On May 27, 2010, Ohio Governor Ted Strickland signed into law House Bill 190, establishing an oral health access supervision program in which dental hygienists may provide dental hygiene services in non-office settings without a dentist having previously seen the patient. In order to participate in the program, a dental hygienist must have received an oral health supervision permit from the State Dental Board along with written authorization from a dentist who has obtained a similar permit. The oral health access supervision program requires the dentist to review and evaluate the patient’s medical and dental history before the hygienist provides care; however, it does not require the dentist to examine the patient before the hygienist provides care.

The State Dental Board is required to report the status of the oral health access supervision program to the governor and general assembly annually. The report must include the number of dentists and dental hygienists who applied for the oral health supervision permit and were granted the permit, the number of patients who received care from dental hygienists, the location where the services were provided and the number of patients who received a clinical evaluation from a dentist following the provision of dental hygiene services.

In addition to establishing the oral health supervision program, the bill raises the minimum continuing education requirement for dental hygienists to 24 hours biennially, due December 31, 2011—increased from the current 12-hour requirement. The bill also creates a reciprocity mechanism for hygienists to administer local anesthesia in Ohio if they were qualified and trained in other states for this duty. House Bill 190 also reestablishes a school-based fluoride mouth rinse program for qualifying schools that may be administered by an employee of the department of health or a dental hygienist.

Several bills have been introduced in North Carolina that concern making dental services more accessible to the disabled. Senate Bill 1192/House Bill 1692 charges the state Medicaid agency with “exploring issues concerning dental care available for the special needs population.” These would include Medicaid reimbursement for fluoride and periodontal therapy for high-risk adults. House Bill 1693/Senate Bill 188 would mandate a study through the University of North Carolina at Chapel Hill and East Carolina University, the North Carolina Community College System and current dental providers serving the special needs population to “identify opportunities to increase the dental workforce supply that is available and willing to treat the special needs population.” Recommendations would be due to the North Carolina Study Commission on Aging by August 1, 2011.

South Carolina Senate Bill 286, originally introduced in January 2009, became law without the governor’s signature in June of this year. The measure requires that the Department of Health and Environmental Control, contingent upon funding, implement a dental screening and referral program in schools in three to five counties for kindergarten, third, seventh and 10th grade students. Dentists, dental hygienists, certified dental assistants, physicians, nurses and anyone who qualifies by completing department training may screen.

Stateline is prepared by the ADHA Division of Governmental Affairs.

Successful Arizona Senate Bill 1419 has made a seemingly small, but very significant, change concerning dental hygiene affiliated practice by removing a provision that prevented affiliated practitioners from billing for an examination. Affiliated hygienists, who operate according to a collaborative agreement with a dentist, typically contract with a public health agency or institution, a public or private school or other government sponsored program to treat patients who meet certain access to care need criteria. Although the dental hygienists consult with and refer patients to the affiliated dentist, because they see patients who have not already been examined, their assessment examination is an important part of the services they provide.

Arizona became the first state to add a representative of the dental businesses in the state as a voting member of the dental board (HB 2125). Arizona is one of the few states that allow non-dentists to own a dental practice. The change replaces one of the three public members of the board with a “business entity member” who may not be a person licensed by the board. The six dentist members and two dental hygienist members of the board remain unchanged.

A newly signed Colorado law (House Bill 1175) will make it easier for recently licensed dentists and dental hygienists to be licensed by credentials in the state. (Licensure by credentials exempts applicants who otherwise meet Colorado’s qualifications for licensure from having to retake a clinical exam). The old law required dental credentialing applicants to have been in practice for five out of the last seven years, and dental hygiene applicants for one year out of the past three. The new law permits the applicant to qualify by providing “evidence that they have demonstrated competence” as a dentist or dental hygienist “as determined by the board.”

The Connecticut state legislature adjourned on May 5, 2010, without passing House Bill 5630, an act to establish an advanced dental hygiene practitioner pilot program. The bill overwhelmingly passed out of the Human Services Committee earlier in the session, but failed to receive an up or down vote on the House floor.

The Louisiana Dental Hygienists’ Association, along with support from the Louisiana Dental Association, submitted a bill to allow dental hygienists who have obtained a permit to administer nitrous oxide inhalation analgesia under the direct supervision of a dentist. Senate Bill 214 (SB 214) directs the Louisiana Board of Dentistry to develop additional rules including educational requirements. SB 214 passed the Louisiana State Senate and was scheduled for debate on the House floor the week of May 24, 2010.

Maryland Senate Bill 719, a bill to allow dental hygienists to practice dental hygiene in long-term care facilities under general supervision, was signed into law on May 20, 2010. The bill allows dental hygienists who have at least two years of clinical practice experience and a specified written agreement with their supervising dentist to provide care without the presence of a dentist. The written agreement shall contain the services the dental hygienist may provide including toothbrush prophylaxis, fluoride application, dental hygiene instructions, assessment and other duties delegated by the supervising dentist. The dental hygienist may provide subsequent dental hygiene services under general supervision if the supervising dentist examines the patient within the past seven months and authorizes the treatment. The Maryland Department of Health and Mental Hygiene will issue a report evaluating the use, effectiveness and impact of the act on or before December 31, 2013. The Rules and Regulations for this act are being written. The act takes effect on October 31, 2010.

The Maryland State Board of Dental Examiners (MSBODE) has accepted the proposed rules and regulations pertaining to the administration of local anesthesia by dental hygienists. The Secretary of Health and Mental Hygiene must sign the proposed rules and regulations before they are enacted.

Dental hygienists who receive a local anesthesia permit from the MSBODE may administer local anesthesia through infiltration under direct supervision for dental hygiene procedures. In order to qualify for a local anesthesia permit, dental hygienists must complete a board-approved course, consisting of 20 hours of didactic learning and eight hours of clinical lab in a dental hygiene program accredited by the Commission on Dental Accreditation in Maryland. In addition, applicants must pass didactic and clinical examinations with a score of 75 percent or higher as well as the Northeast Regional Board Examination’s (NERB) Local Anesthesia examination with a score of 75 percent or higher. 

Dental hygienists who have obtained certification for local anesthesia in another state must provide written documentation (e.g., a notarized letter) to the MSBODE demonstrating that the applicant has administered a minimum of 25 injections in the last two years and has passed the NERB Local Anesthesia Examination with a score of 75 percent or higher. Dental hygienists who have obtained certification in another state but do not meet these requirements must take a local anesthesia certification course in Maryland.
The first local anesthesia certification course will be given at the University of Maryland, July 13–July 15, 2010. Please visit www.MyMDHA.com for updates concerning local anesthesia courses.

Missouri House Bill 2226, which became the final home for a measure establishing expanded function permits for dental hygienists and dental assistants, went to the governor for his signature in May. The bill would require five-year renewable permits, and authorize the board to establish the necessary qualifications for those permits, for the delegation of expanded functions. The measure does not list what those duties would be, but defines them as “reversible acts that would be considered the practice of dentistry as defined in section 332.071 that the board specifies by rule may be delegated to a dental assistant or dental hygienist who possesses an expanded-functions permit.” Services considered the exclusive practice of dental hygiene as defined in statute, including scaling, also would be prohibited as delegated functions to non-hygienists.

