Revised 20250916 Dental Treatment Performance Work Statement.docx

Performance Work Statement (PWS) Nevada Army National Guard (NVARNG) Dental Services

1.0 General:

1.1 Scope: The contractor shall provide all personnel, equipment, tools, materials, supervision, and quality control necessary, except as specified in Paragraph 3.0 as Government Furnished, to perform Dental Readiness Services, as defined in this PWS.

1.1.1 The objective of this PWS is to provide the contractor with the information necessary to provide necessary dental services to ensure NVARNG is able receive dental treatment to maintain Department of Defense (DoD) established dental classification in accordance with HA Policy 02-11. DoD, which requires dental screening examinations and remediation documented on ≥ 90% mission ready. Members of the NVARNG will receive an annual dental screening examination to determine their dental classification. Contractor shall be prepared to conduct the aforementioned exams and dental treatment at designated dental office to ensure the highest Dental Deployable Rate for Soldiers in the Nevada Army National Guard (NVARNG) as defined in this PWS.

1.2 Background:

1.2.1 Individual Medical Readiness (IMR) and Fully Medically Ready (FMR) are the basic principles of force-sustainment for Nevada Army National Guard (NVARNG) forces. Dental health is vital for force health protection and failure to achieve a standard of dental health could preclude a Soldier from deploying. NVARNG has approximately 3300 Service Members (SMs) who will require dental treatment, 65 of which require complex treatment and are the focus of this requirement. Preventative dentistry efforts maintain dental readiness by promoting oral health, general wellness, and overall fitness. Oral diseases are widespread in the Army population and impair daily functioning and quality of life. The goal of the Dental Readiness Program is to minimize oral disease and injury of SMs, reduce non-combat dental casualties, and enhance unit readiness. SMs who deploy with untreated dental disease are at increased risk of becoming dental casualties and depriving units of needed manpower at potentially critical times during mission execution. SMs with uncorrected, severe dental deficiencies have a more likely chance of experiencing a dental emergency within one year. Oral diseases can suddenly develop into dental emergencies that are painful, debilitating, and sometimes even life threatening. The minimum goal for overall dental readiness is greater than 90%.

1.3 Period of Performance (POP): The Period of Performance shall be approximately six (6) months. If the program is successful, the Government will solicit for a longer term contract.

1.4 General Information:

1.4.1 Place of Performance of Services: These services will be performed at a dental office within a 50-miles radius of Carson City, Nevada and of Las Vegas, NV area (meaning at least one facility in each location) that provides dental treatment services.

1.4.1.1 Telework: N/A

1.4.1.2 N/A

1.4.1.3 N/A

1.4.2 Recognized Holidays: N/A

1.4.3 Quality Control (QC): The contractor shall develop and maintain an effective QC Plan (QCP) to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor's QCP is the means by which it assures itself that its work complies with the requirements of the contract. As a minimum, the contractor shall develop QC procedures that address the areas identified in Technical Exhibit 1, Performance Requirements Summary (PRS). A final QCP shall be submitted to the Contracting Officer Representative (COR) no later than 10 days after the contract award. After acceptance of the QCP, the contractor shall obtain the Contracting Officer's (KO's) acceptance in writing of any proposed changes to its QCP.

1.4.4 Quality Assurance (QA): The Government will evaluate the contractor's performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government will do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and acceptable quality level(s) or defect rate(s).

1.4.5 Installation Access and Security Requirements: N/A

1.4.5.1 For contractors requiring Common Access Card (CAC): N/A

1.4.5.2 N/A

1.4.5.3 N/A

1.4.5.4 N/A

1.4.5.5 N/A

1.4.5.6 Use of Government Information Systems (IS): N/A

1.4.5.7 N/A

1.4.5.8 N/A

1.4.5.9 N/A

1.4.5.10 Protection of Personally Identifiable Information (PII). The contractor shall protect all PII encountered in the performance of services in accordance with Defense Federal Acquisition Regulation Supplement (DFARS) 224.103 Personally Identifiable Information and Department of Defense Directive (DoDD) 5400.11, Department of Defense Privacy Program, and DoD 5400.11-R. If a PII breach results from the contractor’s violation of the above-mentioned policies, the contractor shall bear all notification costs, call-center support costs, and credit monitoring service costs for all individuals whose PII has been compromised.

