ATTACHMENT A1 Veterans Health Administration Dental Program - VHA Directive 1130.pdf

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Department of Veterans Affairs VHA DIRECTIVE 1130 Veterans Health Administration Transmittal Sheet Washington, DC 20420 March 6, 2020

VETERANS HEALTH ADMINISTRATION DENTAL PROGRAM

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive establishes the policy for oral health care services for eligible Veterans and the responsibilities of the oral healthcare delivery personnel. It describes the essential components for implementing the Department of Veterans Affairs (VA) Dental Program nationally to ensure eligible Veterans have access to seamless dental care through VA medical facilities or community care.

2. SUMMARY OF MAJOR CHANGES: Major changes include:

a. Revising definitions in paragraph 3.

b. Adding responsibilities in paragraph 5 for the Under Secretary for Health, the Deputy Under Secretary for Health for Operations and Management, the Assistant Under Secretary for Health for Dentistry, the Deputy Dental Program Director, the Director of Dental Operations, the Director of Dental Informatics and Analytics, the Director of Dental Laboratory Operations, and the Chief, Dental Service.

c. Adding appendices for Clinical Recommendations and Guidance in Published Documents; Process for Dental Expectations of Care; Dental Laboratory Services;

Qualification Standards for Dentists, Dental Hygienists, and Dental Assistants; and Dental Care Requirements Based on Point of Service: Outpatient, Inpatient, Long-term Care, Community Care, and Virtual Care Programs.

d. Incorporating information previously found in VHA Handbook 1130.01, Veterans Health Administration Dental Program, dated February 11, 2013. VHA Handbook

1130.01 will be amended as 1130.01(1) with the publication of this directive.

3. RELATED ISSUES: VHA Handbook 1130.01(1), Veterans Health Administration Dental Program, dated February 11, 2013; VHA Directive 1065.01, Productivity and Staffing Guidance for Specialty Provider Group Practice, dated May 4, 2015; VHA Directive 1116(2), Sterile Processing Services (SPS), dated March 23, 2016; VHA Directive 1230, Outpatient Scheduling Processes and Procedures, dated July 15, 2016;

VHA Directive 1232(1) Consult Processes and Procedures, dated September 23, 2016;

VHA Directive 1400.09, Education of Physicians and Dentists, dated September 9, 2016; VHA Directive 1501, VHA Homeless Programs, dated October 21, 2016; VHA Directive 1601A.02, Eligibility Determination, dated July 27, 2017; VHA Handbook 1100.19, Credentialing and Privileging, dated October 15, 2012.

4. RESPONSIBLE OFFICE: The Assistant Under Secretary for Health for Dentistry is responsible for the content of this VHA directive. Questions may be referred to the Office of Dentistry (10NC7) at VHA10NC7Action@va.gov.

mailto:VHA10NC7Action@va.gov

March 6, 2020 VHA DIRECTIVE 1130

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5. RESCISSIONS: VHA Directive 1130, Dental Program for Department of Veterans Affairs (VA) Medical Facilities, dated October 26, 2016, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of March 2025. This VHA directive continues to serve as national VHA policy until it is recertified or rescinded.

BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Renee Oshinski Deputy Under Secretary for Health for Operations and Management

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on March 10, 2020.

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CONTENTS

VETERANS HEALTH ADMINISTRATION DENTAL PROGRAM

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. QUALITY MANAGEMENT

7. TRAINING

8. RECORDS MANAGEMENT

9. REFERENCES

APPENDIX A

CLINICAL RECOMMENDATIONS AND GUIDANCE IN PUBLISHED DOCUMENTS .A-1

APPENDIX B

PROCESS FOR DENTAL EXPECTATIONS OF CARE ...............................................B-1

APPENDIX C

DENTAL LABORATORY SERVICES .......................................................................... C-1

APPENDIX D

QUALIFICATION STANDARDS FOR DENTISTS, DENTAL HYGIENISTS, AND

DENTAL ASSISTANTS ............................................................................................... D-1

APPENDIX E

DENTAL CARE REQUIREMENTS BASED ON POINT OF SERVICE: OUTPATIENT,

INPATIENT, LONG-TERM CARE, COMMUNITY CARE AND VIRTUAL CARE

PROGRAMS ................................................................................................................E-1

VETERANS HEALTH ADMINISTRATION DENTAL PROGRAM

1. PURPOSE

This Veterans Health Administration (VHA) directive updates the Department of Veterans Affairs (VA) Dental Program. This directive informs all VA staff of the role of dentistry in VA’s mission and the responsibility to provide care for eligible Veterans that will prevent or remedy diseases, disabilities, and injuries of the teeth, jaws and related structures within the scope of applicable Federal statutes and regulations. NOTE:

Eligibility for dental care, including eligibility classifications, is addressed in VHA Handbook 1130.01(1), Veterans Health Administration Dental Program, dated February 11, 2013. AUTHORITY: Title 38 United States Code (U.S.C.) 1710(c), 1712, 1720D, 2062, 7305, 7306, and Title 38 Code of Federal Regulation (CFR) 17.160 – 17.166.

2. BACKGROUND

The goal of VA Dentistry is to provide safe, efficient, cost-effective, and evidence-based oral health care services to eligible Veterans. All VA dental providers must be knowledgeable of the dental classifications and the respective scope of care. The Office of Dentistry and individual VA dental services will integrate the functions of quality, safety, and high reliability to achieve value for Veterans; recognize current and emerging Veteran needs; align with VHA strategic guidance and resource allocation;

and consistently perform with VA Core Values of Integrity, Commitment, Advocacy, Respect, and Excellence.

