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Dental Services

 

Description of Federal Requirements
Comparison of State Requirements
Table Comparing States
Complete Transcript of State Requirements on Dental Services (PDF)

Federal Regulations & Related F-tags for 483.55 Applicable Federal Regulation
Dental Services
(a) Dental Services/Skilled Nursing Facilities | F411
(b) Dental Services/Nursing Facilities | F412
 
483.55 Dental Services

 

Description of Federal Requirements    (TOP)    (NEXT)

According to the federal regulations on dental services (483.55), the facility must help the residents obtain routine dental services and 24-hour emergency dental care. As necessary, facilities must help the resident make dental appointments and arrange transportation to and from dentists' offices, and facilities must promptly refer residents with lost or damaged dentures to a dentist. Medicaid residents must be assisted to secure routine dental care to the extent covered by the state plan. Medicare residents may be charged extra for dental services, and the regulation clarifies that the facility is under no obligation to pay for routine dental services.

Dentistry and oral health are mentioned a few other places in the federal regulations. Under Resident's Rights 483.10 (c) (8) (i) (E), Protection of Resident Funds, residents covered by Medicaid or Medicare have the right without charge to various supplies, among which are specified toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss. Under the Resident Assessment standard, 483.20 (b) (1) (xi), the comprehensive resident assessment must include dental and nutritional status. Under the Administration standard, 483.75 (h) (1), the facility is responsible for contracting with qualified personnel, including dental personnel.

Comparison of State Requirements    (TOP)    (NEXT)

NOTE:  The examples below may not list all States with similar language; always check your state for specifics.

Eighteen (18) states echo all or part of the federal regulations (Indiana, New Mexico, North Carolina, South Dakota, Utah, Vermont, and Virginia) or are silent on dental regulations (Alaska, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, New Hampshire, North Dakota, Ohio, and Washington).

The remaining states typically elaborate briefly on the requirements, mentioning the need for oral hygiene to be provided, the need to keep a list of consultant dentists, the need for written policies, and/or the need for dentistry to be part of in-service educations. The most elaborate provisions spell out the elements that are included in emergency dental care and routine dental care, and the minimum provisions of a dental program in terms of frequency of examinations, use of dental hygienists, and the like. The dental provisions are all cast within the understanding that many residents have limited or no payment system for most dental care, though residents covered by Medicaid will be eligible for whatever dental services are included in the State plan; after outlining dental services, the states often specify that they are not required to pay for such services. Some states describe the characteristics of a high-quality dental program, and clarify that the resident (or resident's guardian) is to be asked at intervals if they want to receive dental treatments at their own expense.

Minnesota routine dental services include: " dental examinations and cleanings, fillings and crowns, root canals, periodontal care, oral surgery, bridges and removable dentures, orthodontic procedures, and adjunctive services that are provided for similar dental patients in the community at large, as limited by third party reimbursement policies."

In West Virginia routine dental services include "annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings, minor dental plate adjustments, smoothing of broken teeth, and limited prosthodontic procedures such as impressions of dentures and fit."

There are variations on the theme of keeping a list of dentists. Colorado specifies that if the local medical association has a list of dentists who will provide care in nursing homes, the facility must give that list residents. Idaho states that the list of dentists must be in a reasonable geographic area. Minnesota states that the list of emergency dentists must be accessible to residents.

The federal regulation requires that residents who lose their dentures must be referred to a dentist for replacement. Several states take this further, either by stipulating that if dentures are ill-fitting the referral should be made (Colorado, Idaho, West Virginia) and/or that dentures should be marked and that other efforts be made to prevent losing them. (e.g., Colorado, Idaho, Illinois, Oklahoma, Oregon, Pennsylvania). Idaho, for example, states that" identification of malfunctioning and ill-fitting dentures" is required, and several states state that nursing home staff need to be trained to detect the need for dentures. [NH Regs Plus Comment: Care and attention to protecting dentures and replacing lost dentures is an attribute of attentive care that is important to many residents; a laissez-faire attitude to lost dentures and/or missing teeth with resorting to soft diets instead of dental care is insensitive to how dental care and its cosmetic nature have had life-long importance to the self-esteem of many residents.] Among isolated examples, Georgia new construction rules call for "adequate arrangements" for dental care, and Florida rules require pediatric dentistry if children are in the facility.