1.4.5.11 N/A

1.4.5.12 N/A

1.4.5.13 Access to Classified Information. N/A

1.4.6 Physical Security: N/A

1.4.6.1 Key Control. N/A

1.4.7 Special Qualifications: The contractor shall ensure all employees possess all required licenses necessary in the performance of this contract. This does not include education or other qualifications for the position in which the contractor employee is performing, dress codes, or other information. (NOTE: The Government does not provide training to contractors. Contractors must ensure that any personnel performing under a contract are fully trained, licensed, certified, and otherwise qualified to provide services.)

1.4.8 Post Award Conference/Periodic Progress Meetings: The contractor agrees to attend any post award conference convened by the KO in accordance with FAR 42.5. The KO, COR and other Government personnel, as appropriate, may meet periodically with the contractor to review the contactor’s performance. At these meetings, the KO will apprise the contractor of how the Government views the contractor’s performance and the contractor shall apprise the Government of problems, if any, being experienced. The contractor shall resolve outstanding issues raised by the Government. Contractor attendance at these meetings shall be at no additional cost to the Government.

1.4.9 Contract Manager (CM): The contactor shall designate a CM who shall ensure performance under this contract. The name of this person, and an alternate who shall act for the contractor when the CM is absent, shall be designated in writing to the KO. The CM or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The CM shall work through the COR, to resolve issues, receive technical instructions, and ensure adequate performance of services. The CM shall ensure that contractor employees do not perform any services outside the scope of the contract without an official modification issued by the KO. The CM shall ensure contractor employees understand that services performed outside the scope of the contract are performed wholly at the expense of the contractor.

1.4.10 Identification of Contractor Employees: N/A

1.4.10.1 N/A

1.4.11 Combating Trafficking in Persons: The United States Government has adopted a zero-tolerance policy regarding trafficking in persons. Contractors and contractor employees shall not engage in severe forms of trafficking in persons during the period of performance of the contract; procure commercial sex acts during the period of performance of the contract; or use forced labor in the performance of the contract. The Contractor shall notify its employees of the United States Government’s zero tolerance policy, the actions that will be taken against employees for violations of this policy. The contractor shall take appropriate action, up to and including termination, against employees or subcontractors that violate the US Government policy as described at FAR 22.17.

1.4.12 Contractor Travel. N/A

1.4.13 Data Rights. The Government has unlimited rights to all documents/materials produced under this contract. All documents and materials, to include the source codes of any software, produced under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership/copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the contractor without written permission from the KO. All materials supplied to the Government shall be the sole property of the Government and may not be used for any other purpose. This right does not abrogate any other Government rights.

1.4.14 Organizational Conflicts of Interest (OCI): The contractor and subcontractor personnel performing services under this contract may receive, have access to or participate in the development of proprietary or source selection information (e.g., cost or pricing information, budget information or analyses, specifications or work statements, etc.) or perform evaluation services which may create a current or subsequent OCIs, as defined in FAR Subpart 9.5. The contractor shall notify the KO immediately whenever it becomes aware that such access or participation may result in any actual or potential OCI and shall promptly submit a plan to the KO to avoid or mitigate any such OCI. The contractor’s mitigation plan will be determined to be acceptable solely at the discretion of the KO. In the event the KO unilaterally determines that any such OCI cannot be satisfactorily avoided or mitigated, the KO may impose other remedies as he or she deems necessary, including prohibiting the contractor from participating in subsequent contracted requirements which may be affected by the OCI.

