Chapter 2 - Oral Health Program

3-2.1  INTRODUCTION

1. PURPOSE. .  The Oral Health Program chapter establishes operational policy, objectives, staff responsibilities, and organizational relationships for the delivery of oral health services in the Indian Health Service (IHS or Agency).
2. Background.  Oral health impacts the physical, mental, social, and spiritual health of American Indian and Alaska Native (AI/AN) Peoples. Compared to the general United States (U.S.) population, AI/ANs are significantly more likely to experience untreated tooth decay, gum disease, and tooth loss. Additionally, poor oral health is linked with medical conditions, such as diabetes, cancer, and heart disease, reinforcing the importance of maintaining optimal oral health throughout life. The IHS Division of Oral Health (DOH) is committed to supporting the overarching Agency mission of raising the physical, mental, social, and spiritual health of AI/ANs to the highest level through quality, evidence-based oral and systemic healthcare infused with culturally responsive practices and partnerships.
3. Goals.  The goals of the IHS Oral Health Program are to:
   1. Ensure comprehensive, safe, and culturally acceptable oral health services are available and accessible to AI/ANs;
   2. The IHS Oral Health Program will conduct ethical, high quality, and evidence-based oral health promotion and disease prevention activities that will include:
      1. Development and deployment of oral health education programs for patients, communities, and oral health teams;
      2. Collaboration and cooperation with other healthcare disciplines in the planning and coordination of oral and systemic healthcare activities as an integral part of the IHS Improving Patient Care, Patient Centered Medical Home model, and Patient Centered Dental Home model; and
      3. Collaboration and cooperation with Tribal and local partners in the promotion and advocacy of sound oral health initiatives.
   3. Provide systematic monitoring and reporting of oral health outcomes, using continuous quality improvement activities to:
      1. Assess efficacy of current activities;
      2. Guide future development of oral health program initiatives and sustainable resource management; and
      3. Develop oral health education programs based on local and national needs.
4. Policy.  It is the IHS policy that all IHS oral health programs operate in compliance with relevant federal laws, including but not limited to the Privacy Act, Health Insurance Portability and Accountability Act, and the Indian Health Care Improvement Act, to deliver safe and efficacious healthcare.
5. Definitions.  
   1. Employee.  Any person employed by the IHS.
   2. Dental Health Care Providers (DHCP).  The dentists, dental hygienists, dental assistants, dental health aides, and dental health aide therapists that provide dental and oral healthcare within the IHS healthcare system. A DHCP can be an IHS employee, contractor, volunteer, or trainee.
   3. Dental Specialists.  Dental specialists are dentists who have received additional training beyond a degree in general dentistry to specialize in a branch of dentistry. The types of dental specialties in the IHS include dental anesthesia, dental public health, endodontics, oral and maxillofacial surgery, orthodontics, pediatric dentistry, periodontics, and prosthodontics.
   4. Dentistry.  The practice of evaluating, diagnosing, preventing and treating the diseases, disorders, and conditions of the oral-maxillofacial area and associated structures and their impact on the body.

