PeaceCorps

Technical Guideline 180

DENTAL POLICY

1. PURPOSE
The purpose of this guideline is to outline the pre-service,in-service and post-service
componentsof the PeaceCorps dental program.

2. BACKGROUND

Dental problems are one of the most commonin-service healthproblems for Volunteers and
are a leading causeof medical evacuations(medevacs)and post-serviceFederal Employees'
CompensationAct (FECA) claims. Many Volunteers serve in areaswith limited or no access
to dental facilities.

The pre-service dental evaluationis designedto:

.Establish a baselinedental health statusprior to PeaceCorps service;
.Identify dental problems that need to be correctedprior to PeaceCorps service;
.Determine if an individual's dental healthrequiresa country assignmentthat can support
an anticipateddental or periodontal need.

The in-servicedental program will provide:

.Support for preventive dental hygieneto maintain dental health;
.Restorative care for dental problems that arise during service;.
.A dental exam at Close of Service (CaS);
.Routine dental prophylaxis (dental cleaning) at cas.

The post-servicedental program will provide:

.Evaluation of service-relateddental conditions;
Treatment for service-relateddental conditions underFECA.

3. PRE-SERVICE

3.1 Pre-ServiceDental Clearance

The applicant is examined by a dentistof his/her choice and any recommendeddental
treatmentis performed. The dentist thencompletesthe Report of Dental Examination, Form
PC-1790 (Dental) ATTACHMENT A and sendsit with a complete set of dental x-rays to
the Office of Medical Services(OMS).

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The PeaceCorps dental consultantreviews the Report of Dental Examination and the x -rays,
and applies the following criteria for dentalclearance:
.Decayed teeth must be restoredor extracted.
Fractured teeth must be restoredor extracted.
Fracturedrestorationsmust be repaired with a new restoration or the tooth must be
extracted.
Periodontal diseasethat has the potential to becomesymptomatic must be corrected by
periodontal surgeryor extraction.
Abscessedteeth must be treated with root canal therapyor extraction.
Teeth with irreversible pulpitis mustbe treatedwith root canal therapy or extraction.
Teeth with previous root canal therapythat is failing must be retreated (either
conventionally or surgically) or extracted.
Temporal Mandibular Joint (TMJ) diseasemust be treatedand the applicant must be
without functional limitation for a period of one year prior to service.
Temporary restorations(including stainlesssteel crowns) must be replaced with
permanentrestorations.
Active orthodontic therapymust be completedand the bandsremoved. Retainers (either
fixed or removable)are acceptable.
Applicants with impacted wisdom teethare acceptedif, in the view of the examining
dentist and the OMS consultant, they are unlikely to need treatmentover the next two
years.
Applicants with bruxism and a recommendationfrom their dentist for an occlusal guard
must have the device fabricated prior to service.
Missing teethdo not need to be replaced.

The Report of Dental Examination and x-rays are maintained in the Volunteer's health
record.

3.2 Accommodation of Special Dental Needs

If an applicant's dentistrecommendsin-service preventive dental care due to a pre-

existing condition, e.g., periodontal diseaserequiring in-service periodontal therapy,the
casewill be reviewed by the PeaceCorps dental consultant.If the need for in-service
preventive dental care is confirmed and can be supportedoverseas,the applicant will be
assignedto a country that hasdental facilities that can provide the anticipatedneed.

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4. IN-SERVICE DENTAL PROGRAM

4.1 Prevention
Good dental hygiene is known to reducethe incidence of decay.Dental hygiene must
be emphasizedin both initial and continuing health educationprograms.The following
dental hygiene techniquesshould be stressedto Volunteers:
.Brush at leasttwice daily with good quality fluoride toothpaste.
.Floss at leastonce daily.
.Exercise caution when eatingfoods that may have foreign objects that could chip or
otherwise damageteeth.

Toothpaste,toothbrushes,and dental floss are provided either through the Volunteer

living allowance or supplied through the healthunit.

4.2 Mid-Service Dental Examination and Prophylaxis

PeaceCorps supportsan annualdental check-up(including prophylaxis and bitewing x-

rays) when there is a qualified dentist or dental hygienist identified at post. The rnid-
service dental examinationhas two objectives:

Routine dental cleaning;

2. Identificationandtreatmentof earlydisease

Medical evacuation(medevac)is not authorizedfor the purposesof providing an

annual dental check-up.However, dental care,including an annualcheck-up, while in
the U.S. on personalbusinessmay be authorized through the use of the PC-127C
"Authorization of Paymentof Medical/Dental Services" (see section6 below). The
rationale for annual versussemiannualdental examinationand prophylaxis is outlined
below.

