WSR 08-07-099

PROPOSED RULES

DEPARTMENT OF HEALTH


(Dental Quality Assurance Commission)

[ Filed March 19, 2008, 10:51 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 07-16-062 and 07-16-065.

Title of Rule and Other Identifying Information: Amending chapter 246-817 WAC, Credentialing and scope of practice requirements for dental assistants and expanded function dental auxiliaries.

Hearing Location(s): Department of Health, Point Plaza East, Room 152/153, 310 Israel Road S.E., Tumwater, WA 98501, on May 1, 2008, at 5:45 p.m.

Date of Intended Adoption: May 1, 2008.

Submit Written Comments to: Jennifer Bressi, P.O. Box 47867, Olympia, WA 98507, web site http://www3.doh.wa.gov/policyreview/, fax (360) 664-9077, by April 15, 2008.

Assistance for Persons with Disabilities: Contact Jennifer Bressi by April 15, 2008, TTY (800) 833-6388 or 711.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rules provide clear credentialing requirements for registration of dental assistants (DAs) and licensure of expanded function dental auxiliaries (EFDAs). Proposed changes and new sections also provide detailed scope of practice for DAs and EFDAs. Licensing standards for education and examination are proposed for EFDAs.

Reasons Supporting Proposal: Legislation passed in 2007, SHB 1099, requires persons practicing as DAs to obtain a registration with the department of health (DOH). Legislation additionally requires persons practicing as EFDAs to be licensed with DOH. The legislation also requires rules to be established for DA and EFDA services related to patient care and laboratory duties. The proposed rules establish minimum competency for credentialing and detailed dental services allowable.

Statutory Authority for Adoption: RCW 18.260.120 and 18.32.0365.

Statute Being Implemented: Chapter 18.260 RCW.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of health, dental quality assurance commission, governmental.

Name of Agency Personnel Responsible for Drafting and Implementation: Jennifer Bressi, 310 Israel Road S.E., Tumwater, WA 98504, (360) 236-4893; and Enforcement: Allen Spaulding, 310 Israel Road S.E., Tumwater, WA 98504, (360) 236-4863.

No small business economic impact statement has been prepared under chapter 19.85 RCW. A small business economic impact statement was not prepared. The proposed rule would not impose more than minor costs on businesses in an industry.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Jennifer Bressi, P.O. Box 47867, Olympia, WA 98504, phone (360) 236-4893, fax (360) 664-9077, e-mail jennifer.bressi@doh.wa.gov.

March 19, 2008

Jennifer Bressi

Health Services Consultant 3

OTS-1202.4


NEW SECTION
WAC 246-817-190   Dental assistant registration.   To be eligible for registration as a dental assistant you must:

(1) Provide a completed application on forms provided by the secretary;

(2) Pay applicable fees as defined in WAC 246-817-990;

(3) Provide evidence of completion of seven clock hours of AIDS education and training as required by chapter 246-12 WAC Part 8; and

(4) Provide any other information determined by the secretary.

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NEW SECTION
WAC 246-817-195   Licensure requirements for expanded function dental auxiliaries (EFDAs).   To be eligible for licensure as an EFDA in Washington an applicant must:

(1) Provide a completed application on forms provided by the secretary;

(2) Pay applicable fees as defined in WAC 246-817-990;

(3) Provide evidence of:

(a) Completion of a dental assisting education program accredited by the Commission on Dental Accreditation (CODA); or

(b) Obtain the Dental Assisting National Board (DANB) certified dental assistant credential, earned through pathway II, which includes:

(i) A minimum of three thousand five hundred hours of experience as a dental assistant within a continuous twenty-four through forty-eight month period;

(ii) Employer-verified knowledge in areas as specified by DANB;

(iii) Passage of DANB certified dental assistant examination; and

(iv) An additional dental assisting review course, which may be provided on-line, in person or through self-study; or

(c) A Washington limited license to practice dental hygiene; or

(d) A Washington full dental hygiene license and completion of a course in taking final impressions affiliated with or provided by a CODA accredited dental assisting program, dental hygiene school or dental school.

