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Appendix A: clinical dental privileges form
46
HOSPITAL/CENTER
DEPARTMENT OF ORAL &DENTAL SURGERY
PRIVILEGING FROM
Requested =1
Granted =2
Not Granted =3
Name of Dental Practitioner:……………………………………………………………………………………
ID Number :…………………………………..………………………………………………
Current Position :………………………………………………………………………………….
Section :………………………………………………………………………………….
Qualifications :…………………………………………………………………………………..
1 PRIVILEGES 2 3 4
Requested DENTISTRY CORE PRIVILEGES Granted Not GDHAR
Granted (DAPC)
Approval
▢ Examination, Diagnosis and treatment plan
▢ Caries control
▢ Preventive measures (Flouride application and
Fissure sealant)
▢ Direct operative restorations
▢ Simple extractions
▢ Incision and drainage for fluctuate intra oral
swelling
▢ Management of acute periodontal lesion
▢ Non-surgical periodontal therapy
▢ Pulp extirpation
▢ Endodontic treatment for single canal teeth
▢ Pulpotomy
SPECILA NON-CORE PRIBILEGES (See Qualifications and Specific Criteria*)
To be eligible to apply for the special non-core privileges listed below, the applicant must
demonstrate successful Completion of an approved, recognized course when such exists, or
47
acceptable supervised training in residency, fellowship or other acceptable experience, and
provide documentation of competence in performing the requested procedure consistent
with criteria set forth in dental staff policies governing the exercise of specific privileges.
1 PRIVILEGES 2 3 4
Requested 1.RESTOEATIVE/ESTHETICDENTISTRY Granted Not GDHAR
Granted (DAPC)
Approval
▢ Indirect restorations, inlay and only.
▢ Veneers ceramic.
▢ Fixed prosthodontics
▢ Implant restorations
▢ Vital tooth bleaching
▢ Non-vital tooth bleaching
▢ Limited occlusal adjustment
HOSPITAL/CENTER
DEPARTMENT OF ORAL &DENTAL SURGERY
PRIVILEGING FROM
Requested =1
Granted =2
Not Granted =3
Name of Dental Practitioner:……………………………………………………………………...……………..
ID Number :…………………………….…………………..…………………………………
Current Position :………………………………..………………………………………………….
Section :……………...…………………………………………………………………….
Qualifications :………..…………………………………………………………………………..
1 PRIVILEGES 2 3 4
Requested 2.PEDIATRIC DENTISTRY Granted Not GDHAR
Granted (DAPC)
Approval
▢ Operative restoration for pediatric patients
48
▢ Extraction of primary and permanent teeth
▢ Space maintainers
▢ Pulpotomy/ pulpectomy
▢ Management of dental trauma
▢ Stainless steel crown
▢ Strip crown
▢ Habit breaking appliances
▢ Dental treatment under GA
1 PRIVILEGES 2 3 4
Requested 3.ORTHODONTICS Granted Not GDHAR
Granted (DAPC)
Approval
▢ Orthodontic evaluation & treatment plan
▢ Orthodontic up righting appliances
▢ Preventive /interceptive orthodontic appliances
▢ Comprehensive orthodontic treatment
▢ Utilization of fixed orthodontic appliances
▢ Utilization of removable orthodontic appliances
▢ Functional appliance.
49
HOSPITAL/CENTER
DEPARTMENT OF ORAL &DENTAL SURGERY
PRIVILEGING FROM
Requested =1
Granted =2
Not Granted =3
Name of Dental Practitioner:……………………………………………………………………………………..
ID Number :………………………………………………………………………….………..
Current Position :………………………………………………………………………………….
Section :…………………………………………………………………..……………….
Qualifications :…………………………………………………………………..………………..
