Arestin Policy
The chemotherapeutic agent Arestin is available in the prep-dispense for pre-doctoral dental student and dental hygiene student use. Please read the following to assist you in providing this patient service.
- Arestin is available in every prep dispense area. It is not stored in the refrigerator because it is very moisture sensitive and condensation would cause the material to set before placement.
- Delivery of the antibiotic requires use of a special syringe, also available in the prep-dispense.
- A requisition slip is needed to obtain the material from the prep-dispense. It must be signed by a dentist (usually a Periodontist or GP Manager).
- One delivery tip (which includes the medication), to be used on one tooth, will be dispensed per requisition slip. If additional tips are needed, additional forms must be signed by faculty.
- The appropriate ADA Code to use when delivering Arestin is D4381. The fee is $50 (fifty dollars) per tooth treated. A complete description of the ADA code is at the end of this memo. Please note that the treatment code is “by tooth, by report”. This means that a written description of the treatment will be needed for insurance reimbursement. A complete progress note should be written in the patient chart and should describe the diagnosis, the tooth and site being treated, and name the dentist prescribing the treatment. As always, supervising faculty should countersign the progress note. Insurance companies may not pay for this treatment without proper documentation in the patient chart.
- When entering the ADA code into Axium, you should indicate the surface where Arestin is used (example #30, Buccal). Note that if an additional site is treated on the same tooth, it should be documented accordingly (example #30, Distal). Seek faculty guidance for clarification. Of course, the patient should be appropriately notified of the expected fees for this treatment.
- Generally, patients should be instructed not to brush the area of application for 12 hours and not to floss the area for 10 days. Seek faculty guidance for additional information.
- If you are using Arestin from our Student Access Program; there is NO CHARGE to the patient and the code should not be entered, however you must note as usual in the EPR notes regarding administration.
ADA CODE and description of procedure according to CDT 2016: D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report FDA approved subgingival delivery devices containing antimicrobial medication(s) are inserted into periodontal pockets to suppress the pathogenic microbiota. These devices slowly release the pharmacological agents so they can remain at the intended site of action in a therapeutic concentration for a sufficient length of time.
NOTE ARESTIN STUDENT ACCESS PROGRAM IS IN EFFECT; thus seniors will have arestin via a GRANT from Orapharma and will not need to go to prep dispense or charge out a fee. ASK YOUR FACULTY FOR ARESTIN if using the Student Access program Arestin.
ASA Classifications for Local Anesthetic
| ASA Class |
Definition |
| ASA I |
Patients are considered to be normal and healthy, non-smoking, with no or minimal alcohol use. All major organs and organ systems appear in good health. Patients are able to walk up one flight of stairs or two level city blocks without for all dental treatment, distress. Little or no anxiety. Little or no risk. This classification represents a "green flag" usually not needing a medical consult unless other flags go up about patient hiding medical concerns when presented with an unhealthy general physical assessment." |
| ASA II |
Patients have mild to moderate systemic disease or are healthy ASA I patients who demonstrate a more extreme anxiety and fear toward dentistry. Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop functional limitations. Minimal after completion of the exercise because of distress since they do not have substantive risk during treatment. This classification represents a "yellow flag" for treatment, with a slight t warning flag indicating to proceed with caution with all dental care. Examples: History of well-controlled disease states including non-insulin dependent diabetes, prehypertension, epilepsy, asthma, or thyroid conditions; ASA I with a a mild respiratory condition, pregnancy, and/or active allergies as well as current smoker and/or social alcohol drinker including obesity (30 < BMI <40). May need medical consultation before all dental care. |
| ASA III |
Patients have one or more moderate to severe systemic diseases that limits activity, but is not incapacitating. Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop enroute because of distress and thus have substantive functional limitations. If dental care is indicated, stress reduction protocol and other treatment modifications are indicated. This classification represents a "yellow flag" for treatment, with a slight to strong warning flag indicating to proceed with extreme caution with all dental care. Examples: History of more than three months of angina pectoris, transient ischemic attack, myocardial infarction, cerebrovascular accident, congestive heart failure, coronary artery disease with stents, slight chronic obstructive pulmonary disease, and poorly controlled insulin dependent diabetes or hypertension as well as morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, end-stage renal disease undergoing regularly scheduled dialysis. Will need medical consultation before all dental care. |
| ASA IV |
Patients have severe systemic disease that limits activity and is a constant threat to life. Patients are unable to walk up one flight of stairs or two level city blocks. Distress is present even at rest. Patients pose significant risk since patients in this category have a severe medical problem of greater importance to the patient than the planned dental treatment. Whenever possible, planned dental care should be postponed until such time as the patient's medical condition has improved to at least an ASA III classification. This classification represents a "red flag", with a strong warning flag indicating that the risk involved in treating the patient is too great to allow planned dental care to proceed. Examples: History of less than three months of unstable angina pectoris, myocardial infarction, cerebrovascular accident, severe congestive heart failure, coronary artery disease with stents, ongoing ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, disseminated intravascular coagulation, moderate to severe chronic obstructive pulmonary disease, including uncontrolled diabetes, hypertension, epilepsy, or thyroid condition as well as renal failure with refractory ascites and end-stage renal disease not undergoing regularly scheduled dialysis. If emergency treatment is needed, medical consultation is still indicated. |
| ASA V |
Patients are moribund and are not expected to survive more than 24 hours with or without an operation. These patients are almost always hospitalized, terminally ill patients. Elective dental treatment is definitely contraindicated; however, emergency care, in the realm of palliative treatment may be necessary. This classification represents a “red flag" for dental care and any care is done in a hospital situation. Examples: History of ruptured abdominal or thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ or system dysfunction. |
| ASA E |
Emergency operation of any variety; used to modify one of the above classifications, i.e., ASA III-E. |
Updated 5/2016
Policy for local anesthesia when dental hygiene student is delivering the anesthetic.