Congratulations to Jennifer Porter, RDH on her election as president of the Montana Board of Dentistry in March. A member of the board since 2006, she is now in her second term to which she brings a rich background of professional experience. She has served the Montana Dental Hygienists’ Association in several leadership positions, including president, as well as being a hygiene and anesthesia examiner for the Western Regional Examining Board (WREB) and a member of the WREB Process of Care Examination Committee. Reflecting on her new duties, Porter says, “Personally, my election to president of the board of dentistry represents recognition of dental hygienists as knowledgeable professionals, and proof that dentistry and hygiene can work together showing mutual respect for each other’s knowledge. The common goal of protecting the public has brought our board together and has demonstrated the ideal collaborative relationship between dentistry and dental hygiene.”

It appears that ADA’s announced intentions to use Oklahoma FQHCs to pilot a rural CDHC project using CDHC candidates trained in a program housed in the University of Oklahoma’s dental school has been scaled back. Last December the Oklahoma attorney general (in response to a request from a legislator) issued the opinion on laws governing a CDHC training program. He said that Oklahoma licensure laws prohibited any clinical training of unlicensed persons not enrolled as dental or dental hygiene students, which included licensed dental or dental hygiene services. At a recent dental board meeting and in recent correspondence the Dean of the dental school confirmed that any community training for clinical services would also be limited to services permitted to dental assistants. This is a departure from previous statements that CDHCs will administer a range of services outside of the dental assistant scope, as highlighted in the CDHC Competencies developed by the ADA. It has been reported that many or all CDHCs currently enrolled in the Oklahoma program are already dental assistants.

A newly adopted rule from the Texas State Board of Examiners may be the first of its kind in the nation. It creates a process for a person considering a dental hygiene career who “has reason to believe that he or she may be ineligible for licensure due to a conviction or deferred adjudication for a felony or a misdemeanor offense” to petition the board for a “Criminal History Evaluation Letter.” As long as the individual has provided complete and accurate information about the offense to the board and no additional issues are involved, the board will decide within 90 days whether the offense will make the person ineligible for licensure—even if the person has not yet attended dental hygiene school.

Congress Passes Sweeping Health Reform
Containing Significant Oral Health Provisions

On March 22, 2010, the U.S. House of Representatives voted for passage of HR 3950, the health reform bill subsequently signed into law on March 24. Reconciliation bill HR 4872 was then passed by the House to amend some of the provisions contained within the health reform package, with the Senate vote following later that week.

ADHA has been involved in the national dialogue on health reform for more than a year. The association has not taken a position for or against health reform, but has been guided by ADHA’s Statement on Health Reform, which asserts that if Congress undertakes comprehensive health reform, oral health provisions should be included as oral health is a vital component to individuals’ total health.

HR 3590 contains a number of oral health provisions outlined in the table.

Connecticut ADHP Bill

A bill to establish an Advanced Dental Hygiene Practitioner Pilot Program, HB 5355, was introduced in the Connecticut General Assembly. The bill seeks to create a pilot program in which graduates of an advanced dental hygiene master’s program could provide direct patient care in public health facilities. The pilot will take place in the city of Bridgeport for a period of one year. If passed, the program would commence on or before January 1, 2013, and would terminate on January 1, 2014. The Commissioner of Social Services, in consultation with the Commissioner of Public Health, would be required to report the results of the pilot to the Public Health and Human Services Committees not later than July 1, 2014.

On March 23, 2010, HB 5355 passed the Connecticut Legislature’s Human Services Committee by a vote of 14 to 5 and was sent to the House Floor. The bill can be tracked online at ADHA’s legislative tracking site: http://www.adha.org/governmental_affairs/tracking.htm.

Citing a finding that “cultural awareness and cultural competence are essential skills for providing quality health care to a diverse patient population,” the Georgia General Assembly will be considering mandated CE in this area for physicians, podiatrists, physicians’ assistants, chiropractors, dentists, dental hygienists, registered professional nurses and licensed practical nurses. Georgia House Bill 844 would require a class of at least two hours every two years that covers not only “culturally competent” health care, but also updates providers “on new research findings or national treatment guidelines related to health care decisions based on race, ethnicity, and gender.”

Hawaii SB 2188, which would include “tooth whitening” within the definition of the practice dentistry, has been carried over from 2009 for consideration this year. If the measure is successful, no person other than a dentist or person supervised by the dentist would be permitted to perform, or offer to perform, “any phase of any operation incident to teeth whitening, including the instruction or application of teeth whitening materials.”

Congratulations to Denise Maus, RDH, BS, who, on February 12, became the first dental hygienist elected to be president of the nine-member Kansas Dental Board. She has been on the board for six years. Prior to her appointment to the board, Maus served terms as legislative chair and is a past president of the Kansas Dental Hygienists’ Association.

The current Missouri practice statute has a general provision recognizing dental assistants who have completed a course and exam and can “show proof” of competence in a specific function as “expanded functions dental assistants.” The current Missouri dental board rules do not use the term “expanded-function” assistant, but do provide that dental assistants who have completed board-approved coursework and “show proof” of competence may perform a number of orthodontic and restorative services. SB 953 proposes to evolve provisions for expanded functions by requiring that a dental assistant wishing to perform them must obtain a permit from the board. The board would set the specific requirements for the permit by rule. Permits would need to renewed every five years and would be subject to board discipline.

Arizona House Bill 2125 would replace one of the three public members of the board of dental examiners with a “business entity” member. The six dentist members and two RDH members remain the same. Arizona is one of handful of states that permits non-dentists to own corporations that provide dental services. These entities must maintain annual registration with the board.

Both the Florida Senate (SB972) and House (HB537) are considering legislation to require dentists and dental hygienists to submit demographic information beginning with the 2012 license renewal cycle. Information gathered will include when and where the individual graduated from professional school, the year they began practice in Florida and the practice address. For a dentist, it would also ask the number of dental hygienists and dental assistants employed and the average number of patients treated per week. Dental hygienists will also report how many patients they see a week, as well as the settings where they deliver care. Both groups also will answer questions concerning volunteer service provided and amount of care provided to specific groups such as children, older people and Medicaid recipients. The Florida Department of health would be responsible for compiling the information.

An Iowa bill, House File 2036, would increase the services performed by dental assistants to include “placement of sealants; the removal of supragingival plaque, stains or hard natural or synthetic materials; and other services.” It is unclear who requested the bill, although the Iowa dental board has declined to support the measure.