3. DEFINITIONS

a. Central Dental Laboratory. An organizational entity of the Office of Dentistry under the Director of Dental Laboratory Operations that provides dental prosthetic products and services to VA medical facilities where dental care is provided.

b. Compensation and Pension Dental Exams. Oral examinations completed in compliance with the Compensation and Pension program requirements. Requests for these examinations are submitted to a dental service by the Veterans Benefits Administration (VBA).

c. Episode of Dental Care. The systematic dental treatment plan formulated by a licensed dentist and provided from initiation through completion.

d. Dental Auxiliary. Dental auxiliaries are dental staff who assist with dental treatment as assigned. They include dental assistants, dental hygienists, and dental laboratory technicians.

e. Encounter. An encounter is a professional contact between a patient and a practitioner. Encounters occur in both outpatient and inpatient settings. Professional contact can include face-to-face interactions or those accomplished through telecommunications technology. Use of email does not constitute an encounter.

Telephone contact between a practitioner and a patient is an encounter when documentation includes the appropriate elements of a face-to-face encounter, namely history and clinical decision-making.

f. Precious Metals. Precious metals are gold, platinum, or palladium, including any combination containing one of those metals. It does not include solder or other products containing precious metals of negligible value.

g. Prosthesis. Prosthesis is any device replacing one or more missing teeth and, if required, associated structures. Prosthesis is a term that includes abutment crowns and abutment inlays and onlays, bridges, dentures, obturators, and gingival prostheses.

h. Reusable Medical Equipment. Reusable medical equipment (RME) is equipment intended for repeated use on different patients with appropriate decontamination and other processing between uses.

i. TeleDentistry. TeleDentistry is the use of information technology and telecommunications to facilitate the delivery of oral health care, consultation, and education when the provider and patient are not in the same physical location.

4. POLICY

It is VHA policy to provide dental and oral health care services to eligible Veterans at VA medical facilities or by authorized VA community care providers. NOTE:

Depending upon VA medical facility requirements, there may be local standard operating procedures further defining and supporting the provision of dental services.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management is responsible for:

(1) Ensuring communication of the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Ensuring each VISN Director has sufficient resources to implement this directive in all VHA medical facilities within each VISN.

(3) Providing oversight of VISNs to assure compliance with this directive, relevant standards, and applicable regulations.

c. Assistant Under Secretary for Health for Dentistry. The Assistant Under Secretary for Health for Dentistry is responsible for policy development regarding the Dental Program and is responsible to the Under Secretary for Health for the operation of dental service. The Assistant Under Secretary for Health for Dentistry is responsible for:

(1) Providing overall operational oversight of VA Dental Programs and the Directorates in the Office of Dentistry.

(2) Appointing VISN Lead Dentists in collaboration with VISN leadership (e.g., VISN Directors and VISN Chief Medical Officers [CMOs]).

d. Deputy Dental Program Director. The Deputy Dental Program Director supports the Assistant Under Secretary for Health for Dentistry and is responsible for:

(1) Directing the development of programmatic policies and operational plans relating to field operations, personnel matters, dental practice, eligibility, dental facility design, staffing models, sharing agreements, and contracts.

(2) Providing oversight and guidance of VA dental clinic operations.

(3) Enhancing the operation and administrative functions within the Office of Dentistry.

(4) Serving as a liaison with dental program officials in other Federal agencies and appropriate national professional organizations.

e. Director of Dental Operations. Dental Operations provides direction, oversight, and guidance on processes which enable the dental services to operate efficiently and effectively to provide dental treatment for outpatients and inpatients in accordance with their statutory eligibility. The Director of Dental Operations is responsible for:

(1) Developing, implement, and provide oversight of policies for VA dental programs.

(2) Providing dental operations consultative services to VISNs, VA medical facilities, and dental services.

(3) Partnering with VHA Office of Community Care and Member Services to advise VA medical facilities on Veteran dental care eligibility.

(4) Collaborating with VHA National Program Office for Sterile Processing (SPS) in the development of joint policies for dental RME reprocessing.

f. Director of Dental Informatics and Analytics. Dental Informatics and Analytics oversees the continued development, implementation, and maintenance of VA’s enterprise Electronic Dental Record, as well as the development and application of dental-specific clinical and business decision systems designed to improve organizational performance. The Director of Dental Informatics and Analytics is responsible for:

(1) Directing the management and enhancement of the Dental Encounter System databases.

(2) Developing relevant reporting and analysis services.

g. Director of Homeless Veterans Dental Program. The Homeless Veteran Dental Program promotes access to focused dental services for qualifying Veterans who have experienced or are at-risk for homelessness. The Director of Homeless Veterans Dental Program is responsible for:

(1) Overseeing the Homeless Veterans Dental Program.

(2) Serving as a resource for issues related to the oral health and dental care delivery of Veterans experiencing homelessness.

h. Director of Dental Education Program. The Dental Education Program develops and promotes a variety of educational opportunities for all VA staff, with a focus on supporting the lifelong learning habits in dental professionals who are entrusted with delivering optimum health care to Veterans. The Director of Dental Education is responsible for:

(1) Providing VA medical facility dental staff with educational and development opportunities.

(2) Consulting on issues related to academic training programs involving dentistry in collaboration with the Office of Academic Affiliations (which has primary responsibility for oversight and funding of dental trainees [undergraduate, graduate, and auxiliary]).