(4) Except for applicants qualified under subsection (3)(d) of this section, provide evidence of completing an EFDA education program approved by the commission where training includes:

(a) In a didactic, clinical and laboratory model to the clinically competent level required for close supervision:

(i) In placing and finishing composite restorations on a typodont and on clinical patients; and

(ii) In placing and finishing amalgam restorations on a typodont and on clinical patients; and

(iii) In taking final impressions on a typodont; and

(b) In a didactic, clinical and laboratory model to the clinically competent level required for general supervision:

(i) In performing coronal polish, fluoride treatment, and sealants on a typodont and on clinical patients; and

(ii) In providing patient oral health instructions; and

(iii) In placing, exposing, processing, and mounting dental radiographs; and

(c) The basic curriculum shall require didactic, laboratory, and clinical competency for the following:

(i) Tooth morphology and anatomy;

(ii) Health and safety (current knowledge in dental materials, infection control, ergonomics, mercury safety, handling);

(iii) Placement and completion of an acceptable quality reproduction of restored tooth surfaces -- laboratory and clinic only;

(iv) Radiographs (covered in path II) -- laboratory and clinic only;

(v) Ethics and professional knowledge of law as it pertains to dentistry, dental hygiene, dental assisting, and EFDA;

(vi) Current practices in infection control;

(vii) Health history alerts;

(viii) Final impression;

(ix) Matrix and wedge;

(x) Rubber dam;

(xi) Acid etch and bonding;

(xii) Occlusion and bite registration;

(xiii) Temporary restorations;

(xiv) Dental emergencies;

(xv) Risk management and charting;

(xvi) Intra-oral anatomy;

(xvii) Pharmacology; and

(xviii) Bases, cements, liners and sealers.

(5) Except for applicants qualified under subsection (3)(d) of this section, attain a passing score on:

(a) A written restorations examination approved by the commission; and

(b) A clinical restorations examination approved by the commission.

(6) Provide evidence of completion of seven clock hours of AIDS education and training as required by chapter 246-12 WAC Part 8.

(7) Provide any other information determined by the secretary.

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NEW SECTION
WAC 246-817-200   Licensure without examination for expanded function dental auxiliary (EFDA).   To be eligible for a license as an EFDA without examination you must:

(1) Provide a completed application on forms provided by the secretary;

(2) Pay applicable fees as defined in WAC 246-817-990;

(3) Provide evidence of:

(a) A current license in another state with substantially equivalent licensing standards as determined by the commission; or

(b) A Washington full dental hygiene license and completion of a course in taking final impressions affiliated with or provided by a CODA accredited dental assisting program, dental hygiene school or dental school.

(4) Provide evidence of completion of seven clock hours of AIDS education and training as required by chapter 246-12 WAC Part 8; and

(5) Provide any other information determined by the secretary.

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AMENDATORY SECTION(Amending WSR 98-05-060, filed 2/13/98, effective 3/16/98)

WAC 246-817-210   Expired ((license)) credential.   (1) If the ((license)) credential has expired for three years or less, the practitioner must meet the requirements of chapter 246-12 WAC, Part 2.

(2) If the ((license)) credential has expired for over three years, the practitioner must:

(a) Comply with the current statutory conditions;

(b) Meet the requirements of chapter 246-12 WAC, Part 2.

[Statutory Authority: RCW 43.70.280. 98-05-060, 246-817-210, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 18.32.035. 95-21-041, 246-817-210, filed 10/10/95, effective 11/10/95.]


AMENDATORY SECTION(Amending WSR 95-21-041, filed 10/10/95, effective 11/10/95)

WAC 246-817-510   Definitions for WAC 246-817-501 through 246-817-570.   (1) "Close supervision" means that a licensed dentist whose patient is being treated has personally diagnosed the condition to be treated and has personally authorized the procedures to be performed. A dentist shall be physically present in the treatment facility while the procedures are performed. Close supervision does not require a dentist to be physically present in the operatory; however, an attending dentist must be in the treatment facility and be capable of responding immediately in the event of an emergency.

(2) "Coronal polishing" means a procedure limited to the removal of plaque and stain from exposed tooth surfaces, utilizing an appropriate rotary instrument with rubber cap or brush and a polishing agent.

This procedure shall not be intended or interpreted as an oral prophylaxis as defined in WAC 246-817-510 a procedure specifically reserved to performance by a licensed dentist or dental hygienist. Coronal polishing may, however, be performed by dental assistants under close supervision as a portion of the oral prophylaxis. In all instances, however, a licensed dentist shall determine that the teeth need to be polished and are free of calculus or other extraneous material prior to performance of coronal polishing by a dental assistant.

