CCHD Fellowship

Program Background

The CCHD Dental Fellowship Program at TAMCOD sponsors two full-time fellows who serve for a period of 12 months, beginning July 1 of each year. Fellows responsibilities include dental care at two local children’s hospitals and several community clinics. Patients eligible for dental care have concomitant medical disease, behavioral management problems, or require emergency dental care. These ‘special’ patients present a unique challenge to the dentist and require treatment in the hospital environment. In alignment with many other general practice residency (GPR) programs, this program is designed to provide the recent graduate with an opportunity to become proficient in all areas of hospital, community, and sedation dentistry.

Our department offers a one-year fellowship in Compromised Care & Hospital Dentistry open to graduates of CODA-accredited U.S. dental schools as well as to graduates of dental schools outside of the United States. This fellowship, like most across the country, is not a CODA-approved program. Dental fellowships are considered rare, and a mechanism for accreditation does not yet exist. Graduates of the CCHD program are awarded a dual Fellowship Certificate in Compromised Care & Hospital Dentistry and Special Care Dentistry upon completion of all program requirements.

Our program is strongly rooted in hospital and community dentistry while striving to enhance competence and confidence in the various clinical disciplines that are integral components of general dentistry. Some specific goals of our program include:

Broaden the perspectives of the recent dental school graduate by affording the opportunity to observe, treat, practice, and experience techniques not common to the undergraduate curriculum.
Enhance the knowledge of the various physical systems in relation to diseased and traumatic conditions of the oral tissues.
Enhance the graduate's ability to make judgments (i.e., in arriving at a diagnosis, in planning treatment and in decision-making during treatment).
Provide formal instruction and clinical experience in medical risk assessment to insure the provision of high-quality dental care.
To aid the graduate dentists in the pursuit of career goals.

Program Goals and Objectives

The overall objectives of the program are to provide:

Advanced training in the clinical practice of dentistry at the postdoctoral level in a simulated private practice setting;
Fellow’s in diagnosis and treatment planning in a problem-based manner using total patient evaluation;
Provide clinical (hospital and community) service in comprehensive and emergency oral care to a wide range of patients with dental complexity, medically, physically and mentally compromising conditions, including age and socioeconomic status (indigent and privileged);
Extensive clinical, didactic and hospital opportunities for interdisciplinary interaction between the fellow and other health care providers;
Didactic information and clinical guidance in communicative, behavioral management and practice management skills and apply them to the practice of dentistry;

An appropriate environment for critical review and presentation of literature and the pursuit of individual research interests and career goals

Fellows will be able to:

Provide comprehensive dental care for all patients.
Perform medical risk assessment on each patient and evaluate the need for special precautions prior to dental treatment.
Answer and obtain appropriate medical consultations.
Understand the process and provide competent dental care in the operating room.
Understand the process of admitting and discharging patients from the hospital.
Understand and participate in the various community agencies providing indigent dental care.
Participate in didactic seminars and incorporate knowledge into clinical dental care.
Understand and perform the various conscious sedation techniques and pharmacology of drugs used.

Every effort is made to expand and amplify the basic principles learned in dental school and to apply them in the treatment of patients requiring the hospital setting. The Fellowship curriculum includes training and didactic programs in anesthesiology, pharmacology, oral surgery, orthodontics, fixed and removable prosthodontics, endodontics, pediatric dentistry, periodontics, and operative dentistry. The fellow will practice hospital dentistry in the various dental clinics and in the operating room at Children’s Health- Dallas and Texas Scottish Rite Children’s Hospital.

Position Overview: The position of trainee involves a combination of supervised, progressively more complex and independent patient evaluation and/or management functions, formal educational, and research activities. Provision of healthcare and other professional services provided by the trainee is commensurate with the trainee’s level of advancement and competence, under the general supervision of appropriately privileged attending teaching faculty.