See VHA Handbook 1400.04, Supervision of Associated Health Trainees, dated March 19, 2015; and VHA Handbook 1400.05, Disbursement Agreement Procedures for Physician and Dentist Residents, dated August 14, 2015.

i. Director of Oral Health Quality Group. The Oral Health Quality Group aims to improve the oral health of Veterans by promoting clinical practice based on the best evidence available, utilizing VA-based data and scientific literature. The Director of the Oral Health Quality Group is responsible for collaborating with internal and external stakeholders to identify oral health quality-related issues and promote best practices to clinicians.

j. Director of Dental Research Program. VA Dental Research is to be a reference point for dental clinicians and others interested in pursuing areas of dental research that impact the oral healthcare provided to Veterans. The Director of Dental Research Program is responsible for providing resource information and guidance to encourage research, particularly research related to oral and dental health.

k. Director of Dental Laboratory Operations. The Director of Dental Laboratory Operations is responsible for:

(1) Managing Central Dental Laboratory (CDL) operations.

(2) Ensuring the financial viability of CDL.

(3) Providing national contracts for dental laboratory services.

(4) Ensuring dental laboratory compliance with national policy.

(5) Reviewing customer feedback received from VA dental providers through the CDL Quality Feedback Electronic Form located at https://vaww.infoshare.va.gov/sites/dental/PH/CDLFeedback.aspx. NOTE: This is an internal VA Web site that is not available to the public.

l. Veterans Integrated Services Network Director. The VISN Director is responsible for:

(1) Ensuring Veterans have access to an appropriate spectrum of services to include oral health and dental services.

(2) Appointing licensed dentists as VISN Lead Dentists in consultation and collaboration with the VHA Office of Dentistry.

(3) Granting written approval to a VA medical facility Director upon request for local reimbursement payments higher than the 50th percentile rate on the schedule in the Dental Analytics System.

m. Veterans Integrated Services Network Lead Dentists. VISN Lead Dentists are responsible for:

(1) Providing leadership in dental operations at all VA medical facilities within their respective VISN, to include but not limited to:

(a) Conducting site visits at each dental service within the VISN and leading monthly Dental Service Chief conference calls to outline performance goals and strategic plans that are consistent with VA Dental Program policy, priorities, and goals.

(b) Assessing the unique oral and dental health care needs of the eligible Veteran population in the VISN and monitoring for any disparity in the provision of dental services to Veterans by identifying dental service gaps and needs through VISN-wide assessments, performance measures, or other means.

(c) Overseeing interventions aimed at targeting disparities, setting up systems for tracking progress related to recommended interventions, and proposing areas for programmatic or facility improvement.

(2) Assisting the Office of Dentistry in the oversight, development, and execution of clinical and administrative programs and functions pertaining to dentistry at this level.

(3) Assisting in the execution of national dental programs and policies.

(4) Providing support and guidance for the development and implementation of Office of Dentistry’s recommendations within their respective VISN.

https://vaww.infoshare.va.gov/sites/dental/PH/CDLFeedback.aspx

(5) Providing recommendations to the Assistant Under Secretary for Health for Dentistry and the Office of Dentistry for development of national policies and procedures.

(6) Advising the VISN Director and CMO on issues pertinent to VA Dentistry, including but not limited to:

(a) Identifying the unique oral and dental health care needs of the eligible Veterans in the VISN.

(b) Analyzing data and identifying factors that limit access and decrease Veteran satisfaction and recommending areas for programmatic or facility improvement.

(c) Reviewing facility and VISN-level dental service data dashboards that include, but are not limited to, workload, quality measures, access, and cost.

(d) Creating and collaborating on systems and strategic plans to achieve goals consistent with VA Dentistry and VISN direction.

(7) Maintaining cooperative relationships with stakeholders such as VBA Regional Offices, Veterans Service Organizations, and congressional offices.

n. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring VA medical facilities conform to the contents of this directive.

(2) Ensuring adequate staffing, training, and resources to implement effective dental programs in accordance with VA operational requirements, Centers for Disease Control and Prevention (CDC) recommendations, Joint Commission standards, and other external surveying bodies’ standards and requirements.

(3) Appointing licensed and credentialed dentists as Chief, Dental Service in each VA medical facility with supervisory authority over all dental service operations.

(4) Ensuring the Chief, Dental Service meets and maintains the requirements outlined in VA Handbook 5005, Part II, Appendices G3 and H2 and the proper credentials and current privileges at the VA medical facility.

(5) Designating a responsible official, other than a dental service employee, to audit receipts and balances of precious metal inventories at least annually.

(6) Ensuring written approval is obtained from the VISN Director for local reimbursement payments higher than the 50th percentile rate on the schedule in the Dental Analytics System.

o. Chief, Dental Service. The Chief, Dental Service is the primary subject matter expert to VA facility leadership on all oral health care matters. The Chief, Dental

Service is responsible for planning, organizing, leading, and controlling the operations of the dental service, including:

(1) Ensuring dental staff provide appropriate dental care to promote, preserve, and restore the oral health of Veterans according to generally accepted standards of dental practice and scope of services based upon statutory eligibility.

(2) Rendering, or assigning designee to render, decisions on all Class III and Class VI eligibility determinations when the oral condition is aggravating a treated medical condition. See VHA Handbook 1130.01(1), Veterans Health Administration Dental Program, dated February 11, 2013.

(3) Directing and confirming the use of the Electronic Dental Record for entry of diagnostic findings, dental care plans, and completed procedures for all patients.

(4) Upholding standards for the correct documentation and coding of completed dental procedures. VHA Dental Coding Standards and Requirements may be found at http://vaww.va.gov/DENTAL/reporting_analytics.asp. NOTE: This is an internal VA Web site that is not available to the public.

(5) Reviewing dental provider panels and clinical productivity goals/expectations and manage them accordingly.