2.0 Definitions and Acronyms:

2.1 Definitions:

2.1.1 Contractor: A vendor awarded a contract to provide specific supplies or service to the Government. The term used in this contract refers to the prime.

2.1.2 Contracting Officer (KO): A person with authority to enter into, administer, or terminate contracts, and make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

2.1.3 Contracting Officer Representative (COR): An employee of the U.S. Government designated by the KO to monitor contractor performance. Such appointment will be in writing and will state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as that direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have the authority to change the terms and conditions of the contract.

2.1.4 Defective Service: A service output that does not meet the standard of performance associated with the PWS.

2.1.5 Deliverable: Anything that can be physically delivered and includes non-manufactured things such as reports, dental records, or dental images.

2.1.7 Key Personnel: Contractor personnel that are evaluated in a source selection process and that may be required to be used in the performance of a contract by the PWS. When key personnel are used as an evaluation factor in best value procurement, an offer can be rejected if it does not have a firm commitment from the persons that are listed in the proposal.

2.1.6 Physical Security: Actions that prevent the loss or damage of Government property.

2.1.7 Quality Assurance: The Government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

2.1.8 Quality Assurance Surveillance Plan (QASP): An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

2.1.9 Quality Control: All necessary measures taken by the Contractor to ensure that the quality of an end product or service shall meet contract requirements.

2.1.10 Subcontractor: One that enters into a contract with a prime contractor. The Government does not have privet of contract with the subcontractor.

2.2 Acronyms:

3.0 Government Furnished Property, Material, Equipment and Services: N/A

4.0 Contractor Furnished Property, Materials, and Equipment:

4.1 General: Except for those items specifically stated to be Government-Furnished in Paragraph 3.0, the contractor shall furnish everything required to perform these services.

4. Contractor Security Clearance: The contractor’s employees performing work in support of this contract shall have at minimum a Tier 1, National Agency Check with Inquiries (NACI) clearance.

5.0 Requirements: The contractor shall:

5.1 Service Contract Reporting: N/A

5.2 N/A

5.3 System of Award Management (SAM)

5.3.1. The contractor shall completely fill in all required data fields using the following web address: https://sam.gov. Log in and select Entity Registrations and then select Service Contract Reporting

5.3.2 The Contractor shall report the required information annually by October 31, for services performed under this contract during the preceding Government fiscal year (October 1-September 30).

5.3.3 Contractor shall be prepared to provide services for each Dental Readiness Category listed in Appendix A.

5.3.4 The Contractor shall provide a listing all clinic personnel supporting NVARNG SMs to the State Surgeon Office, Deputy State Surgeon (DSS). The contractor shall provide necessary staffing of Dentists and dental support to conduct comprehensive oral examinations and treatments for the following Class 3 Soldiers.

5.3.5. Intent: Vendor/Contractor shall provide an onsite case management and professional support service team to assist the NVARNG State Surgeon and NV Medical Detachment with the management, maintenance and improvement of the NVARNG health and wellness program.

5.4 Required Positions, Qualifications, & Duties

5.4.1 DENTAL TREATMENT: Contractor shall provide invasive dental treatment with all necessary clinical supplies, equipment, and instruments. Dental treatment will include any invasive procedures needed to correct any Class 3 dental deficiencies. Contractor should be prepared to provide a minimum of 20 invasive dental treatment (minimum of 5 Soldiers per day) and must coordinate staffing to successfully complete all dental treatments. APPENDIX B lists authorized dental treatments. APPENDIX C lists unauthorized dental procedures or treatments, unless directly approved by a NVARNG State Dental Officer and the DSS.

5.5 QUALIFICATIONS: The requirements for this contract include but are not limited to:

5.5.1 The contractor is responsible for ensuring that all staff members are licensed in the state of Nevada for dental professionals.

5.5.2 The contractor shall have a full understanding of Individual Medical Readiness (IMR) – Dental Readiness in order to provide services to the NVARNG

5.5.3 The contractor shall abide by the requirements of Dental Readiness for the State of Nevada and per Federal Regulations.