Responsibilities (essential job functions) of a trainee include:

70% Clinical Services, 25% Didactics, and 5% Research

Satisfactory progress in training program as measured by program goals and objectives and milestones as applicable
Meeting Technical Performance Standards
Participation in safe, effective and compassionate healthcare
Development of an understanding of the ethical, socioeconomic and medical/legal issues that affect healthcare and of how to apply cost containment measures in the provision of healthcare
Participation in institutional orientation, the educational activities of the training program, and other required education programs, within the institution or at a participating site
Assumption of responsibility for teaching and supervising other trainees and students and participation in other activities involving the clinical staff, as appropriate
Participation in institutional committees and councils to which the trainee is appointed or invited
Maintenance of certification (ACLs, PALS, ATLS, etc.) as required by enrolled training program
Maintenance of the appropriate licensure, where necessary, while appointed by TAMCOD to a training program
Documentation of cases and procedures, where appropriate, as directed by the enrolled training program and mandated accreditation body
Performance of duties in accordance with the established practices, procedures, and policies of training programs, TAMCOD, clinical departments, and other participating institutions to which the trainee is assigned
Recognition of personal conditions or situations which may affect patient safety or progress in training, and communication of this to program leadership
Compliance with TAMCOD policies and enrolled training program clinical and work hour requirements which include:
- Work within typical business hours, beyond typical business hours, unpredictable hours, or a combination of all
- Work up to 80 hours per week, averaged over a four-week period, inclusive of all in-house call, clinical and educational activities, and clinical work done from home
- Work multiple consecutive days including weekends with a minimum of one day in seven, free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call
- Return to work after eight hours off between scheduled clinical work and education periods
- Work a maximum of 24 hours of continuous duty in the hospital followed by up to an additional 4 hours on-site for patient safety, education, and effective transitions of care
- Limit moonlighting activities to comply with clinical and work hours requirements and moonlighting policies

Specific Competency Objectives upon Completion of Training

By the end of the training period, the trainee will be able to:

State the etiology and prevalence of various common and uncommon medical, developmental, psychiatric, and behavioral disorders.
List common pharmacologic agents used in the medical management of these conditions and their systemic effects.
Describe significant oral and systemic manifestations of handicapping conditions.
Be aware of major national and local advocacy and support services available in the community.
List and know the proper use of various specialized equipment that may be needed to facilitate the dental management of individuals with disabilities.
Describe the relevance of professional or other appropriate consultations in the treatment of individuals with disabilities and obtain further evaluations when necessary.
Be familiar with and obtain experience in various forms of light and deep conscious sedation, general anesthetic, and emergency management modalities and medications. Be familiar with and obtain experience in physiologic monitoring and electronic monitoring equipment and record keeping necessary for sedation and GA cases. Be familiar with and obtain experience in using emergency medical equipment and drugs.
Know the legal requirements concerning consent for dental treatment in Texas State and be able to obtain all necessary consents.
Take a comprehensive health history, obtain medical or other needed consultations, and evaluate and diagnose existing oral conditions.
Develop an appropriate treatment plan based on the health and psychosocial history, incorporating pertinent management factors such as methods of anxiety and pain control, optimum time and length of appointments, and use of support persons.
Develop and implement an individual program for preventive care, given the specific problems presented by a patient with a disability.
Demonstrate proper transport, transfer, and positioning of patients.
Demonstrate appropriate verbal and nonverbal communication skills in the treatment of patients.
Perform specialized dental procedures such as modified radiographic, restorative, prosthetic, or other specialized techniques, when appropriate.
Make an appropriate decision concerning the management of a patient with noncompliant behavior.

Curriculum Plan

The overall goal of the Fellowship program is to prepare qualified advanced general dentists to provide care to a wide variety of patients. In the context of providing such comprehensive care, specific areas of focus are listed below, followed by discipline-specific goals and objectives:

Restorative Dentistry

Increasing experience in the use of new restorative- materials, gaining knowledge in the biological aspects of dental materials and increasing confidence and competence in the planning and execution of advanced operative dentistry.
Understand properties, indications and placement of contemporary restorative materials
Develop efficiency in preparation and placement of restorations while maintaining high quality
1. Develop skill in 4-handed dentistry and use of indirect vision.
2. Fellow proficiency is examined informally during clinical treatment, and formally during each Fellow's quarterly performance review.

Fixed and Removable Prosthodontics

Providing an increased proficiency in diagnosis, treatment planning and provision of fixed prosthodontic care.
Refining skills in dental preparations and understanding the usage of newer material and devices used in this discipline are considered as well.
Increasing proficiency in diagnosis and treatment planning, in order to refine skills in the fabrication and completion of complete and partial dentures;
Utilizing new impression techniques
Understand the indications and limitations of pre-prosthetic surgery
Understand the relationship between occlusion and dental rehabilitation with fixed and removable prosthetics.
Provide an increased proficiency in diagnosis, management of temporomandibular disorders and orofacial pain; and learn when to refer to specialist
Develop greater depth of understanding of occlusal disorders.
Develop skill in communication with dental lab technicians.
Fellows proficiency is examined informally during clinical treatment, and formally during each fellow's quarterly performance review

Periodontal Therapy

Development of expertise in nonsurgical periodontics (e.g. scaling, root planning, etc.)
Understanding the indications for periodontal surgery and gaining skills in the more routine of these techniques, including an understanding of flap techniques, osseous recontouring, and gingivoplasty.
Fellow proficiency is examined informally during clinical treatment, and formally during each Fellow's quarterly performance review.