Kentucky House Bill 256 seeks to add another dental hygienist to the Kentucky Board of Dentistry, resulting in a 10-person board, two of which are registered dental hygienists. In addition, HB 256 would allow hygienists practicing in a volunteer community health setting to perform the following services without the supervision of a dentist: dental health education, nutritional counseling, preparing a generalized oral screening with subsequent referral to a dentist, applying fluoride on patients, demonstration of oral hygiene technique and sealants. Dental hygienists licensed by the board would be allowed to practice as a public health hygienist and may provide dental hygiene services as part of a dental health program operated through the Department for Public Health or a governing board of health. The dental hygienist would perform according to accepted standardized protocols reviewed and approved by the Board of Dentistry and either the Department for Public Health or the dentist member of the governing board of health, as set out in administrative regulation.

The Maine State Legislature is considering a bill that would allow independent practice dental hygienists to be directly reimbursed for their services under the MaineCare program. Legislative Document 233 would lift restrictions on what dental services qualify for MaineCare payments.

“If passed by the legislature and signed into law, this bill would make it much easier for people with MaineCare to receive good preventive dental treatment,” said Representative Pat Jones (D-Mount Vernon), who holds a degree in dental hygiene and managed the School Dental Health Program as part of her service during her 24 years at the Maine Bureau of Health.

“Access to quality affordable dental care is important for everyone’s health, especially young children,” said Jones. “Going to the dentist isn’t just about getting a cavity filled; it’s about good preventative treatment (dental cleanings, fluoride, sealants) and encouraging good dental habits that prevent serious problems later on. Encouraging preventative dental care early goes a long way towards lowering the costs of care later in life for both families and taxpayers.” Independent practice dental hygienists can bill private insurers for their services but not MaineCare.

The Joint Standing Committee on Health and Human Services made an “ought-to-pass” recommendation, moving the bill forward to a floor vote in each chamber. The bill would take effect on October 1, 2010.

Missouri House Bill 1588 would make the practice of dentistry or dental hygiene without a license a class C felony. Currently, it is a class A misdemeanor. While the misdemeanor classification limits possible punishment to less than a year incarceration, a class C felony can be punished with up to seven years imprisonment

The Montana limited access permit program reached a milestone when the dental board approved the first school-based, non-reservation LAP setting. The Limited Access Permit (LAP) program allows dental hygienists to provide most hygiene services under public health supervision without the prior authorization of a dentist in public health facilities.

The practice act law recognizes nursing homes; extended care facilities; home health agencies; group homes for the elderly, disabled and youth; and some other sites including public health facilities. Ongoing LAP sites in Montana already exist in nursing homes and the Great Falls Rescue Mission. But because schools are not specifically listed in the law, it required board approval for this new program at an alternative high school in Great Falls.

Kim Dunlap, RDH, BS, the LAP who will practice at the school, commented, “Very exciting. This should open the door for other alternative schools in Montana to open up for clinics sites.”

New Jersey Assembly Number 464 seeks to increase the membership on the New Jersey State Board of Dentistry to 11 members from the current nine. In addition to adding a state executive department member, the bill would add another dental hygienist to the board.

New York Assembly Bill 5704 and Senate Bill 4086 seek to allow dental hygienists to perform block anesthesia. Currently, dental hygienists in New York are permitted to administer local anesthesia through infiltration only.

New York Senate Bill 1041 would establish a state board for dentistry and a state board for dental hygiene. The state board for dental hygiene would be appointed by the board of regents on the recommendation of the commissioner for the purpose of assisting the board of regents and the Department of Matters of Professional Licensing and Professional Conduct. The board would be composed of no fewer than 12 people.

Tennessee House Bill 2634 seeks to revise the definition of dental hygiene to state that a dental hygienist is a primary health care professional, licensed under this act to provide preventive, educational and therapeutic services supporting total health for the control of oral diseases and the promotion of oral health, who has graduated from a dental hygiene program accredited by the American Dental Association’s Commission on Dental Accreditation (CODA). Dental hygiene services include the removal of all hard and soft deposits and the stain from the human teeth to the depth of the gingival sulcus, polishing natural and restored surfaces of teeth, performing clinical examination of teeth and surrounding tissues for diagnosis by the dentist, and performing other such procedures as may be delegated by the dentist, under the supervision of a licensed dentist.

Washington State House Bill 2761 proposes to add “clinics owned or operated by physicians or nurse practitioners” to the listing of health care facilities where dental hygienists may practice unsupervised. Currently, dental hygienists with two years’ experience may perform the prophylaxis and most other dental hygiene services without supervision in hospitals, nursing homes, group homes serving the elderly and several other similar types of institutions, as well as public health facilities.

The Alaska Board of Dentistry has adopted rules to implement collaborative practice for dental hygienists, a practice option approved by the legislature in 2008. Collaborative practice is a form of direct access that allows a dental hygienist to assess patients and provide services without specific authorization of a dentist according to a practice agreement established with a “collaborating” (or “consulting” or “affiliated”) dentist.

Dental hygienists with 4,000 hours of clinical experience in the past five years, current CPR certification and proof of liability insurance are eligible. To maintain collaborative status, a dental hygienist will need to complete four hours of CE every two years (in addition to the standard CE requirement in one or more of several specified areas, which include medical emergencies, public health, general medicine and diagnosis and patient management).

There are no specific limitations on where the dental hygienist may practice; however, the agreement must identify those locations, as well as the procedures the hygienist may perform; contain standing orders and include a requirement concerning referrals to the affiliated dentist for patients whom the dental hygienist has assessed to have treatment needs beyond his or her scope.

Development of public health supervision has been on the table for several years in Florida. In 2008, Florida’s governor, Charlie Crist, supported a bill that included public health supervision when it was introduced—a feature amended out before the bill passed.

In April 2008, the Florida Health Practitioner Oral Healthcare Workforce Ad Hoc Committee was convened by the state surgeon general and developed recommendations to evaluate and strategically address the complex range of oral health workforce concerns. The report, published in February 2009, included a recommendation “that the State investigate policy reform that would expand the scope of practice and eliminate or reduce supervisory requirements for dental hygienists practicing in health access settings in order to improve access to dental care.”

Then, in December 2008, federal funding enabled the Florida Department of Health Oral Healthcare Workforce Workgroup to continue studies and develop access recommendations for the statewide health plan. Workforce members included representatives from the dental, dental hygiene and dental assistants associations, as well as the Board of Dentistry, state policy makers, community health centers, county health departments and consumer advocacy groups (many on this committee also served on the Ad Hoc Committee). The final report, not yet published as of December 17, 2009, includes support for regulatory and legislative changes.

Public health supervision moved another step forward in October 2009, when the Board of Dentistry approved rule changes that would increase the ability of both dental hygienists and dental assistants to provide services in “health access settings.” These settings are defined in the practice act as community health centers, head start centers and various state-run programs. The rule changes would allow dental assistants who had graduated from board-approved or accredited dental assisting programs and maintained current CPR to provide sealants, X-rays and several other traditional services under general supervision. Dental hygienists would be authorized to chart, measure vital signs, perform a prophylaxis and apply fluorides and sealants “without the presence, prior examination or authorization of a dentist.”