3-2.2  ORGANIZATIONAL RESPONSIBILITIES

1. Director, Indian Health Service  The Director, IHS, will support and promote the implementation of a comprehensive oral health program as defined by this chapter. The Director, IHS, will:
   1. ensure that the IHS operations comply with applicable federal laws, regulations and standards;
   2. support the development, implementation, and evaluation of the DOH program so all IHS oral health programs are operating in compliance with relevant federal laws including but not limited to the Privacy Act, Health Insurance Portability and Accountability Act, and the Indian Health Care Improvement Act to deliver safe, efficacious healthcare;
   3. provide leadership and assume overall responsibility for implementing, maintaining, and monitoring performance of the DOH program;
   4. support dental clinics at all service locations of the Agency by providing adequate budgets, equipment, materials, authority, and staff to implement the oral health programs as resources permit;
   5. ensure the Agency budget submission includes appropriate financial and other resources to effectively implement and administer the IHS oral health programs; and
   6. support the recognition of superior performance of oral health programs by an individual or group. The DOH staff and committees may establish recognition criteria and awards for employees and DHCPs.
2. Chief Medical Officer, IHS  The IHS Chief Medical Officer is administratively responsible for the issuance of this policy.
3. Director, Office of Clinical and Preventive Services  The Office of Clinical and Preventive Services Director serves as the primary coordinator for the development of policies, allocation of the budget, and advocacy for clinical, preventive, and public health programs throughout the IHS.
4. Director, Division of Oral Health  The DOH Director serves as the coordinator, consultant, and advisor for all matters relating to the oral health programs throughout the IHS.
5. Division of Oral Health Staff  The functional responsibilities of the DOH Staff may best be described in two complementary components: Policy and Resource Development, and Field Support and Program Development.
   1. The Policy and Resource Development responsibilities include:
      1. development of policy for oral health programs;
      2. development of resource opportunities;
      3. formulation, monitoring, and evaluation of oral health resource utilization; and
      4. development of liaison and advocacy relationships within the IHS, and other Federal, State, and professional programs which may impact the oral health of AI/ANs.
   2. The Field Support and Program Development component is the principal provider of support to the IHS and of technical assistance, as available, to Tribal health programs (THP) contracted under the Indian Self-Determination and Education Assistance Act in areas of staff development, information management, prevention, and community-based health promotion, and is responsible for:
      1. planning, implementation, and evaluation of staff development and continuing dental education for oral health providers;
      2. assisting the IHS Office of Human Resources with the recruitment of professional staff for the dental program;
      3. continuous evaluation and development of the electronic health record system to ensure maximum integration of patient health information, population demographics, and data aggregation between the electronic dental record and the electronic health record; and
      4. developing and coordinating applied research and surveillance in areas of oral disease prevention, health promotion, and cultural and behavioral aspects of oral health status and services delivery.
6. Area Dental Officer (ADO)  The ADO or Area/Regional Dental Consultant is appointed by either official memorandum or position description by an Area Office. The ADO serves as the coordinator, consultant, and advisor to the DOH staff, Area Director, Area program staff, Service Unit (SU) staff, and THPs (as appropriate) on all matters relating to an Area’s delivery of dental services and oral health initiatives. Responsibilities include planning, coordinating, implementing, and evaluating the clinical and community oral health activities within the Area so resources are used in the most effective manner possible. Carrying out these responsibilities requires:
   1. monitoring the utilization of resources;
   2. facilitation of staff development and training for the oral health providers in the Area;
   3. evaluation of the quality of clinical and community oral health services provided within the Area; and
   4. the development of liaison and advocacy relationships within the IHS and other Federal and State programs that may have a positive impact on the oral health of AI/ANs.
7. Service Unit (SU) Staff  Dental program activities at the SU level are the responsibility of the Chief, Dental Unit. The staffing of each SU dental program is a function of the size of the population served and the clinical facilities available. The SU may contain one or more facilities. Responsibilities include planning, coordinating, implementing, and evaluating SU clinical and community oral health activities within the framework of the Area program. Carrying out these responsibilities requires:
   1. the delivery of evidence based and safe, high quality clinical and community oral health services that address the needs of the community;
   2. monitoring the utilization of SU oral health resources;
   3. (ongoing staff development for dental personnel within the SU;
   4. evaluation of the quality and safety of clinical and community oral health services provided within the SU; and
   5. development of liaison and advocacy relationships within the SU and the community to integrate oral health activities with the full complement of other healthcare programs.
8. National Oral Health Council (NOHC)  The NOHC is a permanent council of IHS comprising all federal dental staff in the IHS/Tribal/Urban Indian Organization (I/T/U) programs and chaired by the DOH Director or an appointee of the DOH Director. The primary purpose of the NOHC is to advocate for improvements in the oral health of AI/ANs by advising and assisting the IHS leadership concerning relevant health issues and policies while promoting integration of oral health into overall health.
9. Interagency Relationships  The IHS Oral Health Program has a predominantly clinical orientation. Periodically, however, the opportunity arises for collaboration with organizations, which may have differing missions but mutual areas of interest. These interagency relationships may be long standing, ongoing agreements, or arrangements of more limited duration to facilitate accomplishment of a short-term objective.

   The IHS may enter into joint projects with other agencies of the Federal Government, Tribal governments, State health departments, academic institutions, voluntary or proprietary institutions, or international health agencies, as permitted by law. These projects may offer the opportunity to exchange information and share expertise with other parties, ultimately enabling the IHS to carry out its mission in a more effective way.

