HB 1364

Brief Description: Establishing the practice of dental therapy.

Sponsors: Representatives Cody, Macri, Clibborn, Pettigrew, Farrell, Stonier, Jinkins, Kagi, Fitzgibbon, Gregerson, Tharinger, Robinson, Appleton and Kloba.

Hearing Date: 1/27/17

Staff: Jim Morishima (786-7191).

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 perceptorship 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."

Summary of Bill:

Dental Therapists.

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

• completion of a dental therapist program accredited by the Commission on Dental Accreditation;

• passage of an examination;

• completion of a 400-hour preceptorship under the supervision of a dentist; and

• payment of applicable fees.

A dental therapist may perform the following services and procedures:

• oral health instruction and disease prevention education, including nutritional counseling and dietary analysis;

• preliminary charting of the oral cavity;

• making radiographs;

• mechanical polishing;

• prophylaxis;

• periodontal scaling and root planing;

• application of topical preventative or prophylactic agents, including fluoride varnishes and pit and fissure sealants;

• pulp vitality testing;

• application of desensitizing medication or resin;

• fabrication of athletic mouth guards;

• placement of temporary restorations;

• fabrication of soft occlusal guards;

• tissue conditioning and soft reline;

• atraumatic restorative therapy;

• dressing changes;

• tooth reimplantation;

• administration of local anesthetic;

• administration of nitrous oxide;

• emergency palliative treatment of dental pain;

• the placement and removal of space maintainers;

• cavity preparation;

• restoration of primary and permanent teeth;

• placement of temporary crowns;

• preparation and placement of preformed crowns;

• pulpotomies on primary teeth;

• indirect and direct pulp capping on primary and permanent teeth;

• stabilization of reimplanted teeth;

• extractions of primary teeth;

• suture removal;

• brush biopsies;

• repair of defective prosthetic devices;

• recementing of permanent crowns;

• oral evaluation and assessment of dental disease and the formulation of an individualized treatment plan;

• the supervision of expanded function dental auxiliaries and dental assistants. A dental therapist may supervise no more than a total of four expanded function dental auxiliaries and dental assistants in any one practice setting. A dental therapist or advanced dental therapist may not supervise an expanded function dental auxiliary or dental assistant with respect to tasks that the dental therapist is not authorized to perform;

• nonsurgical extractions of periodontally diseased permanent teeth with tooth mobility of plus 3 to plus 4 if the teeth are not unerupted, are not impacted, are not fractured, and do not need to be sectioned for removal; and

• the dispensation and administration of the following drugs: non-narcotic analgesics, anti-inflammatories, preventive agents, and antibiotics. The dental therapist may dispense sample drugs, but may not dispense or administer narcotic drugs.

A dental therapist must practice pursuant to a written practice plan contract with a dentist. The contract must be signed and maintained by both the contracting dentist and the dental therapist, be submitted to the Department of Health (DOH) annually, and be made available at the practice of the dental therapist. The contract must specify:

• practice settings;

• limitations on the services or procedures that are provided;

• age and procedure-specific practice protocols;

• procedures for creating and maintaining dental records;

• a plan to manage medical emergencies;

• a quality assurance plan;

• protocols and limits for the administering and dispensing medications;

• criteria for serving patients with specific medical conditions or complex medical histories; and

• specific protocols for situations in which the needs of the patient exceed the dental therapist's scope of practice or capabilities.

A contracting dentist must make arrangements for the provision of advanced procedures and services needed by the patient or any treatment that exceeds the dental therapist's scope of practice or capabilities. The contracting dentist must also ensure that he or she, or another dentist, is available for instant communication during treatment. A dentist may enter into a practice plan contract with no more than five dental therapists at any one time.

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

A dental therapist may practice only in:

• a federally qualified health center;

• a clinic operated by an accredited school of dentistry or school of dental hygiene;

• a clinic operated by a tribal health program or an urban Indian organization; or

• any clinic or practice setting in which at least 35 percent of the patient base of the dental therapist consists of patients 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.

A federally recognized Indian tribe, tribal organization, or urban Indian organization is authorized to train, employ, or contract with a dental health aide therapist (DHAT). A dentist employed or contracted by a federally recognized Indian tribe, tribal organization, or urban Indian organization may supervise a DHAT. The DHAT must be certified by a federal Community Health Aide Program (CHAP) or an Indian tribe that has adopted equivalent or higher standards than the CHAP with respect to curriculum, training, scope of practice, continuing education, and supervision.

A DHAT may only perform procedures allowed by a CHAP or an Indian tribe with equivalent or higher standards. The DHAT's practice is further limited by federal law and any limitations in his or her practice agreement. A DHAT may only practice in settings operated by an Indian health program or an urban Indian organization.

The DOH must convene a DHAT work group consisting of:

• a representative from a community college considering establishing a dental therapist program;

• a representative from a four-year university considering establishing a dental therapist program;

• the director of a clinic hiring a registered dental hygienist who is also a dental therapist;

• a tribal college considering establishing a DHAT or dental therapist program;

• a DHAT education expert;

• a tribal liaison from the DOH;

• a member of the Dental Hygiene Examining Committee;

• a tribal representative of an Indian tribe employing a DHAT;

• a representative of the Washington Dental Hygienists' Association;

• the director of a dental hygiene therapy education program;

• a representative of the Commission on Dental Accreditation;

• a member of the Alaska CHAP Certification Board who is not an educator;

• a representative of the American Indian Health Commission of Washington;

• a representative from an urban Indian program dental clinic; and

• a representative of the Northwest Portland Area Indian Health Board.

The work group must develop and recommend criteria for establishing a pathway for DHATs licensed by tribes or tribal organizations, or certified by a CHAP, to become a licensed dental therapist in Washington. The work group must also evaluate the accreditation standards and competencies of existing tribes' or tribal organizations' DHAT certification programs and make recommendations for any additional education, clinical experiences, and evaluation and examination processes necessary to meet Washington's dental therapist licensure standards.

The work group must be convened by July 1, 2017, and must report its findings to the Legislature by December 1, 2017.

Appropriation: None.

Fiscal Note: Available.

Effective Date: This bill takes effect 90 days after adjournment of the session in which the bill is passed, except for section 10, relating to dental health aide therapists, which takes effect immediately, and sections 1 through 9, 11 through 20, and 22, relating to licensing dental therapists, which take effect January 1, 2018..