Endodontics

Will be competent in diagnosing, treatment planning and managing pulpal and periapical disease through either treatment of restorable and uncomplicated cases or referral to specialist when appropriate
Techniques involving the use of examples of the latest technology will be taught and used during conventional endodontic treatment of single and multiple rooted teeth with uncomplicated morphology.
May be exposed to diagnosis, treatment planning and management of previously endodontically treated teeth with procedural errors.
Become competent in management restoring the endodontically treated tooth.
Become competent in reevaluation of the endodontically treated tooth over extended periods of time.
Fellow proficiency is examined informally during clinical treatment, and formally during each Fellow's quarterly performance review.

Anesthesia and Pain and anxiety control utilizing behavioral and pharmacological techniques

Fellows will be expected to develop skills in preoperative evaluation, assessment of the effects of pharmacologic agents, especially those agents commonly used in treating oral and systemic diseases, venipuncture technique and administration of intravenous agents, patient monitoring, airway management, anesthetic induction and intubation, administration of anesthetic agents, prevention and treatment of anesthetic emergencies, and assessment of patient recovery from anesthesia.
Fellows also gain experience in prescribing medications for patient under their care, and receive advanced instruction and clinical experience in the control of pain and anxiety in the conscious patient, through the use of behavioral management, local anesthesia, and conscious sedation techniques, and are knowledgeable of the indication, contraindications and potential adverse reactions of medications used.
Fellows proficiency is examined informally during clinical treatment, and formally during each fellow's quarterly performance review and after month rotation with Anesthesia, OMFS, Emergency medicine rotation and Pediatric Dentistry clinic.

Emergency Medicine and Dental Care

Goals include increasing fellows’ familiarity with emergency medicine and dental emergency procedures which enable them to anticipate, diagnose and treat emergencies that may occur concurrently with dental procedures.
Fellows will be able to review a medical history to recognize factors which may predispose a patient to a systemic emergency during dental treatment, anticipate systemic emergencies by preoperative evaluation and management, diagnose the primary systemic abnormalities in a patient with a medical emergency, support a patient's respiration and/or circulation when required because of systemic collapse, evaluate and manage seizure and sudden loss of consciousness in patients, and treat allergic reactions encountered in the course of dental treatment.
Fellows are provided formal training in emergency procedures by becoming certified in Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS). Fellows also rotate through the hospital's emergency department to gain experience in managing medical emergencies.
In addition, each fellow shares "on-call" responsibilities for all afterhours dental emergencies for both the hospital's dental patients, as well as the dental patients of record of the Texas A&M School of Dentistry. Here, fellows gain experience in the diagnosis, patient assessment, and treatment of emergency problems related to the oral cavity.
1. This includes the diagnosis and provision of primary care of acute infections of oral origin, acute disorders of the oral mucosa, hemorrhage of the oral cavity, and traumatic injuries to the dental and maxillofacial structures, (wound debridement, treatment of dental and alveolar fractures, and early or initial management of fractures of facial bones).
Fellow proficiency is examined informally during clinical treatment, and formally during each fellow's quarterly performance review and after month rotation with OMFS, Emergency medicine rotation and General Dentistry clinic.

Oral Pathology and Oral Medicine

Goals include increasing fellows’ ability to recognize and differentiate pathologic structures, and to become familiar with biopsy procedures, techniques, and evaluation. Fellows will be exposed to a wide variety of oral manifestations of systemic diseases, oral dermatological conditions, and acute and chronic infections and their proper treatments.

Management of Inpatients and Same-Day Surgery Patients

Fellows with experience and training in the comprehensive management of individual inpatients or same-day surgery patients from admission to discharge. This includes training in the admission and discharge of patients, obtaining medical histories and conducting appropriate physical examinations, prescribing treatment and medications, providing dental care in the operating room, preparing the patient record, including notation of pre- and postoperative orders, progress notes, description of surgical procedures an~ discharge summaries.
Assessment is measured by fellows OR outcomes analyses, as well as by an outcomes exam, sections of which pertain to topics of inpatient and same-day surgery patients.