Advisory Dentists    (TOP)    (NEXT)

The most usual addition is the requirement that facilities contract with a licensed dentist to advise on and oversee policies and education concerning dental practices, dental hygiene, and emergency dental care. States variously call this contracted individual (or firm) an Advisory Dentist, a Consultant Dentist, or simply a contracted dentist. With or without an Advisory Dentist requirement, the States often specify that dentists participate in in-service education for nursing staff, that nursing staff implement the recommendations of the attending dentists, and that policies be developed to manage dental care. Additionally, Arizona and Tennessee specify that the Medical Director be responsible for ensuring a dental program. The examples below show the range in the way Advisory Dentist requirements are treated:

- In Arkansas, facilities shall establish a written cooperative agreement with an advisory dentist or dental service. The agreement shall include provisions for a dentist to participate annually in the staff development program and to recommend oral hygiene policies and practices.

- In Idaho, the facility shall identify, in writing, the dentist(s) utilized to provide advice and guidance to the facility regarding policies and procedures, training of staff in dental and oral care and who is available for emergencies.

- In Kentucky, an advisory dentist shall provide consultation, participate in in-service education, recommend policies concerning oral hygiene, and shall be available in case of emergency.

- In New Mexico, the facility shall retain an advisory dentist to participate in the staff development program for nursing and other appropriate personnel to recommend oral hygiene policies and practices for the care of residents.

- In Maryland, an advisory dentist, licensed to practice in the State, shall: (1) Recommend oral hygiene policies and practices for the care of the patients and for arrangements for emergency treatment; (2) Assist in the formulation of dental health policies; and Provide direction for in-service training to give the nursing staff an understanding of patients' dental problems.

- In Massachusetts, a SNCFC shall appoint a consultant dentist with experience or training in developmental disabilities who shall participate in the development of patient care policies related to dental health, familiarize him/herself with the dental condition, needs and care of each patient, and as necessary, participate in periodic staff conferences.

- In Minnesota, a nursing home must maintain a written dental provider agreement with at least one dentist, licensed by the Board of Dentistry, who agrees to provide: A. routine and emergency dental care for the nursing home's residents; B. consultation on the nursing home's oral health policies and procedures; and oral health training for nursing home staff.

- In Oregon, the facility shall have a consulting dentist who shall: (a) Participate in the development of written policies and procedures for routine dental care, dental emergencies, and oral hygiene (OAR 411-085-0210); (b) Be available in case of a dental emergency or arrange for another dentist to be available; (c) Recommend procedures for oral health in-service training. This training shall be provided to appropriate staff at least annually; and (d) Instruct or arrange for a dental hygienist to instruct registered nurses on the facility staff in how to perform oral screenings.

- Texas has a similar provision that the facility shall have an advisory dentist who shall provide consultation, develop and participate in in-service education, and recommend policies concerning oral hygiene. Texas further stipulates that "records of in-service education meet¬ings shall be in writing."

- In Wisconsin, the facility shall retain an advisory dentist to participate in the staff development program for nursing and other appropriate per¬sonnel and to recommend oral hygiene policies and practices for the care of residents.

One of the common duties of Advisory Dentists or a Dental Program is to provide written policies for dental care. Some states go into considerable detail on the expected nature of these policies and what they will cover.

In New Jersey, the facility follows established protocols for providing all residents with regularly scheduled routine prophylactic dental services and treatments when indicated, delivered by a dentist or a dental hygienist, "except for residents whose medical records contain an explanation of why such services would not benefit the resident. " New York regulations also contemplate times that dental care might not be indicated for other physical or mental health reasons or that patient might refuse dental care; thus in New York , "the decision to defer treatment of identified dental conditions shall be documented based on physical or mental contraindications for care and the resident's informed choice."

Schedule of Dental Exam    (TOP)    (NEXT)

Some States specify a schedule for an initial dental examination and/or ongoing dental examination. A great deal of variation is found in the time requirements for the initial and the follow up examination. For example:

- In Colorado, upon admission, each resident of a facility upon his/her consent or upon the consent of a responsible person, shall have an oral examination by a licensed dentist or an initial oral inspection by a licensed dental hygienist designated by a dentist. . . . In lieu of the admission examination, the resident may present written results, for entry into his/her medical record, of an oral examination administered during a period not to exceed six months prior to admission.

- In Massachusetts, a nursing home shall ensure each patient has a complete dental examination annually and periodic dental inspection every six months.