5.5.4 Contractor shall provide a DD2813 to the NVARNG Office of the State Surgeon, Case Management to input into Soldiers medical records system (MedChart).

5.5.5 The Contractor staff must be Health Insurance Portability and Accountability Act (HIPAA) certified, Privacy Act, Occupational Safety and Health Administration (OSHA) and American Dental Association (ADA) compliant. Experience working with military personnel is highly desired.

5.6 DUTIES: Scope of work for the position includes but is not limited to:

5.6.1 Conduct and complete Dental Restorative Care services for mobilizing and non-mobilizing Service Members of the NVARNG. Dental Restorative Care Services shall be coordinated with the Office of the State Surgeon.

5.6.2 Conduct dental treatment in a clinic setting and shall conform to the standards of HIPAA, ADA, Privacy Act and OSHA when examining or treating Class 3 Soldiers and other dental classification types as directed by the COR. Authorized dental treatments are listed in APPENDIX B.

5.6.3 Ensure dental services are performed by Nevada licensed and certified dental professionals. Contractor shall be licensed for any equipment operated during the examination or dental procedure. All dental assistants and staff shall be trained and professional with good morals and ethics.

5.6.4 The contractor shall provide a weekly roster including name, unit, and Social Security number of all Soldiers receiving contracted services, services provided, medications prescribed along with pharmacy documents, and final status of the Soldier no later than the end of each week on Friday. The report will be validated against hard copy documentation by the NVARNG State Surgeon’s Office representative. The contractor will be required to remedy any deficiencies found in the validation process. Acceptance of invoice will be withheld until corrections are made.

5.6.6 All dental staff shall possess the required licenses and certifications that are current, unrestricted and in good standing, including Basic Life Support or Advanced Cardiovascular Life Support. All dental assistants and staff shall be trained and professional with good morals and ethics.

5.6.7 Issue a prescription to Soldiers upon receipt of dental treatment as deemed necessary. Prescriptions shall not be for more than a 5-days’ supply. NVARNG State Dental Officer will be notified of each prescription issued to Soldiers.

5.6.8 Conduct as necessary follow-up conversations between NVARNG treated soldier and/or NVARNG Office of the State Surgeon Case Manager. This shall depend on the complexity of treatment and, if any, prescription medication for postoperation(s).

5.6.9 Conduct periodic dental exams IAW AR 40-501 and AR 40-35. Dental exams shall include digital bitewings and digital panoramic radiographs (if clinically indicated). The contractor shall provide a hard copy or digital copy of all exam and digital radiographs to NVARNG Office of the State Surgeon Case Manager to upload into the DENCLASS system. The contractor shall ensure all soldiers have a current panoramic radiograph on file and if missing, the contractor shall perform new radiographs. Film or ‘digitized’ radiographs shall not be accepted in lieu of an exam.

5.6.10 The periodic dental exam shall assess the current state of oral health, risk for future dental disease as well as assessing general health factors that relate to the treatment of the patient. The following measures are required for each periodic dental exam.

5.6.10.1 Carries risk assessment – Classify Soldiers as low, moderate or high risk for caries as outlined by the American Dental Association’s (ADA). This assessment will allow the Army Dental Care System (ADCS) to identify those at high risk for future disease and appropriately manage their care.

5.6.11 Periodontal assessment – Periodontal Screening and Recording (PSR), a screening procedure endorsed by the ADA and the American Academy of Periodontology, should be utilized to determine the need for periodontal treatment.

5.6.12 Tobacco risk assessment – Classify Soldiers as a smoker, user of smokeless tobacco or as both.

5.6.13 Oral cancer screening – Perform a thorough oral cancer screening.

5.6.14 Digital radiographs should be taken only for clinical reasons according to Federal Drug Administration (FDA) guidelines or as determined by the SM’s dentist. Radiographs should be of diagnostic quality, properly identified and dated. A panograph is required to be present in the dental record. It shall be of adequate quality for diagnostic/identification purposes.

