Minnesota Department of Corrections

 

Division Directive:                 500.056                       Title: Juvenile Dental Services

Issue Date:                             11/5/13

Effective Date:                      11/19/13

 

Authority:           Minn. Stat. §241.01, subd. 3a

 

Purpose:    To establish procedures for delivery of dental services to juvenile residents.

 

Applicability:    Minnesota Department of Corrections (DOC); all juvenile facility dental clinics

 

Directive: A Minnesota-licensed dentist provides and/or directs responsive, clinically appropriate emergency, and urgent dental care to juvenile residents.  Access is accomplished via examination, referral, kite, or sick call.  Security, severity, time of day, staffing, and resident cooperation and consent are taken into consideration.  Routine dental care is provided as availability permits.  To the fullest extent possible in the correctional facility environment, the following apply:

A.        Dental screening on admission must be completed in accordance with Division Directive 202.040, “Offender Intake Screening and Processing” and Division Directive 500.050, “Health Screenings and Full Health Appraisals.”

 

B.        A department dentist completes a receiving facility examination (RFE) within 60 days of admission.

 

C.        The attending dentist prioritizes treatment based on six levels of dental care.

1.         Emergency dental care – level one: all juvenile residents have access to emergency care at any time through staff referral and proper use of kites and/or sick call.

 

2.         Urgent dental care – level two: urgent care needs are prioritized for treatment contingent upon a department dentist’s authorization and appointment availability.  Level two care is available to all juvenile residents regardless of time served.

 

3.         Routine dental care - restorative – level three: provided as availability permits.  Juvenile residents are eligible for level three dental care treatment based upon their admission date.  Eligibility for routine restorative dental care is available regardless of length of sentence and prioritized by date of admission.

 

4.         Routine dental care - prosthetics – level four: provided as availability permits.  Dental prosthetics are classified as routine treatment to be considered only after the resident's routine restorative treatment is completed and the resident meets the outlined criteria.  The attending dentist classifies the treatment as necessary or elective, as outlined in this directive.  Criteria used before starting prosthetic treatment are:

a)         Pre-existing medical conditions must be conducive to a successful prosthetic replacement outcome.

 

b)         Pertinent medical conditions identified by the medical staff are considered when implementing this directive.

 

c)         Prosthetics must not normally be provided for esthetic considerations.

d)         Available treatment alternatives are considered.

 

e)         Patient needs and provider expectations must be ascertained before initiating prosthetic treatment.  This is a professional decision made by the department dentist only and is based on both objective and subjective criteria including resident:

(1)       Systemic health is stable;

(2)       Understands treatment limitations;

(3)       Consents to the prosthetic treatment plan;

(4)       Is cooperative with realistic expectations;

(5)       Exhibits the strong desire, physical capacity, and mental capacity to commence and complete the learning process necessary to become proficient in using a prosthetic device;

(6)       Has documented stable and improving periodontal status;

(7)       Has excellent oral hygiene;

(8)       Restorative treatment is complete;

(9)       Is edentulous or resident’s remaining teeth do not provide minimally adequate chewing capacity - defined as the ability to soften and swallow the normal diet of food provided by DOC food services; and

(10)     Remaining teeth should be capable of being retained long-term.  Non-viable and questionable teeth should be removed.

 

5.         Elective dental care – open to review – level five: routine procedures that are of limited therapeutic value.  Level five treatments are not considered under normal circumstances.

a)         These procedures are not normally considered in the corrections setting, but lend themselves to consideration in unusual circumstances.

 

b)         The decision to authorize or deny includes the following considerations:

(1)       The urgency of the procedure and the length of the resident’s remaining sentenced stay.  Whether the surgery/procedure could be or could not be reasonably delayed without causing a significant progression, complication, or deterioration of the condition and would not otherwise be in clear violation of sound dental principles.

 

(2)       The necessity of the procedure/therapy:

(a)       Any relevant functional disability and the degree of functional improvement to be gained;

(b)       Medical necessity-the overall morbidity of the condition if left untreated;

(c)       Pre-existing conditions, whether the condition existed prior to the resident’s incarceration and, where prior treatment was not obtained, the reasons for not obtaining treatment should be ascertained;

(d)       The probability the procedure/therapy will have a successful outcome along with relevant risks;

(e)       Alternative therapy/procedures that may be appropriate;

(f)        Resident’s desire for the procedure and the likelihood of the resident’s cooperation in the treatment efforts, including post-incarceration care;

(g)       Risk/benefits, if known;

(h)       Cost/benefits if known; and

(i)        Pain complaints/pain behaviors.

 

6.         Elective dental care – not open to review - level six: routine procedures cosmetic in nature or of extremely limited therapeutic value and not authorized during incarceration.

 

Residents may obtain services for this level of care from an outside provider at the residents’ own expense in accordance with Division Directive 500.135, “Offender Requested Private Health Care.”  Department dentists are not obligated to carry out any recommendations or treatment plans formulated by these outside practitioners if ongoing care is required.

 

D.        The attending dentist establishes the level of care for dental problems.  Emergency care is always the first priority.

 

E.         Nursing assessment and/or standing orders are used to handle dental problems at times when the dental staff is not available.