Senate Bill 490, which closely resembles the efforts of the workforce workgroups and the Florida Board of Dentistry, was filed October 20, 2009. The 2010 legislative session runs from March through May.

Public Health Dental Hygienist

In 2009, Virginia passed a law establishing an access to care pilot program, in which dental hygienists employed by the Virginia Department of Health may practice under the remote supervision of a public health dentist in three dental health professional shortage areas. The pilot program seeks to assess the impact of dental hygienists practicing in an expanded capacity on increasing access to dental health care for these underserved populations. Hygienists practicing in these settings may provide education, assessment, prevention and clinical services under the remote supervision of a public health dentist, as authorized in a protocol established by the Department of Health. Remote supervision does not require the dentist to be present or perform an initial examination, but it does require regular, periodic communications between the supervising dentist and public health dental hygienist regarding patient treatment.

Virginia Dental Hygienists’ Association Government and Professional Affairs Chair Kelly Tanner Williams, RDH, MSDH, noted, “Success of this law is a result of collaborative efforts between dental and health professionals in Virginia. The pilot program will allow hygienists to provide preventive care to the public in these select remote areas and will lay the foundation for hygienists to be utilized as prevention specialists in a variety of settings.”

In December 2009, the Pennsylvania Board of Dentistry adopted rules to allow dental hygienists to administer local anesthesia through infiltration and block under the direct supervision of a dentist. In order to qualify to do so, hygienists must have completed a board approved 30-hour local anesthesia course sponsored by an accredited dental or dental hygiene program and received a local anesthesia permit from the board of dentistry.

In addition, the board adopted rules to implement the public health dental hygiene practitioner. The public health dental hygiene practitioner may provide preventive, therapeutic, educational, radiologic and intraoral services without the supervision of a dentist in many public health settings, including nursing homes, group homes, health clinics, medical offices, institutions, free and non-profit dental clinics, head start, day care, public and private schools, correction facilities, older adult day centers and all federally qualified health centers (FQHC).

In order to be certified as a public health dental hygiene practitioner, a dental hygienist must have completed 3,600 hours of supervised practice experience and carry liability insurance. The certificate must be renewed with each licensure period. Additionally, public health dental hygiene practitioners must complete five hours of continuing education in public health each licensure period.

The New Hampshire Dental Hygienists’ Association introduced a bill to establish a board of dental hygienists separate from the board of dental examiners to regulate the dental hygiene profession. House Bill 1593 would create a nine-member board of dental hygienists, comprising four dental hygienists, one dentist and four public members, each appointed by the governor. A similar bill was introduced and passed the New Hampshire State Senate last year.

Stateline is prepared by the ADHA Division of Governmental Affairs.

Bills Relating to Dental Hygiene Signed into Law, July 2008 through
September 2009

Arizona SB 1400                             Signed 2/13/09
This bill removes the provision that restricted affiliated practice care to children. Affiliated practice means the dental hygienist has an agreement with a consulting dentist and provides services according to protocols established in that agreement to patients enrolled in a federal, state, county or local health program or who have income below twice the poverty level.
 
Arkansas HB 1367                          Signed 2/20/09
This bill allows dental hygienists to provide dental hygiene services in correctional facilities under general supervision if the patient has been examined by a dentist. The physical presence of a dentist is not required, but the hygienist is required to administer care in accordance with a protocol developed by a dentist.
 
Colorado SB 129                             Signed 4/22/09
This bill adds duties to the list of what constitutes the practice of unsupervised and supervised dental hygiene. It adds diagnosis and X-rays to unsupervised practice, moves local anesthesia to general supervision and defines the dental hygiene diagnosis.
 
Iowa HB 380                                   Signed 4/10/09
This bill removes the prohibition against faculty members serving on the dental board. It includes tooth-whitening procedures in the practice of dentistry and limits it to dental professionals.
 
Kentucky HB 336                            Signed 3/20/09
This bill adds dental hygiene assessment to the dental hygiene scope of practice. It removes the three-day notification to patients for general supervision and allows for a dental hygienist to perform an unsupervised dental screening for children before they enter school.
 
Maine LD 100                                  Signed 5/26/09
This document expands health screening in schools to include oral health screening. It requires oral health screening for students prior to entering kindergarten and for students who are new to a school district entering grades 1 to 6 and periodically thereafter.
 
Maryland SB 602                            Signed 5/19/09
This bill expands the practice of dental hygiene to include manual curettage and administration of local anesthesia. Dental hygienists will be permitted to administer local anesthesia by infiltration under the direct supervision of a dentist. In addition, the time a dental hygienist can work under general supervision in a private office is increased to 60 percent of the dental hygienist’s total time worked in a three-month period.

Massachusetts SB 2819                Signed 1/15/09
This bill creates a public health hygienist who works in public health settings via a collaborative agreement with a dentist. In order to qualify, a dental hygienist must have at least three years of full-time clinical experience practicing in public health settings and receive appropriate training as determined by the department of public health. This hygienist also would be allowed to bill Medicaid directly for services. The Medicaid rules must be amended to reflect this directive from the legislature.
 
Minnesota SF 2083                         Signed 5/18/09
This file creates the dental therapist and advanced dental therapist mid-level providers. A dental therapist provides basic preventive and limited restorative services and extractions of primary teeth and has limited prescriptive authority. A number of services can be administered without onsite supervision; however, all restorative services and extractions require the presence of a dentist. The advanced dental therapist is a master’s-level educated provider licensed to practice as a dental therapist. The advanced dental therapist scope of practice includes evaluation, assessment and treatment planning, and nonsurgical extractions of permanent teeth as well as all services administered by a dental therapist without the requirement for onsite supervision. Both providers work via a collaborative management agreement in settings that serve low-income, uninsured and underserved patients.
 
Missouri SB 296                              Sent to the governor 5/29/09
This bill initiates a volunteer license for retired dentists and dental hygienist who have practiced in any state for 10 years and retired less than four years ago. It includes tooth-whitening procedures in the practice of dentistry, and limits them to dental professionals.
 
Montana SB 226                             Chaptered 4/20/09
61st Legislature SB0226: This bill allows for the temporary volunteer licensure of nonresident dentists and dental hygienists.
 
New Hampshire HB301                 Sent to the governor 5/6/09
This bill establishes a task force to study access to dental care. The task force will study the problem of access to dental care for low-income, uninsured and underinsured persons and shall make recommendations for improving the delivery of services to this population. Areas of focus shall include, but not be limited to, education; Medicaid and other reimbursement for children and adults; promoting a “dental home” to lessen the reliance on emergency rooms for dental care; geographical disparities in available dental services; barriers to care such as transportation, language and other health problems; and provider models from other states. In addition, the task force shall create a detailed action plan for improving access to dental care. The 15-member taskforce will be composed of various stakeholder organizations including the New Hampshire Dental Hygienists’ Association, the New Hampshire Dental Society, state legislators and other issue stakeholders.
 
New Mexico HB 286                       Signed 4/07/09
This bill reinstates the Board of Dental Health Care until July 1, 2016, following a “sunset review” in 2008 with no changes to the practice act.
 
