Delineation of Clinical Privileges
General Dentistry
(D.D.S. or D.M.D.)
Qualifications for Privileges: To be eligible for General Dentistry privileges, the applicant must be a
successful graduate of an American Dental Association (ADA) accredited dental school with a
Doctor of Dental Surgery (D.D.S.) or Doctor of Medical Dentistry (D.M.D.) degree. Applicants must
be eligible for Illinois licensure upon submission of the application and in possession of an Illinois
Dental license, Illinois Controlled Substance license and Drug Enforcement Administration (DEA)
certification at the time of granting privileges. The initial granting, renewal, and revision of clinical
privileges will be based on the individual’s demonstrated current competence.
Core Privileges: The term core privileges refers to those clinical activities within a specialty that any
appropriately trained, actively practicing practitioner with good references would be competent to
perform.
Special Privileges: The term special privileges refers to those clinical activities within a specialty
available at Eagle View Community Health System, Inc. sites consistent with those performed in the
organization and relevant to the mission of the organization. Applicants requesting special privileges
must be able to demonstrate and/or document competence in performing any requested procedure.
Special privileges will be granted only if the clinical site has adequate facilities, equipment, number
and types of qualified support personnel, and other required support services.
General Dentistry Core Privileges:
 Preliminary diagnosis, initial treatment, or stabilization of oral manifestations of systemic
disease
 Management of odontogenic infections and disease through pharmacologic means and
incision and drainage
 Preventive dentistry services
 Administration and monitoring of nitrous oxide
 Administration of local anesthesia
 Resorative dentistry; inlays, onlays, amalgams, composites, bonding, veneers, pin or post
retention
 Pulp caps, pulpotomy, pulpectomy
 Deciduous root canal treatment (pulpotomy)
 Occlusal adjustment (limited)
 Occlusal adjustment (complete)
 Provisional splinting
 Occlusal splint
 Hawley appliances
 Root planning
 Apexification and apexogenesis
 Gingivectomy and gingivolplasty
 Gingival curettage
 Complete or partial dentures; new, reline, rebase, repair, immediate (uncomplicated)
 Overdenture (complete and partial)
General Dentistry Privileges
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Crown, retainer, and pontic (uncomplicated) service not increasing the vertical dimension of
occlusion
Resin-bonded fixed partial denture
Post and core procedures
Tooth extraction (routine) including vertical or mesioangular, high partially encapsulated third
molars
Post trauma replantation
Alveoloplasty concurrent with extractions
Repair traumatic wounds (less than 2cm and not crossing vermilion border)
Soft tissue excision/biopsy
Frenectomy
Foreign body removal in the treatment of acute trauma
Osteitis and pericoronitis treatment
Limited osseous resective surgery to facilitate restorative dentistry (crown lengthening
procedures)
Complete uncomplicated, nonsurgical root canal therapy for permanent teeth
Hemisection, bicuspidization, and root amputation
Replaced periodontal flap procedures for debridement in mild or moderate periodontitis cases
Bleaching of discolored teeth
Space maintenance
Removable orthodontic appliances to effect minor tooth movement or habit correction
Minor tooth movement (fixed appliances)
Habit correction appliances
Nonsurgical management of tempromandibular disorders
General Dentistry Special Privileges:
 Root-end resection and root-end filling (uncomplicated anterior)
 Tooth extraction (including fully-encapsulated third molars requiring bone removal, but
excluding full-bony impactions)
REQUEST FOR PRIVILEGES
Provider Name (Please print): ________________________________________
 General Dentistry Core Privileges as described above only.
 General Dentistry Core Privileges with the following exceptions:
_________________________________
_________________________________
_________________________________
 General Dentistry Core Privileges along with the following special privileges:
(please attach additional training or competence documentation)
_________________________________
_________________________________
_________________________________
_________________________________
General Dentistry Privileges
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ACKNOWLEDGEMENT OF PRACTITIONER
I have requested only those privileges for which, by education, training, current experience and
demonstrated performance, I am qualified to perform, and that I wish to exercise at Eagle View
Community Health System, Inc.
I understand that in exercising any clinical privileges granted, I am constrained by the policies and
procedures set forth by Eagle View Community Health System, Inc.
Applicant Signature: ____________________________
Date:__________________
I have reviewed the requested clinical privileges and supporting documentation for the above named
practitioner and recommend the following action:
 Recommend Core Privileges
 Recommend Core Privileges with requested exceptions
 Recommend the following Special Privileges
_____________________________
_____________________________
_____________________________
_____________________________
________________________________
Departmental Director
______________________
Date
Approved by the Eagle View Community Health System Board of Directors on: ___________(date)
________________________________
EVCHS Board Representative
___________________
Date
Form approved for use by the EVCHS Board of Directors – July 28, 2009