BILL REQ. #:  H-0814.2 

Read first time 01/18/11.   Referred to Committee on Health Care & Wellness.

     AN ACT Relating to dental therapists; amending RCW 18.32.030, 18.32.0351, 18.260.010, 18.260.040, 18.260.070, and 18.260.080; reenacting and amending RCW 18.130.040; adding a new chapter to Title 18 RCW; creating a new section; and providing an effective date.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1   The definitions in this section apply throughout this chapter unless the context clearly requires otherwise:
     (1) "Advanced dental therapist" means a person licensed under this chapter who provides dental therapy pursuant to a written collaborative agreement with a dentist.
     (2) "Committee" means the dental hygiene examining committee established in chapter 18.29 RCW.
     (3) "Dental therapist" means a person licensed under this chapter who provides dental therapy under the off-site supervision of a dentist pursuant to a written collaborative agreement with a dentist.
     (4) "Dental therapy" means the services and procedures specified in section 4 of this act.
     (5) "Dentist" means a person licensed to practice dentistry under chapter 18.32 RCW.
     (6) "Department" means the department of health.
     (7) "Off-site supervision of a dentist" means supervision that does not require the dentist to be physically present or to personally examine or diagnose the patient.
     (8) "Secretary" means the secretary of health.
     (9) "Supervision of a dentist" means that a supervising dentist:
     (a) Has personally examined and diagnosed the patient and has personally authorized the procedures to be performed;
     (b) Is continuously on-site while the procedure in question is being performed; and
     (c) Is capable of responding immediately in the event of an emergency.

NEW SECTION.  Sec. 2   No person may practice dental therapy or represent himself or herself as a dental therapist or an advanced dental therapist without being licensed by the department under this chapter.

NEW SECTION.  Sec. 3   (1) The department shall issue a license to practice as a dental therapist to any applicant who:
     (a) Pays any applicable fees established by the secretary under RCW 43.70.110 and 43.70.250;
     (b) Submits, on forms provided by the secretary, the applicant's name, address, and other applicable information as determined by the secretary; and
     (c) Demonstrates that the following requirements have been met:
     (i) Possession of a high school diploma or equivalent;
     (ii) Successful completion of a dental health aide therapist education program approved by the secretary; and
     (iii) Completion of a four hundred hour preceptorship under the supervision of a dentist.
     (2) The department shall issue a license to practice as an advanced dental therapist to any applicant who:
     (a) Pays any applicable fees established by the secretary under RCW 43.70.110 and 43.70.250;
     (b) Submits, on forms provided by the secretary, the applicant's name, address, and other applicable information as determined by the secretary; and
     (c) Demonstrates that the following requirements have been met:
     (i) Possession of a license in good standing as a dental hygienist under chapter 18.29 RCW;
     (ii) Successful completion of a post-baccalaureate advanced dental hygiene therapy education program at an institution accredited by the American dental association commission on dental accreditation or other national accreditation organization approved by the committee;
     (iii) Completion of two hundred fifty hours of advanced dental therapy clinical practice under the supervision of a dentist; and
     (iv) Passage of an examination approved by the committee.