(6) Monitoring, reviewing, and implementing plans to improve dental service performance on the Office of Dentistry Dental Quality Indicators. Information pertaining to the Office of Dentistry Quality Indicators may be found at https://spsites.cdw.va.gov/sites/CO_DENTAL/Pages/quality.aspx. NOTE: This is an internal VA Web site that is not available to the public.

(7) Ensuring dental laboratory case submission requirements for CDL are met.

Submission requirements for dental providers may be found at http://vaww.va.gov/cdl.

NOTE: This is an internal VA Web site that is not available to the public.

(8) Ensuring all prostheses are fabricated in the United States of America using materials approved by the Food and Drug Administration (FDA) if commercial dental laboratory services are used.

(9) Ensuring the dental service follows VHA policies.

(10) Ensuring dental service compliance with the Office of Dentistry Infection Control Standards for VA Dental Clinics. See http://vaww.infoshare.va.gov/sites/dental/PH/FromtheOfficeofDentistry.aspx. NOTE:

This is an internal VA Web site that is not available to the public.

(11) Ensuring VA medical facility-level dental service operational procedures and SOPs are consistent with national policies and guidelines.

http://vaww.va.gov/DENTAL/reporting_analytics.asp https://spsites.cdw.va.gov/sites/CO_DENTAL/Pages/quality.aspx http://vaww.va.gov/cdl http://vaww.infoshare.va.gov/sites/dental/PH/FromtheOfficeofDentistry.aspx

(12) Enforcing personnel policies, ethical standards, and performance standards;

and promoting the VA Core Values of Integrity, Commitment, Advocacy, Respect, and Excellence.

(13) Ensuring all dental hygienists have an appropriate functional statement. NOTE:

Dental hygienists are not independent practitioners in the VA. The care provided by dental hygienists follows an assigned functional statement within the defined scope of duties for the state in which they are licensed.

(14) Collaborating with the VISN Lead Dentist to ensure implementation of VHA national policy and VISN policy at the VA medical facility.

(15) Providing regular dental service briefings to VA medical facility leadership on all matters affecting the delivery of dental care.

(16) Serving as the VA medical facility liaison to dental professional organizations, departments within the VA medical facility, and other government agencies. All professional communications about the dental service are conducted through the Chief, Dental Service, or designee.

(17) Participating in the development and review of relevant sharing agreements, service agreements, and inter-VA medical facility agreements.

(18) Carrying out fiscal and budgetary planning activities.

(19) Managing affiliation and VA Commission on Dental Accreditation (CODA) accredited residency programs in collaboration with the VA medical facility Designated Education Officer.

(20) Ensuring compliance with relevant VHA, Occupational Safety and Health Administration, and Joint Commission standards.

(21) Assisting the VA medical facility Director in following recommendations set by the VA Office of Inspector General, the Joint Commission, and other survey bodies.

(22) Ensuring prompt response to assigned Congressional, White House, and Inspector General dental service inquiries.

(23) Collaborating with the Office of Community Care and administer dental service responsibilities for care provided through community providers by:

(a) Determining eligibility of Veterans for community care.

(b) Ensuring community care is utilized to improve access and clinical outcomes for Veterans using one or more of the following factors:

1. The distance between the Veteran and the facility or facilities that could provide the required care or services;

2. The nature of the care or services required by the Veteran;

3. The frequency the Veteran requires the care or services;

4. The timeliness of available appointments for the required care or services;

5. The potential for improved continuity of care;

6. The quality of the care provided; or

7. Whether the Veteran faces an unusual or excessive burden in accessing a VA facility based on consideration of the following:

(a) Excessive driving distance;

(b) Whether care and services are available from a VA facility that is reasonably accessible;

(c) Whether a medical condition of the Veteran affects the ability to travel;

(d) Whether there is a compelling reason that the Veteran needs to receive care and services from a non-VA facility;

(e) The need for an attendant (which is defined as a person who provides required aid or physical assistance to the Veteran, for a Veteran to travel to a VA medical facility for hospital care or medical services).

(c) Reviewing the clinical appropriateness of community care emergency treatment to determine if delaying immediate attention was a hazard to life or health.

(d) Determining if the dental care recommended by community dental providers is needed to promote, preserve, or restore the oral health of the Veteran and is in accord with generally accepted standards of dental practice.

(e) Reviewing and determining clinical appropriateness of care provided to Veterans through community care over $1,000 within 12-months.

p. Chief, Acquisition and Material Management Service. The Chief, Acquisition and Material Management service is responsible for receiving scrap precious metals and maintaining documentation of the ingots in accordance with Appendix C of this directive.

q. VA Medical Facility Dental Staff. The VA medical facility dental staff is responsible for:

(1) Maintaining knowledge of this VHA directive and VA medical facility dental service operational procedures.

(2) Being knowledgeable of CDL protocols when using the CDL. Specific requirements can be found on the CDL intranet Web site http://vaww.va.gov/cdl.

NOTE: This is an internal VA Web site that is not available to the public.

(3) Performing dental service activities in accordance with VHA directives and the dental service operational procedures of the VA medical facility.

(4) Obtaining informed consent for all dental treatments and procedures as part of the process for dental care outlined in Appendix D. See VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures, dated August 14, 2009 for additional details.

6. QUALITY MANAGEMENT

The VA Office of Dentistry develops, tracks, reviews, benchmarks, and reports oral health specific quality indicators that align with the overall strategic priorities for VHA.