Many dentists in the United Statesrecommenda dental examinationand

prophylaxis every six months.However,professional dental organizations
do not specify the frequency ofprophylaxisfor individuals with healthy
periodontia. The American Dental Association (ADA) recommends
"periodic dental examinations." The ADA has no policy regarding the
frequency of thoseexams.The U.S. PreventiveServicesTasksForce, the
preeminent source ofpreventive health recommendationsin the US, states
that "there is little evidencethat annual or semiannualdental check-ups
are necessaryfor persons without clinical evidence of dental disease."

Additionally, there is no scientific evidenceto support the premise that

semi-annualprophylaxis verseslessfrequent prophylaxis has any long-
term benefit on dental health. Multiple studieshave shown that in

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individuals with healthyperiodontia, annual scaling is as effectiveas

morefrequent scaling in maintainingperiodontal health.

There is strong evidencethat tooth brushing andflossing are effective

means of maintaining periodontal health.

Individuals with active periodontal diseaseidentified by a dentist may require more frequent
examsand scaling. In thesecasesPeaceCorps supportsand provides all necessarycare.
However, for Volunteers in good dental health, the PeaceCorps dental policy of annual
examinationsand prophylaxis, where available,is medically sound.

Dental examinationsand preventive care (cleaning and scaling)offered in country are often
limited. However, most dentistsare able to identify and treat asymptomaticcaries. When
available, cleaning and scalingshould be performed annually.

Unless the local dental care is unacceptablefor evensimple examination and treatment, all
Volunteers should have a mid-service dental examination.

4.3 In-Country Management of Dental Problems

GeneralPrinciples

The dental care available in country is frequently limited and restorative work may
needto be redone after cas. This is particularly true for crowns, root canal fillings,
and bridge work. It is often in the Volunteer's interestto delay treatmentuntil after
cas (see section8 below).

PeaceCorps does not provide dental care to treat aestheticconditions, e.g. orthodontia,
dental veneers,or whitening procedures,or to correctpre-existing structural problems,
e.g., malocclusion.

Authorizing Dental Care

All treatments except for routine check-ups, cleaning, and small fillings require
prior authorization from the OMS dental consultant.
In general,the minimum restorativedental work possible should be done in
country.
Non-destructive, temporaryproceduresshould be used wheneverpossible, thereby
allowing definitive treatmentto be carried out after COSoFor example, it may be
preferable to have a large filling done in country rather than a crown. A crown
could be applied after return to the U.S.
Treatmentto correct a pre-existing aestheticproblem is not authorized by Peace
Corps and is not allowed in country.

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Treatmentto replacepre-existing missing teethis not authorized by PeaceCorps

and is not allowed in country.
Medevac is not authorizedfor the purposesof providing routine preventive dental
care.

Management of Dental Problems

A Volunteer who requires, or is requesting,dental treatmentmay be referred to a

local dentist. The dentist will provide a diagnosis,treatmentplan and estimatedcost
of the treatmentin writing.
In all cases,except when a small filling is required, details of the treatmentplan and
cost should be sent,via a field consult through the IHC, to the OMS dental
consultantwho will advise on the bestcourseof action.
The dental consultantwill adviseone of the following three options:
~ Treatmentcanbe deferreduntil COSo
~ A temporaryprocedureshould be carried out.
~ A restorativeprocedureis required.The dental consultantwill determineif
the procedurecanbe done in country or requires medevac(regional or U.S.)

How to Contact the OMS Dental Consultant

In urgent cases,e.g., trauma,dental infections or unremitting pain:

.Send a cable or fax to OMS. Include the patient's symptoms,the treating dentist's
diagnosis, treatmentplan and estimatedcost of the treatment,as well as expected
cas date.

In non-urgentcases:
Senda cable or fax to OMS as outlined above.M~il or pouch the pre-servicex-rays,
current x-rays and a copy of the pre-serviceFonn PC-1790 (Dental) to OMS. This
provides the dental consultantwith adequateinfonnation to evaluatethe case.

Except in emergencies,the dental consultant's responseis required before authorizing

treatment.

5. ASSESSINGIN-COUNTRY DENTAL SERVICES

Volunteers must only be sentto a dentistwhose serviceshave beenassessedby the PCMO.

