WSR 16-22-025

PROPOSED RULES

DEPARTMENT OF HEALTH

(Dental Quality Assurance Commission)

[Filed October 24, 2016, 2:42 p.m.]

Supplemental Notice to WSR 16-09-100.

Preproposal statement of inquiry was filed as WSR 10-23-081.

Title of Rule and Other Identifying Information: WAC 246-817-510, 246-817-520, 246-817-525, 246-817-540 and 246-817-545, amending rules on dentist delegation of duties to dental assistants and expanded function dental auxiliaries. This is a supplemental proposal to rules filed April 19, 2016, as WSR 16-09-100.

Hearing Location(s): Department of Health, Point Plaza East, Room 152/153, 310 Israel Road S.E., Tumwater, WA 98501, on December 9, 2016, at 8:05 a.m.

Date of Intended Adoption: December 9, 2016.

Submit Written Comments to: Jennifer Santiago, P.O. Box 47852, Olympia, WA 98501, e-mail https://fortress.wa.gov/doh/policyreview, fax (360) 236-2901, by December 2, 2016.

Assistance for Persons with Disabilities: Contact Jennifer Santiago by December 2, 2016, TTY (800) 833-6388 or 711.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rule amendments update the scope of practice for registered dental assistants and licensed expanded function dental auxiliaries (EFDA) to current practice standards eliminating confusion for dental professionals and the public receiving dental care. The original proposal lacked clarity for dental assistants for polishing restorations, taking impressions for temporary oral devices, and semi-permanent restorations. The original proposal also lacked clarity for expanded function dental auxiliaries for placing and carving direct restorations and a correction to a WAC reference. The current proposal is different from the previous proposal with changes to WAC 246-817-520 [(4)](r) and (v)(ii), 246-817-525 (5)(b), 246-817-540(2), and 246-817-545(4).

Reasons Supporting Proposal: The scope of practice for registered dental assistants and licensed EFDAs has been an area of confusion for dental professionals as the current rules are not specific enough. Proposed rule amendments clarify what tasks dentists are currently delegating in dental facilities.

Statutory Authority for Adoption: RCW 18.260.040, 18.260.070, and SB 5606 (chapter 20 [120], Laws of 2015).

Statute Being Implemented: Chapter 18.260 RCW and SB 5606 (chapter 20 [120], Laws of 2015).

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

Name of Proponent: Dental quality assurance commission, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Jennifer Santiago, 111 Israel Road S.E., Tumwater, WA 98501, (360) 236-4893.

No small business economic impact statement has been prepared under chapter 19.85 RCW. 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 Santiago, P.O. Box 47852, Olympia, WA 98501, phone (360) 236-4893, fax (360) 236-2901, e-mail jennifer.santiago@doh.wa.gov.

October 24, 2016

C. Madden, Chair

Dental Quality

Assurance Commission

AMENDATORY SECTION (Amending WSR 09-15-075, filed 7/13/09, effective 8/13/09)

WAC 246-817-510 Definitions ((for WAC 246-817-501 through 246-817-570)).

The definitions in this section apply throughout WAC 246-817-501 through 246-817-570 unless the context clearly requires otherwise.

(1) "Close supervision" means that a ((licensed)) supervising dentist whose patient is being treated has personally diagnosed the condition to be treated and has personally authorized the procedures to be performed. ((A)) The supervising dentist ((shall be)) is continuously on-site and physically present in the treatment facility while the procedures are performed by the assistive personnel and capable of responding immediately in the event of an emergency. Close supervision does not require a supervising 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)) using an appropriate instrument and polishing agent.

This procedure ((shall)) is not ((be)) intended or interpreted ((as)) to be an oral prophylaxis as defined in ((WAC 246-817-510)) subsection (8) of this section a procedure specifically reserved to ((performance)) be performed 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 procedure. ((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 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)) means 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)) that a supervising dentist has examined and diagnosed the patient and provided 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)) to be performed by the assistive personnel, but does not require that the dentist be physically present in the treatment facility.

