Delineation of Clinical Privileges

General Dentistry Privileges

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Delineation of Clinical Privileges

General Dentistry

(D.D.S. or D.M.D.)

Qualifications for Privileges: To be eligible for General Dentistry privileges, the applicant must be a successful graduate of an American Dental Association (ADA) accredited dental school with a Doctor of Dental Surgery (D.D.S.) or Doctor of Medical Dentistry (D.M.D.) degree. Applicants must be eligible for Illinois licensure upon submission of the application and in possession of an Illinois Dental license, Illinois Controlled Substance license and Drug Enforcement Administration (DEA) certification at the time of granting privileges. The initial granting, renewal, and revision of clinical privileges will be based on the individual’s demonstrated current competence.

Core Privileges: The term core privileges refers to those clinical activities within a specialty that any appropriately trained, actively practicing practitioner with good references would be competent to perform.

Special Privileges: The term special privileges refers to those clinical activities within a specialty available at Eagle View Community Health System, Inc. sites consistent with those performed in the organization and relevant to the mission of the organization. Applicants requesting special privileges must be able to demonstrate and/or document competence in performing any requested procedure. Special privileges will be granted only if the clinical site has adequate facilities, equipment, number and types of qualified support personnel, and other required support services.

General Dentistry Core Privileges:

·  Preliminary diagnosis, initial treatment, or stabilization of oral manifestations of systemic disease

·  Management of odontogenic infections and disease through pharmacologic means and incision and drainage

·  Preventive dentistry services

·  Administration and monitoring of nitrous oxide

·  Administration of local anesthesia

·  Resorative dentistry; inlays, onlays, amalgams, composites, bonding, veneers, pin or post retention

·  Pulp caps, pulpotomy, pulpectomy

·  Deciduous root canal treatment (pulpotomy)

·  Occlusal adjustment (limited)

·  Occlusal adjustment (complete)

·  Provisional splinting

·  Occlusal splint

·  Hawley appliances

·  Root planning

·  Apexification and apexogenesis

·  Gingivectomy and gingivolplasty

·  Gingival curettage

·  Complete or partial dentures; new, reline, rebase, repair, immediate (uncomplicated)

·  Overdenture (complete and partial)

·  Crown, retainer, and pontic (uncomplicated) service not increasing the vertical dimension of occlusion

·  Resin-bonded fixed partial denture

·  Post and core procedures

·  Tooth extraction (routine) including vertical or mesioangular, high partially encapsulated third molars

·  Post trauma replantation

·  Alveoloplasty concurrent with extractions

·  Repair traumatic wounds (less than 2cm and not crossing vermilion border)

·  Soft tissue excision/biopsy

·  Frenectomy

·  Foreign body removal in the treatment of acute trauma

·  Osteitis and pericoronitis treatment

·  Limited osseous resective surgery to facilitate restorative dentistry (crown lengthening procedures)

·  Complete uncomplicated, nonsurgical root canal therapy for permanent teeth

·  Hemisection, bicuspidization, and root amputation

·  Replaced periodontal flap procedures for debridement in mild or moderate periodontitis cases

·  Bleaching of discolored teeth

·  Space maintenance

·  Removable orthodontic appliances to effect minor tooth movement or habit correction

·  Minor tooth movement (fixed appliances)

·  Habit correction appliances

·  Nonsurgical management of tempromandibular disorders

General Dentistry Special Privileges:

·  Root-end resection and root-end filling (uncomplicated anterior)

·  Tooth extraction (including fully-encapsulated third molars requiring bone removal, but excluding full-bony impactions)

REQUEST FOR PRIVILEGES

Provider Name (Please print): ______

q  General Dentistry Core Privileges as described above only.

q  General Dentistry Core Privileges with the following exceptions:

______

______

______

q  General Dentistry Core Privileges along with the following special privileges:

(please attach additional training or competence documentation)

______

______

______

______

ACKNOWLEDGEMENT OF PRACTITIONER

I have requested only those privileges for which, by education, training, current experience and demonstrated performance, I am qualified to perform, and that I wish to exercise at Eagle View Community Health System, Inc.

I understand that in exercising any clinical privileges granted, I am constrained by the policies and procedures set forth by Eagle View Community Health System, Inc.

Applicant Signature: ______Date:______

Approved by the Eagle View Community Health System Board of Directors on: ______(date)

______

EVCHS Board Representative Date

Form approved for use by the EVCHS Board of Directors – July 28, 2009