5.6.15 Panographic radiographs are valid for five (5) years unless clinically indicated by a certified Dentist. However, the panographic radiograph must adequately represent the current oral condition of the Soldier. Digital radiographs shall be performed on all service members who do not have a panograph on file in the DENCLASS system, regardless of when the hardcopy pantograph is dated.

5.6.16 Removed.

5.6.17 As requested, provide timely feedback, work progress, number of completed dental examinations, and completion status to the Office of the State Army Surgeon or designated government representative. This includes providing a timeline and any factors which may negatively impact the processing the requirement as specified. Contractor must notify the Office of the State Surgeon or designated government representative at the end of day.

5.6.18 N/A

5.7 Rules of Engagement (ROEs) & Additional Credentials:

5.7.1 The contractor will maintain and manage their dental credentials.

6.0 Applicable Publications: Publications applicable to this PWS are listed below:

Publication (Chapter/Page)

Occupational Safety and Health Standards.

Title 29, Code of Federal Regulations, Part l910

Occupational Safety and Health Standards, Medical and Dental Offices

OSHA 3187-09R

Health Standards, Bloodborne Pathogens Standard (29 CFR1910.1030)

Ionizing Radiation (29 CFR1910.1096)

Exit Routes (29 CFR Subpart E1910.35, 1910.36,1910.37, and 1910.38 and 1910.39)

Mandatory

Dental Board of Nevada- Regulations, (Chapter 631.271 Dentistry)

Mandatory https://www.leg.state.nv.us/nrs/nrs-631.html

https://armypubs.army.mil/ProductMaps/PubForm/AR.aspx

35_Final_Web_ARN641.pdf

Federal Acquisition Regulation https://www.acquisition.gov/?q=browsefar

Protection of Personally Identifiable Information (PII)

DFARS 224.103

Department of Defense Privacy Program DoD5400.11

Federal Information Processing Standards (FIPS) Publication 201-2 Personal Identity Verification (PIV) of Federal Employees and Contractors (paragraph 9) August 2013 http://nvlpubs.nist.gov/nistpubs/FIPS/NIST.FIPS.20 1-2.pdf

Defense Federal Acquisition Regulation Supplement http://www.acq.osd.mil/dpap/dars/dfarspgi/current/index.html or https://www.acquisition.gov/dfars

https://www.dhs.gov/homeland-securitypresidential-directive-12

https://www.esd.whs.mil/Directives/issuances/dodi/

https://www.esd.whs.mil/Directives/issuances/dodm/

https://www.esd.whs.mil/Directives/issuances/dodd/

DoD 8570.01-M Information Assurance Workforce Improvement Program 12/19/2005 (Change 4:

11/10/2015) https://www.esd.whs.mil/Directives/issuances/dodm/

DoD 5220.22-M National Industrial Security Program Operating Manual (NISPOM) 02/28/2006 (Change 2: 05/18/2016) https://www.esd.whs.mil/Directives/issuances/dodm/

AR 25-2 Information Assurance

04/04/2019 http://armypubs.army.mil/ProductMaps/PubForm/AR.aspx

http://armypubs.army.mil/ProductMaps/PubForm/AR.aspx

https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/AR%2040-35_Final_Web_ARN641.pdf

https://armypubs.army.mil/epubs/DR_pubs/DR_a /ARN37720-AR_40-501-002-WEB-4.pdf

https://armypubs.army.mil/ProductMaps/PubForm/Details.aspx?PUB_ID=66994

https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/602519p.pdf?

ver=R2OKfDXWHtMkQ9hrl8wdOw%3D%3D

6.1 Applicable Forms: Forms applicable to the PWS are listed below:

TECHNICAL EXHIBIT 1

Performance Requirements Summary (PRS)

This PRS includes performance objectives the Government will use to determine contractor performance and will compare contractor performance to the Acceptable Quality Level (AQL).

examination completed within 24 hours of initial visit.