Physical Evaluation and Medical Risk Assessment

Development of the ability to evaluate a patient's general health status
Interpret physical signs and symptoms of systemic disease.
Utilization of laboratory data to assess the presence of abnormal systemic diseases
To recognize those medical conditions which might prejudice the provision of routine dental care is stressed.
Fellows will increase their ability to obtain a patient's medical history, perform a physical evaluation, read and understand medical charts, understand basic physiology, order and interpret basic and advanced laboratory tests, radiographic data, and commonly prescribed medications through a rotation through the Emergency Room at affiliated hospitals
Fellows participate in a didactic course (teleconference), including integrated didactic and clinical components, designed specifically to enhance the fellow's ability
1. To recognize significant deviations from normal health status which may affect dental management, make informed judgments on the risk of dental procedures to both hospitalized and ambulatory patients, and identify the need for medical consultation.
2. This course contains lectures, seminars and demonstrations covering medical history taking, including major organ systems, physical examination and interpretation of clinical laboratory studies and data.
3. Upon completion of this course fellows are able to take, record and interpret a complete medical history, understand the indications for and interpretations of laboratory studies and other techniques used in the diagnosis of oral and systemic diseases, interpret the physical evaluation performed by a physician with an understanding of the process, terms and techniques employed, use the techniques of physical examination (i.e. inspection, palpation, percussion and auscultation), conduct a physical examination of a patient's general appearance, skin, head and neck, thorax and lungs, abdomen, lymph nodes, heart, blood pressure and pulse, and neurologic and mental status.
4. Fellows are formally assessed by means of an outcomes exam, sections of which pertain to topics of physical evaluation covered in this seminar series, as well as review of each fellow's assessment of patient "History and Physical" (H&P) examinations, performed as a precursor to patient admission for inpatient or same-day surgery general anesthesia cases.

Technical Performance Standards

Trainees must demonstrate the ability to meet the following technical performance standards which are an integral part of the Trainee (Dental Fellow) Job Description. These requirements may be achieved with or without reasonable accommodations.

Program Evaluation and Assessment

In order to maintain a high degree of quality control, many aspects of the Dental Fellowship program will be subject to periodic review by the Program Director and Department Chair.

Fellow Evaluation for CCHD Program

Fellows will undergo the following evaluation procedures:

Daily:
- Evaluation of previous day's treatment, as well as planned treatment for the day. Areas of concern can be identified and corrected before impacting on patient care
Quarterly: Areas to be addressed include:
- Chart Review
- Infection Control
- Clinical Skills Evaluation
- Attitude & Motivation
- Communication Skills (written and oral)
- Didactic Evaluation

Patient Care and Procedural Skills

Provide healthcare under the supervision of faculty; the faculty member with direct responsibility for the trainee has the authority to decide which activities the trainee will be allowed to perform within the context of the assigned levels of responsibility
Gain competence and progressive autonomy, progressing from on-site and contemporaneous supervision to more indirect and periodic supervision as training progresses
Understand and interpret complex healthcare information
Synthesize information acquired in person and via remote technology
Interpret causal connections and make accurate, fact-based conclusions based on available data and information
Formulate a hypothesis, investigate the potential answers and outcomes, and reach appropriate and accurate conclusions
Identify emergency situations and respond in a timely manner
Meet applicable safety standards for the environment and follow universal precaution procedures

Dental/Medical Knowledge

Learn through a variety of modalities, including, but not limited to, providing healthcare under the supervision of faculty, didactic instruction, simulation and other laboratory instruction, physical demonstrations, team and collaborative activities, individual study, preparation and presentation of reports, and use of technology Practice Based Learning & Improvement
Demonstrate capacity for self-reflection and life-long learning
Set learning and improvement goals
Demonstrate progress on educational milestones
Incorporate formative feedback into daily practice

Interpersonal and Communication Skills

Demonstrate effective communication, participation, and collaboration in person and in writing
Perceive, appropriately interpret, and respond to another’s emotional state, including verbal and nonverbal communication
Communicate publically, including teaching and group presentations

