Dental Personnel in Washington. Washington has a variety of credentialed dental providers who provide assistance to licensed dentists.

Dental Hygienists.  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. To be licensed, dental hygienists must complete an educational program, pass an examination, and fulfill continuing education requirements.

Dental Assistants.  Dental assistants are authorized to perform patient care and laboratory duties as authorized by the Dental Hygiene Quality Assurance Commission (Dental Commission) in rule. Dental assistants must register with the Dental Commission.

Expanded Function Dental Auxiliaries.  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. 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 Dental Commission and pass an examination.

Dental Anesthesia Assistants.  Dental anesthesia assistants perform duties related to dental anesthesia under the supervision of an oral and maxillofacial surgeon or dental anesthesiologist. 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 a supervisor's attestation.

Dental Health Aide Therapists. The federal Community Health Aide Program (CHAP) is a workforce model available in tribal communities that includes three different provider types that act as extenders of their licensed clinical supervisor. The national CHAP currently includes a behavioral health aide, community health aide, and dental health aide.

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

In 2017, the Legislature authorized DHAT services in Washington 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 and are operated by an Indian health program;
• services are provided within the scope of practice set by a 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 therapist services are exempt from licensing requirements for other dental professions. The Health Care Authority was directed to coordinate with the Centers for Medicare and Medicaid services to provide that DHAT services are eligible for federal funding up to 100 percent.

License Requirements. A person may not practice dental therapy or represent themself as a dental therapist without being licensed by the Department of Health (DOH). DOH must issue a license to practice as a dental therapist to any applicant who:

• successfully completes a dental therapist program that is:
  1. accredited or has received initial accreditation by the Commission on Dental Accreditation (CODA);
  2. not accredited by CODA, if the applicant successfully completed the dental therapy program before September 31, 2022, and the Dental Commission determines the program is substantially equivalent to CODA standards;
• passes an examination approved by the Dental Commission; and
• pays applicable fees.

Applicants who attended a program that is not accredited must also complete a 400-hour preceptorship under the close supervision of a dentist.

When considering and approving the exam required for licensure, the Dental Commission must consult with tribes that license dental health aide therapists and with dental therapy education programs in Washington. The Secretary of Health (secretary), in consultation with the Dental Commission, may adopt rules to implement these requirements. DOH must establish continuing education requirements for license renewal in rule.

Applicants holding a valid license and engaged in current practice in another state may be granted a license without examination, if the secretary determines the other state's licensing standards are substantially equivalent.

Limited License. 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;
• has graduated from a CODA accredited dental therapy school, or a dental therapy education program that the Dental Commission determines is substantially equivalent to an accredited education program, if the applicant graduated before September 30, 2022;
• demonstrates knowledge of Washington dental therapy laws; and
• pays required fees.

A person practicing with a limited license may perform only the procedures that the person was licensed or certified to practice in the jurisdiction they held an active license. A person who demonstrates competency in the scope of practice may apply for licensure as a dental therapist. The term of a limited license is the same term as an initial limited dental hygiene license, which is 18 months. DOH may adopt rules to implement and administer the limited license.

Scope of Practice. A dental therapist may perform the following services and procedures under supervision of a licensed dentist to the extent authorized by the supervising dentist:

• oral health instruction and disease prevention education, including nutritional counseling and dietary analysis;
• comprehensive 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 and soft occlusal guards;
• placement of temporary restorations;
• tissue conditioning and soft reline;
• atraumatic restorative therapy and interim restorative therapy;
• dressing changes;
• administration of local anesthetic and nitrous oxide;
• emergency palliative treatment of dental pain limited to authorized procedures;
• 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 for adults;
• indirect and direct pulp capping on primary and permanent teeth;
• stabilization of reimplanted teeth;
• extractions of primary teeth;
• suture removal;
• brush biopsies;
• minor adjustments and repairs on removable prostheses;
• recementing of permanent crowns;
• oral evaluation and assessment of dental disease and the formulation of an individualized treatment plan;
  1. when possible, a dental therapist must collaborate with the supervising dentist to formulate a patient's individualized treatment plan;
• identification of oral and systemic conditions requiring evaluation and treatment by a dentist, physician, or other health care provider, and management of referrals;
• the supervision of expanded function dental auxiliaries, dental assistants, and dental hygienists;
  1. a dental therapist may supervise no more than a total of three expanded function dental auxiliaries, dental assistants, and dental hygienists at any one time in any one practice setting;
  2. a dental therapist may not supervise an expanded function dental auxiliary, dental assistant, or dental hygienist with respect to tasks that the dental therapist is not authorized to perform;
• nonsurgical extractions of erupted permanent teeth under limited conditions; and
• the dispensation and administration of the following drugs: non-narcotic analgesics, anti-inflammatories, preventive agents, and antibiotics;
  1. the dental therapist may dispense sample drugs, but may not dispense or administer narcotic drugs.
  2. a dental therapist does not have the authority to prescribe drugs.

A dental therapist may only practice in federally qualified health centers (FQHCs), tribal FQHCs, and FQHC lookalikes.

Practice Plan Contract. A dental therapist may only practice under the supervision of a dentist licensed in Washington or exempt from licensure under the Indian Health Care Improvement Act 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 under off-site supervision, which is supervision that does not require the dentist to be personally on-site when services are provided or to previously examine or diagnose the patient. The Contract must be signed and maintained by both the contracting dentist and the dental therapist and 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 may be 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;
• criteria for serving patients with specific medical conditions or complex medical histories; and
• 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. A supervising dentist that is licensed in Washington who knowingly permits a dental therapist to provide a service or procedure not authorized in the Contract, and any dental therapist who provides a service or procedure that is not authorized, commits unprofessional conduct. A supervising dentist may not supervise more than five dental therapists at any one time. 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; and
• ensure that they, 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 dental therapist must submit a signed copy of the contract to the Secretary at the time of licensure renewal and must submit any revisions. A dental therapist must obtain liability insurance with coverage equivalent to that of the supervising dentist.

A dentist providing services at a FQHC is not required to enter a practice plan contract and may not face retaliation or default on a loan repayment contract if the dentist refuses to enter into a practice plan contract or supervise a dental therapist.

Other Provisions. The Dental Commission membership is increased to 21 members, adding four licensed dental therapists. The Dental Commission is established as the disciplining authority for dental therapists for the purposes of the Uniform Disciplinary Act.

For purposes of the legend drug chapter, dental therapists are added to the definition of practitioner, to the extent authorized in the dental therapy chapter.

A dental therapist must complete a one-time training in suicide assessment, treatment, and management.

A dental assistant, an expanded function dental auxiliary, and a dental hygienist may perform services under the supervision of a dental therapist. DOH must adopt any rules necessary to implement this act.

PRO: This bill will help address the workforce crisis and provide access to those who currently lack it. It is a modest step to provide access to most underserved communities. DHATs have broken the cycle of failed dental delivery for tribal members, and access has dramatically increased in those communities.   Dental therapists are heavily trained on the allowable procedures.  American Indians and Alaska Natives are more likely to experience poor oral health and dental therapists have helped to address this disparity.

CON: Some dentists would not undertake some procedures included in the dental therapy scope of practice in this bill.  The bill should require in-person supervision for irreversible procedures. Vulnerable patients deserve the highest quality care and this bill does not go far enough to protect them. Simple procedures can turn complicated. Legislation in other states has not increased access in remote areas.  Dental therapists do not receive sufficient training to perform the procedures allowed under the bill.