(3) "Debridement at the periodontal surgical site" means curettage ((and/))or root planing after reflection of a flap by the supervising dentist. This does not include cutting of osseous tissues.

(4) "Elevating soft tissues" is defined as part of a surgical procedure involving the use of the periosteal elevator to raise flaps of soft tissues. Elevating soft tissue is not a separate and distinct procedure in and of itself.

(5) "General supervision" means supervision of dental procedures based on examination and diagnosis of the patient and subsequent instructions given by a licensed dentist but not requiring the physical presence of the supervising dentist in the treatment facility during the performance of those procedures.

(6) "Incising" is defined as part of the surgical procedure of which the end result is removal of oral tissue. Incising, or the making of an incision, is not a separate and distinct procedure in and of itself.

(7) "Luxation" is defined as an integral part of the surgical procedure of which the end result is extraction of a tooth. Luxation is not a distinct procedure in and of itself. It is the dislocation or displacement of a tooth or of the temporomandibular articulation.

(8) "Oral prophylaxis" means the preventive dental procedure of scaling and polishing which includes complete removal of calculus, soft deposits, plaque, stains and the smoothing of unattached tooth surfaces. The objective of this treatment shall be creation of an environment in which hard and soft tissues can be maintained in good health by the patient.

(9) "Periodontal soft tissue curettage" means the closed removal of tissue lining the periodontal pocket, not involving the reflection of a flap.

(10) "Root planing" means the process of instrumentation by which the unattached surfaces of the root are made smooth by the removal of calculus ((and/))or deposits.

(11) "Supportive services" means services that are related to clinical functions in direct relationship to treating a patient.

(12) "Suturing" is defined as the readaption of soft tissue by use of stitches as a phase of an oral surgery procedure. Suturing is not a separate and distinct procedure in and of itself.

(13) "Treatment facility" means a dental office or connecting suite of offices, dental clinic, room or area with equipment to provide dental treatment, or the immediately adjacent rooms or areas. A treatment facility does not extend to any other area of a building in which the treatment facility is located.

(14) "((Unlicensed)) Noncredentialed person" means a person who is ((neither)) not a dentist ((duly)) licensed ((pursuant to the provisions of)) under chapter 18.32 RCW ((nor a)); dental hygienist ((duly)) licensed ((pursuant to the provisions of)) under chapter 18.29 RCW; expanded function dental auxiliary licensed under chapter 18.260 RCW; or a dental assistant registered under chapter 18.260 RCW.

[Statutory Authority: RCW 18.32.035. 95-21-041, 246-817-510, filed 10/10/95, effective 11/10/95.]


AMENDATORY SECTION(Amending WSR 95-21-041, filed 10/10/95, effective 11/10/95)

WAC 246-817-520   ((Acts)) Supportive services that may be performed by ((unlicensed persons)) registered dental assistants.   A dentist may allow ((an unlicensed person)) registered dental assistants to perform the following ((acts)) supportive services under the dentist's close supervision:

(1) Oral inspection, with no diagnosis.

(2) Patient education in oral hygiene.

(3) Place and remove the rubber dam.

(4) Hold in place and remove impression materials after the dentist has placed them.

(5) Take impressions solely for diagnostic and opposing models.

(6) Take impressions and wax bites solely for study casts.

(7) Take impressions, fabricate, and deliver bleaching and fluoride trays.

(8) Remove the excess cement after the dentist has placed a permanent or temporary inlay, crown, bridge or appliance, or around orthodontic bands.

(((8))) (9) Perform coronal polish.

(((9))) (10) Give fluoride treatments.

(((10))) (11) Place periodontal packs.

(((11))) (12) Remove periodontal packs or sutures.

(((12) Placement of)) (13) Place a matrix and wedge for a ((silver restoration)) metallic and nonmetallic direct restorative material after the dentist has prepared the cavity.

(((13))) (14) Place a temporary filling (as zinc oxide-eugenol (ZOE)) after diagnosis and examination by the dentist.

(((14))) (15) Apply tooth separators as for placement for Class III gold foil.

(((15))) (16) Fabricate, place, and remove temporary crowns or temporary bridges.

(((16))) (17) Pack and medicate extraction areas.