This includes the identification and dissemination of evidence-based practices supporting improvements in oral health to VA dental services and other program offices as appropriate. NOTE: For additional information, see VHA Directive 1026, VHA Enterprise Framework for Quality, Safety, and Value, dated August 2, 2013.

7. TRAINING

The following VA-sponsored, American Dental Association (ADA) accredited Talent Management System (TMS) courses are recommended training resources for dental professionals:

a. (VA 20852) Principles and Practice of Dental Radiology and Radiographic Safety (5 CEUs).

b. (VA 33828) VA Dental Infection Control Training (1 CEU).

c. (VA 33552) C.A.R.E. in Dentistry (1.5 CEUs).

d. (VA 27841) Mastering Common Dental Tasks- MCDT 1 - Dental Dam, Retraction Cord, and Provisional Fabrication (1.5 CEUs).

e. (VA 27957) Mastering Common Dental Tasks- MCDT 2 - Alginate Impressions, Stone Cast, and Custom Tray Fabrication (1 CEU).

f. (VA 28209) Mastering Common Dental Tasks- MCDT 3 - Mouth Guards, Various Stent Fabrication, and Denture Repairs (1 CEU).

g. (VA 15633) Healthy Smiles for Veterans Training for Daily Oral Care (1 CEU).

h. (VA 34893) Prevention of Aspiration Pneumonia through Daily Oral Care (1 CEU).

8. RECORDS MANAGEMENT

http://vaww.va.gov/cdl

All records, regardless of format (paper, electronic, electronic systems), created in this directive shall be managed per the National Archives and Records Administration (NARA) approved records schedules found in VA Records Control Schedule 10-1.

Questions regarding any aspect of records management should be addressed to the appropriate Records Manager or Records Liaison.

9. REFERENCES

a. 38 U.S.C. 1710(c).

b. 38 U.S.C. 1712.

c. 38 U.S.C. 1720D.

d. 38 U.S.C. 2062.

e. 38 U.S.C. 2062.

f. 38 U.S.C. 7305 (Divisions of Veteran Health Administration).

g. 38 CFR 17.160 – 17.166, 17.169.

h. VA Handbook 5005, Part II, Appendix G3 Staffing, Qualification Standard for the Appointment of Dentists, dated November 20, 2017.

i. VA Handbook 5005, Part II, Appendix G36 Staffing, Qualification Standard for the Appointment of Dental Assistants, dated April 19, 2011

j. VA Handbook 5005, Part II, Appendix G37 Staffing, Qualification Standard for the Appointment of Dental Hygienists, dated May 12, 2014.

k. VA Handbook 5005, Part II, Appendices G3 and H2, dated March 1, 2017.

l. VHA Directive 1026, VHA Enterprise Framework for Quality, Safety, and Value, dated August 2, 2013.

m. VHA Directive 1039, Ensuring Correct Surgery and Invasive Procedures In and Out of the Operating Room, dated November 28, 2018.

n. VHA Directive 1046, Compensation and Pension Disability Examinations, dated December 6, 2018.

o. VHA Directive 1065.01, Productivity and Staffing Guidance for Specialty Provider Group Practice, dated May 4, 2015.

p. VHA Directive 1116(2), Sterile Processing Services (SPS), dated March 23, 2016.

q. VHA Directive 1230, Outpatient Scheduling Processes and Procedures, dated July 15, 2016.

r. VHA Directive 1232(1) Consult Processes and Procedures, dated September 23, 2016.

s. VHA Directive 1400.09, Education of Physicians and Dentists, dated September 9, 2016.

t. VHA Directive 1501, VHA Homeless Programs, dated October 21, 2016.

u. VHA Directive 1601A.02, Eligibility Determination, dated July 27, 2017.

v. VHA Directive 2012-030, Credentialing of HealthCare Professionals, dated October 11, 2012.

w. VHA Handbook 1100.19, Credentialing and Privileging, dated October 15, 2012.

x. VHA Handbook 1130.01(1), Veterans Health Administration Dental Program, dated February 11, 2013.

y. VHA Handbook 1400.01, Supervision of physician, dental, optometry, chiropractic, and podiatry residents, dated November 7, 2019.

z. VHA Handbook 1400.04, Supervision of Associated Health Trainees, dated March 19, 2015.

aa. VHA Handbook 1400.05, Disbursement Agreement Procedures for Physician and Dentist Residents, dated August 14, 2015

bb. VHA Office of Connected Care. TeleDentistry Operations Manual Supplement, dated November 2016.

cc. “The quality of fixed prosthodontic impression: An assessment of crown and bridge impressions received at commercial laboratories,” Journal of the American Dental Association, June 2017.

dd. U.S. Department of Veterans Affairs, Veteran Health Administration, Active Duty Dental Program Network Participation Agreement, dated September 20, 2018.

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APPENDIX A

CLINICAL RECOMMENDATIONS AND GUIDANCE IN PUBLISHED DOCUMENTS

NOTE: The following are internal Department of Veterans Affairs (VA) Web sites that are not available to the public.

1. OFFICE OF DENTISTRY SHAREPOINT

https://vaww.infoshare.va.gov/sites/dental/default.aspx.

2. HEAD AND NECK RADIATION

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/HNRT- Recomendations_12-20-2017.pdf.

3. OBSTRUCTIVE SLEEP APNEA

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendat ion%20-%20Obstructive%20Sleep%20Apnea.pdf.

4. USE OF SILVER DIAMINE FLUORIDE

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Recs-for-the-Use-of- SDF_2016-09-30.pdf.

5. MANAGEMENT OF EDENTULOUS PATIENTS UNDERGOING COMPLETE

DENTURE TREATMENT

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Timely_Mgmt_of_Fully_E dentulous_Pt_per_Prosthetics_Treatment.pdf.

