HOUSE BILL REPORT

HB 1317

As Reported by House Committee On:

Health Care & Wellness

Appropriations

Title: An act relating to the profession of dental therapist.

Brief Description: Establishing the profession of dental therapist.

Sponsors: Representatives Cody, Tharinger, Jinkins, Robinson, Entenman, Stonier, Pettigrew, Slatter, Kloba, Gregerson, Shewmake, Macri, Fitzgibbon, Lekanoff, Appleton, Frame and Ryu.

Brief History:

Committee Activity:

Health Care & Wellness: 2/13/19, 2/22/19 [DP];

Appropriations: 2/27/19, 2/28/19 [DPS].

Majority Report: Do pass. Signed by 9 members: Representatives Cody, Chair; Macri, Vice Chair; Davis, Jinkins, Riccelli, Robinson, Stonier, Thai and Tharinger.

Minority Report: Do not pass. Signed by 5 members: Representatives Schmick, Ranking Minority Member; Caldier, Assistant Ranking Minority Member; Chambers, DeBolt and Maycumber.

Minority Report: Without recommendation. Signed by 1 member: Representative Harris.

Staff: Kim Weidenaar (786-7120).

Background:

Dental Personnel in Washington.

Washington has a variety of credentialed 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 (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.

Dental Health Aide Therapists.

The federal Community Health Aide Program (CHAP):

• trains Alaska Natives as health aides or community health practitioners;

• uses health aides or community health practitioners to provide health care, health promotion, and disease prevention services to Alaska Natives in rural Alaska; and

• establishes teleconferencing capacity in health clinics in or near Alaskan villages for use by health aides or community health practitioners.

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/clinical program, and complete a preceptorship of at least 400 hours with a supervising dentist.

The federal government is authorized to expand the CHAP nationally; the expansion authority does not generally include the DHAT program. The DHAT program may, however, be expanded upon the election of an Indian tribe or tribal organization located in a state where "the use of [DHAT] services or midlevel dental health provider services is authorized under [s]tate law to supply such services in accordance with [s]tate law."

In 2017 Senate Bill 5079 authorized DHAT services 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;

• services 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 therapists services are exempted from licensing requirements for other dental professions.

The Health Care Authority is 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.

–––––––––––––––––––––––––––––––––

Summary of Bill:

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:

• completes a dental therapist program that is accredited or has received initial accreditation by the Commission on Dental Accreditation;

• passes an examination;

• completes a 400-hour preceptorship under the supervision of a dentist; 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. The Secretary, in consultation with the Dental Hygiene Examining Committee, may adopt rules to implement these requirements.

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;

• files with the Secretary documentation certifying that the applicant:

  • has graduated from an accredited dental therapy school;

  • has successfully completed the national dental therapy exam, or until that exam is developed, the national dental hygiene exam; and

  • is licensed or certified to practice in another state or Canadian province, or by a federal or tribal governing board in the previous two years;

• demonstrates knowledge of Washington laws regarding the practice of dental therapy;

• pays required fees; and

• meets requirements for acquired immune deficiency syndrome certification.

A limited license is limited to 18 months. A person practicing under a limited license may perform only the dental therapy procedures that the person was licensed or certified to practice in their previous state, tribe, or Canadian province. 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:

• 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 and interim 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 placement and 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 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 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.

Written 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. The contract 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 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 for the administering and dispensing of medications, including the specific circumstances under which the medications may be dispensed and administered;

• 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.

The supervising dentist must accept responsibility for all services and procedures authorized and provided by the dental therapist pursuant to the contract. 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 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 supervising dentist must also 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 supervising dentist may not supervise more than five dental therapists at any one time.

Practice Settings.

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 an Indian Health Service, Indian Health Service Direct, Tribal 638, or an Urban Indian Health Program system of care; or

• any clinic or practice setting, including mobile or temporary dental clinics, in which at least 35 percent of the patient base of the dental therapist consists of patients 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 and do not have dental coverage.

Dental Health Aide Therapists.

The practice settings in which a dental health aide therapist may practice is changed to include practice settings operated by an Indian Health Service, Indian Health Service Direct, Tribal 638, or an urban Indian Health Program system of care.

Other Provisions.

The Washington State Dental Quality Assurance Commission (DQAC) consists of 18 members, rather than 16, including two licensed dental therapists.

Dental therapists are added to the definition of health professions 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 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 of the Revised Code of Washington. The DOH and the DQAC must adopt any rules necessary to implement this act.

–––––––––––––––––––––––––––––––––

Appropriation: None.

Fiscal Note: Available.

Effective Date: The bill takes effect on January 1, 2020, except for section 10, relating to pertaining to initial limited license, which contains an emergency clause and takes effect immediately.

Staff Summary of Public Testimony:

(In support) This bill will improve access to dental care for many people who are locked out of the dental system, including children and adults without dental coverage.  Dental therapists have been providing safe and high quality dental care in Alaska since 2005.  Dental therapists provide a very limited set of services and basic restorative care.  Studies show that dental therapists provide the same quality of care and the level of post treatment complications is the same between dentists and dental therapists. 

Based on data from Alaska, dental therapists have also improved access to dental care.  More children and adults received preventative care and kept natural teeth in communities where dental therapists practiced.  Dental therapists could have a significant impact in Washington and can make a positive difference.  There are thousands in Washington who cannot access dental care.  This bill is an evidence based solution.

Community health centers where most underserved populations are served, particularly in rural areas, have a very difficult time recruiting dentists.  It can take several months and sometimes a year to recruit a dentist to these centers.  Establishing dental therapists would alleviate a great need, particularly in rural areas.  Only about a quarter of adults and half of all children have access to dental care. 

