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  1. 1. DELINEATION OF PRIVILEGES DEPARTMENT OF DENTISTRY Please check all that apply regardless of specialty. General/Pedodontics Requested Approved DeniedExamination, x-rays and other diagnosticproceduresDental restorationsProphylaxis, fluoride treatmentsStabilizing appliancesImpressionsDental extractions (simple)Dental extractions (surgical)Placement of intra-oral appliances OrthodonticsTooth bandingSpace maintainersStabilizing appliances for loose teethOrthopedic appliancesHabit appliances PeriodonticsBone grafts (intra-oral and extra-oral donor site)Placement and servicing of implantsGingivectomyOsteoplastyExtractions with alveolectomy and suturingRoot planingVestibuloplastiesFrenectomiesApproved: 10/01Reviewed:Department of Dentistry Delineation of Privileges Page 1 of 5
  2. 2. Subgingival curettageSoft tissue graft EndodonticsRoot canal therapyApicoectomies with osseous curettageHemisections and root amputationsReplace avulsed teethRe-Implantation of teethPulp capPulpotomy Oral and Maxillofacial SurgeryNon-surgical extraction of teethSurgical removal of erupted teethSurgical removal of impacted teethApiocectomyExposure and bonding of unerupted teethBx-oralBx-bone of face or jawBx-extraoralRepair of oral lacerationsRepair of extraoral lacerationsAlveoloplastyRepair of fistulas, sinus or nasalRepair of cleft alveolusCaldwell-Luc procedureClosed reduction of facial bone fracturesOpen reduction of facial bone fracturesTracheostomyOsteotomy of facial bonesBone grafts to maxillofacial regionHarvesting of bone graftsHarvesting of iliac crest bone graftHarvesting of cranial bone graftHarvesting of rib graftApproved: 10/01Reviewed:Department of Dentistry Delineation of Privileges Page 2 of 5
  3. 3. Cartilage grafts to maxillofacial regionSkin graft to maxillofacial regionHarvesting of skin graftsSensory nerve repairNerve graftRemoval of foreign body – maxillofacial regionIncision and drainage of head and neck infectionsTMJ surgery and reconstruction (open)TMJ arthroscopyTMJ total joint reconstructionSequestrectomy of mandible and maxillaExcision of benign and malignant lesion of themouth, face and jawsPlacement of facial bone implantsPlacement of dental implantsVestibuloplastiesOther preprosthetic procedureLaser surgeryApproved: 10/01Reviewed:Department of Dentistry Delineation of Privileges Page 3 of 5
  4. 4. Other procedures not listed:_______ MODERATE (CONSCIOUS) SEDATION ANALGESIAThis protocol shall assist in determining the competence of non-anesthesiologists (M.D./D.O./D.D.S./D.M.D.) to direct moderate sedation/analgesia for procedures performed at thehospital. This protocol endorses the ASA Guidelines for Sedation and Analgesia by Non-anesthesiologists and ASA Physical Status Classes I-IV in determining appropriatecandidates for moderate sedation.QUALIFICATIONS/CRITERIA 1. Eligibility: An individual must meet one of the following prerequisite criteria: • Have completed an ACGME/AOA residency or oral surgery residency. • Have attained ABMS Board Certification. • Maintain a current ACLS Certificate. 2. Training/Experience in Sedation/Analgesia. In addition to A.1, one of the following is required. • Formal Training: Specialized training in anesthesiology, if attained in an accredited program, as confirmed by the program director. Eligible Oral Surgeons are deemed to have special training in sedation when a current anesthesiology permit is maintained. • Hospital/Privileges: The physician’s approved privileges from a hospital listing sedation/analgesia privileges, or verification of it from the physician responsible for clinical review (Chairman/Chief/Medical Director). •Clinical Proficiency: Review of educational and self-assessment materials documenting ability to supervise sedation/analgesia, to include pharmacology, timely intervention and adverse occurrences. 3. Self-Assessment Proficiency: The applicant will possess proficiency as follows: • Pharmacology: Familiarity with the pharmacology, contraindications, agonists, and antagonists used for sedation/analgesia; familiarity with pharmaceutical contraindicationsApproved: 10/01Reviewed:Department of Dentistry Delineation of Privileges Page 4 of 5
  5. 5. and adverse results of agonists and antagonists (use appendix D of this Policy). • Didactic Review: Completion of the following: o RRMC Guidelines/Protocol for Moderate Sedation/Analgesia for Procedures. o Summary of ASA Guidelines for Sedation and Analgesia by Non-anesthesiologists. • Successful completion of moderate sedation post test, which evaluates knowledge of pharmacology and didactic review.Mentoring and ReappointmentOngoing proficiency is required to maintain privileges. Mentor reports for concurrentlyperformed invasive procedures may be accepted to document initial proficiency.PRIVILEGES, REAPPOINTMENT, AND MENTORINGInitial granting, and biennial renewal, of privileges in the Department of Dentistry shall bereviewed by the Dental Privileges Committee, which shall meet as necessary and makeappropriate recommendations to the Credentials and Privileges Committee. Privileges shallbe granted to applicants in accordance with training, experience and demonstrated ability.An Associate Staff member of the Department of Dentistry must be proctored by an ActiveStaff member of the Department of Dentistry who is not affiliated with the Associate Staffmember. Surgical privileges shall be limited to those procedures approved by the DentalPrivileges Committee and as listed on the Surgical Privileges Card._________________________________________ __________________Applicant Date_________________________________________ __________________Chief, Department of Dentistry DateDate of Recommendation by the Credentials & Privileges Committee: ____________Date of Recommendation by the Executive Committee: ____________Date of Approval by the Board of Governors: ____________Approved: 10/01Reviewed:Department of Dentistry Delineation of Privileges Page 5 of 5