6. COMPREHENSIVE PERIODONTAL CARE

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendat ion%20-%20Comprehensive%20Periodontal%20Care%20and%20FAQs.pdf.

7. SERVICE ANIMALS IN DENTAL TREATMENT AREAS

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Service-Animals-in- Dental-Treatment-Areas.pdf.

8. CARIES RISK ASSESSMENT

https://spsites.cdw.va.gov/sites/CO_DENTAL/Documents/QIDocs/dent2/2015%20C aries%20Risk%20Assessment%20and%20Fluoride%20Recommendations%20Table.p df.

https://vaww.infoshare.va.gov/sites/dental/default.aspx https://vaww.infoshare.va.gov/sites/dental/HiddenContent/HNRT-Recomendations_12-20-2017.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/HNRT-Recomendations_12-20-2017.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Obstructive%20Sleep%20Apnea.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Obstructive%20Sleep%20Apnea.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Recs-for-the-Use-of-SDF_2016-09-30.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Recs-for-the-Use-of-SDF_2016-09-30.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Timely_Mgmt_of_Fully_Edentulous_Pt_per_Prosthetics_Treatment.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Timely_Mgmt_of_Fully_Edentulous_Pt_per_Prosthetics_Treatment.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Comprehensive%20Periodontal%20Care%20and%20FAQs.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Comprehensive%20Periodontal%20Care%20and%20FAQs.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Service-Animals-in-Dental-Treatment-Areas.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Service-Animals-in-Dental-Treatment-Areas.pdf https://spsites.cdw.va.gov/sites/CO_DENTAL/Documents/QIDocs/dent2/2015%20Caries%20Risk%20Assessment%20and%20Fluoride%20Recommendations%20Table.pdf https://spsites.cdw.va.gov/sites/CO_DENTAL/Documents/QIDocs/dent2/2015%20Caries%20Risk%20Assessment%20and%20Fluoride%20Recommendations%20Table.pdf https://spsites.cdw.va.gov/sites/CO_DENTAL/Documents/QIDocs/dent2/2015%20Caries%20Risk%20Assessment%20and%20Fluoride%20Recommendations%20Table.pdf

APPENDIX A

A-2

9. DENTAL MANAGEMENT OF MEDICATION-RELATED OSTEONECROSIS OF

THE JAWS

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendat ion%20-%20Dental%20Management%20of%20MRONJ%20(Clinician).pdf.

10. USE OF CONE BEAM CT IN VA DENTAL FACILITIES

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendat ion%20-%20Cone%20Beam%20CT.pdf.

11. USE OF LASERS IN DENTISTRY

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendat ion%20-%20Use%20of%20Lasers.pdf.

12. JUNE 2014 DENTAL SERVICE DESIGN GUIDE

https://vaww.infoshare.va.gov/sites/dental/OODPublications/Dental%20Service%20 Design%20Guide%20June%202014.pdf.

13. FEBRUARY 2014 DENTAL BENEFITS FOR VETERANS PAMPHLET IB 10-442

https://www.va.gov/healthbenefits/resources/publications/IB10- 442_dental_benefits_for_veterans.pdf.

14. FEBRUARY 2017 ACTIVATIONS READINESS CHECKLIST

https://vaww.visn10.portal.va.gov/sites/NAO/activationchecklist/Shared%20Docume nts/Final/ActivationsChecklist_Dentistrysignedbyhull.pdf.

15. APRIL 2012 VARIABLES AFFECTING VA DENTIST PRODUCTIVITY

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/2012-06- 04%20Office%20of%20Dentistry%20Workforce%20Study%20(2011).pdf#search=Workf orce%20Study.

16. OFFICE OF DENTISTRY INFECTION CONTROL STANDARDS SHAREPOINT

DOCUMENTS

https://vaww.infoshare.va.gov/sites/dental/default.aspx.

17. AUGUST 2014 SPACE PLANNING CRITERIA VA 222 DENTAL SERVICE

https://vaww.infoshare.va.gov/sites/dental/OODPublications/VA%20222%20Dental% 20Service%20Space%20Planning%20Criteria%20August%202014.pdf.

https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Dental%20Management%20of%20MRONJ%20(Clinician).pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Dental%20Management%20of%20MRONJ%20(Clinician).pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Cone%20Beam%20CT.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Cone%20Beam%20CT.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Use%20of%20Lasers.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Use%20of%20Lasers.pdf https://vaww.infoshare.va.gov/sites/dental/OODPublications/Dental%20Service%20Design%20Guide%20June%202014.pdf https://vaww.infoshare.va.gov/sites/dental/OODPublications/Dental%20Service%20Design%20Guide%20June%202014.pdf https://www.va.gov/healthbenefits/resources/publications/IB10-442_dental_benefits_for_veterans.pdf https://www.va.gov/healthbenefits/resources/publications/IB10-442_dental_benefits_for_veterans.pdf https://vaww.visn10.portal.va.gov/sites/NAO/activationchecklist/Shared%20Documents/Final/ActivationsChecklist_Dentistrysignedbyhull.pdf https://vaww.visn10.portal.va.gov/sites/NAO/activationchecklist/Shared%20Documents/Final/ActivationsChecklist_Dentistrysignedbyhull.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/2012-06-04%20Office%20of%20Dentistry%20Workforce%20Study%20(2011).pdf#search=Workforce%20Study https://vaww.infoshare.va.gov/sites/dental/HiddenContent/2012-06-04%20Office%20of%20Dentistry%20Workforce%20Study%20(2011).pdf#search=Workforce%20Study https://vaww.infoshare.va.gov/sites/dental/HiddenContent/2012-06-04%20Office%20of%20Dentistry%20Workforce%20Study%20(2011).pdf#search=Workforce%20Study https://vaww.infoshare.va.gov/sites/dental/default.aspx https://vaww.infoshare.va.gov/sites/dental/OODPublications/VA%20222%20Dental%20Service%20Space%20Planning%20Criteria%20August%202014.pdf https://vaww.infoshare.va.gov/sites/dental/OODPublications/VA%20222%20Dental%20Service%20Space%20Planning%20Criteria%20August%202014.pdf

