Background:

A variety of credentialed providers 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 (DQAC) in rule. Dental assistants must register with the DQAC.
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 DQAC 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 the permit of the oral and maxillofacial surgeon or dental anesthesiologist where the dental anesthesia assistant will be performing his or her services.

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Summary of Substitute Bill:

A person may not practice dental therapy or represent himself or herself as a dental therapist without being licensed by the Dental Quality Assurance Commission. A dental therapist must meet the following qualifications for licensure:

completion of a dental therapist program accredited by the Commission on Dental Accreditation;
passage of an examination;
completion of a 400-hour preceptorship under the supervision of a dentist; and
payment of applicable fees.

A dental therapist may perform the following services and procedures:

oral health instruction and disease prevention education, including nutritional counseling and dietary analysis;
preliminary 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;
placement of temporary restorations;
fabrication of soft occlusal guards;
tissue conditioning and soft reline;
atraumatic restorative therapy;
dressing changes;
tooth reimplantation;
administration of local anesthetic;
administration of nitrous oxide;
emergency palliative treatment of dental pain;
the placement and removal of space maintainers;
cavity preparation;
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 removal;
brush biopsies;
repair of defective prosthetic devices;
recementing of permanent crowns;
oral evaluation and assessment of dental disease and the formulation of an individualized treatment plan;
the supervision of expanded function dental auxiliaries and dental assistants. A dental therapist may supervise no more than a total of four expanded function dental auxiliaries and dental assistants in any one practice setting. A dental therapist or advanced 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 3 to plus 4 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 must practice pursuant to a written practice plan contract with a dentist. The contract must be signed and maintained by both the contracting dentist and the dental therapist, be submitted to the Department of Health (DOH) annually, and be made available at the practice of the dental therapist. The contract must specify:

practice settings;
limitations on the services or procedures that are 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 and limits for administering and dispensing medications;
criteria for serving patients with specific medical conditions or complex medical histories; and
specific protocols for situations in which the needs of the patient exceed the dental therapist's scope of practice or capabilities.

A contracting 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. The contracting dentist must also ensure that he or she, or another dentist, is available for instant communication during treatment. A dentist may enter into a practice plan contract with no more than five dental therapists at any one time.

A dental therapist may only provide services and procedures under the off-site supervision of the contracting dentist, who must accept responsibility for all of the services and procedures provided by the dental therapist. A contracting dentist who knowingly allows a dental therapist to perform services or procedures that are not authorized in the collaborative agreement, or any dental therapist who performs such service or procedures, commits unprofessional conduct for purposes of the Uniform Disciplinary Act.

Until December 31, 2021, a dental therapist may only practice in a federally qualified health center, a community health clinic, or a rural health clinic. Beginning January 1, 2022, a dental therapist may practice only in:

a federally qualified health center;
a clinic operated by an accredited school of dentistry or school of dental hygiene;
a clinic operated by a tribal health program or an urban Indian organization; or
any clinic or practice setting in which at least 35 percent of the patient base of the dental therapist consists of patients with no dental coverage who are enrolled in Medicaid, have a medical disability or chronic condition that creates a significant barrier to receiving dental care, or have incomes of less than 133 percent of the federal poverty level.

Staff Summary of Public Testimony:

(In support) Dental care is just as essential as medical care. Lack of dental care can lead to illness, missed work, and missed school days. People with lower incomes often find it difficult to access a dentist, sometimes waiting for hours in the rain for a free clinic. Dental therapists are safe and effective members of the oral health care team. They can be trained in less time than a dentist, because they learn fewer procedures. All published evidence shows that dental therapists provide safe, quality, and effective care. Dental therapy programs in other states and nations have been successful. Dental therapists work in rural areas and treat underserved populations. Dental therapists achieve the triple aim of health care. Curricula to train dental therapists are ready to go. Prevention will help avoid severe hospital costs down the line. Dental therapists help patients avoid the emergency department, which often does not treat the underlying condition leading to repeated visits. Dental therapy would facilitate tele-dentistry in rural areas. There is a similar relationship between a dentist and dental therapist as exists between a physician and a physician assistant. Dental therapists will work under the supervision of a dentist and are not out practicing by themselves. This bill will reduce inequities in the provision of health care and treat people who do not presently have dental care with the respect that is due to them.

(Opposed) Washington already has a strong safety net for children. There are already resources available to help connect people without dental care with a dentist. Many dentists accept Medicaid and provide a lot of preventive care for children. Dental therapists look good on paper, but are not the solution—they are not reaching the populations they are designed to serve in other states. Countries that have dental therapy programs treat fewer kids than Washington does now without a dental therapy program. Studies from other states about the effectiveness of dental therapists are inaccurate. Higher Medicaid reimbursement rates will lead to more low-income patients being treated. Programs encouraging dentists to practice in rural areas, like residencies, are effective in getting dentists to work in underserved areas. Low-income people often have extensive dental needs, which are outside the scope of practice of dental therapists. People with access to care issues need professionals with more training, not less.