Alaska dentists and dental hygienists agreed to the merger into one bill of a dental association initiated bill (allowing dental assistants to polish and provide restorative services) with a dental hygienists’ association proposal (for collaborative practice and general supervision for local anesthesia). Dental hygienists would also be able to qualify to perform restorative services.

Now on the governor’s desk, House Bill 319 would allow dental hygienists with at least 4,000 hours of experience in the last five years to practice according to a written collaborative agreement with a dentist. The board would need to approve the collaborative agreement, which could allow the dental hygienist to initiate services without the dentist’s individual diagnosis and treatment plan at settings other than the dentist’s usual place of practice. The collaborative hygienist could perform virtually any traditional dental hygiene service, including local anesthesia, pursuant to the terms of the agreement, whether or not the dentist was present.

The Minnesota State Senate overwhelming passed an amended Omnibus Higher Education Bill that contained a provision to put language in statute that creates the Oral Health Practitioner (OHP) and convenes a workgroup to make recommendations and propose legislation to define the scope, supervision and education of the provider. The amendment codifies that the OHP will be a licensed, educated provider who works under the supervision of a dentist via a collaborative management agreement. The amendment stipulates that OHPs must practice in underserved areas and cannot begin lawful practice prior to 2011.

The scope of practice the workgroup is directed to design for the provider includes primary diagnostic, educational, palliative, therapeutic and restorative (cavity preps, restoration of permanent teeth, temporary crowns, placement of preformed crowns, pulpotomies on primary teeth, pulp capping) services, as well as extractions of primary and permanent teeth, placing and removing sutures and prescriptive authority (anti-infective, non-narcotic pain management and prevention).

The various stakeholders including representatives from Metropolitan State University, the University of Minnesota, the Minnesota Dental Hygienists’ Association, the Minnesota Dental Association, the state board of dentistry, Safety Net Coalition and several other dentists representing various public health and special interest groups, as well as two state agency representatives, will populate the workgroup. The majority of dentists on the workgroup will have to have specific public health experience. The workgroup is charged with completing its work by December 15, 2008, and draft legislation to enact specific recommendations will be required by January 15, 2009.

Dental hygienists in Maine can practice independently in all settings, thanks to a proposal submitted by a denturist. Independent practice for dental hygienists was among the four proposals under consideration by the state’s Department of Professional and Financial Regulation during their sunrise review. The other three were licensure of graduates of foreign dental schools, creation of a separate licensing board for denturists and hygienists, creation of an advanced practice dental hygiene practitioner, and independent practice. The Joint Committee in Business, Regulation and Economic Development released its recommendation from the sunrise review in late February. Their recommendation:independent practice. Facing no opposition by organized dentistry, the bill sailed through the Maine legislature and was signed into law by the governor in mid-April.

Independent practice dental hygienists are required to possess a bachelor’s degree from a dental hygiene program accredited by the Commission on Dental Accreditation (CODA) and 2,000 work hours of clinical practice in a private dental practice; or possess an associate degree from a CODA-accredited dental hygiene program and 6,000 work hours of clinical practice in a private dental practice. They are also required to provide a referral plan to patients in need of additional care by a dentist.

Indiana became the 41st state, including Washington, D.C., to allow dental hygienists to administer local anesthesia. Under the new law, dental hygienists who have completed a board-approved course and received a board-issued dental hygiene anesthetic permit may administer local anesthesia under direct supervision. The bill also contained a provision to expand the current law to allow prescriptive supervision in hospitals, clinics, fixed charitable institutions, public health settings and correctional institutions. Under prescriptive supervision, a licensed dentist is not required to be physically present but needs to have examined the patient and prescribed the patient care within the previous 45 days. As a trade-off with the Indiana Dental Association, dental assistants who have completed a board-approved curriculum are allowed to polish coronally and apply fluoride under the direct supervision of the dentist. The Indiana State Board of Dentistry must finalize the rules and regulations for the law to take effect.