Missed no more than 1% of dental exams of the scheduled 125 Service Members Random Monitoring and Periodic Inspection/COR

Upon completion of dental examination and treatment, Soldier’s data will be provided and entered into electronic medical record with in DENCLASS to include physical findings, assessment and treatment plan.

dental treatments are completed within 24 hours of initial visit with a less than 5% complication rate (except for those which require case management).

Missed no more than 1% of dental treatment of the scheduled 125 Service Members Random Monitoring and Periodic Inspection/COR

Complete dental examinations and treatments before end of shift.

Completion of entire shift from start to finish, unless mutual agreement is met, and alternate coverage is available.

100% of exams and treatments for the scheduled 125 service members Patient Feedback/COR

TECHNICAL EXHIBIT 2

Deliverables Schedule

TECHNICAL EXHIBIT 3

Estimated Workload Data This information is provided for historical background only. It is not a guarantee of workload quantities.

APPENDIX A

Department of Defense

Oral Health and Readiness Classification System

The oral health status of uniformed personnel shall be classified as follows:

a. Class 1: (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

b. Class 2: Patients with a current dental examination, which require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental class 2 may exhibit the following:

(1) Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient.

(2) Interim restorations or prosthesis that can be maintained for a 12-month period. This includes teeth that have been restored with permanent restorative materials for which protective cuspal coverage is indicated.

(3) Edentulous areas requiring prostheses but not on an immediate basis.

(4) Periodontium that:

(a) requires oral prophylaxis

(b) requires maintenance therapy

(c) requires treatment for slight to moderate periodontitis and stable cases of more advanced periodontitis

(5) Unerupted partially erupted or malposed teeth that are without historical, clinical or radiographic signs or symptoms of pathosis, but which are recommended for prophylactic removal.

(6) Active orthodontic treatment. The provider should consider placing the patient in passive appliances for deployment for up to six months. For longer periods of deployment, the provider should consider removing active appliances and placing the patient in passive retention.

(7) Temporomandibular disorder patients in remission. The provider anticipates the patient can perform duties while deployed without ongoing care and any medications or appliances required for maintenance will not interfere with duties.

c. Class 3: Patients who require urgent or emergent dental treatment. Class 3 patients normally are not considered to be worldwide deployable.

(1) Treatment and/or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient.

(2) Interim restorations or prostheses that cannot be maintained for a 12-month period.

(3) Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months.

(a) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(b) Active progressive moderate or advanced periodontitis.

(c) Periodontontal abscess

(d) Progressive mucogingival condition

(e) Periodontal manifestations of systemic disease or hormonal disturbances

(f) Heavy subgingival calculus

(4) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(5) Unerupted, partially erupted or malposed teeth with historical, clinical or radiographic signs or symptoms of pathosis that are recommended for removal.

(6) Chronic oral infections or other pathologic lesions including:

(a) Pulpal, periapical or resorptive pathology requiring treatment.

(b) Lesions requiring biopsy or awaiting biopsy report.

(7) Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections or provide timely follow-up care (e.g., drain or suture removal) until resolved.

(8) Acute Temporomandibular disorders requiring active treatment that may interfere with duties.

d. Class 4. Patients who require periodic dental examinations or patients with unknown dental classifications. Class 4 patients normally are not considered to be worldwide deployable

Listing of Required Dental Treatment Services (Revised 9/16/2025)

APPENDIX B

AUTHORIZED DENTAL TREATMENT

1. The following dental procedures are authorized:

(a) Diagnostic Services which are funded through NG6H 2065 Medical Readiness Funding:

D0120-Periodic Oral Evaluation D0150-Comprehensive Oral Evaluation D0330-Panoramic Film D0272-Bitewings-Two Films D0274-Bitewings-Four Films D0220/D0230- Periapical (limited)

(b) Restorative Services which are funded through NG6H 2065 Medical Readiness Funding

D2140-Amalgam-One Surface D2150-Amalgam-Two Surfaces D2160-Amalgam-Three Surfaces D2161-Amalgam-Four or More Surfaces D2330-Composite-One Surface D2331-Composite-Two Surfaces D2332-Composite-Three Surfaces

Posterior composites will be authorized only when a posterior composite is necessary to provide a quality restoration and no other alternative is available.