North Dakota HB 1091                  Signed 4/09/09
This bill authorizes a registered dental hygienist to orally transmit a prescription to a pharmacist if the supervising dentist has authorized the hygienist to do so.

North Dakota HB 1176                  Signed 4/08/09
This bill redefines the conditions in which a dental hygienist may practice under general supervision. General supervision may be used if the procedures are authorized in advance by the supervising dentist, except for procedures that may be performed only under direct supervision as established by the board by rule.
 
Oklahoma HB 1059                        Signed 5/14/09
This bill creates a special volunteer license for Oklahoma dental hygienists and temporary volunteer license for out-of-state hygienists.
 
Oregon HB 3204                             Signed 6/25/09
Oregon became the first state to specifically authorize unsupervised dental hygienists holding a limited access permit (LAP) to practice in medical offices or offices operated or staffed by nurse practitioners, physician assistants or midwives. Hospitals were also added as an LAP setting.
 
Texas S97/H456                            Effective after 9/01/09
This bill adds community health centers to settings where a dental hygienist may provide delegated services before the dentist examines the patient, and extends the length of time for performing services to six months.
 
Utah HB 121                                    Signed 3/25/09
The Retired Volunteer Health Care Practitioner Act, covering most health professions, includes dentists and dental hygienists. It provides for a license that will allow practice at “charity locations.” Individual boards will make additional rules.
 
Virginia SB 1202                             Signed 3/27/09
This bill establishes a pilot project where dental hygienists employed by the Virginia Department of Health may provide dental hygiene services in Virginia Dental Health Professional Shortage Areas. The dental hygienist shall practice pursuant to a protocol developed jointly by the medical directors of each of the districts, dental hygienists employed by the Department of Health, the Director of the Dental Health Division of the Department of Health and representatives from the Virginia Dental and Dental Hygienists’ Associations.
 
Vermont HB 86                               Signed 5/23/09
This bill directs the director of the Office of Professional Regulation to file a report with the general assembly by January 1, 2010, recommending whether to restructure the Board of Dental Examiners to improve the regulation of dental hygienists. If the board determines that restructuring is necessary, it shall make appropriate recommendations.
 
Washington HB 1309                     Signed 5/04/09
This bill makes permanent a provision allowing dental hygienists direct access to patients in “senior centers.”
 
West Virginia HB 2191                   Signed 3/27/09
This bill authorizes dental hygienists who meet specific requirements to provide dental hygiene services without the supervision of a dentist in hospitals, schools, correctional facilities, jails, community clinics, long-term care facilities, nursing homes, home health agencies, group homes, state institutions under the Department of Health and Human Resources, public health facilities, homebound settings and accredited dental hygiene education programs. In order to qualify, a dental hygienist is required to have two years and 3,000 hours of clinical dental hygiene experience; and six additional continuing education hours that include three hours in medical emergencies and three hours in general public health content. The dental hygienist and supervising dentist must submit an annual report to the West Virginia Board of Dental Examiners of services rendered.
The bill also authorizes dental hygienists who meet specific requirements to work under general supervision in a dental office or treatment facilities. The hygienist cannot work when the supervising dentist is not physically at the location for more than 15 consecutive days.
 
Wisconsin AB 103                           Signed 5/13/09
This bill authorizes the board to issue a permit to practice dental hygiene, without compensation, for a period of not more than 10 days in a year and in a specified area, to a person who is licensed to practice dental hygiene in another state. The board must determine that the person’s services will improve the welfare of Wisconsin residents and that the person is qualified to obtain and satisfies current criteria for obtaining a permanent license in Wisconsin based on licensure in another state. The board may not require an examination on state statutes and rules relating to dental hygiene. Under the bill, the board may renew a permit but may not charge a fee for issuance or renewal.

Direct Access Settings Expanded

Arizona and Oregon both recently passed bills expanding existing access to care programs. (Earlier this year Texas added community health centers as locations where direct access hygienists can practice, and Washington State made a provision for “off site supervision” in senior centers permanent.)

Arizona Senate Bill 1400, signed by the governor on July 13, opens up affiliated practice care to patients of all ages, so long as they are enrolled in a federal, state, county or local health program or have income below twice the poverty level. Affiliated practice means the dental hygienist has an agreement with a consulting dentist and provides services according to protocols established in that agreement. The dentist need not examine patients prior to initial dental hygiene treatment. 

This legislation was the result of extensive negotiations between the Arizona State Dental Hygienists’ Association (ASDHA) and the Arizona Dental Association. ASDHA explains that the organizations were committed to finding a workable compromise that includes elements that both associations felt were important to the success of affiliated practice agreements and getting care to underserved populations.

The Arizona Board of Dental Examiners has 33 affiliated practice agreements currently on file with the restriction to treat patients 18 years of age or younger. There are three programs up and running: two located in elementary schools and one at a community center. The Arizona State Dental Hygienists’ Association anticipates that with the age restriction removed, more dental hygienists will seek affiliated practice agreements based on comments from members wishing to work with adult/senior populations.

Oregon became the first state to specifically authorize direct access dental hygienists to practice in medical offices or offices operated or staffed by nurse practitioners, physician assistants or midwives when the governor signed House Bill 3204 on June 25. Hospitals were also added as a setting for dental hygienists with a limited access permit (LAP). LAPs are already permitted to practice in a dozen other listed settings, including nursing homes, schools and nursery schools, community health centers and the residences of homebound persons. (LAPs may provide almost all dental hygiene services without supervision.)

Consumer Added to Dental Board

Also in Oregon, House Bill 2058, signed in June, made changes to a number of health professional boards, among them adding a second consumer to the Oregon Board of Dentistry. The new composition is six dentists, two dental hygienists and two public members. The new law also specifies that public members may not be either licensees or related to licensees of the board. And, for the first time, the governor will be required to consider “ethnic” and “geographical” balance in making appointments. 

Minnesota Passes Legislation Allowing Mid-level Oral Health Provider

Minnesota Governor Tim Pawlenty signed a bill establishing a mid-level oral health provider, allowing students who are educated under the Advanced Dental Hygiene Practitioner (ADHP) model to become licensed to practice as a mid-level provider in the state. The amended Omnibus Higher Education bill (Senate File 2083) contained a provision establishing the Dental Therapist and Advanced Dental Therapist providers.

The Dental Therapist/Advanced Dental Therapist provider language was the culmination of nearly two years of work spearheaded by Minnesota State Senator Ann Lynch, who first brought legislation to establish a new oral health provider forward in 2008. Senator Lynch, along with Representative Cy Thao in the House, was integral  in both supporting legislation for the new providers and forging a compromise among the various stakeholders. Proponents of the oral health practitioner, including the Minnesota Safety Net Coalition and the Minnesota Dental Hygienists’ Association and nearly 50 other organizations, advocated for this legislation. The Minnesota Dental Association was not opposed to the compromise legislation.