1 PRIVILEGES 2 3 4
Requested 4.PROSTHODONICS Granted Not GDHAR
Granted (DAPC)
Approval
▢ Complete Dentures
▢ Immediate Dentures
▢ Chrome cobalt based removable partial Dentures
▢ Acrylic removable partial denture
▢ Denture retained by attachments
▢ Implant retained /supported dentures
▢ Fixed prosthodontics
▢ Fixed prosthodontics with vertical dimension
modification
▢ Implant restorations
▢ Maxillofacial prosthodontics
▢ Obturator for Cleft Palate
1 PRIVILEGES 2 3 4
Requested 5.ENDODONTICS Granted Not GDHAR
Granted (DAPC)
Approval
▢ Diagnosis of dental orofacial pain
▢ Anterior root canal treatment
50
▢ Bicuspid root canal treatment
▢ Molar root canal treatment
▢ Management of incompletely developed roots
▢ Removal of post and separated instruments
▢ Management of perforations
▢ Root canal retreatment
▢ Management of traumatized teeth
▢ Endodontic surgery
HOSPITAL/CENTER
DEPARTMENT OF ORAL &DENTAL SURGERY
PRIVILEGING FROM
Requested =1
Granted =2
Not Granted =3
Name of Dental Practitioner:………………………………………………………………………………………………..
ID Number :…………………………………..…………………………………………………………..
Current Position :……………………………………………………………………………………………….
Section :……………………………………………………………………………………………….
Qualifications :………………………………………………………………………………………..……..
1 PRIVILEGES 2 3 4
Requested 6.PERIODONTICS Granted Not GDHAR
Granted (DAPC)
Approval
▢ Deep Scaling & Root Planning
▢ Distal & Proximal wedge procedures
▢ Gingivectomy and gingivoplasty
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▢ Mucogingival Surgery
▢ Periodontal Osseous re-contouring Surgery
▢ Periodontal Osseous Grafting procedures
▢ Gingival soft tissue grafting procedures
▢ Management of erosive or vesicular oral lesions
▢ Periodontal Splinting
▢ Occlusal Adjustment
▢ Gingival Flap Procedure
▢ Crown lengthening surgery
▢ Surgical Exposure of impacted or Underrated
Tooth to aid eruption
▢ Periodontal maintenance procedures
1 PRIVILEGES 2 3 4
Requested 7.IMPLANT DENTISTRY "SURGICAL'*** Granted Not GDHAR
Granted (DAPC)
Approval
▢ Osteo-integrated dental implant surgery-limited
▢ Osteo-integrated dental implant surgery-comlex
▢ Bone grafting procedures
▢ Soft tissue grafting procedures
▢ Intra-oral autogenous bone harvesting
(Chin/ramus)
▢ Internal sinus lift procedures
▢ External sinus lift procedures
▢ Surgical implant removal
▢ Non-surgical and surgical managements of peri-
implantitis
52
HOSPITAL/CENTER
DEPARTMENT OF ORAL &DENTAL SURGERY
PRIVILEGING FROM
Requested =1
Granted =2
Not Granted =3
Name of Dental Practitioner:………………………………………………………………………………………………..
ID Number :…………………………………..……………………………………………...……………
Current Position :…………………………………………………………………………………………..….
Section :……………………………………………………………………………………………….
Qualifications :………………………………………………………………………………………………..
1 PRIVILEGES 2 3 4
Requested 8.ORAL SURGERY Granted Not GDHAR
Granted (DAPC)
Approval
▢ Tooth Extractions
▢ Surgical extractions
▢ Surgical removal of impacted teeth
▢ Ora Antral Fistula Closure
▢ Alveloplasty /Alveolectomy
▢ Intra-oral biopsy
▢ Removal of bony exostosis
▢ Surgical repair of tongue lacerations
▢ Surgical Exposure of impacted or Underrated Tooth
to aid eruption
▢ Maxilla closed reduction, teeth immobilized
▢ Mandible closed reduction
▢ Alveolus stabilization of teeth, splinting
▢ Closed reduction of TMJ dislocation
53
HOSPITAL/CENTER
DEPARTMENT OF ORAL &DENTAL SURGERY
PRIVILEGING FROM
Requested =1
Granted =2
Not Granted =3
Name of Dental Practitioner:………………………………………………………………………………………………..
ID Number :……………………………….…..…………………………………………………………
Current Position :……………………………………………………………………………………………….
Section :……………………………………………………………………………………………….
Qualifications :…………………………………………………………………….………………………..