   Examples of such relationships include interagency agreements with the Centers for Disease Control and Prevention (CDC), the National Institutes of Health; collaborations with the World Health Organization; and memoranda of agreement with Tribal governments and dental schools.

3-2.2  ORAL HEALTH PROGRAM OPERATIONS

1. Staffing  Dental staff recommendations consist of DHCP and support staff with the goal to most efficiently balance the treatment needs of the communities served with the available resources. Dental staffing recommendations may be found on the IHS website at https://www.ihs.gov/dper/planning/rrm-references/dental/.
2. Credentials  Ensuring appropriately credentialed staff is vital to ensuring all staff are qualified for duties listed in position descriptions. Duties are assigned by supervisors. Oral health services carried out by DHCP will fall within the scope of practice authorized by their license, certification, etc., and IHS policy. Those DHCPs that are licensed independent practitioners will have privileges approved by the facility governing board after recommendation from the medical staff.
3. Education  
   1. Dentists.  Dentists must have a Doctor of Dental Medicine or Doctor of Dental Surgery degree from a school approved by the American Dental Association or the Commission on Dental Accreditation or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained.
   2. Dental Specialists.  Dental Specialists must meet the educational requirements for dentists and have proof of successful completion of a specialty dental program accredited by an accrediting institution recognized by the U.S. Department of Education at the time the program was completed.
   3. Dental Hygienists.  Educational and/or experience requirements vary per vacancy.
   4. Dental Health Aides (DHA) and Dental Health Aide Therapists (DHAT).  DHAs and DHATs must the educational requirements outlined in the Indian Health Service Circular No. 20-06 or any superseding circular establishing the policy for the National Community Health Aide Program (CHAP) policy for the contiguous 48 states.
4. Licensure  All dentists and dental hygienists employed by the IHS must have a current, full, and unrestricted license to practice dentistry in a U.S. State, the District of Columbia, the Commonwealth of Puerto Rico, or a territory of the U.S.
5. Certification  
   1. DHAs and DHATs.  To provide care under the CHAP, DHAs and DHATs must be certified by the CHAP National Certification Board or a CHAP Area Certification Board, as required by the IHS CHAP policy.
   2. Dental Assistants (DA).  Unless certified by the American Dental Assistant Association, DAs taking dental radiographs will annually certify to demonstrate competency taking dental radiographs. The process is found on the dental portal. A login is required to access the competency materials.
6. Recruitment  The IHS has opportunities for scholarships, externships, and loan repayment. There are also multiple career paths to consider. The IHS Headquarters (HQ) DOH continuously updates and maintains www.ihs.gov/dentistry for recruitment of oral health professionals for all I/T/U dental programs. Dental provider vacancies are kept up to date with contact information and USAJOBS.GOV links. This is the main landing webpage for DOH’s recruitment efforts that houses up-to-date information about the dental opportunities available at the IHS.
7. Continuing Dental Education  The IHS HQ DOH continues to improve the delivery of services through a sustained (20+ years) continuing dental education (CDE) program and provision of long-term training opportunities. The IHS CDE program provides American Dental Association Commission for Continuing Education Provider Recognition approved quality education with approximately 250 clinical and public health courses for dentists, dental hygienists, dental assistants, and dental public health leadership in federal, Tribal and urban Programs.
8. Performance Standards  
   1. Staff Performance Evaluations.  
      1. Performance Management Appraisal Program (PMAP).  Federally employed staff undergo annual evaluation through the PMAP system. It is encouraged that employees participate in establishing their PMAPs so that performance expectations are clearly understood. Supervisors are responsible for ensuring the elements and standards focus on specific, measureable, attainable and timely results. Final decisions on critical elements and standards rest with the supervisory official.
      2. Commissioned Officers’ Effectiveness Report (COER).  Dental officers are annually evaluated using the COER. Dental efficiency and performance standards used to evaluate civilian staff may be used by the supervisor as a basis for COER completion. The process usually begins in September but may be completed at other times by the supervisor.
   2. (2) Program Evaluations .  
      1. Division of Oral Health Effectiveness and Efficiency Standards.  The IHS DOH recommends that Area Dental Officers, Dental Support Centers, or Dental Chiefs/Dental Directors assess clinical efficiency and effectiveness annually or at least biannually. The DOH developed and maintains dental clinic efficiency and effectiveness standards by which the I/T/U dental programs can measure clinical productivity, staffing ratios, and specific clinical efficiency indicators against national averages. Collectively, these indicators serve only as a recommendations for assessing clinical productivity, efficiency, effectiveness, and quality of care provided. The IHS DOH Effectiveness and Efficiency Standards are found in the dental portal (login required).
      2. Government Performance and Results Act (GPRA.  The GPRA of 1993 required federal agencies to demonstrate measurable results or benefits gained by the consumers of federal programs. In 2011, the Government Performance and Results Act Modernization Act of 2010 (GPRAMA), Public Law No. 111-352 was signed into law. The GPRAMA strengthens GPRA by requiring federal agencies to use performance data to drive decision making. The GPRAMA creates a government-wide planning and reporting framework, amends Agency-level planning and reporting requirements, requires leadership involvement and accountability, requires key performance management skills and competencies and creates an annual process to reduce duplicative and outdated planning and reporting. At the time this policy takes effect, there are three dental budget measures:
         1. Increase the percentage of individuals receiving at least one topical fluoride application.
         2. Increase the percentage of individuals receiving dental sealants.
         3. Increase annual access to dental services for the AI/AN population.
      3. Access to oral health services is the foundation upon which disease prevention and mitigation is formed. The GPRA access to dental care measure is based upon one of the eleven oral health objectives in the U.S. Department of Health and Human Services’ Healthy People 2030 Initiative (Healthy People), Oral Health Objective 08: “increase use of the oral healthcare system.” Specifically, the Healthy People objective aims to increase the proportion of children, adolescents, and adults who use the oral healthcare system each year.
9. Levels of Care  The IHS Schedule of Dental Services categorizes all types of oral health services into Levels of Care, a priority-based listing that assists community dental programs in managing their resources effectively to provide access to care. The categories are reviewed and updated every four years. The most current schedule in its entirety may be found below:

   Indian Health Service Schedule of Dental Services (Levels of Care)

   Services that alleviate pain or prevent disease are given a higher priority than those intended to contain disease, or correct damage caused by disease. Thus, emergency care has the highest priority (Level I), while providing access to complex rehabilitative care (Level V) is given the lowest priority for expending the available resources.

   The IHS Dental Levels of Care:

   1. Level I Emergency Oral Health Services
   2. Level II Preventive Oral Health Services
   3. Level III Basic Oral Health Services
   4. Level IV Basic Rehabilitation Oral Health Services
   5. Level V Complex Rehabilitation Oral Health Services
   6. Level IX Exclusions

   The majority of treatment needs in AI/AN communities falls within the first three levels, sometimes called “basic care,” which comprise the most cost-effective services to provide on a community-wide basis. As additional funds become available for dental care, the schedule can be used to expand access to care beyond basic services in an orderly, equitable, and cost-effective manner.

   The schedule forms a consistent structure for program planning as well as for the treatment planning of individual patients. However, it is intended to be a flexible tool which can be adapted to the situation of each community and of dental patients. Factors such as the availability of alternate resources, community water fluoridation, patient age, and the prognosis for success, as well as other conditions, each play a role in determining how the schedule should be applied to individuals and target groups. The general principle for implementing the schedule is always to use the available resources for providing the greatest health benefit to the greatest number of people for the longest time possible.