(((17))) (18) Deliver ((a)) an oral sedative drug ((capsule)) to patient.

(((18))) (19) Place topical anesthetics.

(((19) Placement of)) (20) Place retraction cord.

(((20))) (21) Polish restorations at a subsequent appointment.

(((21))) (22) Select denture shade and mold.

(((22))) (23) Acid etch.

(((23))) (24) Apply sealants.

(((24))) (25) Place dental X-ray film and expose and develop the films.

(((25))) (26) Take intra-oral and extra-oral photographs.

(((26))) (27) Take health histories.

(((27))) (28) Take and record blood pressure and vital signs.

(((28))) (29) Give preoperative and postoperative instructions.

(((29))) (30) Assist in the administration of inhalation anxiolysis (nitrous oxide) analgesia or sedation((, but shall not start the administration of the gases and shall not adjust the flow of the gases unless instructed to do so by the dentist. Patients must never be left unattended while nitrous oxide-oxygen analgesia or sedation is administered to them. The dentist must be present at chairside during the entire administration of nitrous oxide and oxygen analgesia or sedation if any other central nervous system depressant has been given to the patient. This regulation shall not be construed to prevent any person from taking appropriate action in the event of a medical emergency)).

(((30))) (31) Select orthodontic bands for size.

(((31))) (32) Place and remove orthodontic separators.

(((32))) (33) Prepare teeth for the bonding or orthodontic appliances.

(((33))) (34) Fit and adjust headgear.

(((34))) (35) Remove fixed orthodontic appliances.

(((35))) (36) Remove and replace archwires and orthodontic wires.

(((36))) (37) Take a facebow transfer for mounting study casts.

(38) Take impressions for space maintainers.

(39) Take impressions for orthodontic retainers.

(40) Take impressions for night guards.

[Statutory Authority: RCW 18.32.035. 95-21-041, 246-817-520, filed 10/10/95, effective 11/10/95.]


NEW SECTION
WAC 246-817-525   Supportive services that may be performed by expanded function dental auxiliaries (EFDAs).   (1) A dentist may allow EFDAs to perform the following supportive services under the dentist's close supervision:

(a) Oral inspection, with no diagnosis.

(b) Place and remove the rubber dam.

(c) Take preliminary and final impressions and bite registrations, to include computer assisted design and computer assisted manufacture applications.

(d) Take impressions, fabricate, and deliver bleaching and fluoride trays.

(e) Remove the excess cement after the dentist has placed a permanent or temporary inlay, crown, bridge or appliance, or around orthodontic bands.

(f) Place periodontal packs.

(g) Remove periodontal packs or sutures.

(h) Place a matrix and wedge for a metallic and nonmetallic direct restorative material after the dentist has prepared the cavity.

(i) Place a temporary filling (as zinc oxide-eugenol (ZOE)) after diagnosis and examination by the dentist.

(j) Apply tooth separators as for placement for Class III gold foil.

(k) Fabricate, place, and remove temporary crowns or temporary bridges.

(l) Pack and medicate extraction areas.

(m) Deliver an oral sedative drug to patient.

(n) Place topical anesthetics.

(o) Place retraction cord.

(p) Polish restorations.

(q) Select denture shade and mold.

(r) Acid etch.

(s) Take intra-oral and extra-oral photographs.

(t) Take health histories.

(u) Take and record blood pressure and vital signs.

(v) Give preoperative and postoperative instructions.

(w) Assist in the administration of inhalation anxiolysis (nitrous oxide) analgesia or sedation.

(x) Select orthodontic bands for size.

(y) Place and remove orthodontic separators.

(z) Prepare teeth for the bonding or orthodontic appliances.

(aa) Fit and adjust headgear.

(bb) Remove fixed orthodontic appliances.

(cc) Remove and replace archwires and orthodontic wires.

(dd) Take a facebow transfer for mounting study casts.

(ee) Place and carve direct restorations.

(ff) Take impressions for space maintainers.

(gg) Take impressions for orthodontic retainers.

(hh) Take impressions for night guards.

(2) A dentist may allow EFDAs to perform the following supportive services under the dentist's general supervision:

(a) Perform coronal polishing.

(b) Give fluoride treatments.

(c) Apply sealants.

(d) Place dental X-ray film and exposing and developing the films.

(e) Give patient oral health instructions.