The new providers will focus their practice on care for under-served populations in the state and will administer educational, preventive, palliative, therapeutic and restorative services.

The Dental Therapist language outlines practice for a provider educated under the University of Minnesota’s model, which would develop a provider to offer some basic preventive services, limited restorative services and extractions of primary teeth, and to have limited prescriptive authority. Dental therapists will be able to administer a number of services without the dentist onsite, but all restorative services, extractions and services that are more involved would require the presence of a dentist. The dental therapist would be a graduate of an approved bachelor’s or master’s education program and would work under a collaborative management agreement with a dentist.

The advanced dental therapist provision facilitates a master’s level educated provider who is licensed to practice as a Dental Therapist and will have a more advanced scope of practice. Advanced Dental Therapists will evaluate, assess and treatment plan, perform nonsurgical extractions of permanent teeth, and administer all services of a dental therapist without the requirement for onsite supervision. Like dental therapists, advanced dental therapists will work with a supervising dentist via a collaborative management agreement.
The new law paves the way for students educated under the ADHP model at Metropolitan State University in St. Paul, Minn., to be licensed and enter the workforce as advanced dental therapists. The Metropolitan State program builds on the dental hygiene education model by requiring that students of the master’s program be licensed dental hygienists prior to entry. That program, which is structured on the ADHP Competencies developed by ADHA, will develop providers who have the full preventive skill set of a dental hygienist in addition to the advanced dental therapist skill set. 

Both Metropolitan State’s and the University of Minnesota’s programs are slated to begin in the fall of 2009. The first practitioners could begin practice as early as 2011.

For additional information about the effort in Minnesota, please visit www.adha.org.

In May, the New Hampshire General Court passed legislation establishing a task force to study access to dental care. The bill, House Bill 301, was introduced at the request of last year’s study committee on the advanced dental hygiene practitioner. The 15-member taskforce will be composed of various stakeholder organizations including: the New Hampshire Dental Hygienists’ Association, New Hampshire Dental Society, postsecondary education commission, the New Hampshire Community College System, Delta Dental Plan of New Hampshire, New Hampshire Health Care Association, New Hampshire School Nurses Association, Bi-State Primary Care Association, New Hampshire Minority Health Coalition, New Hampshire Public Health Association, New Hampshire Medical Society, the House of Representatives, the Senate and the Department of Health and Human Services. New Hampshire Governor John Lynch is expected to sign the bill into law later this month.

The Maryland General Assembly passed legislation expanding the practice of dental hygiene to include manual curettage and administration of local anesthesia. Through Senate Bill 602 and House Bill 576, dental hygienists will be permitted to administer local anesthesia by infiltration under the direct supervision of a dentist in the state of Maryland. In addition, the bill increases the time a dental hygienist can work under general supervision in a private office to 60 percent of the dental hygienist’s total time worked in a three-month period. Previously, the number of unsupervised clinical hours worked by a supervised dental hygienist in any given calendar week is less than 60 percent of the dental hygienist’s total hours.
The governor is expected to sign the bill later this month. Once the bill becomes law, the State Board of Dental Examiners will create rules regarding the education and examination requirements needed before dental hygienists can administer local anesthesia and manual curettage.

Bleaching Restrictions

The same Iowa bill that removed the prohibition on dental educators serving on the dental board (House Bill 380) was amended to prevent lay persons from providing tooth whitening before being signed into law in April. Whitening was defined as any process to whiten or lighten teeth by the application of chemicals, whether or not a light source is used. Instructing or assisting in the process is also considered a whitening function. Hawaii passed a similar bill restricting bleaching procedures to dental professionals earlier this year, as has Missouri, where Senate Bill 296 has gone to the governor’s desk. This omnibus professional regulation bill includes language that limits professional bleaching to dental professionals, stating that any use of whitening products not available over the counter will be deemed the practice of dentistry, as will any supportive services, including instructions or preparation of bleaching trays. However, dental hygienists and dental assistants are specifically permitted to apply whiteners under the supervision of a dentist.

Volunteer Licensure

Also part of the omnibus Missouri Senate Bill 296 currently pending signature by the governor is language that creates parallel volunteer license programs for dentists and dental hygienists. Dental hygienists previously licensed in good standing in any state for at least 10 years, whose license has been expired no more than four years, are eligible. The license must be renewed every two years and requires CPR certification and 25 hours of CE every two years. Under the license, pro bono services could be provided to family members or at various health department facilities, public elementary or secondary schools, federally qualified health centers and other community health centers.

A new Oklahoma law creates a volunteer license category for retired dental hygienists – similar to the dental volunteer program. Many states have volunteer licenses, but the Oklahoma provision is also available for active licensees from out of state who are in the state to donate services to assist in emergency situations, public health initiatives and even community service events sponsored by government health departments. 

Visiting volunteer licenses for out-of-state professionals will expire soon after the event for which they are issued, but the provision will be put to good use in February 2010 when the Oklahoma Mission of Mercy (OKMOM) will provide two days of dentistry. Volunteers from the dental hygienists’ and dental associations will be joined by visiting volunteers to perform services in Tulsa with the support of many corporate sponsors.

Access to Preventive Care

Texas dental hygienists are waiting for the governor to sign a measure (Senate Bill 97/House Bill 456) that will allow them greater access to a variety of patients in alternative settings. Under current law, a dentist can authorize a dental hygienist working in a nursing home or school clinic to provide one-time preventive services to patients without a prior dental exam. The new law will allow the hygienist to perform an unlimited number of delegated procedures for a period of six months before the patient sees the dentist.

Perhaps more importantly, the new law adds a new setting where this access-based supervision will be allowed—community health centers. Community health centers are not-for-profit community clinics often referred to as safety net providers because they will not refuse patients, regardless of inability to pay. Economically disadvantaged patients may be charged on a sliding scale, or may have their treatment costs covered by Medicaid, public health service funds or even philanthropic grants. The number of health centers is on the upswing nationally—as well as the number of centers with dental clinics. In 2007, more than 770,000 Texans received services at nearly 300 sites.

Texas Dental Hygienists’ Association President Nancy Cline, RDH, MPH, commented, “We are pleased that this new legislation will open alternative settings for hygienists and, of even more importance, will allow underserved or un-served populations to receive preventive care from hygienists. The Texas Dental Hygienists’ Association will be encouraging hygienists to go into schools, nursing homes and community health clinics and  will help in providing training for hygienists wishing to initiate care in these settings.”

A Procedural Victory

Nebraska dental hygienists and dental assistants opposing a seemingly unstoppable bill (giving the Nebraska dental board virtually unrestricted authority over qualifications for dental assistant expanded duties) had unexpected success this year—thanks to a rare filibuster, the first and only filibuster of the 2009 legislative session. After three hours of debate, the Senator who introduced Legislative Bill 542 (LB 542), Senator Kathy Campbell, motioned to withdraw the bill, which essentially allows the bill to be “laid over” to the following year’s legislative session. Under Nebraska procedure, the speaker could have continued for an additional five hours before a vote to close debate could be taken. However, presumably determining there would not be votes from 33 of the 49 senators needed to cloture (end debate), she voluntarily withdrew LB 542.