1 PRIVILEGES 2 3 4
Requested 9.ORAL AND MAXILLOFACIAL SURGERY* Granted Not GDHAR
Granted (DAPC)
Approval
▢ Surgical extractions
▢ Surgical removal of impacted teeth
▢ Oral Antral Fistula Closure
▢ Alveloplasty/Alveolectomy
▢ Intra-oral biopsy
▢ Removal of bony exostosis
▢ Surgical repair of tongue lacerations
▢ Surgical Exposure of impacted or unerrupted tooth
to aid eruption
▢ Admit patient
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▢ Biopsy
▢ Sinus lift procedure for dental implant placement
▢ Bone grafting to mandible, maxilla & zygomatico-
maxillary complexes
▢ Closed reduction maxillary fracture
▢ Closed reduction of zygomatico-maxillary complex
▢ Harvesting & placement of mucosal grafts
▢ Harvesting bone for grafting-rib
▢ Harvesting bone grafting calvarium and iliac crest
▢ Harvesting skin grafts for intra oral placement
▢ ORIF and closed nasal fractures in conjunction with
other multiple fractures
▢ ORIF and closed reduction mandibular fractures
▢ ORIF mandibular fractures
▢ ORIF maxillary fractures
▢ ORIF orbital fractures
▢ ORIF zygomatico-maxillary complexes
▢ Placement of external pin fixation devices for jaws
& head frames
▢ Reconstruction of craniofacial area
▢ Removal of benign tumors, non-odontogenic
HOSPITAL/CENTER
DEPARTMENT OF ORAL &DENTAL SURGERY
PRIVILEGING FROM
Requested =1
Granted =2
55
Not Granted =3
Name of Dental Practitioner:…………………………………………………………………………………………..
ID Number :……………………………………………………………………………………………
Current Position :…………………………………………………………………………………………….
Section :……………………………………………………………………………………………….
Qualifications :………………………………………………………………………………………………..
▢ Removal of benign tumors, odontogenic
▢ Removal of benign bodies
▢ Removal of para-oral cyst
▢ Removal of torus palatines
▢ Repair of intra-oral lacerations
▢ Repair of oral-antral & oral-nasal fistulae
▢ Surgery of temporomandibular joint
▢ Surgical correction of cleft lip & palate
▢ Surgical correction of maxillary & mandibular
micrognathism
▢ Surgical correction of maxillary & mandibular
prognathism
▢ Surgical correction of other dento-facial deformities
▢ Surgical treatment of benign jaw pathology
1 PRIVILEGES 2 3 4
Requested 10.UNSPECIFIED** Granted Not GDHAR
Granted (DAPC)
Approval
▢ Laser treatment for oral conditions
▢ Nitrous oxide analgesia
▢ Oral conscious sedation
▢ IM conscious sedation
▢ Rectal conscious sedation
▢ IV conscious sedation
56
HOSPITAL / CENTER
DEPARTMENT OF ORAL & DENTAL SURGERY
PRIVILEGING FORM
REQUESTED =1
GRANTED =2
NOT GRANTED =3
NAME OF DENTAL PRACTITIONER:………………………………………… ……………………….
ID Number :…………………………………………………………………….. ……………
Current Position :……………………………………………………………………………………
Section :…………………………………………………………………………………….
Qualifications :…………………………………………………………………………………….
Qualification and Specific Criteria
Oral and Maxillofacial Surgery *
Requested
Minimum formal training for oral and maxillofacial surgery : OMFS must demonstrate
Successful completion of a residency-training program in oral and maxillofacial surgery not
less than four years SCHS accredited program.
Required previous experience for initial appointment : the OMFS who is a recent graduate
(i.e., within two years) of an oral and maxillofacial surgery residency must be able to
demonstrate that he or she has successfully performed major oral and maxillofacial
surgery
On a minimum of 75 patients- no more than five of whom required dent alveolar
surgery during the OMS residency.
The OMFS who has completed oral and maxillofacial surgery training in excess of two years
before application for initial privileges must be able to document successful performance of
at least two cases in the past 12 months in each of the major surgery categories for which
privileges are requested.
References: A letter of reference must come from the director of the applicant‘s oral and
maxillofacial surgery training program. Alternatively, letters of reference regarding
competence should come from the chief of oral and maxillofacial surgery or the credentialed
supervising OMFS at the institution where the applicant most recently practiced.
Administration of moderate sedation **
Requested
The applicant must provide, either:
57
Documentation of successful completion of an approved , recognized course in moderate
sedation that include training in 1 ) the safe administration of sedative
HOSPITAL / CENTER
DEPARTMENT OF ORAL & DENTAL SURGERY
PRIVILEGING FORM
REQUESTED =1
GRANTED =2
NOT GRANTED =3
NAME OF DENTAL PRACTITIONER:………………………………………………………………………
ID Number :………………………………………………………………………………………
Current Position :………………………….……………………………………………………………
Section :………………………………..……………………………………………………
Qualifications :…………………………………………………………………………………….