10. Oral Health Promotion/Disease Prevention  The DOH manages technical assistance to I/T/U programs for oral health promotion and disease prevention activities in support of direct patient care.
    1. Oral Health Surveillance Program  The IHS HQ DOH assesses the care provided by its programs through a continuing oral health surveillance program. The 2021-2030 Oral Health Surveillance Plan is 508 Compliant and is available here: IHS Oral Health Surveillance Plan, 2022-2030 (PDF - 1.13 MB). The results of all surveillance since 2010 are available on the dental portal under the data briefs tab at www.ihs.gov/doh. The IHS Oral Health Surveillance Data is also included in the CDC National Oral Health Surveillance System, allowing public health advocates to compare AI/AN disease prevalence with individual state or national data.
    2. Oral Health Initiatives  Nationally, oral health initiatives are developed after reviewing epidemiology data and evaluation of national program performance with the overall goal of improving oral health outcomes. Recent projects include the early childhood caries collaborative, promotion of self-care through oral health literacy, and improving access to care through the alternative workforce models initiative.
    3. Dental Clinical and Preventive Support Centers (DCPSC) Program  The DCPSCs were created within the IHS DOH with appropriated funds. Since their inception in 2000, DCPSCs have been funded in five year cycles through a competitive proposal process with program awards for Area offices and grants for Tribal programs. While all centers play a role in supporting GPRA along with national initiatives, each center evolves to meet the perceived needs of their primary area. Many coordinate continuing dental education through annual area dental meetings, online courses, and onsite training. Some produce high quality, culturally appropriate patient education materials; many support community-based surveillance and prevention projects; and others provide onsite consulting services to field programs. The DCPSCs also rigorously measure and evaluate their work with the goal of demonstrably improving oral health outcomes through the technical assistance and services they provide. Centers may work simultaneously to improve many different oral health programs in a region by providing support, guidance, training, and enhancement to these programs.
11. Dental Data System  The IHS has established a dental data aggregation process capable of securely collecting and storing dental/oral health treatment data transmitted from I/T/U healthcare facilities to the IHS National Data Warehouse (NDW). This data includes information related to all IHS oral health patient visits, which provides essential information for all levels of oral health program management and administration. The IHS DOH utilizes dental/oral health data to support AI/AN oral health advocacy through the management of the overall IHS Oral Health Program, including budget requests. Area Dental Consultants use dental data to evaluate an Area’s dental programs and promote oral health initiatives. Local oral health program managers use dental/oral health data to analyze the service population’s access to care, the breakdown of services by level of care, age group, and the oral health program as a whole. In addition, dental/oral health data is used to accurately reflect diagnosis and treatment for the purpose of accurate third party billing at the program level.
    1. Electronic Health Record (EHR  The IHS EHR meets common data processing needs of facility-based programs and provides data for all disciplines in I/T/U settings.
    2. Electronic Dental Record (EDR  The EDR, interfaces with the EHR to provide an integrated, electronic patient dental record. The EDR includes clinical examination data, patient appointment scheduling, staff and resource management, clinic note templates, document scanning/management, and digital imaging management software.
    3. Coordination of EHR and EDR Data  
       1. EDR/EHR Transmission.  When a patient record is created or updated in the EHR, demographic information and record numbers are transmitted to the EDR, creating/updating a patient chart with EHR demographic information. Oral health visit data (i.e. date of service, provider, procedure and diagnostic codes) is transmitted back to EHR upon completion in EDR, automatically creating a patient visit in the EHR. The IHS EDR has the capability to merge patient accounts (within the EDR system) if duplicates are created from EHR patient registration transmissions.
       2. Implementation and Upgrades.  The DOH manages the overall development and capabilities of the dental office management software, EDR system. The EDR improves the delivery of dental services by providing patient care management efficiencies including scheduling, individual patient and clinic population health tracking, data collection and reporting capabilities for program planning, and the evaluation of oral health initiatives. To ensure data is securely processed and archived, the EDR software requires continuous evaluation, development, and management, including initial EDR implementation, software and hardware updates, and system security review, even though the EDR software programs are installed and maintained locally at program facilities. As funding allows, and as permitted by law, the DOH is prepared to assist federal, Tribal and urban clinics with the IHS EDR implementation and upgrades. Interested programs may send inquiries to ihsedr@ihs.gov or visit the frequently asked questions (FAQ) on the dental portal at https://www.ihs.gov/doh/edr/.
    4. National Dental Data Mart (NDDM)  Data from both the EHR and EDR flow into the IHS National Patient Information Reporting System (NPIRS) environment. The NPIRS architecture includes functional Data Marts that are populated with specific program-related information. The NDDM provides oral health treatment data related to the DOH to support national reporting. The NDDM has several report functions to provide DOH with information containing basic counts of direct data as well as proportional data from all I/T/U programs reporting data to the NPIRS/NDW environment.