Dental Personnel in Washington.
Washington has a variety of credentialed dental providers who provide assistance to licensed dentists. For example:

• Dental hygienists remove deposits and stains from the surfaces of teeth, apply topical preventive or prophylactic agents, polish and smooth restorations, perform root planing and soft tissue curettage, and perform other operations and services delegated to them by a dentist.  In order to be licensed, dental hygienists must complete an educational program, pass an examination, and fulfill continuing education requirements.
• Dental assistants are authorized to perform patient care and laboratory duties as authorized by the Dental Quality Assurance Commission (Dental Commission) in rule.  Dental assistants must register with the Dental Commission.
• Expanded function dental auxiliaries may perform the duties of a dental assistant and may also perform coronal polishing, give fluoride treatments, apply sealants, place dental x-ray film and expose and develop the films, give the patient oral health instruction, place and carve direct restorations, and take final impressions.  In order to be licensed, an expanded function dental auxiliary must complete a dental assistant education program and an expanded function dental auxiliary education program approved by the Dental Commission and pass an examination.
• Dental anesthesia assistants perform duties related to dental anesthesia under the supervision of an oral and maxillofacial surgeon or dental anesthesiologist.  In order to be certified, a dental anesthesia assistant must complete a training course, complete a course in basic life support and cardiac pulmonary resuscitation, and provide a supervisor's attestation.

 
Dental Health Aide Therapists.
The federal Community Health Aide Program (CHAP) is a workforce model available in tribal communities that includes three different provider types that act as extenders of their licensed clinical supervisor.  The national CHAP currently includes a behavioral health aide, community health aide, and dental health aide.
 
As part of the CHAP, dental health aide therapists (DHATs) are authorized to provide a variety of services pursuant to an agreement with a supervising dentist, including fillings and preventive services.  A DHAT may only perform pulpal therapy (not including pulpotomies on deciduous teeth) or extractions of adult teeth after consultation with a dentist who determines that the procedure is a medical emergency that cannot be resolved with palliative treatment.  A DHAT may not otherwise perform oral or jaw surgeries other than uncomplicated extractions.  A dental health aide therapist must have a high school education, complete a two-year educational and clinical program, and complete a preceptorship of at least 400 hours with a supervising dentist.
 
In 2017 the Legislature authorized DHAT services in Washington under the following conditions:

• the person providing services is a DHAT certified by a CHAP or a federally recognized Indian tribe that has adopted certification standards that meet or exceed those of a CHAP;
• services are rendered within the boundaries of a tribal reservation and are operated by an Indian health program;
• services are provided within the scope of practice set by the CHAP or tribe and pursuant to any written orders from a supervising dentist; and
• when a person is working within the scope and direction of a certified DHAT training program.

 
Dental health aide therapist services are exempted from licensing requirements for other dental professions.  The Health Care Authority was directed to coordinate with the Centers for Medicare and Medicaid services to provide that DHAT services are eligible for federal funding of up to 100 percent.

License Requirements.
A person may not practice dental therapy or represent himself or herself as a dental therapist without being licensed by the Department of Health (DOH).  The DOH must issue a license to practice as a dental therapist to any applicant who:

• successfully completes a dental therapist program:
  • that is accredited or has received initial accreditation by the Commission on Dental Accreditation (CODA); or
  • that has not received accreditation by CODA;
• for applicants who attended a program that is not accredited, completes a 400-hour preceptorship under the close supervision of a dentist;
• passes an examination; and
• pays applicable fees.

 
The Secretary of Health (Secretary) must establish the date and location of the exam, and any applicant who meets the education requirements must be scheduled for the next exam following the filing of the application.  The exam must contain subjects appropriate to the scope of practice and laws of Washington.  The Secretary, in consultation with the Dental Hygiene Examining Committee, may adopt rules to implement these requirements.  The DOH must establish continuing education requirements for license renewal in rule.
 
Applicants holding a valid license and engaged in current practice in another state may be granted a license without examination, if the Secretary determines the other state's licensing standards are substantially equivalent.
 
Limited License.
The DOH must issue a limited license to any applicant who:

• holds a valid license, certification, or recertification in another state, Canadian province, or has been certified or licensed by a federal or tribal governing board in the previous two years that allows a substantially equivalent scope of practice; 
• is engaged in active practice in another state, Canadian province, or tribe;
• has graduated from a CODA accredited dental therapy school or a dental therapy education program that the dental hygiene examining committee determines is substantially equivalent to an accredited education program;
• demonstrates knowledge of Washington dental therapy laws; and
• pays required fees.

 
A person practicing with a limited license may perform only the procedures that the person was licensed or certified to practice in the jurisdiction they held an active license.  A person who demonstrates competency in the scope of practice may apply for licensure as a dental therapist.
 