D2335-Composite-Four or More Surfaces D2391-Composite-One Surface D2392-Composite-Two Surfaces D2393-Composite-Three Surfaces D2394-Composite-Four or More Surfaces D2799-Provisional Crown D2931-Prefabricated Stainless Steel Crown D2950-Core Buildup, including any pins D2954-Prefabricated Post and Core

(c) Endodontic Services which are funded through NG6H 2065 Medical Readiness Funding

D3310-Anterior Root Canal Therapy D3320-Bicuspid Root Canal Therapy D3330-Molar Root Canal Therapy D3346-Anterior Root Canal Retreatment D3347-Bicuspid Root Canal Retreatment D3348-Molar Root Canal Retreatment

(d) Periodontal Services which are funded through the VFRE 2020 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS Mission):

D4355-Full Mouth Debridement D4342-Periodontal Scaling and Root Planning, 1 to 3 teeth per quadrant

Periodontal scaling and root planning is authorized only when a periodontal abscess is present)

(e) Prosthodontic Services which are funded through NG6H 2065 Medical Readiness Funding

D5110-Complete Denture-Maxillary D5120-Complete Denture-Mandibular D5211-Maxillary Partial Denture-Resin Base D5212-Mandibular Partial Denture-Resin Base

(f) Oral Surgery Services which are funded through NG6H 2065 Medical Readiness Funding

D7140-Extraction, Erupted Tooth or Exposed Root D7210-Surgical Removal of Erupted Tooth D7220-Removal of Impacted Tooth, Soft Tissue D7230-Removal of Impacted Tooth, Partial Bony D7240-Removal of Impacted Tooth, Completely Bony

(g) Orthodontic Services which are funded through NG6H 2065 Medical Readiness Funding

D8680-Orthodontic Retention

2. The following dental procedures are not authorized:

Bridges and/or implants Removal of Asymptomatic third molars Routine Prophylaxes (cleanings) Restorations for aesthetics only Restorations for small (non-class 3) caries Extensive Root plane/scaling Osseous Surgery Other diagnostic services

The above listings are guides to assist the State Dental Officer or his/her designee in the determining treatment to be authorized. The treatment provided to NVARNG to get the Soldier from a dental class 3 to a dental class 2 only.

3. If a Soldier needs all of his/her remaining teeth in an arch extracted and a denture placed, the Soldier will not be available for deployment for at least 6 months and shall be disqualified from immediate deployment. However, if the Soldier is otherwise deployable (passes all medical, personnel and training requirements) and, after extraction and placement of prosthesis, would be deployable, the dental treatment could be provided and the Soldier could be considered as a replacement at a later date.

4. If a Soldier will have a number of teeth extracted to the extent mastication and speech are adversely affected, then an acrylic removable partial denture will be authorized, if there is sufficient time for healing and construction of the partial denture prior to departure to Mobilization Station.

5. Soldiers requiring extensive periodontal treatment will be disqualified from deployment and educated on the TRICARE Dental Program. If he/she obtains the required therapy (from his/her private dental provider) and reaches a maintenance level, then he/she would become deployable.

6. The State Dental Officer (or designated representative) will review any dental treatment plan for dental care which exceeds $500.00 to ensure that the above clinical guidelines are met. Exceptions can be made, but they must be coordinated with the Deputy State Surgeon, State Dental Officer or Designee.

PERFORMANCE WORK STATEMENT – MEDICAL and DENTAL READINESS – Oct 2009