NEW SECTION.  Sec. 4   (1) Subject to the limitations in this section and section 5 of this act, a dental therapist may provide the following services and procedures:
     (a) Oral health instruction and disease prevention education, including nutritional counseling and dietary analysis;
     (b) Preliminary charting of the oral cavity;
     (c) Making radiographs;
     (d) Mechanical polishing;
     (e) Application of topical preventative or prophylactic agents, including fluoride varnishes and pit and fissure sealants;
     (f) Pulp vitality testing;
     (g) Application of desensitizing medication or resin;
     (h) Fabrication of athletic mouth guards;
     (i) Placement of temporary restorations;
     (j) Fabrication of soft occlusal guards;
     (k) Tissue conditioning and soft reline;
     (l) Atraumatic restorative therapy;
     (m) Dressing changes;
     (n) Tooth reimplantation;
     (o) Administration of local anesthetic;
     (p) Administration of nitrous oxide;
     (q) Emergency palliative treatment of dental pain;
     (r) The placement and removal of space maintainers;
     (s) Cavity preparation;
     (t) Restoration of primary and permanent teeth;
     (u) Placement of temporary crowns;
     (v) Preparation and placement of preformed crowns;
     (w) Pulpotomies on primary teeth;
     (x) Indirect and direct pulp capping on primary and permanent teeth;
     (y) Stabilization of reimplanted teeth;
     (z) Extractions of primary teeth;
     (aa) Suture removal;
     (bb) Brush biopsies;
     (cc) Repair of defective prosthetic devices;
     (dd) Recementing of permanent crowns;
     (ee) Oral evaluation and assessment of dental disease and the formulation of an individualized treatment plan;
     (ff) The supervision of expanded function dental auxiliaries and dental assistants. A dental therapist or advanced 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;
     (gg) 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
     (hh) The dispensation and administration of the following drugs: Analgesics, anti-inflammatories, preventive medicaments, and antibiotics.
     (2) Subject to the limitations in this section and section 5 of this act, an advanced dental therapist may provide the following services and procedures:
     (a) The services and procedures authorized for dental therapists under subsection (1) of this section; and
     (b) Any services and procedures within the scope of practice of a licensed dental hygienist under chapter 18.29 RCW.

NEW SECTION.  Sec. 5   (1) A dental therapist or an advanced dental therapist may only practice dental therapy pursuant to a written collaborative agreement with a dentist. The agreement must, at a minimum, contain the following elements:
     (a) Practice settings where services and procedures may be provided;
     (b) Any limitations on the services or procedures the dental therapist or advanced dental therapist may provide;
     (c) Age and procedure-specific practice protocols, including case selection criteria, assessment guidelines, and imaging frequency;
     (d) Procedures for creating and maintaining dental records for patients treated by the dental therapist or advanced dental therapist;
     (e) A plan to manage medical emergencies in each practice setting where the dental therapist or advanced dental therapist provides care;
     (f) A quality assurance plan for monitoring care provided by the dental therapist or advanced dental therapist, including patient care review, referral follow-up, and a quality assurance chart review;
     (g) Protocols for administering and dispensing medications, including the specific circumstances under which the medications may be dispensed and administered;
     (h) Criteria relating to the provision of care to patients with specific medical conditions or complex medical histories, including requirements for consultation prior to the initiation of care; and
     (i) Specific written protocols governing situations where the dental therapist or advanced dental therapist encounters a patient requiring treatment that exceeds the dental therapist's or advanced dental therapist's scope of practice or capabilities.
     (2)(a) In addition to the elements specified in subsection (1) of this section, a written collaborative agreement with a dental therapist must specify the services and procedures the dental therapist is authorized to provide.
     (b) All of the services and procedures the dental therapist provides pursuant to the collaborative agreement must be provided under the off-site supervision of the collaborating dentist. The collaborating dentist shall accept responsibility for all services and procedures authorized and provided by the dental therapist pursuant to the collaborative agreement.
     (c) A collaborating dentist who knowingly permits a dental therapist to provide a service or procedure that is not authorized in the collaborative agreement, or any dental therapist who provides a service or procedure that is not authorized in the collaborative agreement, commits unprofessional conduct for purposes of chapter 18.130 RCW.
     (3) A dentist who enters into a written collaborative agreement with a dental therapist or an advanced dental therapist shall:
     (a) Directly provide or arrange for another dentist or specialist to provide any necessary advanced procedures or services needed by the patient or any treatment that exceeds the dental therapist's or the advanced dental therapist's scope of practice or capabilities; and
     (b) Ensure that he or she or another dentist is available to the dental therapist or advanced dental therapist for timely consultation during treatment if needed.
     (4) Collaborative agreements must be signed and maintained by both the collaborating dentist and the dental therapist or advanced dental therapist. The agreements must be submitted to the department on an annual basis.
     (5) A collaborating dentist may enter into a collaborative agreement with no more than a total of five dental therapists and advanced dental therapists at any one time.
     (6) An advanced dental therapist may practice without the supervision or off-site supervision of a dentist.