- In Minnesota, within 90 days after admission, a resident must be referred for an initial dental examination unless the resident has received a dental examination within the six months before admission. After the initial dental examination, a nursing home must ask the resident if the resident wants to see a dentist and then provide any necessary help to make the appointment, on at least an annual basis. This opportunity for an annual dental checkup must be provided within one year from the date of the initial dental examination or within one year from the date of the examination done within the six months before admission.

- New York spells out the schedule in greater detail, including a time expectation from the identification of an oral problem to the initiation of treatment. In New York, an initial screening of each resident's oral health status shall be conducted within 48 hours of admission to determine the need for emergency care to alleviate pain, infection, or swelling. The presence and functioning of any oral prostheses shall be observed, and, with the resident's consent, the prostheses shall be indelibly marked for identification. A complete oral examination of each resident shall be conducted by a licensed and currently registered dentist or dental hygienist within 7 days following completion of the initial comprehensive assessment t and by a dentist at least annually thereafter. Based on treatment priorities determined at each time of examination, an individual plan of continuing oral hygiene and dental care meeting generally accepted standards of dental and dental hygiene care and services shall be established, or updated, and carried out for each resident. If treatment by a dentist is needed, such treatment shall begin within 30 days of the examination. This shall include arrangements for transportation when the services of a provider outside the facility are required.

- In South Carolina, when a person is admitted to a nursing home, an oral assessment by a physician, dentist or registered nurse shall be conducted within two weeks to determine the consistency of diet which the resident can best manage and the condition of gums and teeth. A written report of this assessment shall be placed in the medical record.

- In Wisconsin, every resident shall have a dental examination by a licensed dentist within 6 months after admission unless a dental examination has been performed within 6 months before admission, but subsequent dental health care shall be provided or arranged for the resident "as needed."

Choice of Dentist   (TOP)    (NEXT)

A few states stipulate that residents should have access to the dentist of their choice (Hawaii, Massachusetts, Minnesota, Rhode Island, South Carolina and Texas). Some of the wording is illustrated below.

- Hawaii states that "the patient or patient's guardian shall select the dentist of their choice."

- Massachusetts says "resident or next of kin of incompetent residents can choose dentist of their choice."

- Oklahoma describes a process of using a different dentist if the patient's s own dentist cannot be contacted in an emergency.

- Rhode Island refers to "a right to a dentist one's choice."

- South Carolina regulations say that the facility shall "encourage" residents to use the dentists of their choice

Oral Hygiene    (TOP)    (NEXT)

Specifications on oral hygiene also vary:

- Arkansas requires oral hygiene twice once a day.

- California stipulates that the oral hygiene program should eliminate offensive odors.

- Delaware specifies oral hygiene for unconscious residents.

- Illinois contains an elaborate proviso for a dental hygienist to train nurses on oral hygiene, including use of ultrasonic methods to clean teeth and dentures.

Table Comparing States        (TOP)

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope. The Table summarizes content on Dental Services by State (with a link to each State's specific language). Link to a downloadable PDF document containing all State requirements on Dental Services.