In addition to obtaining reports from previous patients,a visit to the dental office is generally
required. The PCMO should considerthe following factors when assessingdental services.

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Sterilization and Anti-SepsisPractices

New disposablegloves, mask, needlesand syringesand anestheticampules must be used

for eachpatient. An adequatestock mustbe seen.
Instruments must be autoclavedbetweenpatients.
All surfacesmust be disinfected betweenpatients.
Shielding for dental x-rays should be available (seeTO 350 "Use of Medical X-Rays").
SeeTO 260 "Infection Control" for additional information on infection control practices.

Dental Technique

Look at x -rays of previous root canal treatments.The tooth should be filled to within one
millimeter of its tip.
Assesshow crowns fit on a dental model, the crown should be flush with the finish line
of the preparedtooth.
Ask previous patients if they are satisfied with the service they received.
A thorough dental cleaningand scaling by a skilled dental technician typically takes30-
45 minutes. In most PeaceCorps countries, only limited dental cleanings are performed.

6. DENTAL EXAMS AND TREATMENT IN THE U.S. WHILE ON LEAVE

Volunteers may have elective dental work done in the u.s. while on leave. A PC-127C
may be issued by the PCMO as per Technical Guideline 340 "PC-127C Form
, Authorization for Paymentof Medical/Dental Services'." Unless previously authorized
by the OMS dental consultant, only evaluationand simple treatmentsshould be
authorized.PCMOs should instruct the Volunteer to contactOMS if more complex care
is required.
For mid-service dental examinationsthe 127C should read:

There are two options for payment/reimbursementfor care authorized by a 127C:

The dental provider acceptsthe 127C and submits a claim to the PeaceCorps Health
Benefit Program.This is the preferredmethod.

? The Volunteer pays for the medical care and submitsa claim for reimbursementto the
PeaceCorps Health Benefits Program.

This information, including all necessarydocumentationfor submitting a claim, is

highlighted in red, bold type in the center of the 127C.

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Claims submitted to the PeaceCorps Health Benefits Programwill be reimbursed

accordingto the PeaceCorps Health Benefits fee scheduleonly.
Prior to receiving care, the Volunteer should read and understandthe information on
payment/reimbursementfor medical care authorizedby a 127C.
A11127Cauthorizationsshouldbe submittedto the PeaceCorps Health Benefits Program
for payment or reimbursement.This includes 127Csissuedby post or by OMS, 127Cs
issued for use in the U.S. or overseas,and 127Csissued for use during service or after
COSo

7. CDS EXAMINATIONS

Refer to TG 330 "Post-ServiceHealth Benefits and Close of Service and Extension of

Service Health Evaluations."
Dental examinationsand bite-wing x-rays are provided for all Volunteers if 12 or more
months have elapsedsince their pre-servicedentalexamination.
Dental examinationsshould be performed in-country, wheneverpossible. Simple dental
treatments,suchas fillings and cleanings,canbe performed at this time. More complex
proceduresshould generallybe done after cas, unless excellent and affordable in-
country servicesare available.
The dental examinationand anytreatmentsprovided should be recorded by the
examining dentist on form PC-1790(Dental).
If qualified dental care is not available in country, a dental examination may be
authorized through a 127C.This authorizationshouldread:

8. DOCUMENTATION OF DENTAL CARE

The PC-1790 (Dental) form must be used for all pre-serviceand cas dental examinations.
Mid-service use of the PC-1790 (Dental) form is encouragedbut not required. The dentist's
office documentationof the mid-service exam is acceptableif it is accurateand complete.

9. POST-SERVICE DENTAL BENEFITS

9.1 Evaluation
Evaluation of service-relateddental conditions are authorizedusing a 127C.This
authorizationis valid for 180 dayspost-serviceand does not authorize treatment. If

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indicatedatcas, PCMOsmayissuea 127Cfor specificdentalevaluation.Whena

service-related
dentalproblemariseswithin 180daysaftercas the Post-Service
Unit
will alsoissueanauthorization.

9.2 Treatment
Dental benefits are available underFECA. The Departmentof Labor (DOL)
administersFECA. The DOL authorizesthe OMS Post-ServiceUnit to manageclaims
less than $1,000. Both the DOL and the Post-ServiceUnit use dental x-rays and
documentationmaintained in the Volunteer healthrecord to processclaims.

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