The Virginia Board of Dentistry established guidelines, criteria and regulations to enable licensed hygienists to practice local anesthesia and administer nitrous oxide. A dental hygienist who completed a 36-hour course and successfully passed a CODA-accredited exam is certified to administer nitrous oxide and local anesthesia to patients 18 years of age or older under the direction of a dentist.

ADHP News

The Minnesota state legislature made history earlier this year by introducing legislation to establish an Advanced Dental Hygiene Practitioner. House File 3247 (HF 3247) and the Senate companion bill, Senate File 2895 (SF 2895), direct that the new provider will be a licensed dental hygienist, educated at the master’s level and permitted to practice an advanced scope by the state board of dentistry. The ADHP will have an expanded role in treating patients by providing basic oral health primary care services including diagnostic, preventive, prescriptive, therapeutic and restorative services directly to the public. The new provider will be focused on practice in public health settings and will enter into a collaborative management agreement with a licensed dentist in the state, which will lay out protocol for patient referral, provider communication and guidelines for emergency situations.

Since introduction in February, the ADHP legislative efforts are progressing quickly. On March 13, the Senate Health and Human Services Budget Division voted in favor of passing SF 2895 on to the full Senate Finance Committee. The house companion bill, HF 3247, was scheduled for a hearing in the full House Committee on Health and Human Services but was later pulled due to lack of votes.

There is a great deal of support for the concept within the state, but certainly, there are those who are not in favor. The Minnesota Dental Hygienists’ Association, Minnesota State Colleges and Universities, and the Safety Net Coalition will continue their hard work to advocate in favor of the legislation in coming months. The three groups have been working heartily for months to generate support and educate legislators about the need for the new provider.

In other ADHP news, the New Hampshire State House recently passed legislation that establishes a commission to study the creation of an Advanced Dental Hygiene Practitioner to increase access to oral health care. House Bill 1487 passed on a voice vote by the full house and will now move onto the senate for consideration.

Workforce Model Update

On February 25, legislation in Minnesota, SF 3122 and HF 3254, was introduced that included a provision to study the Community Dental Health Coordinator model. Both bills passed through a number of committees and are currently awaiting hearings in the House and Senate Finance Committees respectively.

Missouri House Bill 1976, scheduled for a committee hearing in late March, would explicitly add “removal of hard and soft deposits from teeth” to duties permitted to all dental assistants. Although the board would be allowed to set conditions for dental assistants to scale, they would not be required to mandate any additional education or special regulation for scaling assistants.

Public Health Hygienist

Florida dental hygienists have expressed strong support for Governor Crist’s "Access to Oral Health Act" proposal, sent to the legislature in March as one of his top priorities for this session. The proposal (companion bills Senate Bill 2760/House Bill 1367), begins with a preamble that recognizes the importance of preventive services and the fact that in Florida dental care for low-income and other underserved patients is provided primarily through publicly funded programs.

There are three major public health related components of the measure. The initial section revises the composition of the dental board to require that two of the seven dentist members of the 11-person board must either have practiced in the public health sector in two of the last five years or hold an advanced degree in public health.

Second, although Florida has been one of the handful of states with no provision for any kind of licensure by endorsement or reciprocity, this measure would allow licensed dentists from other states to obtain a license without retaking the clinical examination for practice in public health facilities. A dentist holding such a public health license could apply to convert it to a general license after a minimum of 3,000 hours of public health service.

Finally, the proposal would allow dental hygienists to practice under public health supervision in public health settings. They could provide a full range of services without the prior examination or presence of a dentist in public health programs, institutions of the Department of Children and Family Services, the Department of Juvenile Justice, non-profit community health centers, a Head Start center, or a federally qualified health center.

In addition, the bills would allow physicians and nurses to be reimbursed by Medicaid for applying fluoride varnish for children up to three years old during Well Child visits and fund increased community dental services in rural areas for disabled people.

The Maryland General Assembly introduced the Public Health Dental Hygiene Act in early February. House Bill 1280 and its senate companion, Senate Bill 818, are a direct response to the state’s access-to-care crisis that claimed the life of 12-year-old Deamonte Driver last February. Secretary Colmer of the Maryland State Department of Health and Mental Hygiene formulated the Dental Action committee to study this problem. The Public Health Hygienist was a priority of this committee.