Both the Nebraska Dental Hygienists’ Association and the Nebraska Dental Assistants’ Association agree that a scope of practice needs to be established in statute for dental assistants, and that regulators alone should not determine “education, preparation, and training for dental assistants.” The dental hygienists also supported dental assistant efforts to establish required certification for the dental assisting profession. Dentists were split—testifying both for and against the measure. According to Nebraska dental hygienists, several senators expected their constituents to lobby hard for bills related to property taxes, education or the death penalty, but never expected to hear from so many constituents regarding the dental assistants bill. Without a doubt, the majority of senators would agree that LB 542 has been the most heavily lobbied bill heard this legislative session. Many senators are hopeful the three oral health care associations can work collaboratively over the summer and fall months to establish a compromise that all three professions can support.

On April 17, 2009, the Minnesota State Senate passed an amended Omnibus Higher Education Bill (Senate File 2083) that contained a provision defining licensure, scope of practice and supervision for the Oral Health Practitioner (OHP). The vote was a significant victory for OHP proponents.

The legislation, based on the OHP workgroup recommendations including representatives from Metropolitan State University, the University of Minnesota, Minnesota Dental Hygienists’ Association, Minnesota Dental Association, the Safety Net Coalition and other stakeholders, allows the OHP to provide care in settings serving low-income, uninsured and underserved populations pursuant to a collaborative management agreement. The agreement outlines the relationship between the OHP and dentist and includes a list of settings, practice limitations, age-specific protocols and a referral mechanism, which would allow the OHP to practice in locations where the dentist is not present.

The Minnesota Safety Net Coalition has spearheaded the effort to change state law to allow for OHP practice. Dozens of other organizations within the state, including the Minnesota State Colleges and Universities (MnSCU) system and Minnesota Dental Hygienists’ Association, are supportive of the proposed legislation, which was put forward by the Minnesota Department of Health.

The Omnibus bill also contained language to establish a dental therapist in the state, who would be educated at the University of Minnesota’s Dental School. The dental therapist scope contains many of the same services as that of the OHP; however, this provider is not proposed to be educated to administer a full range of preventive services and would instead focus mainly on restorative care with some prevention and patient education to underserved populations. One of the key differences between the OHP and proposed dental therapy models is that onsite supervision by a dentist would be required for many of the services administered by a dental therapist. In contrast, the OHP would provide care in settings serving the low-income, uninsured and underserved pursuant to a collaborative management agreement.

Passage of the OHP language opens the door to licensure of a dental hygienist educated as an Advanced Dental Hygiene Practitioner (ADHP). The first ADHP Master’s program will begin at Metropolitan State University in St. Paul, Minn., in mid-2009.

Connecticut State Representative Vickie Nardello, RDH, BS, MS, introduced a bill to establish the ADHP in Connecticut (House Bill 5630). The legislation marks the first time ADHP legislation has been introduced in the state. The Connecticut General Assembly’s Joint Committee on Public Health held several hearings on the ADHP bill but opted not to vote on the bill, due to the fiscal note that came with establishing a new licensure category. Like the rest of the country, Connecticut is facing a budget shortfall.

Legislation pertaining to water fluoridation was introduced in Pennsylvania and New Jersey this year. Pennsylvania House Bill 584 would grant the Department of Environmental Protection, in consultation with the Department of Health, the power to make rules regarding the fluoride content of water served by public water suppliers with 500 domestic water connections, ensuring that the measured amount of fluoride content in the water is between 0.7 milligrams per liter and 1.2 milligrams per liter. The bill is currently being considered by the House Committee on Health and Human Services. New Jersey Assembly Bill 3709 would allow the Commissioner of Environmental Protection, in conjunction with the Commissioner of Health and Senior Services, to adopt rules and regulations relating to the fluoridation of public water systems (minimum of 15 service connections used by year-round residents or regularly serving at least 25 year-round residents). The bill was reported out of the Assembly Health and Senior Services Committee and referred to Assembly Appropriations Committee.

Arkansas recently passed a law, Act 203, allowing dental hygienists to provide dental hygiene services in correctional facilities under general supervision. The law does not require the dentist to be present but requires the hygienist to administer care in accordance with a protocol developed by a dentist. The law also stipulates that a dentist must have examined the patient.

California is moving toward recognition of the Western Regional clinical examination as an alternative to California’s state test for initial licensure of dental hygiene candidates. Assembly Bill 403 would specify in the statute that applicants could take the California state clinical exam or the WREB or “any other clinical dental hygiene examination” approved by the Dental Hygiene Committee of California. The new Dental Hygiene Committee of California (DHCC) under the Department of Consumer Affairs, was created by the 2008 California legislature to be the regulatory body for dental hygienists and will go into effect July 1, 2009.

Colorado Senate Bill 129, which creates the first statutory definition of the dental hygiene diagnosis, passed both legislative houses and is on the governor’s desk. The measure also specifies additional services that may be provided without the supervision of a dentist. These include the dental hygiene diagnosis, treatment planning and X-rays. In addition, local anesthesia will be permitted under general (dentist must authorize) instead of direct (dentist must be present) supervision.

The Iowa dental board approved a rule that provides considerable more flexibility for Iowa dental hygienists practicing under public health supervision. Public health supervision hygienists practice in a variety of settings outside the office according to standing orders that are part of a written agreement with a dentist. Until now, the rules provided that a hygienist could provide educational services, assessments, screenings and fluoride without a dentist’s examination, but follow-up services required an exam less than 12 months old. This rule change removes the 12-month limit, leaving the frequency of the exam to be determined by the collaborating dentist and dental hygienist.

Also in Iowa, the governor has signed House Bill 380, which has two very different provisions concerning dentists and dental hygienists. One section removes a prohibition against dental or dental hygiene faculty members serving on the board dentistry. Another includes tooth whitening, “including the instruction or application of tooth whitening materials or procedures at any geographic location” within the practice of dentistry.

Montana legislators have approved two bills in support of volunteer oral health services. Senate Bill 368, signed by the governor, extends the protection against liability for ordinary negligence for dental hygienists who provide unpaid services at community health clinics. Senate Bill 226, sent to the governor, creates a temporary license that allows dentists and dental hygienists licensed in other states to provide free services in certain clinics.

New Mexico House Bill 676, jointly crafted by dentists and dental hygienists, passed the full house and the senate committee easily, but, along with many other dental related bills, ran out of time to get a final senate vote before the legislature closed its 60-day session. The bill had many progressive features. These include a definition of a “dental hygiene focused examination,” limited prescriptive powers for dental hygienists, and authorization for dentists to use teledentistry for some diagnoses.