(6) "Incising" ((is defined as)) means 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)) means 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)) is to create 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 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) (("Noncredentialed person" means a person who is not a dentist licensed under chapter 18.32 RCW; dental hygienist licensed 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.

(15))) "Volunteer dental assistant" means an individual who, without compensation, provides the supportive services ((set forth in)) under WAC 246-817-520 in a charitable dental clinic.

AMENDATORY SECTION (Amending WSR 08-14-010, filed 6/19/08, effective 7/1/08)

WAC 246-817-520 Supportive services that may be performed by registered dental assistants.

((A dentist may allow registered dental assistants to perform the following supportive services under the dentist's close supervision:))

(1) A supervising dentist may delegate the supportive services in subsection (4) of this section under the dentist's close supervision, provided the registered dental assistant has demonstrated skills necessary to perform each task competently.

(2) Delegation of supportive services not in subsection (4) of this section may be subject to disciplinary action.

(3) In addition to supportive services in subsection (4) of this section, registered dental assistants may perform nonclinical tasks.

(4) Supportive services allowed under close supervision:

(a) 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.

(9) Perform coronal polish.

(10) Give fluoride treatments.

(11) Place periodontal packs.

(12) Remove periodontal packs or sutures.

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

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

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

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

(17) Pack and medicate extraction areas.

(18) Deliver an oral sedative drug to patient.

(19) Place topical anesthetics.

(20) Place retraction cord.

(21) Polish restorations at a subsequent appointment.

(22) Select denture shade and mold.

(23) Acid etch.

(24) Apply sealants.

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

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

(27) Take health histories.

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

(29) Give preoperative and postoperative instructions.

(30) Assist in the administration of inhalation minimal sedation (nitrous oxide) analgesia or sedation.

(31) Select orthodontic bands for size.

(32) Place and remove orthodontic separators.

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

(34) Fit and adjust headgear.

(35) Remove fixed orthodontic appliances.

(36) Remove and replace archwires and orthodontic wires.

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

(38) Take impressions for temporary oral devices, such as but not limited to space maintainers, orthodontic retainers, and occlusal guards.)) (b) Take and record blood pressure and vital signs.

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

(e) Perform coronal polish. A licensed dentist shall determine the teeth are free of calculus or other extraneous material prior to dismissing the patient.

(f) Give fluoride treatments.

(g) Give patient education in oral hygiene.

(h) Give preoperative and postoperative instructions.

(i) Deliver an oral sedative drug to patient.

(j) Assist in the administration of inhalation minimal sedation (nitrous oxide) analgesia, including starting and stopping the flow as directed by the supervising dentist.

(k) Place topical anesthetics.

(l) Place and remove the rubber dam.

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

(n) Apply sealants.

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

(p) Place cavity liners and bases.

(q) Perform acid etch and apply bonding agents.

(r) Polish restorations but may not intra-orally adjust or finish permanent restorations.

(s) Sterilize equipment and disinfect operatories.

(t) Place retraction cord.

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

(v) Take impressions, bite registrations, or digital scans of the teeth and jaws for:

(i) Diagnostic and opposing models;

(ii) Fixed and removable orthodontic appliances, occlusal guards, bleaching trays, and fluoride trays; and

(iii) Temporary indirect restorations such as temporary crowns.

(w) Take digital scans of prepared teeth for fabrication of permanent indirect restorations.

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

(y) Fabricate and deliver bleaching and fluoride trays.

(z) Fabricate, cement, and remove temporary crowns or temporary bridges.

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

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

(cc) Pack and medicate extraction areas.

(dd) Place periodontal packs.

(ee) Remove periodontal packs or sutures.

(ff) Select denture shade and mold.

(gg) Place and remove orthodontic separators.

(hh) Select and fit orthodontic bands, try in fixed or removable orthodontic appliances prior to the dentist cementing or checking the appliance.

(ii) Prepare teeth for the bonding of orthodontic appliances.