The Public Health Dental Hygiene Act seeks to increase access by allowing the Public Health Dental Hygienist to work in a variety of public health settings including facilities owned and operated by federal, state or local governments; schools; Head Start programs; and facilities that provide Dental care to the poor, elderly or handicapped. The Public Health Hygienist would be able to work under general supervision to the full scope of dental hygiene practice to include sealants and fluoride agents.

With bipartisan support in the house and senate as well as backing from the Maryland Dental Hygienists’ Association and the Maryland State Dental Society, the bill is expected to easily pass both chambers.

March 2008

While a number of states authorize a dental hygienist to assess and/or treatment plan, if proposed rules are finalized at the next board meeting, Montana will have the distinction of becoming the second state to specifically recognize the dental hygiene diagnosis. The rule proposal, issued by the dental board in early January, states that laws restricting diagnosis to a dentist do not apply to “dental hygiene diagnosis and treatment planning” necessary to provide dental hygiene procedures. Oregon rules four years ago were the first to authorize dental hygiene diagnosis in a similar fashion by specifying that dental hygiene diagnosis was not included in the general prohibition against diagnosis.

The New Hampshire House Committee on Health, Human Services and Elderly Affairs passed HR 1487, a bill that directs the study of the Advanced Dental Hygiene Practitioner (ADHP) model to increase access to oral health. After a series of hearings and an executive session, the committee recognized the need for a mid-level provider and voted 13-4 in favor of establishing a study committee to examine the various workforce models, particularly ADHP, as a solution to the state’s access to care problem. The bill awaits action in the Senate.

The South Dakota Board of Dentistry issued a “Fluoride Varnish Declaratory Ruling” in January, which allows health professionals other than licensed dental providers to apply fluoride varnish when “prescribed by an appropriately licensed practitioner.” The board, voting unanimously, noted the efficacy of fluoride varnish, the fact that no dental instruments are needed and that at least seven other states permit non-dental providers to apply varnish in making its determination. This declaratory ruling is expected to allow dental hygienists to provide fluoride varnish in a variety of settings, including nursing homes, day cares, outreach programs and nursing homes under the prescription of a physician, physician’s assistant or nurse practitioner as well as a dentist.

The Pennsylvania Dental Hygienists’ Association presented State Senator Patricia Vance with the Certificate of Recognition Award for her efforts to increase access to oral health care. The presentation ceremony took place at Harrisburg Area Community College in November. Senator Vance was the primary sponsor of a bill that amended Pennsylvania’s dental law to allow public health dental hygiene practitioners to provide preventive health care to individuals in a variety of public health settings without dental supervision. The governor signed the bill into law last summer.

Februry 2008

The defeat of two sets of proposed rules in late 2007—in Florida and Nebraska—illustrate that the agency rulemaking process is also subject to strict guidelines. The first principle of rulemaking is that the rules cannot contradict statutory law, and that rulemaking agencies such as dental/dental hygiene boards have only as much authority to make rules as the statutory practice act delegates to them.

On December 6, 2007, the Florida Dental Board rejected a request from the Florida Dental Association to add supragingival scaling and periodontal probing to the list of duties permitted to dental assistants. The request was part of a large package asking the board to include some additional restoration-related duties and relax some supervision requirements for dental hygienists and assistants, as well as approval for dentists to provide “dermal fillers” and “injectable botulism toxin.”

The Florida Dental Hygiene Association (FDHA) had strongly opposed allowing unlicensed persons to either scale or probe, pointing out the obvious concerns about supragingival scaling alone being a non-therapeutic procedure and the possibility for physical harm to the patient from either probing or scaling performed by inadequately trained persons.

However, in this case, as FDHA also pointed out, these proposed rules were in conflict with the dental practice act. The Florida statute says that the removal of calculus and accretions can be delegated only to a dental hygienist.