NEW SECTION.  Sec. 6   Nothing in this chapter prohibits or affects:
     (1) The practice of dental therapy by an individual otherwise licensed under this title and performing services within his or her scope of practice;
     (2) The practice of dental therapy in the discharge of official duties on behalf of the United States government, including, but not limited to, the armed forces, coast guard, public health service, veterans' bureau, or bureau of Indian affairs;
     (3) The practice of dental therapy pursuant to an education program described in section 3 of this act; or
     (4) The practice of dental therapy under the supervision of a dentist necessary to meet the clinical experience or preceptorship requirements of section 3 of this act.

NEW SECTION.  Sec. 7   Chapter 18.130 RCW governs the unlicensed practice, the issuance and denial of licenses, and the discipline of persons licensed under this chapter. The secretary is the disciplining authority under this chapter.

Sec. 8   RCW 18.32.030 and 2007 c 269 s 15 are each amended to read as follows:
     The following practices, acts, and operations are excepted from the operation of the provisions of this chapter:
     (1) The rendering of dental relief in emergency cases in the practice of his or her profession by a physician or surgeon, licensed as such and registered under the laws of this state, unless the physician or surgeon undertakes to or does reproduce lost parts of the human teeth in the mouth or to restore or to replace in the human mouth lost or missing teeth;
     (2) The practice of dentistry in the discharge of official duties by dentists in the United States federal services on federal reservations, including but not limited to the armed services, coast guard, public health service, veterans' bureau, or bureau of Indian affairs;
     (3) Dental schools or colleges approved under RCW 18.32.040, and the practice of dentistry by students in accredited dental schools or colleges approved by the commission, when acting under the direction and supervision of Washington state-licensed dental school faculty;
     (4) The practice of dentistry by licensed dentists of other states or countries while appearing as clinicians at meetings of the Washington state dental association, or component parts thereof, or at meetings sanctioned by them, or other groups approved by the commission;
     (5) The use of roentgen and other rays for making radiographs or similar records of dental or oral tissues, under the supervision of a licensed dentist or physician;
     (6) The making, repairing, altering, or supplying of artificial restorations, substitutions, appliances, or materials for the correction of disease, loss, deformity, malposition, dislocation, fracture, injury to the jaws, teeth, lips, gums, cheeks, palate, or associated tissues or parts; providing the same are made, repaired, altered, or supplied pursuant to the written instructions and order of a licensed dentist which may be accompanied by casts, models, or impressions furnished by the dentist, and the prescriptions shall be retained and filed for a period of not less than three years and shall be available to and subject to the examination of the secretary or the secretary's authorized representatives;
     (7) The removal of deposits and stains from the surfaces of the teeth, the application of topical preventative or prophylactic agents, and the polishing and smoothing of restorations, when performed or prescribed by a dental hygienist licensed under the laws of this state;
     (8) A qualified and licensed physician and surgeon or osteopathic physician and surgeon extracting teeth or performing oral surgery pursuant to the scope of practice under chapter 18.71 or 18.57 RCW;
     (9) The performing of dental operations or services by registered dental assistants and licensed expanded function dental auxiliaries holding a credential issued under chapter 18.260 RCW when performed under the supervision of a licensed dentist, by dental therapists and advanced dental therapists licensed under chapter 18.-- RCW (the new chapter created in section 15 of this act), or by other persons not licensed under this chapter if the person is licensed pursuant to chapter 18.29, 18.57, 18.71, or 18.79 RCW as it applies to registered nurses and advanced registered nurse practitioners, each while acting within the scope of the person's permitted practice under the person's license: PROVIDED HOWEVER, That such persons shall in no event perform the following dental operations or services unless permitted to be performed by the person under this chapter or chapters 18.29, 18.57, 18.71, 18.79 as it applies to registered nurses and advanced registered nurse practitioners, and 18.260 RCW:
     (a) Any removal of or addition to the hard or soft tissue of the oral cavity;
     (b) 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;
     (c) Any administration of general or injected local anaesthetic of any nature in connection with a dental operation, including intravenous sedation;
     (d) Any oral prophylaxis;
     (e) The taking of any impressions of the teeth or jaw or the relationships of the teeth or jaws, for the purpose of fabricating any intra-oral restoration, appliance, or prosthesis.