(jj) Bond attachments for clear removable orthodontic aligners.

(kk) Remove and replace archwires and orthodontic wires.

(ll) Fit and adjust headgear.

(mm) Remove fixed orthodontic appliances, orthodontic cement, and orthodontic bonded resin material.

AMENDATORY SECTION (Amending WSR 08-14-010, filed 6/19/08, effective 7/1/08)

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 minimal sedation (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 temporary oral devices, such as but not limited to space maintainers, orthodontic retainers, and occlusal 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.

(d) Place dental X-ray film and exposing and developing the films.)) (1) A supervising dentist may delegate the supportive services in subsection (5) of this section under the dentist's close supervision, provided the EFDA has demonstrated skills necessary to perform each task competently.

(2) A dentist may delegate the supportive services in subsection (6) of this section under the dentist's general supervision, provided the EFDA has demonstrated skills necessary to perform each task.

(3) Delegation of supportive services not in subsection (5) or (6) of this section may be subject to disciplinary action.

(4) In addition to supportive services in subsections (5) and (6) of this section, licensed EFDAs may perform nonclinical tasks.

(5) Supportive services allowed under close supervision:

(a) Supportive services under WAC 246-817-520(4), except for supportive services in subsection (6) of this section.

(b) Place, carve, finish, and polish direct restorations.

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

(6) Supportive services allowed under general supervision are:

(a) Perform coronal polishing.

(b) Give fluoride treatments.

(d) Place, expose, and process radiographs.

(e) Give patient oral health instructions.

AMENDATORY SECTION (Amending WSR 08-14-010, filed 6/19/08, effective 7/1/08)

WAC 246-817-540 Acts that may not be performed by registered dental assistants ((or noncredentialed persons)).

((No dentist shall)) This list is not all inclusive. Delegation of procedures not in subsections (1) through (22) of this section should not be assumed to be allowed. Supportive services approved for delegation to registered dental assistants are under WAC 246-817-520. A dentist may not allow registered dental assistants ((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.

(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 local anesthetic, including intravenous sedation.

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

(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)), other than impressions allowed as a delegated task under WAC 246-817-520.

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

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

(10))) and finish permanent restorations.

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

(((11))) (10) Incise gingiva or other soft tissue.

(((12))) (11) Elevate soft tissue flap.

(((13))) (12) Luxate teeth.

(((14))) (13) Curette to sever epithelial attachment.

(((15))) (14) Suture.

(((16))) (15) Establish occlusal vertical dimension for dentures.

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

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

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

(((20))) (19) Use of any light or electronic device for invasive procedures.

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

(((22))) (21) Place direct pulp caps.

(((23))) (22) Fit and adjust occlusal guards.

AMENDATORY SECTION (Amending WSR 08-14-010, filed 6/19/08, effective 7/1/08)

WAC 246-817-545 Acts that may not be performed by expanded function dental auxiliaries (EFDAs) ((or noncredentialed persons)).

((No dentist shall)) This list is not all inclusive. Delegation of procedures not in subsections (1) through (20) of this section should not be assumed to be allowed. Supportive services approved for delegation to licensed expanded function dental auxiliaries are under WAC 246-817-525. A dentist may not 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)) under WAC 246-817-510 and 246-817-520(((8))) (4)(e).

(5) Any scaling procedure.

(6) Intra-orally adjust ((occlusal of)) and finish permanent 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))) (8) Incise gingiva or other soft tissue.

(((10))) (9) Elevate soft tissue flap.

(((11))) (10) Luxate teeth.

(((12))) (11) Curette to sever epithelial attachment.

(((13))) (12) Suture.

(((14))) (13) Establish occlusal vertical dimension for dentures.

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

(((16))) (15) Insertion and postinsertion adjustments of dentures.

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

(((18))) (17) Use of any light or electronic device for invasive procedures.

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

(((20))) (19) Place direct pulp caps.

(((21))) (20) Fit and adjust occlusal guards.