Dental care often requires a car and money, which many do not have, so dental care is for the privileged.  The lack of dental care is common in many areas as is dental pain. Dental therapy can provide services to those who have been forgotten by health systems. 

Dental therapists are very similar to physician assistants (PAs). When PAs were created in 1969, it was to also solve a rural health access issue, and it has been very successful.  The intention is that dental therapists would work with dentists in a way that mirrors the PA-physician relationship. 

Three schools are looking to provide these programs in this state.

This bill is supported by numerous Indian health boards, clinics, and commissions. It will increase access to oral health care for all.  The tribes are thankful for the previous work on Senate Bill 5079, but it limited the practice of dental therapy to tribal boundaries.  This bill has a provision that would allow the dental therapists to practice in Indian health clinics in urban settings that are not within the tribal boundaries, providing culturally appropriate care to urban Indian populations as well as individuals who are publicly insured and underinsured. It is time to make this evidence-based model available.

(Opposed) Washington has a very strong dental care safety net and leads the nation in the use of Medicaid for dental care services. If the state wants to translate this success to the adult population, there needs to be more funding, not a new set of providers. Ten years into the program, only a fraction of the licensed dental therapists in Minnesota are actually working in rural areas, so it will not improve access to care.  Additionally, Canada closed its program because they could not retain enough dental therapists.

This bill allows dental therapists with minimal training to treat the most vulnerable patients. Underserved populations often present with complex dental cases, which a dental therapist could not handle. There is an access issue for dental care, but the way to fix that is by increasing dental residencies and expanding other programs that are proven solutions.  The University of Washington has a program that provides care to many underserved areas and recruits dental students from rural areas, who often return to these rural areas once they are trained.  Dental therapists are not an effective solution.

Persons Testifying: (In support) Donald Chi, University of Washington School of Dentistry; Alex Narvaez, SeaMar; Beverly Frye, Washington Dental Hygienist Association; Ruth Ballweg; University of Washington School of Medicine; Mercy Crisostomo; Jan Ward Olmstead, American Indian Health Commission; Pam Johnson, Northwest Portland Area Indian Health Board; Christianna Clinton; and Litonya Lester, Children's Alliance.

(Opposed) Trent House, Nadareh Naseri, and David Chi, Washington State Dental Association.

Persons Signed In To Testify But Not Testifying: None.

Majority Report: The substitute bill be substituted therefor and the substitute bill do pass. Signed by 18 members: Representatives Ormsby, Chair; Robinson, 1st Vice Chair; Cody, Dolan, Fitzgibbon, Hansen, Hudgins, Jinkins, Macri, Pettigrew, Pollet, Ryu, Senn, Springer, Stanford, Sullivan, Tarleton and Tharinger.

Minority Report: Do not pass. Signed by 14 members: Representatives Bergquist, 2nd Vice Chair; Stokesbary, Ranking Minority Member; MacEwen, Assistant Ranking Minority Member; Rude, Assistant Ranking Minority Member; Caldier, Chandler, Dye, Hoff, Kraft, Mosbrucker, Schmick, Steele, Sutherland and Ybarra.

Staff: Catrina Lucero (786-7192).

Summary of Recommendation of Committee On Appropriations Compared to Recommendation of Committee On Health Care & Wellness:

The substitute bill removes the requirement that a supervising dentist must accept responsibility for all services and procedures authorized and provided by the dental therapist pursuant to the practice plan contract, and states that the dental therapist must accept all responsibility for services and procedures performed by the dental therapist or any auxiliary dental providers the dental therapist is supervising.

Licensed dental therapists are required to renew their licenses and comply with administrative procedures and requirements, continuing education requirements, and fees for license issuance and renewal. The substitute bill removes the emergency clause for the section providing for limited licenses for dental therapists. It also changes the effective date from January 1, 2020, to July 1, 2020, and allows registered dental assistants to work under the supervision of a dental therapist.

Appropriation: None.

Fiscal Note: Available.

Effective Date of Substitute Bill: The bill takes effect on July 1, 2020.

Staff Summary of Public Testimony:

(In support) Many children enrolled in Apple Health do not have dental access, nor do they receive preventative services.  Authorizing dental therapists can help alleviate this.  Some people claim that dental therapy is sub-prime care.  However, there is no evidence to support this.  Dental therapist care results in fewer children and adults needing extraction.  There have been no reported cases of harm to patients.  Dental therapy is an evidence-based healthcare solution.  There are currently nationally accredited education requirements.  The language in the bill requires a practice plan contract between the therapist and dentist.  This contract describes the scope of practice and level of supervision of that dental therapist.  There is no general fund impact for this bill.  Two years ago, the Legislature passed a bill allowing dental therapists to practice on tribal reservations serving only tribal members.  Unfortunately, the federal government denied the Medicaid State Plan amendment.  The state is appealing this decision.  The passage of this bill would resolve this issue by making the service available statewide to all Medicaid clients. 

(Opposed) Adding a new provider class is not a solution to the access problem.  Training a new provider class is complicated and costly.  There are better ways to increase access to dental services, like increasing the number of dental assistants and hygienists and adding dental residencies.  Medicaid clients have very complex dental needs.  Dental therapists are not equipped to handle this level of need.  Studies have indicated that dental therapists are not trained to treat clients with complicated issues. 

Persons Testifying: (In support) Emily Murphy, Children's Alliance; Melissa Johnson, Washington Dental Hygienists Association; and Davor Gjurasic, Swinomish Tribal Community of Indians.

(Opposed) Trent House and Chris Delecki, Washington State Dental Association.

Persons Signed In To Testify But Not Testifying: None.