Sec. 9   RCW 18.32.0351 and 2007 c 269 s 16 are each amended to read as follows:
     The Washington state dental quality assurance commission is established, consisting of ((sixteen)) eighteen members each appointed by the governor to a four-year term. No member may serve more than two consecutive full terms. In appointing the initial members of the commission, it is the intent of the legislature that, to the extent possible, members of the previous boards and committees regulating these professions be appointed to the commission. Members of the commission hold office until their successors are appointed. The governor may appoint members of the initial commission to staggered terms of from one to four years. Thereafter, all members shall be appointed to full four-year terms. Twelve members of the commission must be dentists, one member must be a dental therapist licensed under chapter 18.-- RCW (the new chapter created in section 15 of this act), one member must be an advanced dental therapist licensed under chapter 18.-- RCW (the new chapter created in section 15 of this act), two members must be expanded function dental auxiliaries licensed under chapter 18.260 RCW, and two members must be public members.

Sec. 10   RCW 18.130.040 and 2010 c 286 s 18 and 2010 c 65 s 3 are each reenacted and amended to read as follows:
     (1) This chapter applies only to the secretary and the boards and commissions having jurisdiction in relation to the professions licensed under the chapters specified in this section. This chapter does not apply to any business or profession not licensed under the chapters specified in this section.
     (2)(a) The secretary has authority under this chapter in relation to the following professions:
     (i) Dispensing opticians licensed and designated apprentices under chapter 18.34 RCW;
     (ii) Naturopaths licensed under chapter 18.36A RCW;
     (iii) Midwives licensed under chapter 18.50 RCW;
     (iv) Ocularists licensed under chapter 18.55 RCW;
     (v) Massage operators and businesses licensed under chapter 18.108 RCW;
     (vi) Dental hygienists licensed under chapter 18.29 RCW;
     (vii) East Asian medicine practitioners licensed under chapter 18.06 RCW;
     (viii) Radiologic technologists certified and X-ray technicians registered under chapter 18.84 RCW;
     (ix) Respiratory care practitioners licensed under chapter 18.89 RCW;
     (x) Hypnotherapists and agency affiliated counselors registered and advisors and counselors certified under chapter 18.19 RCW;
     (xi) Persons licensed as mental health counselors, mental health counselor associates, marriage and family therapists, marriage and family therapist associates, social workers, social work associates--advanced, and social work associates -- independent clinical under chapter 18.225 RCW;
     (xii) Persons registered as nursing pool operators under chapter 18.52C RCW;
     (xiii) Nursing assistants registered or certified under chapter 18.88A RCW;
     (xiv) Health care assistants certified under chapter 18.135 RCW;
     (xv) Dietitians and nutritionists certified under chapter 18.138 RCW;
     (xvi) Chemical dependency professionals and chemical dependency professional trainees certified under chapter 18.205 RCW;
     (xvii) Sex offender treatment providers and certified affiliate sex offender treatment providers certified under chapter 18.155 RCW;
     (xviii) Persons licensed and certified under chapter 18.73 RCW or RCW 18.71.205;
     (xix) Denturists licensed under chapter 18.30 RCW;
     (xx) Orthotists and prosthetists licensed under chapter 18.200 RCW;
     (xxi) Surgical technologists registered under chapter 18.215 RCW;
     (xxii) Recreational therapists;
     (xxiii) Animal massage practitioners certified under chapter 18.240 RCW;
     (xxiv) Athletic trainers licensed under chapter 18.250 RCW;
     (xxv) Home care aides certified under chapter 18.88B RCW; ((and))
     (xxvi) Genetic counselors licensed under chapter 18.290 RCW; and
     (xxvii) Dental therapists licensed under chapter 18.-- RCW (the new chapter created in section 15 of this act).
     (b) The boards and commissions having authority under this chapter are as follows:
     (i) The podiatric medical board as established in chapter 18.22 RCW;
     (ii) The chiropractic quality assurance commission as established in chapter 18.25 RCW;
     (iii) The dental quality assurance commission as established in chapter 18.32 RCW governing licenses issued under chapter 18.32 RCW and licenses and registrations issued under chapter 18.260 RCW;
     (iv) The board of hearing and speech as established in chapter 18.35 RCW;
     (v) The board of examiners for nursing home administrators as established in chapter 18.52 RCW;
     (vi) The optometry board as established in chapter 18.54 RCW governing licenses issued under chapter 18.53 RCW;
     (vii) The board of osteopathic medicine and surgery as established in chapter 18.57 RCW governing licenses issued under chapters 18.57 and 18.57A RCW;
     (viii) The board of pharmacy as established in chapter 18.64 RCW governing licenses issued under chapters 18.64 and 18.64A RCW;
     (ix) The medical quality assurance commission as established in chapter 18.71 RCW governing licenses and registrations issued under chapters 18.71 and 18.71A RCW;
     (x) The board of physical therapy as established in chapter 18.74 RCW;
     (xi) The board of occupational therapy practice as established in chapter 18.59 RCW;
     (xii) The nursing care quality assurance commission as established in chapter 18.79 RCW governing licenses and registrations issued under that chapter;
     (xiii) The examining board of psychology and its disciplinary committee as established in chapter 18.83 RCW; and
     (xiv) The veterinary board of governors as established in chapter 18.92 RCW.
     (3) In addition to the authority to discipline license holders, the disciplining authority has the authority to grant or deny licenses. The disciplining authority may also grant a license subject to conditions.
     (4) All disciplining authorities shall adopt procedures to ensure substantially consistent application of this chapter, the Uniform Disciplinary Act, among the disciplining authorities listed in subsection (2) of this section.