B-1

APPENDIX B

PROCESS FOR DENTAL EXPECTATIONS OF CARE

Veterans eligible for dental care receive treatment that is reasonably necessary and clinically determined by the treating Department of Veterans Affairs (VA) dentist to meet the Veteran’s needs. Dental care results in improved oral health that contributes to general health and well-being. It is the responsibility of each VA dentist to ensure eligible Veterans receive evidence-based, high quality dental treatment consistent with this directive. The following section provides a description of the expected steps involved in an episode of dental treatment.

1. CONSULT OR REQUEST FOR TREATMENT

a. Verify Veteran eligibility.

b. Determine Dental Classification and scope of care.

c. Schedule appointment for examination with a VA dentist. Follow current VA scheduling policies to ensure access to care (see Veterans Health Administration (VHA) Directive 1230, Outpatient Scheduling Processes and Procedures, dated July 15, 2016, amended July 12, 2019).

2. EXAMINATION

a. Update Electronic Dental Record to include Dental Classification and Primary Dental Provider.

b. Diagnostic Findings. Depending on dental classification and scope of care, documentation for examinations may include the following elements:

(1) Determination of chief complaint and patient’s treatment goals (patient-centered care focus).

(2) Vital signs.

(3) Past medical history.

(4) Current medications.

(5) Social history.

(6) Soft tissue evaluation.

(7) Radiographs per American Dental Association (ADA) Protocol.

(8) Charting of dentition with radiographic findings.

(9) Periodontal assessment. Must perform full periodontal charting if Periodontal

APPENDIX B

B-2

Screening Record (PSR) indicates the need per ADA standard. See also Office of Dentistry’s Comprehensive Periodontal Care Clinical Recommendations (https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendatio n%20-%20Comprehensive%20Periodontal%20Care%20and%20FAQs.pdf) which provides the basis for preventive care, and restorative/prosthodontic treatment planning.

NOTE: This is an internal VA Web site that is not available to the public.

(10) Temporomandibular joint findings.

(11) Occlusal findings.

3. PATIENT EDUCATION

a. Discuss examination findings and review potential risks and benefits of dental care.

b. Discuss how significant delays in initiation of treatment may result in further progression of disease which may significantly change treatment options discussed at the current appointment today.

c. On occasion, Veterans may request certain treatment that is not evidence-based or clinically indicated. The VA dentist should not approve these treatments. In such instances, the VA dentist should provide the Veteran with a detailed explanation regarding why the requested treatment option is not in the Veteran’s best interest.

d. When teeth are planned for extraction, the VA dentist discusses the following issues with the Veteran and documents the discussion in the Electronic Dental Record:

(1) Interim and permanent replacement options as well as the option not to replace missing teeth.

(2) Healing times.

(3) Risk of complications or negative outcomes.

e. VA Providers must obtain informed consent for all dental treatments and procedures. Consult VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures, dated August 14, 2009, for additional details.

f. Document discussion in the record.

4. TREATMENT PLAN

a. Use of the Electronic Dental Record Treatment Planning functionality is essential in establishing the treatment plan. Sequencing of care should include resolution of active oral disease prior to continuation of definitive restorative care.

(1) Emergent care to resolve patients with acute pain, swelling, bleeding or active https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Comprehensive%20Periodontal%20Care%20and%20FAQs.pdf https://vaww.infoshare.va.gov/sites/dental/HiddenContent/Clinical%20Recommendation%20-%20Comprehensive%20Periodontal%20Care%20and%20FAQs.pdf

APPENDIX B

B-3 oral infection.

(2) Caries Control and Periodontal Therapy.

(3) Restorative care to include all aspects dental care once the patient’s oral health is stable and etiologic factors are removed.

(4) Maintenance, Reevaluation, and Recare as determined by eligibility. At a minimum, an active patient should receive an oral examination at least once every two years.

b. Specialty Dental Care can be provided on site, virtually (TeleDentistry), or with a Community Care Referral.

(1) Endodontic treatment following confirmation of restorability of the tooth or teeth.

(2) Periodontal treatment following assessment of restorative prognosis based on periodontal diagnosis. Patients with persistent, unresolved moderate to severe chronic periodontitis should be considered for referral to a periodontist.

(3) Oral surgery to include hard/soft tissue grafting and supportive pre-prosthetic care.

(4) Prosthodontic considerations for replacing missing teeth and tissue should be determined based on patient needs and clinical presentation.

(5) Implant Therapy is a supportive and foundational aspect of prosthetic treatment when determined to be clinically indicated.

5. MAINTENANCE AND ONGOING DENTAL CARE

VA recommends recare dental visits (oral examination, prophylaxis, and periodontal treatment) based upon eligibility guidelines and intervals determined by the primary VA dental provider.