And analgesic drugs used to establish a level of moderate sedation ,2 ) use of
reversal agents for opioids and benzodiazepines , 3 ) monitoring of patients‘
physiologic parameters during sedation , and 4 ) recognition of abnormalities in
monitored variables that require intervention by the nonanesthesiologist sedation
practitioner or anesthesiologist . or
Documentation of competence in performing moderate sedation from directors of residency
or fellowship training programs which include moderate sedation as part of the curriculum.
Dental implant surgery ***
58
Requested
Documentation of successful completion of an SCHS approved residency with a minimal of
two years training in a specialty or subspecialty which included training in surgical implant
placement and implant prosthetics.
DATE: ………………………………………………...
APPLICANT NAME: ………………………………
SIGNATURE: ………………………………………..
HOSPITAL / CENTER
DEPARTMENT OF ORAL & DENTAL SURGERY
PRIVILEGING FORM
REQUESTED =1
GRANTED =2
NOT GRANTED =3
NAME OF DENTAL PRACTITIONER:………………….………………………………………………….
ID Number :…………………………….…………………………………………………..……
59
Current Position :………………………………………………………………………………………
Section :……………………………………………………………………………….………
Qualification :………………………………………………………………………………….…….
Acknowledgement of the applicant
I have requested only those privileges for which my education, training current experience,
and demonstrated performance I am qualified to perform, and that I wish to exercise at
__________
Hospital.
60
HOSPITAL / CENTER
DEPARTMENT OF ORAL & DENTAL SURGERY
PRIVILEGING FORM
REQUESTED =1
GRANTED =2
NOT GRANTED =3
NAME OF DENTAL PRACTITIONER :………………………………………………………………………
ID Number :………………………………………………………………………………………..
Current Position :………………………………………………………………………………………
Section :…………………………………………………………………………..…………….
Qualifications :…………………………………………………………………………………..……………………….
HOSPITAL APPROVALS:
Name Title Signature date
Requested By:
Approved By : Head of Section
Head of Department
Medical director
Chairman of Hospital
committee, credentialing
privileging
61
HOSPITAL / CENTER
DEPARTMENT OF ORAL & DENTAL SURGERY
PRIVILEGING FORM
REQUESTED =1
GRANTED =2
NOT GRANTED =3
NAME OF DENTAL PRACTITIONER:……………………………..…………………………………..…….
Current Position :………………………………………………………………………………………
ID Number :………………………………………………………………………………………
Section :………………………………………….……………………………………………
Qualification :……………………………………………………………………………………….
GDHAR APPROVLAS:
Name Title Signature Date
Approved By:
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Chairman of the
privileging
Committee
Appendix B: Dental privileges Process Map
63
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Clinical Privileges Request (Checklist)
Applicant's Name: …............................... Nationality:
.......................................
ID/Iqama No.: ......................................... SCFHS No.: ......................................
Please check the appropriate option below:
☐ New Application ☐ Reapplication (reasons):
- Extra privileges request
- Privileges request rejected
- Privileges request paused for further
verification
Current Job:
☐ G.P. ☐ Specialist .................................... ☐ Consultant
........................
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Dental Center/ Hospital:
................................................................................
Type of request:
☐ Core privileges ☐ Special (non-core) privileges ☐ Extra privileges
Required documents:
For core privileges and special (non-core) privileges:
☐signed, stamped and completed clinical dental privileges form
☐copy of qualifying education and training
☐copy of the Saudi commission for health specialties registration
☐Copy of Identification Card, Iqama as appropriate
☐current personal photo
66
For Extra privileges:
In addition to the above documents, the practitioner who apply for extra privileges should submit
the following:
☐an updated CV
☐signed ,stamped and completed clinical dental privileges form(including the requested extra
privileges)
☐Copies of qualifying education & training certificates, courses/workshops/seminars attended,
experience credentials, and published research If any which are related to the requested
privileges.
I hereby request the specific privileges as indicated on this delineation of
privileges listing.
Signature of Applicant___________________________________ Date_____________________
APPROVED:
Medical/Dental Director__________________________________ Date______________________
67