Sec. 11   RCW 18.260.010 and 2007 c 269 s 1 are each amended to read as follows:
     The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
     (1) "Advanced dental therapist" means an individual who holds a license to practice as an advanced dental therapist under chapter 18.-- RCW (the new chapter created in section 15 of this act).
     (2) "Close supervision" means that a supervising dentist, dental therapist, or advanced dental therapist whose patient is being treated has personally diagnosed the condition to be treated and has personally authorized the procedures to be performed. The supervising dentist, dental therapist, or advanced dental therapist 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. The term does not require a supervising dentist, dental therapist, or advanced dental therapist to be physically present in the operatory.
     (((2))) (3) "Commission" means the Washington state dental quality assurance commission created in chapter 18.32 RCW.
     (((3))) (4) "Dental assistant" means a person who is registered by the commission to provide supportive services to a licensed dentist to the extent provided in this chapter and under the close supervision of a dentist.
     (((4))) (5) "Dental therapist" means an individual who holds a license to practice as a dental therapist under chapter 18.--- RCW (the new chapter created in section 15 of this act).
     (6) "Dentist" means an individual who holds a license to practice dentistry under chapter 18.32 RCW.
     (((5))) (7) "Department" means the department of health.
     (((6))) (8) "Expanded function dental auxiliary" means a person who is licensed by the commission to provide supportive services to a licensed dentist, dental therapist, or advanced dental therapist to the extent provided in this chapter and under the specified level of supervision of a dentist, dental therapist, or advanced dental therapist.
     (((7))) (9) "General supervision" means that a supervising dentist, dental therapist, or advanced dental therapist has examined and diagnosed the patient and provided subsequent instructions to be performed by the assistive personnel, but does not require that the dentist, dental therapist, or advanced dental therapist be physically present in the treatment facility.
     (((8))) (10) "Secretary" means the secretary of health.
     (((9))) (11) "Supervising advanced dental therapist" means an advanced dental therapist licensed under chapter 18.--- RCW (the new chapter created in section 15 of this act) who is responsible for providing the appropriate level of supervision for dental assistants and expanded function dental auxiliaries.
     (12) "Supervising dental therapist" means a dental therapist licensed under chapter 18.-- RCW (the new chapter created in section 15 of this act) who is responsible for providing the appropriate level of supervision for dental assistants and expanded function dental auxiliaries.
     (13) "Supervising dentist" means a dentist licensed under chapter 18.32 RCW that is responsible for providing the appropriate level of supervision for dental assistants and expanded function dental auxiliaries.