C-1

APPENDIX C

DENTAL LABORATORY SERVICES

1. DENTAL SERVICE DENTAL LABORATORIES

a. Dental laboratory services are available to all Department of Veterans Affairs (VA) medical facilities where dental care is provided. These services may be provided by an on-site dental laboratory, by the Central Dental Laboratory (CDL), by contract laboratory services or by any combination of the above.

b. Commercial laboratory services may be used for situations anticipated to be non-recurring and not of significant dollar value. If these two conditions cannot be met, Acquisition and Material Management Service must be consulted to determine the appropriateness of establishing a contract.

c. Use of dental casting alloys. Noble or high noble dental casting alloys should be used for casting dental crowns and fixed dental prostheses for all metal or porcelain-fused to metal restorations. Base metals should be limited to those instances when metal is to be bonded to enamel as in an acid-etched (Maryland bridge) prosthesis.

Dental services who develop contractual arrangements with commercial sector laboratories should ensure that the contract specifies Noble or High Noble metal alloy be used in dental restorations.

d. Dental providers should take care to ensure the highest standards of quality when submitting cases to the dental laboratory. High quality submissions apply to cases submitted to the Department of Veterans Affairs (VA) Central Dental Laboratory as well as to commercial dental laboratories under contract to the VA. The CDL website has guidelines for case submissions. This information can be accessed at http://vaww.va.gov/CDL and describes requirements for submitting both fixed and removable prosthodontic cases. NOTE: This is an internal VA Web site that is not available to the public.

e. VA Form 10-2804 is the required dental laboratory prescription form to be used when submitting cases to the CDL and can be accessed electronically (https://vaww.va.gov/CDL/docs/VA_Form_10_2804_Master.pdf. NOTE: This is an internal VA web site that is not available to the public.). This form can be downloaded from the Web site and submitted with the case. If a commercial laboratory is used to provide laboratory support, they will typically request the submitting dental service use the contracted laboratory’s prescription form. VA dental services can also use page 3 of VA Form 10-2804 which is absent patient information for submission to contract laboratories on the National Dental Laboratory Services Contract.

f. Infection prevention and control procedures should be followed when submitting cases to any laboratory. Impressions must be disinfected before entering the laboratory at the dental service. Impressions must also be disinfected before mailing to the CDL or commercial laboratory (https://vaww.infoshare.va.gov/sites/dental/field/InfControl/1/Infection%20Control%20St http://vaww.va.gov/CDL https://vaww.va.gov/CDL/docs/VA_Form_10_2804_Master.pdf https://vaww.infoshare.va.gov/sites/dental/field/InfControl/1/Infection%20Control%20Standards%20VA%20Dental%20Clinics%202013-10_EMBED.docx

APPENDIX C

C-2 andards%20VA%20Dental%20Clinics%202013-10_EMBED.docx. NOTE: This is an internal VA Web site that is not available to the public.).

g. The quality of the submission is paramount to ensure a good outcome for the dental prosthesis that is requested. Impressions that lack the necessary detail required to fabricate the restoration should not be forwarded to the laboratory. Similarly, errors in the articulation of casts can lead to inaccuracies. Care should be taken to ensure all appropriate measures are taken to improve quality. Recent studies indicate that commercial laboratories determined that 86 percent of the impressions submitted to the laboratory had at least one detectable error, and 55 percent of the noted errors were critical errors pertaining to the finish line. (For additional information, see “The quality of fixed prosthodontic impression: An assessment of crown and bridge impressions received at commercial laboratories,” Journal of the American Dental Association, June 2017.)

h. The dental laboratory encourages customer feedback to inform the laboratory of the clinical outcome. Customer feedback assists the laboratory in developing training plans for the staff to improve processes and streamline procedures. The dental laboratory urges the use of the electronic dental laboratory feedback form to the CDL, found here: http://r01scrsql003.r01.med.va.gov/cdlfb/.

i. Dental services are required to use dental laboratory products whose final point of fabrication is in the United States. This requirement is subject to the “Buy American” Act (41 United States Code (U.S.C.) 8301). The purpose is to ensure the highest standards of materials meeting Food and Drug Administration standards apply to dental casting alloys.

2. CENTRAL DENTAL LABORATORY

a. The CDL is resourced to provide removable partial denture frameworks; porcelain fused-to-metal, ceramic, and all metal fixed prostheses; implant-supported prostheses;

and other special intra-oral prostheses, such as obturators and splints. A minimal co-payment (cost share) is assessed for these services. Acrylic and thermoplastic oral prosthetic fabrication have recently been added to the CDL at contract pricing.

b. The Office of Dentistry develops policies, standards, and scope of CDL activities.

These activities include, but are not limited to, oversight of overall performance such as customer satisfaction, turn-around time, and cost-effectiveness.

3. CUSTODY AND DISPOSITION OF PRECIOUS METALS

a. Precious metals maintained at each VA medical facility should be inventoried in accordance with local guidance. For this directive, precious metals are defined as gold, platinum or palladium, including any combination containing one of those metals. It does not include solder or other products containing precious metals of negligible value.

b. The employee having custody of precious metals issues the quantity and type needed by the dentist or technician and records the date, quantity issued, and type of https://vaww.infoshare.va.gov/sites/dental/field/InfControl/1/Infection%20Control%20Standards%20VA%20Dental%20Clinics%202013-10_EMBED.docx http://r01scrsql003.r01.med.va.gov/cdlfb/

C-3 prosthesis. On completion of the prosthesis, all unused precious metals are returned to the custodian for reissue. Buttons, crowns, and other items which are unserviceable for reissue are collected as scrap precious metal and melted into one ingot for subsequent turn-in to the Chief, Acquisition and Material Management Service. Turn-in documents should be maintained for one year in accordance with VA Records Control Schedule 10-

1. Turn-in should be…