infection Control Guidelines;
•	Supply of portable water, and hand-washing and toilet facilities; and
•	Other equipment necessary for services being rendered.

Reporting to the Massachusetts Department of Public Health

•	The PHDH will be required to report specific measures of all patients treated to the Office of Oral Health, including:
•	 The dates of each session with name and address of the   site where public health dental hygiene services were provided; and
•	The number of patients served and the type(s) and quantity(ies) of each service provided.
•	Go to the PHDH Toolkit Main Page for the specific information on Reporting Requirements 

Patient Records: Confidentiality, Retention, and Availability

•	The PHDH must practice in accordance with 234 CMR 5.14
•	All patient records should be maintained in a manner to ensure confidentiality and access for patients and authorized practitioners who may wish to obtain a copy of patient records
•	Patient records must be maintained for a minimum of 7 years from the date of the last patient treatment.  The patient record or a minor must be retained for a minimum of 7 years or 3 years from when the patient has reached the age of majority, whichever is later.
•	In both school and nursing home or residential treatment facility settings, if treatment is rendered the PDHD must provide a written summary of services rendered/results to the facility officials

A Patient Record Contains…
•	Patient Information
•	Dental charts
•	Photographs
•	Patient histories
•	Dental hygiene examination results
•	Diagnoses (including dental hygiene diagnoses)
•	Treatment Plan 
•	Progress Notes
•	Prescriptions
•	Orthodontic Records
•	Radiographs
•	Patient consents 
•	Billing records

For detailed information on what must be included in a patient record review 234 CMR 5.15
Picture- Stack/pile of patient records/file folders

Progress Notes…
•	The patient record should include written documentation of the treatment provided by the dentist and/or dental auxillary (phdh), including, but not limited to:
•	Administration of medicines and medicaments including the type, amount, and route of administration;
•	A statement of services provided including patient reaction, if any, during the treatment visit, procedures performed and diagnoses;
•	A description of the pre- and post-treatment instructions including, if applicable, plans for subsequent treatment;
•	Documentation of any referral for specialty treatment, including the name of the specialist the patient is referred to; and
•	A dated written or electronic signature by the dentist or dental auxiliary (PHDH) who treated the patient.

Documentation- Information Sheet

•	A PDHD must provide each patient with a written Information Sheet at the conclusion of each visit. Go to the PHDH Documents and Resources Page for a sample information sheet.
•	The Information Sheet should contain the following:
•	Results of the DH examination;
•	Name(s)/signatures of the PHDH and any licensed dentist and/or other dental auxiliaries who provided any services
•	Description of the treatment rendered, including billed service codes and fees associated with treatment
•	Contact information for the PDHD, or person(s) responsible for rendering treatment
•	Referral for emergency assessment (if necessary)
•	Referral must be made to a patient’s dentist of record; however, if no dentist of record exists, the patient must be provided with sources for dental treatment

Maintaining HIPAA Compliance

•	Patients’ privacy and confidentiality must be protected in public health settings just as it must be in private practice.
•	Patient data must be kept in a locked and safe environment.
•	Go to the PHDH Documents and Resources Page for a sample HIPAA form

Picture- cartoon picture of file folders
Patient Abandonment

•	Upon permanent cessation of a mobile/portable dental operation, the PHDH (permit holder) must:
•	Within 30 days, notify the Board in writing of the last day of operations of the final date of service and the disposition of patient records.
•	Notify all permit holder’s patients who have received treatment within 2 years of the date of cessation of operations.
•	Within 30 days make arrangements with patients to have records, radiographs, etc. transferred to another practitioner.
•	A minimum of 30 days prior to cessation of operation, notify any and all entities for whom the mobile/portable dental operation is providing services or who are hosting these services.

Facilitating the Establishment of a ‘Dental Home’ 

•	The ‘Dental Home’ is a concept modeled after the American Academy of Pediatrics' ‘Medical Home.’
•	A ‘Dental Home’ should deliver oral health in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist.
•	Children and adults who have a Dental Home are more likely to receive appropriate preventive and routine oral health care (AAPD).
•	The PHDH is required to facilitate their patients who may need restorative work and/or follow-up care to a dental home

Table
There is a table describing ideal characteristics and practical advantages of a dental home. 

Dental Home is accessible.
-	Care provided in the child’s community
-	All insurance accepted and changes in coverage accommodated
-	Source of care is close to home and accessible to family
-	Minimal hassle encountered with payment
-	Office ready for treatment in emergency situations
-	Office is nonbiased in dealing with children with special health care needs, or CSHCN
-	Dentist knows community needs and resources (fluoride in water)

Dental Home is family-centered.
-	Recognition of the centeredness of the family
-	Unbiased complete information is shared on an ongoing basis
-	Low parent/child anxiety improve care
-	Care protocols are comfortable to family (behavior management)
-	Appropriate role of parents in home care is established

Dental Home is continuous
-	Same primary care providers from infancy through adolescence
-	Assistance provided with transitions (for example, to school)
-	Appropriate recall intervals are based on child’s needs
-	Continuity of care is better owing to recall system vs. episodic care
-	Coordination of complex dental treatment is possible (traumatic injury)
-	Liaison with medical providers for CSHCN is improved (congenital heart disease)

Dental Home is comprehensive
-	Health care available 24 hours per day, seven days per week
-	Preventive, primary, tertiary care provided
-	Emergency access is ensured
-	Care manager and primary care dentist are in same place

Dental Home is coordinated
-	Families linked to support, education and community services
-	Information centralized
-	Records centralized
-	School, workshop, therapy linkages established and known (cleft palate care)

Dental Home is compassionate
-	Expressed and demonstrated concern for child and family
-	Dentist-child relationship is established
-	Family relationship is established
-	Children less anxious owing to familiarity

Dental Home is culturally competent
-	Cultural background recognized, valued, respected
-	Mechanism is established for communication for ongoing care
-	Specialized resources are known and proven if needed
-	Staff may speak other languages and know dental terminology

Resources:

•	American Association for Community Dental Programs
•	National Maternal and Child Oral Health Resource Center
•	American Academy of Pediatric Dentistry Policy on the Dental Home
•	Mobile-Portable Dental Manualhttp://www.first5oralhealth.org/rural_smiles/downloads/chapter6/portable dental equipment manufacturers.pdf
•	List of Portable Dental Equipment Vendors
•	For an article on HIPAA and public health click here
[http://cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm]

What’s next?

•	The next PowerPoint presentation will review mobile and portable dental operations and certification of these operations by the Board of Registration in Dentistry.