Sec. 12   RCW 18.260.040 and 2007 c 269 s 5 are each amended to read as follows:
     (1) The commission shall adopt rules relating to the scope of dental assisting services related to patient care and laboratory duties that may be performed by dental assistants. All dental services performed by dental assistants must be performed under the close supervision of a supervising dentist, a supervising dental therapist, or a supervising advanced dental therapist as the dentist, dental therapist, or advanced dental therapist may allow.
     (2) In addition to any other limitations established by the commission, dental assistants may not perform the following procedures:
     (a) Any scaling procedure;
     (b) Any oral prophylaxis, except coronal polishing;
     (c) Administration of any general or local anesthetic, including intravenous sedation;
     (d) Any removal of or addition to the hard or soft tissue of the oral cavity;
     (e) Any diagnosis of or prescription for treatment of disease, pain, deformity, deficiency, injury, or physical condition of the human teeth, jaw, or adjacent structures; and
     (f) The taking of any impressions of the teeth or jaw or the relationships of the teeth or jaws, for the purpose of fabricating any intra-oral restoration, appliance, or prosthesis.
     (3) A dentist, dental therapist, or advanced dental therapist may not assign a dental assistant to perform duties until the dental assistant has demonstrated skills necessary to perform competently all assigned duties and responsibilities.

Sec. 13   RCW 18.260.070 and 2007 c 269 s 6 are each amended to read as follows:
     (1) The commission shall adopt rules relating to the scope of expanded function dental auxiliary services related to patient care and laboratory duties that may be performed by expanded function dental auxiliaries.
     (2) The scope of expanded function dental auxiliary services that the commission identifies in subsection (1) of this section includes:
     (a) In addition to the dental assisting services that a dental assistant may perform under the close supervision of a supervising dentist, a supervising dental therapist, or a supervising advanced dental therapist, the performance of the following services under the general supervision of a supervising dentist, a supervising dental therapist, or a supervising advanced dental therapist as the dentist, dental therapist, or advanced dental therapist may allow:
     (i) Performing coronal polishing;
     (ii) Giving fluoride treatments;
     (iii) Applying sealants;
     (iv) Placing dental x-ray film and exposing and developing the films;
     (v) Giving patient oral health instruction; and
     (b) Notwithstanding any prohibitions in RCW 18.260.040, the performance of the following services under the close supervision of a supervising dentist, a supervising dental therapist, or a supervising advanced dental therapist as the dentist, dental therapist, or advanced dental therapist may allow:
     (i) Placing and carving direct restorations; and
     (ii) Taking final impressions.
     (3) A dentist, dental therapist, or advanced dental therapist may not assign an expanded function dental auxiliary to perform services until the expanded function dental auxiliary has demonstrated skills necessary to perform competently all assigned duties and responsibilities.

Sec. 14   RCW 18.260.080 and 2007 c 269 s 7 are each amended to read as follows:
     A supervising dentist, a supervising dental therapist, or a supervising advanced dental therapist is responsible for:
     (1) Maintaining the appropriate level of supervision for dental assistants and expanded function dental auxiliaries; and
     (2) Ensuring that the dental assistants and expanded function dental auxiliaries that the dentist, dental therapist, or advanced dental therapist supervises are able to competently perform the tasks that they are assigned.

NEW SECTION.  Sec. 15   Sections 1 through 7 of this act constitute a new chapter in Title 18 RCW.

NEW SECTION.  Sec. 16   The department and the dental quality assurance commission shall adopt any rules necessary to implement this act.

NEW SECTION.  Sec. 17   Sections 1 through 15 of this act take effect January 1, 2012.