Student should present all relevant information to faculty which must include
- Reason for anesthesia i.e. Analgesic, Patient comfort, vasoconstriction, etc.
- Present the suggestions for anesthetic agent to be used and rationale.
- Injection sites planned and duration of procedure.
- Any medical or psychological interactions or concerns.
- If use of anesthetic agent is approved, be sure to follow all safety procedures while delivery the anesthetic.
- Have all supplies needed and on tray or table w/ paper towel covering
Guide to Local Anesthesia conversion from ML to mgs
| Local Anesthetic Cartridges |
½ mg |
1 mg |
1.5 mg |
2 mg |
2.5 mg |
3 mg |
4 mg |
5 mg |
6 mg |
7 mg |
8 mg |
9 mg |
10 mg |
MAX |
| A2% Lidocaine 1.8 ML |
18 Mg |
36 |
54 |
72 |
90 |
108 |
144 |
180 |
216 |
252 |
288 |
324 |
360 |
11
|
| 1:100,000 EPI |
.009 Mg |
.018 |
.027 |
.036 |
.045 |
.054 |
.072 |
.090 |
.108 |
.126 |
.144 |
.162 |
.180 |
| 4% Articaine (Septocaine 1.7 ML |
36 Mg |
72 |
108 |
144 |
180 |
216 |
288 |
360 |
432 |
504 |
576 |
648 |
720 |
9.0
|
| 1:100,000 EPI |
.009 Mg |
.018 |
.027 |
.036 |
.045 |
.054 |
.072 |
.090 |
.108 |
.126 |
.144 |
.162 |
.180 |
| 3% Mepivicaine (Carbocaine) 1.8 ML |
27 Mg |
54 |
81 |
135 |
162 |
216 |
270 |
378 |
-- |
-- |
-- |
-- |
-- |
7.5
|
| NO EPI |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
-- |
| 0.5% Bupivicaine |
4.5 |
9 |
13.5 |
18 |
23.5 |
27 |
36 |
45 |
54 |
63 |
72 |
81 |
90 |
90 mg Absolute |
| (Marcaine) 1.8 ML 1:200,000 EPI |
.0045 |
.009 |
.0135 |
.018 |
.0225 |
.027 |
.036 |
.045 |
.054 |
.063 |
.072 |
.081 |
.090 |
Max |
*****Remember MRD is based on a 180-200 lb. lean healthy male*****
**Calculating from ML to mg: (Cartridges may read 1.7 ML or 1.8ML in the USA. Actual volume is 1.76 so we base calculations on 1.8ML for ALL). NOTE THE VISIT FORM USES 1.7 mg!
1.8 ML of 2% lidocaine:
(x% anesthetic) x (10) = x mg/ML
(x mg/mL) x (x Ml/cartridge) x (X cartridges) = x mg of anesthetic
Ex. ( 2% Lidocaine) x (10) –20 mg/ML Lidocaine
(20 mg/mL lidocaine) x 1.8 mL/cartridge) x (2 cartridges) = 72 mg lidocaine
1:100,000 epi = .01 epi so:
1.8 ML x .01 = .018mg epi, so you would dispense one cartridge 36 mg with .018 mg epinephrine for a 2% lidocaine.
The epi is 1g per milliliters of solution. So, first convert the 1 gram to 1000mg then divide by however many milliliters of solution (100,000 or 20,000 or 50,000 etc.) So for 50,000 it's .02, for 200,000 it's .005 (not .02), for 20,000 it's .05, etc.
See Page 58 in Malamed, table for conversions bottom page
FYI: Percent solutions all are 1000mg/100cc. For example a 2% = 20mg/cc, 5% = 50mg/cc, 5.5% = 55mg/cc, etc...