Nebraska rules concerning dental assistant duties were approved by the board of dentistry and the board of health but were rejected for lack of statutory authority—in this case, following a mandatory review by the state attorney general. The board had proposed a new and longer laundry list of duties for dental assistants. The widely ranging duties would have included application of sealants, performing a brush biopsy, placing retraction material and placing amalgam. In addition, there would have been greatly expanded educational requirements for exposing X-rays, as well as detailed course requirements for several of the newly added duties. The Nebraska Dental Hygienists’ Association consistently opposed the proposed rules but advocated for accredited education and credentialing for dental assistants prior to the delegation of expanded duties.

In addition, the attorney general also rejected the rules on procedural grounds. Nebraska, like other states, has a requirement for regulatory boards to hold public hearings to accept comment on proposed rules. The board may amend the proposed rules based on public input before approving them. However, if the amended rules differ too much from those presented at the first hearing, a second hearing on the new version of the rules is required. In this case, the attorney general found “a number of changes in the text made between the time of newspaper notice and the adoption of the amended regulations, including several deletions and additions to the list of allowable duties for dental assistants,” resulting in regulations “substantially different from” the rules proposed and noticed.

Although registered dental hygienists in alternative practice (RDHAPs) have been California Medicaid providers for a decade, it was not until California Senate Bill 238 was signed in October, 2007, that they were recognized as reimbursable providers in federally qualified health centers (FQHCs). FQHCs, often referred to as “safety net clinics,” are non-profit, privately run community health centers open to anyone regardless of ability to pay, which obtain federal public health funding reimbursement. However, payment is based on a fixed fee per patient “encounter” with an approved provider rather than fee for service.

Both the California Dental Hygienists’ Association and the California Dental Association threw their support behind this measure. Implementation of rules adding both dental hygienists and RDHAPs to the list of approved providers is pending. FQHC patients should be able to access dental hygiene services directly later this year.

Stateline is prepared by the ADHA Division of Governmental Affairs.

January 2008

Prepare for Upcoming Legislative Sessions

State legislatures are just beginning to convene for 2008, and with that will come a flurry of legislative activity. If you enjoy following the lawmaking process, here are some resources to get acquainted with before the activity gets heavy.

Check out these sites for interesting background information:

• Curious about when the legislature in your state meets? StateNet, a well known tracking service, has a 2008_Legislative_Session_Calendar available at: http://www.statenet.com/resources/
  Note that Arkansas, Montana, Nevada, North Dakota, Oregon and Texas meet only every other year and will not be in session in 2008.
• Interested in the partisan make-up of each legislature? See http://www.ncsl.org/statevote/partycomptable2008.htm. This is the site of the National Conference of State Legislatures, an organization that gathers information for legislators and their staff.
• Want information about a particular legislator? Visit www.votesmart.org to see a full page of data including committees served on, voting records and positions on a variety of issues.

For really comprehensive information on what is happening during the session in any state, go directly to the state legislature’s Web site. Most state legislature Web sites are easy to navigate. Typically there is a section labeled “bills” or “legislation” where you can search for bills by number or by key words. The full text of the legislation is virtually always available, plus generally there is information about the progression of legislation through various committees and legislative chambers. Some other typical features of a legislature’s site are links to existing state statutes, how to find and contact your representatives, and information on bills that were considered in previous sessions.

Although, for the most part, state level dental hygiene practice laws determine how you practice every day, federal laws are important too. ADHA is active in Washington, D.C. to advocate on behalf of efforts that advance the practice of dental hygiene and make oral health care more accessible to patients. You are probably aware of recent efforts to obtain federal funding for an advanced dental hygiene practitioner pilot project, as well as work to include mandatory dental benefits in the State Children’s Health Insurance Program (SCHIP).

The place to go for up–to-date information on bills in Congress is “Thomas”– the Library of Congress Web site named for Thomas Jefferson at http://thomas.loc.gov/. Again, you can search by bill number, by topic or by key words. You can also link to federal legislators, the Congressional Record and much more.