 

F.         The attending dentist makes referrals to or consults with specialists in the community when necessary.

 

G.        Division Directive 500.135, “Offender Requested Private Health Care” applies to dental care.

 

H.        The attending dentist provides or directs urgent periodontal dental treatment when indicated.

 

I.          Dentists provide a dental treatment plan before beginning routine treatment.

 

Definitions:

Elective dental care - open to review - level five - routine dental procedures for conditions when treatment may improve the quality of life for the resident, but with minimal results.  These procedures are not normally considered in the corrections setting, but lend themselves to consideration in unusual circumstances.  Includes such examples as: endodontic procedures (where there are adjacent or multiple missing teeth or, in the opinion of the attending dentist, the prognosis is poor), periodontal surgery, and periodontal splinting.

 

Elective dental care - not open to review - level six - routine dental restorative and/or prosthetic procedures that are valuable to certain individuals, but significantly less likely to be cost effective or to produce substantial long-term gain.  These procedures are not considered during incarceration. Includes such examples as: TMJ surgery, orthodontic procedures, tooth bleaching, inlays, implants, cast crowns, fixed bridgework, cosmetic surgery, cosmetic partial dentures and partial dentures replacing posterior teeth (when chewing capacity is adequate).

 

Emergency dental care - level one - dental care that is essential and timely to treat uncontrolled pain, swelling, uncontrollable bleeding, and serious dental/oral injuries, without which rapid deterioration may be an expected, and in some cases potentially fatal, outcome.  Includes such examples as: treatment of acute cellulites, osteomyelitis, acute pulpitis, acute abscess, fractured maxilla/mandible (referral), Ellis Class IV tooth fracture and traumatic tooth avulsion.

 

Receiving facility - facility that admits a resident from an intake facility or a sending facility.

 

Receiving facility examination (RFE) - consists of charting of existing teeth restorations, exam including diagnosis or two bitewings and x-rays, debridement with cavitron and instrumentations.  Oral hygiene instructions brush and floss, full mouth probe on patients at least 18 years of age for periodontal diagnosis, consultation that resident understands diagnosis and treatment plan, a review of the juvenile resident’s dental and medical history, and a verbal or written hygiene instruction and directions for access to care.

 

Routine dental care - prosthetics - level four - acrylic and/or metal oral appliances made by a dental laboratory under a DOC dentist's direction.  These custom-made appliances serve to replace missing teeth used for chewing.  Prosthetic treatment includes: full dentures, removable partial dentures, replacement and repair of dentures, and TMJ appliances.

 

Routine dental care restorative - level three - non-emergent dental procedures and therapies that improve and maintain dental health or cause a return to a previous state of oral health.  Includes such examples as: teeth cleaning, fillings, endodontic treatment, root plane and scaling, crown buildups, prefabricated crowns, simple TMJ splints, and extractions.

 

Returnees - resident returning from extended furlough or recommitment for a technical violation.

 

Urgent dental care - level two - non-emergent dental care without which the resident’s oral condition will almost certainly deteriorate to an emergency situation before the resident is eligible for routine care and before the resident is released.  Includes such examples as: to sedative fillings, acute periodontal treatment, oral pathology consults, excision of tumor, endodontic treatment of a symptomatic tooth, pericoronitis treatment, recementation of crowns, abscessed tooth or root extraction and extraction of symptomatic wisdom teeth.

 

Procedures:

A.        Dental intake screening - a nurse practitioner, registered nurse, licensed practical nurse, or other health screening staff completes a dental screening within 24 hours of the juvenile resident’s arrival to the facility.

 

B.        Dental examination

1.         Intakes - a Minnesota-licensed dentist completes a RFE on each juvenile within 60 days of admission, unless the resident declines.

 

2.         Returnees - a dentist or dental auxiliary reviews a returning juvenile resident’s dental chart upon return from extended furlough or recommitment for technical violation and schedules an examination if the juvenile resident has not had an examination in the past year.

 

C.        Nursing protocol and dental standing orders - nursing dental assessments are available to treat dental emergencies at times when the dental staff is not available.  Twenty-four hour emergency medical and dental care is available through an on-call physician and local hospital emergency care.  After treatment by nursing dental standing orders, the juvenile resident needs to be referred to the next available dental clinic.

 

D.        Necessary outside dental consultations/treatment - essential dental consultations or eligible dental treatments that cannot be performed in a department facility are considered for referral to a specialist in the community.  Certain criteria prior to referral are considered: urgency of need versus length of sentence remaining, overall necessity and functional disability, pre-existing condition prior to incarceration, risk/benefit, cost/benefit, and alternatives.

 

E.         Elective outside dental treatment - juvenile residents may obtain optional dental treatment not available in department dental facilities by seeking treatment from practitioners in the community.  Juvenile residents must follow procedures outlined in Division Directive 500.135, “Offender Requested Private Health Care.”

 

INTERNAL CONTROLS:

A.        All juvenile dental services are documented in a dental record that is maintained with the medical record upon release.

 

Review:       Annually

 

References:         Policy 500.010, “Health Services”

Division Directive 202.040, “Offender Intake Screening and Processing”

Division Directive 500.135, “Offender Requested Private Health Care”

Division Directive 500.040, “Nursing Protocol Manual”

 

Supersession:     Division Directive 500.056, "Juvenile Dental Services," 7/3/12.

All facility policies, memos and other communications, whether verbal, written or transmitted by electronic means regarding this topic.

 

Attachments:    None

 

/s/

Deputy Commissioner, Facility Services