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AMENDATORY SECTION(Amending WSR 95-21-041, filed 10/10/95, effective 11/10/95)

WAC 246-817-540   Acts that may not be performed by ((unlicensed)) registered dental assistants or noncredentialed persons.   No dentist shall allow ((an unlicensed)) registered dental assistants or noncredentialed persons who ((is)) are in his((/)) or her employ or ((is)) are acting under his((/)) or her supervision or direction to perform any of the following procedures:

(1) Any removal of or addition to the hard or soft natural tissue of the oral cavity.

(2) Any placing of permanent or semi-permanent restorations in natural teeth.

(3) Any diagnosis of or prescription for treatment of disease, pain, deformity, deficiency, injury, or physical condition of the human teeth or jaws, or adjacent structure.

(4) Any administration of general or ((injected)) local anesthetic ((of any nature in connection with a dental operation)), including intravenous sedation.

(5) Any oral prophylaxis, except coronal polishing as a part of oral prophylaxis as defined in WAC 246-817-510 and 246-817-520(8).

(6) Any scaling procedure.

(7) The taking of any impressions of the teeth or jaws, or the relationships of the teeth or jaws, for the purpose of fabricating any intra-oral restoration, appliances, or prosthesis. Not prohibited are the taking of impressions solely for diagnostic and opposing models or taking wax bites solely for study casts.

(8) Intra-orally adjust occlusal of inlays, crowns, and bridges.

(9) Intra-orally finish margins of inlays, crowns, and bridges.

(10) Cement or recement, permanently, any cast restoration or stainless steel crown.

(11) Incise gingiva or other soft tissue.

(12) Elevate soft tissue flap.

(13) Luxate teeth.

(14) Curette to sever epithelial attachment.

(15) Suture.

(16) Establish occlusal vertical dimension for dentures.

(17) Try-in of dentures set in wax.

(18) Insertion and post-insertion adjustments of dentures.

(19) Endodontic treatment -- open, extirpate pulp, ream and file canals, establish length of tooth, and fill root canal.

(20) Use of lasers, noncoherent light, intense pulse light, radiofrequency, or plasma to topically penetrate skin and alter human tissue which are classified by the federal Food and Drug Administration as prescription devices.

(21) Intra-oral air polishing air abrasion or mechanical etching devices.

(22) Place direct pulp capping.

(23) Fit and adjust night guards.

[Statutory Authority: RCW 18.32.035. 95-21-041, 246-817-540, filed 10/10/95, effective 11/10/95.]


NEW SECTION
WAC 246-817-545   Acts that may not be performed by expanded function dental auxiliaries (EFDA) or noncredentialed persons.   No dentist shall allow EFDAs or noncredentialed persons who are in his or her employ or are acting under his or her supervision or direction to perform any of the following procedures:

(1) Any removal of or addition to the hard or soft natural tissue of the oral cavity except for placing and carving direct restorations by an EFDA.

(2) Any diagnosis of or prescription for treatment of disease, pain, deformity, deficiency, injury, or physical condition of the human teeth or jaws, or adjacent structure.

(3) Any administration of general or local anesthetic, including intravenous sedation.

(4) Any oral prophylaxis, except coronal polishing as a part of oral prophylaxis as defined in WAC 246-817-510 and 246-817-520(8).

(5) Any scaling procedure.

(6) Intra-orally adjust occlusal of inlays, crowns, and bridges.

(7) Intra-orally finish margins of inlays, crowns, and bridges.

(8) Cement or recement, permanently, any cast restoration or stainless steel crown.

(9) Incise gingiva or other soft tissue.

(10) Elevate soft tissue flap.

(11) Luxate teeth.

(12) Curette to sever epithelial attachment.

(13) Suture.

(14) Establish occlusal vertical dimension for dentures.

(15) Try-in of dentures set in wax.

(16) Insertion and postinsertion adjustments of dentures.

(17) Endodontic treatment -- open, extirpate pulp, ream and file canals, establish length of tooth, and fill root canal.

(18) Use of lasers, noncoherent light, intense pulse light, radiofrequency, or plasma to topically penetrate skin and alter human tissue which are classified by the federal Food and Drug Administration as prescription devices.

(19) Intra-oral air polishing, air abrasion or mechanical etching devices.

(20) Place direct pulp capping.

(21) Fit and adjust night guards.

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Washington State Code Reviser's Office