Professionalism

Demonstrate independent prioritization of conflicting or simultaneous demands
Perform or direct complex, varied or multiple tasks simultaneously
Maintain confidentiality of information
Work effectively within multidisciplinary teams
Exercise good judgment
Complete all responsibilities in a timely manner
Adapt to changing environments and function in the face of uncertainties inherent in healthcare
Demonstrate compassion, integrity, and concern for others
Work with colleagues and provide healthcare for all individuals in a respectful and effective manner regardless of gender identity, age, race, sexual orientation, religion, disability, or any other protected status
Understand, and function within, the legal and ethical aspects of professional practice
Display ethical and moral behaviors commensurate with the role of a professional in all interactions with patients, faculty, staff, trainees, and the public

Systems-based Practice

Learn and comprehend processes and procedures
Recognize safety hazards in the clinical environment, e.g., infection risk, needle sticks, agitated patient etc., and follow standard processes and procedures to mitigate risk

Salary and Benefits

A competitive salary is paid to each fellow in accordance with prevailing rates, as confirmed by contract. No fringe benefits are available with this one-year training program. All applicants must have received a dental degree from an accredited dental school in the United States/Canada and be US citizens.

Dental Fellowship Requirements

To apply for the program, an applicant must fulfill the following requirements:

Must have passed Part I and II of the National Dental Board Examination or the Integrated National Board Dental Exam before enrollment into the program
Must be proficient in the English language.
Must be a graduate of CODA accredited dental school.
Must be eligible for dental licensure

Admission Criteria

Generally, applicants for advanced education programs are considered based on the following criteria:

Grade Point Average (3.25 minimum)
Transcript/Pattern of Academic Achievement including class standing
Completed program application
Copy of National Board Scores
Experience and Training (CV)
Recommendation Letters (3) (At least one faculty from Pediatric and Restorative Dentistry)
Personal interview

Admissions criteria is applied equally to all participants regardless of race, sex, color, national origin, or religion. TAMUCOD and our program strongly encourage minority student applications. Application deadline is February 15th.

Texas State Licensure Requirement

Successful candidates to this program will either hold a current Dentist License (issued by any U.S. State) or be eligible to apply for a Dentist License upon completion of dental school and before Fellowship start date (July 1).

Dental Fellowship Rotations Goals and Objectives

Medical Rotation (Medical Risk Assessment):

Fellows must be assigned to a rotation in medicine that has supervised practical experiences to include:

Taking, recording and interpreting a complete medical history
Understanding the indications of and interpretations of lab studies and other techniques in the diagnosis of oral and systemic disease
Understanding the relationship between oral health and systemic disease
Performing a physical evaluation and collect other date to establish a medical assessment.

Anesthesia Rotation:

Fellows must be assigned to an Anesthesia Rotation with supervised experiences in the following:

Preoperative evaluation
Assessment of effects of pharmacologic and behavioral techniques
Venipuncture technique
Patient monitoring
Airway management and intubation
Administration of pharmacologic agents
Prevention and treatment of anesthetic emergencies
Assessment of patient recovery from anesthesia

Emergency Department:

Fellows must be assigned to an Emergency Department Rotation with supervised experiences to include:

Familiarize the fellows with the treatment of medical emergencies so that they are better able to treat a range of oral emergencies
Expose fellow to the treatment of medical and dental emergencies
Be exposed to patient with primary systemic abnormalities and in a medical emergency and to assess the need for additional diagnostic studies.
Support a patient’s respiration and circulation I case of systemic collapse
Treat allergic reactions
Learn wound management
Learn early fracture management

The remaining months of the year are scheduled rotations in anesthesia, internal medicine, and oral & maxillofacial surgery. Clinical and didactic instruction covers a wide range of disciplines, including clinical dentistry, emergency medical care, inpatient care & hospital organization, pain control and anesthesiology, oral surgery, oral pathology, practice management, research, and special patient care.

Additional information

Loans: Contact your loan provider for available options.

Annual leave: Leave is granted at the discretion of the CCHD program director. Leave may not be taken together and may not be taken during major clinical rotations.

Moonlighting: Fellows are expected to devote 100 percent of their professional activities to the fellowship program. Permission to carry out professional and outside activities beyond the scope of the program can be granted only in by the program director in conjunction with the chair of the Department of Pediatric Dentistry.

Liability: Fellows receive professional liability insurance to cover all activities related to the educational program. Fellows are covered by the Texas A&M College of Dentistry Malpractice Insurance, which provides coverage for all malpractice claims and, in normal circumstances, will cover all other employment-related claims, including punitive damages, which are examined on an individual basis.

Work hours are all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care; time spent on in-house clinical and education activities, clinical work done from home, and scheduled activities, such as conferences. Work hours do not include reading and preparation time spent away from the work site.