Scope of Practice.
A dental therapist may perform the following services and procedures under supervision of a licensed dentist to the extent authorized by the supervising dentist:

• oral health instruction and disease prevention education, including nutritional counseling and dietary analysis;
• comprehensive charting of the oral cavity;
• making radiographs;
• mechanical polishing;
• prophylaxis;
• periodontal scaling and root planing;
• application of topical preventative or prophylactic agents, including fluoride varnishes and pit and fissure sealants;
• pulp vitality testing;
• application of desensitizing medication or resin;
• fabrication of athletic mouth guards and soft occlusal guards;
• placement of temporary restorations;
• tissue conditioning and soft reline;
• atraumatic restorative therapy and interim restorative therapy;
• dressing changes;
• tooth reimplantation;
• administration of local anesthetic and nitrous oxide;
• emergency palliative treatment of dental pain;
• the placement and removal of space maintainers;
• cavity preparation;
• fabrication and restoration of primary and permanent teeth;
• placement of temporary crowns;
• preparation and placement of preformed crowns;
• pulpotomies on primary teeth;
• indirect and direct pulp capping on primary and permanent teeth;
• stabilization of reimplanted teeth;
• extractions of primary teeth;
• suture placement and removal;
• brush biopsies;
• minor adjustments and repairs on removable prostheses;
• recementing of permanent crowns;
• oral evaluation and assessment of dental disease and the formulation of an individualized treatment plan;
• identification of oral and systemic conditions requiring evaluation and treatment by a dentist, physician, or other health care provider, and management of referrals;
• the supervision of expanded function dental auxiliaries and dental assistants.  A dental therapist may supervise no more than a total of three expanded function dental auxiliaries and dental assistants at any one time in any one practice setting.  A dental therapist may not supervise an expanded function dental auxiliary or dental assistant with respect to tasks that the dental therapist is not authorized to perform;
• nonsurgical extractions of periodontally diseased permanent teeth with tooth mobility of plus three to plus four if the teeth are not unerupted, are not impacted, are not fractured, and do not need to be sectioned for removal; and
• the dispensation and administration of the following drugs:  non-narcotic analgesics, anti-inflammatories, preventive agents, and antibiotics.  The dental therapist may dispense sample drugs, but may not dispense or administer narcotic drugs.  A dental therapist does not have the authority to prescribe drugs.

 
A dental therapist may only practice in federally qualified health centers (FQHC) and FQHC lookalikes.
 
Practice Plan Contract.
A dental therapist may only practice under the supervision of a licensed dentist and pursuant to a written practice plan contract (contract) with a supervising dentist.  In circumstances authorized by the supervising dentist in the contract, a dental therapist may provide services without prior examination or diagnosis of a dentist and without the dentist being personally on site when services are provided.  The contract must be signed and maintained by both the contracting dentist and the dental therapist and must specify:

• the level of supervision required and circumstances when the prior knowledge or consent of the supervising dentist is required;
• practice settings;
• limitations on the services or procedures that may be provided;
• age and procedure-specific practice protocols;
• procedures for creating and maintaining dental records;
• a plan to manage medical emergencies;
• a quality assurance plan;
• protocols for the administering and dispensing of medications;
• criteria for serving patients with specific medical conditions or complex medical histories; and
• protocols for situations in which the needs of the patient exceed the dental therapist's scope of practice or capabilities.

 
The supervising dentist must accept responsibility for all services and procedures authorized and provided by the dental therapist.  A supervising dentist who knowingly permits a dental therapist to provide a service or procedure not authorized in the contact, and any dental therapist who provides a service or procedure that is not authorized, commits unprofessional conduct.  A supervising dentist may not supervise more than five dental therapists at any one time.  A supervising dentist must:

• make arrangements for the provision of advanced procedures and services needed by the patient or any treatment that exceeds the dental therapist's scope of practice or capabilities; and
• ensure that he or she, or another dentist, is available for timely communication during treatment.

 
A dental therapist may only perform the services authorized by the supervising dentist and contract and must maintain an appropriate level of contact with the supervising dentist.  A dental therapist must submit a signed copy of the contract to the Secretary at the time of licensure renewal and must submit any revisions.
 
Other Provisions.
The Washington State Dental Quality Assurance Commission (Dental Commission) membership is increased to 19 members adding two licensed dental therapists.  The Dental Commission is established as the disciplining authority for dental therapists for the purposes of the Uniform Disciplinary Act.
 
For purposes of the legend drug chapter, dental therapists are added to the definition of practitioner.  A dental therapist is also permitted to prescribe legend drugs.
 
A dental therapist must complete a one-time training in suicide assessment, treatment, and management.
 
A dental assistant and an expanded function dental auxiliary may perform services under the supervision of a dental therapist.  This act creates a new chapter in Title 18 RCW.  The DOH must adopt any rules necessary to implement this act.