483.55 Dental Services

State Goes beyond Federal Regulations? Subjects Addressed: How State Differs From or Expands On Federal Regulations
Alabama Yes Brief reference to requirement for a dental assessment
Alaska No Alaska regulations have no reference to dental services.
Arizona Yes Brief reference to nurse dental assessment; medical director required to ensure that dental services are received;
Arkansas Yes Cooperative agreement with advisory dentist; dentist participates at least annually; in-service on dental care; dentist recommends oral hygiene practices; charge nurse duties include taking phone orders from dentists; emergency dentist address and phone number available; written policies for dental transportation.
California Yes Written policies; dentist participates in in-service education; oral hygiene requirements; name of dentist on admission agreements
Colorado Yes Written policies; annual in-service on dental care; dental exam by licensed dentist or hygienist recommended by a dentist on admission; must help residents get dental prostheses; marking of oral appliances; if local dental society maintains list of dentists willing to participate in nursing home care, the facility must share that with residents
Connecticut Yes Dental exam within 30 days of admission unless done a year prior and annually thereafter.
Delaware Yes Comprehensive assessment within 14 days of admission includes dental needs; responsibility for oral care of unconscious residents;
District of Columbia Yes Sufficient nursing time for oral care
Florida Yes If children are admitted, pediatric dentistry must be provided
Georgia Yes Organized professional staff includes at least one dentist; adequate equipment & supplies for oral hygiene; new construction provides "arrangements" for dental care.
Hawaii Yes Patient or patient's guardian shall select the dentist of their choice
Idaho Yes Written policies; advisory dentist provides advice on dental care and in-service training; oral care provided, including identification of malfunctioning and ill-fitting dentures; residents receive a list of dentists in reasonable distance of facility
Illinois Yes Dental program directed by dental personnel; training and in-service; details on education on oral hygiene practices and care of dentures, including ultrasonic cleaning methods, assessing abnormalities in the mouth; training films specified; dental prosthesis marking system
Indiana No Indiana regulations on dentistry mirror federal regulations.
Iowa Yes Brief additions: all dental notes are in patient records; dentists be asked to participate in in-service training.
Kansas No Kansas regulations have no reference to dental services
Kentucky Yes Kentucky regulations on dentistry mirror deferral with an added phrase that nursing personnel will assist the patient to carry out the dentist's recommendations.
Louisiana No Louisiana regulations have no reference to dental services.
Maine No Maine regulations have no reference to dental services.
Maryland Yes Oral hygiene policies; in-service on dental issues; nurses assist in carrying out dental care.
Massachusetts Yes Resident or next of kin of incompetent residents can choose dentist of their choice; all prophylactic, therapeutic or emergency dentistry carried out with knowledge of physician or physician-PA or physician-NP team; annual dental exam and dental inspection every 6 months; documentation in medical record;
Michigan No Michigan regulations have no reference to dental services.
Minnesota Yes Routine dental services describe in detail; initial dentist exam referral in 90 days of admission unless an exam was done in previous 6 months; annual exams thereafter; 24 hours to institute emergency dental care; clinical records on dentistry; list of lists who will provide emergency care must be available and accessible to nurses; training in oral hygiene for nursing home staff; must have on-site dentistry for residents who cannot travel.
Mississippi No Mississippi regulations have no reference to dental services.
Missouri No Missouri regulations have no reference to dental services.
Montana Yes Provide supplied for oral hygiene; dentists specified as mandatory reporters of abuse
Nebraska Yes Very slight augmentation of conditions to be referred for dental services.
New Hampshire No New Hampshire regulations have no reference to dental services.
New Jersey Yes Regularly scheduled exams; brief mention of pain or infection as reasons for dental referral.
New Mexico No New Mexico regulations do not go beyond the federal regulations.
New York Yes Written policies; elaborate program for oral hygiene and specification of issues needing emergency or other oral care; Initial screening in 48 hours of admission and exam by dentist or hygienist within 7 days of completion of comprehensive assessment, & annual exams thereafter; if treatment by a dentist is needed it must occur in 30 days after examination; dental care is part of clinical record.
North Carolina No North Carolina regulations do not go beyond the federal regulations.
North Dakota No North Dakota regulations have no reference to dental services.
Ohio No Ohio regulations have no reference to dental services.
Oklahoma Yes Dental prostheses to be marked; one or more advisory dentists; dental supplied must be available; oral hygiene at list daily; list of dental referrals to be maintained by facility.
Oregon Yes Written policies; annual in-service; a dental hygienist to instruct RNs on how to do oral screening; dentures marked; physicians informed on dental care; documentation in clinical record
Pennsylvania Yes Brief allusion to responsibility that dentures are not lost.
Rhode Island Yes Right to dentist of one's choice; maintaining a list of community dentists
South Carolina Yes Oral examination by dentist or physician in 2 weeks to determine consistency of diet needed; maintain list of dentists; "encourage" residents to use dentist of their choice.
South Dakota No South Dakota regulations do not go beyond the federal regulations.
Tennessee Yes Slight addition—policies and procedures concerning dental services provided are available to admitting physicians.
Texas Yes Detailed discussion of coverage for detail care under Texas Medicaid program.
Utah No Utah regulations do not go beyond the federal regulations.
Vermont No Vermont regulations do not go beyond the federal regulations.
Virginia No Virginia regulations do not go beyond the federal regulations.
Washington No Washington regulations have no reference to dental services.
West Virginia Yes Includes a definition of routine dental services.
Wisconsin Yes Dental exam on admission unless done within 6 months before, with subsequent exams "as needed;" staff development; dental records
Wyoming Yes In-service, dental records, oral hygiene

Complete Transcript of State Requirements on Dental Services    (TOP)