Dental and Medical History: To develop an appropriate treatment plan, the oral health care provider will obtain information about the client’s health and medication status. At a minimum, the provider will obtain and review medical history and conduct a limited physical evaluation at the initial appointment and update annually.

This information may include the following:

• Chief complaint
• HIV-related history, including information on the
• client’s HIV-treating provider
• Pregnancy and breastfeeding status
• Current medications, including medications affecting coagulation and osteoporotic medications
• Allergies and drug sensitivities
• Alcohol and other drug use
• Tobacco use
• Physical and mental health diagnoses, including chronic conditions
• Usual oral hygiene
• Date of last dental examination

1. Percentage of clients with a dental and medical health history (initial or updated) at least once in the measurement year

Limited Physical Examination: The oral health provider is responsible for completing an initial limited physical examination in accordance with the Texas Board of Dental Examiners, which will include, at a minimum:

• Blood pressure
• Heart rate

Dental practitioners will also record blood pressure and pulse heart rate prior to invasive procedures involving local anesthetics, sedation or anesthesia. If the dental practitioner cannot obtain a client’s vital signs, they will document the reason the attempt was unsuccessful in the client's dental record.

2. Percentage of clients who had a limited physical examination, consisting of blood pressure and heart rate check at a minimum, performed at least once in the measurement year

Oral Examination: Providers will conduct an initial comprehensive oral exam, a periodic recall oral evaluation, or a problem-focused oral exam once per year. This will consist of one of the following:

• Problem-focused oral evaluation for clients with an acute concern
• Comprehensive oral evaluation, to include x-rays (full mouth and panoramic), new client
• Periodic oral evaluation to include bitewing x-rays, established client

If x-rays are not indicated for a given client, providers should document the reason (e.g., recent x-rays were available from a previous dental provider).

Oral examinations should be documented in the client’s dental record and include the following, as indicated:

• Evaluation and recording of dental caries
• Evaluation and recording of missing, misaligned, or unerupted teeth
• Evaluation and recording of restorations
• Evaluation and recording of occlusal relationships
• Evaluation and recording of lesions concerning for dysplastic oral cancer

3. Percentage of clients who had a documented oral examination completed within the measurement year.

Periodontal Screening or Examination: Providers will conduct a periodontal screen or exam at least annually for clients. This may consist of either a comprehensive initial screen or an annual re-evaluation. Exclusions include:

• Clients who had only an evaluation or treatment for a dental emergency in the measurement year
• Edentulous clients (complete)
• Clients who were younger than13 years of age during the measurement year

The initial periodontal screen will include the assessment of medical and dental histories, the quantity and quality of attached gingiva, bleeding, tooth mobility, and a radiological review of the status of the periodontium and dental implants.

Annual re-evaluation will include follow-up on previously identified issues and evaluation for any new or emerging periodontal concerns.

Some forms of periodontal disease may be more severe in individuals with immune system disorders. Clients with HIV may have especially severe forms of periodontal disease, and the incidence of necrotizing periodontal diseases may increase with clients with AIDS.

4. Percentage of clients who had a periodontal screen or examination at least once in the measurement year, unless exclusions apply.

Dental Treatment Plan: The provider will develop a dental treatment plan that includes preventive care, maintenance, and elimination of oral pathology and will discuss this plan with the client. Oral health providers will select treatment options in collaboration with the client.

Treatment plans will be appropriate for the client’s health status, financial status, and individual preference, and must include, as clinically indicated:

• Provision for the relief of pain
• Elimination of infection
• Preventive care
• Periodontal treatment
• Elimination of caries
• Replacement or maintenance of tooth space or function
• Consultation or referral for conditions where treatment is beyond the scope of services offered
• Determination of adequate recall interval
• Invasive procedure risk assessment (prior to oral surgery, extraction, or other invasive procedure)

The oral health care professional providing the services must sign the dental treatment plan (electronic signatures are acceptable).

5. Percentage of clients who had a dental treatment plan developed or updated at least once in the measurement year. 

Initial Treatment Plan: New clients will receive a treatment plan that includes prevention, maintenance, and elimination of oral pathology resulting from dental caries or periodontal disease. The dental provider will complete this plan within the first year of services. The plan should include, as appropriate:

• Restorative treatment
• Basic periodontal therapy (nonsurgical)
• Basic oral surgery that includes extractions and biopsy
• Non-surgical endodontic therapy if the tooth is restorable
• Space maintenance and tooth eruption guidance for transitional dentition.

If providers complete care on schedule, they will complete the initial treatment within 12 months of initiating treatment. If the provider is unable to complete the initial treatment plan within 12 months, the provider or interdisciplinary staff may document the reasons in the client’s dental record (e.g., client did not return for treatment).

6. Percentage of clients with an initial treatment plan completed within 12 months. 

Oral Health Education: A licensed dentist, dental hygienist, dental assistant, or dental case manager will provide and document oral health education. Education will address the following topics:

• Oral hygiene instruction
• Daily brushing and flossing (or other interproximal cleaning) or prosthetic care to remove plaque
• Daily use of over-the-counter fluorides to prevent or reduce cavities when appropriate and applicable to the client
• Smoking or tobacco cessation counseling as indicated
• The impact of poor oral hygiene and periodontal disease on overall health (oral-systemic health)

Additional areas for instruction may include nutrition. For pediatric clients, staff will provide oral health education to parents and caregivers and ensure that the information is age-appropriate.

7. Percentage of clients who received oral health education at least once in the measurement year. This includes all of the following:
    
   1. Daily brushing and flossing (or other interproximal cleaning) or prosthetic care to remove plaque.
   2. Daily use of over-the-counter fluorides to prevent or reduce cavities when appropriate and applicable to the client.
   3. Smoking or tobacco cessation counseling as indicated.

Referrals: Providers will place referrals for other services when specialized oral health care is indicated or when staff identify other medical issues during dental care. Staff will document the referral and follow-up in the client’s dental record, including the outcomes of the referral.

8. Percentage of clients who received referrals with documentation of the outcomes of the referral in the client’s dental record.

Expenditure Documentation: In the cases of emergency need or where a client needs extensive care, the maximum cost may exceed the $3000 per client per calendar year expenditure cap. Agencies must document the reason for care exceeding the yearly maximum amount in the client’s dental record and must have documented approval from the local AA for the purposes of funds only, but not the appropriateness of the clinical procedure.

9. If the cost of dental care exceeded the annual maximum amount for Ryan White and State Services funding, the agency documented the reason in the client's dental record and the local AA approved a waiver