This is why 2% solution is 20mg/ml
Calculating MRD= MAX REC DOSAGE (based on a 160 lb male) for 2% lidocaine w/ Epinephrine
160 lb. patient:
MRD 3.2 mg/lb
160 x 3.2 mg/lb = 500* rounded
Divide 500 by 36 = 11 = Max cartridges (this is because the dose-limiting factor
2nd example:
100 lb. patient:
MRD 3.2 mg/lb
100x 3.2 mg/lb = 320 mg/lb
320/35 = 10.0 cartridges MAX
MRD Calculations:
Lidocaine HCL w/epi; MRD 3.2 mg/lb
Mepivacaine HCL plain; 3.0 mg/lb
Articaine HCL 1:100,000; 3.6 mg/lb
Articaine HCL 1:200,000; 3.6 mg/lb
Prilocaine HCL 1:200,00; 3.6 mg/lb
Bupivacaine; 0.9 mg/lb (90 mg absolute maximum)
Considerations:
Pregnancy/Breastfeeding Category B (safe) Lidocaine
Category C (uncertain safety): Mepivacaine, Bupivacaine, Articaine
Epinephrine concerns:
Uncontrolled hyperthyroidism-Contraindicated
Tricyclic antidepressants (Elavil, amitryptyline) CARDIAC DOSE, Cannot use synthetic epi Beta Blockers; CARDIAC DOSE=2 cartridges 2% lidocaine with EPI
Pts taking MAO inhibitors (monoamine oxidase) (marplan, Eldepryl, Parnat, Nardil); consult with faculty and DDS Allergy to sodium bisulfite preservative (for epi cartridges) use carbocaine NO cartridges with EPI may be used.
ADA Radiology Guidelines
Recommendations for Prescribing Dental Radiographs
These recommendations are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only
Type of Encounter
|
Patient Age and Dental Developmental Stage |
| Child with Primary Dentition (prior to eruption of first permanent tooth) |
Child with Transitional Dentition (after eruption of first permanent tooth) |
Child with Permanent Dentition (prior to eruption of first permanent tooth) |
Adult, Dentate or Partially Edentulous |
Adult, Edentulous |
| New Patient* being evaluated for oral diseases |
Individualized radiographic exam consisting of |
Individualized radiographic exam consisting of |
Individualized radiographic exam consisting of |
Individualized radiographic exam, based on clinical signs and symptoms. |
| Recall Patient* with clinical caries or at increased risk for caries** |
Posterior bitewing exam |
Posterior bitewing exam at 6-18 month intervals |
Not applicable |
| Recall Patient* with no clinical caries and not at increased risk for caries** |
Posterior bitewing exam |
Posterior bitewing exam at 18-36 month intervals |
Posterior bitewing exam at 24-36 month intervals |
Not applicable |
| Recall Patient* with periodontal disease |
Clinical judgment as to the need for and type |
Not applicable |
| Patient (New and Recall) for monitoring of dentofacial growth and development, and/or assessment of dental/skeletal relationships |
Clinical judgment as to need for and type of radiographic |
Clinical judgement as to need for and type of radiographic images |
Usually not indicated for monitoring of growth and development. Clinical |
| Patient with other circumstances including, but not limited to, proposed or existing implants, other dental and craniofacial pathoses, restorative/endodontic needs, treated periodontal disease and caries remineralization |
Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of these conditions |
Approval
It is Clinic Policy for all Diagnostic Radiographs to be approved within MiPACS AT THE TIME OF SERVICE. If not accomplished at the time of service, Approval should be accomplished within 48 hours.
If you have outstanding unapproved radiographs that are older than 48 hours, the new policy as of summer 2016 states that you will be LOCKED OUT from exposing new radiographs!!
Why this change?
- Medicolegal confusion in date of service versus date of completion
- Financial confusion with patients and lack of ability to bill for service that has not been completed & approved
- Resulting decrease in Clinic Revenue!!
*Clinical situations for which radiographs may be indicated include, but are not limited to:
- Pervios periodontal or endodontic treatment
B. Positive Clinical Signs/Symptoms
- Clinical evidence of periodontal disease
Nine Rules for Determining Clinical Acceptability of a CRS
- Adequate periapical bone must be shown around the teeth, which are included in any given image so that the periapical conditions can be evaluated. Usually there should be at least 1/8th of an inch (3 mm) beyond the apex of the teeth of interest.
- Sufficient surrounding structure should be seen so that the lamina dura and periodontal ligament space can be evaluated.
- A maxillary molar periapical image must show the third molar area, even if the 3rd molar is missing in the jaw.
- All maxillary and mandibular alveolar bone must be shown at least once. This is true whether there are teeth or simply edentulous bone in the area.
- The first molar generally, should appear on the premolar radiograph.
- Interproximal contact areas must be shown for each interproximal area at least once. Contact areas between adjacent teeth should appear to touch, but have no overlap.
- Cone cuts and other artifacts should not interfere with the diagnostic quality of the radiographic image.
- The premolar bite wing must show the:
- Distal aspect of the most anterior canine
- Contacts between canine and premolars of each arch
- Alveolar interproximal crestal bone of each jaw
- The molar bite wing must show:
- Contacts between molars
- Contacts between first molar and second premolar of each arch
- Alveolar interproximal crestal bone of each jaw
A panoramic radiograph should not routinely substitute for a periapical radiographic image. Most patients should have either a CRS or a panoramic image and not both; particularly during the same appointment.