Nevada Senate Bill 320, which would create the Nevada State Board of Dental Hygiene, was unanimously voted out of the Senate Commerce and Labor Committee on April 10 and went on to pass the full senate. House action was expected in early May. The new board would consist of seven members—five dental hygienists, one public member, and one person representing an entity providing health services to the underserved. The representative of the underserved could be a dentist, dental hygienist or other provider such as a registered nurse. The bill does not make any changes to the practice or supervision of dental hygienists.

April hearings were held for Oregon House Bill 3204, which expands the settings where a limited access permit (LAP) hygienist may practice to include hospitals, medical clinics and offices operated or staffed by nurse practitioners, physician assistants or midwives. Limited access dental hygienists currently provide services in a number of other settings, such as nursing homes and a variety of other types of residential care facilities, correctional facilities, homes of homebound patients and schools. The bill would also lower practice experience to qualify for the permit from 2,500 hours to 500 hours for applicants with an associate’s degree in dental hygiene, and remove the experience requirement for applicants with a bachelor’s degree in dental hygiene.

A limited access permit allows a dental hygienist to practice unsupervised and refer patients to a dentist for dental care. The LAP program has been in existence for more than a decade. Today, more than 85 dental hygienists hold the permit.

States Look at Ways to Provide More Services to the Underserved

Three states are considering limited licensure to allow volunteer dental service.

Missouri House Bill 679 would allow a dentist retired from any state to obtain a retired license to provide free services in a variety of public health settings. The license would cost no more than $25 and would require a maximum of hours five of CE annually. The Missouri Dental Hygienists’ Association supports the bill and hopes to amend it to include dental hygienists.

Utah’s “retired volunteer health care practitioner act,” (House Bill 121) would enable not only dental hygienists and dentists, but virtually all health care professionals to obtain a volunteer license at no cost. Pending Montana Senate Bill 226 would permit a restricted temporary license to a nonresident dentist or dental hygienist to provide free services in certain clinics for limited periods. The dental board could make rules to limit the scope of practice of these volunteers, as well as set the number of days each year the license would be valid.

North Carolina legislators are turning their attention to the needs of the special care population. As the trend continues to address meeting the needs of special care citizens in a home and community, rather than an institutional setting, so does the challenge of providing oral health services that are easily accessible. Senate Bill 188 will require the state public health division and several other divisions of the Department of Health and Human Services to collaborate with the dental schools, the North Carolina Dental Society, and current providers of special care dentistry services to examine current care options for special care populations. A report based on the recommendations of this group would go to the North Carolina Study Commission on Aging and the Public Health by February 2010.

While many states have cut Medicaid dental benefits, a Nebraska bill would protect some groups from the loss of dental benefits. Nebraska Legislative Bill 541 exempts pregnant women and people with a dental condition or existing medical condition from loss of benefits in the case that not providing dental treatment would worsen the condition or make it more expensive to treat.

Nevada Assembly Bill 136 would establish a “State Program for Oral Health” within the Department of Health and Human Services Division of Oral Health. The activities of the program would be guided by a 13-member advisory committee drawn from public health professionals, educators and private providers, as well as members of the public and representatives of dental organizations. The duties of the new Health Division would include establishing a database of oral health information, providing educational materials for both providers and the public, and taking actions to increase public awareness of oral health issues. Also, the division would coordinate state and local programs with an eye to increasing access.

South Carolina legislators are considering a pilot “targeted community health program” in the schools to provide dental health education, screening and referrals for children found to need treatment (Senate Bill 286) Three to five counties would be selected. The program would include children in kindergarten and third, seventh and tenth grades, as well as any children entering the public schools for the first time. School nurses would receive the screening results and notify the child’s parent or guardian to seek further professional attention for the child if indicated by the screening. With the permission of the parents, the school also would notify the Community Oral Health Coordinator to facilitate dental attention indicated by the screening.

The South Carolina Department of Health and the South Carolina Department of Education have submitted numbers on the proposed fiscal impact of this bill. It would cost over $300,000 per year to provide just one community coordinator instead of the proposed five. Citing research that indicates that without complete follow-up, screenings do not alter outcomes, the South Carolina Dental Hygienists’ association has stated that, based on the research, it will speak against passage of this bill. The screenings will be a misuse of time, energy and resources without changing outcomes. It is their opinion that the money could and should be used more effectively for preventive services.  

Oregon Legislators Look at Mandatory Whistleblower Law

A far-reaching mandatory reporting bill in Oregon, House Bill 2118, would require all licensed health care professionals to report colleagues who appear to be professionally incompetent or guilty of unprofessional conduct or to be impaired by drug or alcohol dependency or a mental health condition to their board within 10 working days. Licensing boards by rule may require specific professional associations to share information as well, although professionals providing health and well-being and counseling services for the most part are exempt from reporting on other licensees who are their patients. The new law would also grant immunity for those reporting in good faith.

The same Oregon measure would also change the composition of the current board of dentistry by replacing one of the six dentist members with a public member, bringing the board to five dentists, two public members and two dental hygienists. The board could, however, by rule, add an additional dentist member to the board, bringing it up to 10 members.

Dentistry Asserts that Bleaching Is Part of Its Licensed Scope

Three states have bills pending to declare tooth whitening to be the practice of dentistry. An Iowa measure (House File 380) states that any person who performs or assists with any part of tooth whitening procedures (which means the application of “chemicals” to lighten or whiten teeth) for another person is practicing dentistry. Hawaii House Bill 1290/Senate Bill 51) goes a little further, including instruction concerning whitening procedures within the practice of dentistry as well. In Missouri, House Bill 766 limits the “prescription and dispensing” of tooth-whitening procedures to dentists. However, dental hygienists and dental assistants would be explicitly authorized to apply bleaching compounds under the direct supervision of a dentist.

SCHIP Reauthorization with Dental Benefits and Study on Dental Mid-levels Signed into Law by President Obama

Efforts by the 111th Congress have proven that the third try is the charm for State Children’s Health Insurance reauthorization legislation (SCHIP), which was signed into law on February 4, 2009. The new law, which will extend health insurance to approximately 11 million low-income children, ends a nearly two-year effort to complete SCHIP reauthorization. As he signed the new law, President Obama noted that SCHIP was the first step in his commitment to secure health care coverage for all children in the U.S.

SCHIP was established in 1997 to provide coverage for health care services to children and pregnant women from families that are not Medicaid-eligible but are unable to afford private insurance. Reauthorization legislation was twice passed by the 110th Congress and twice vetoed by former President Bush.

Since the 111th Congress convened in early January, legislators have been working quickly to pass legislation to reauthorize the program. The American Dental Hygienists’ Association (ADHA) has been working as part of a larger Dental Access Coalition, alongside the American Dental Association, American Dental Education Association, the Children’s Dental Health Project and others in oral health, to support the reauthorization of SCHIP and the inclusion of oral health provisions in the reauthorization. SCHIP is geared towards disease prevention and early intervention for populations that often struggle to obtain coverage for medical, dental and mental health care services.

The Dental Access Coalition of which ADHA worked as a part has advocated strongly in support of the inclusion of dental provisions in SCHIP. ADHA worked with its partners to support the inclusion of the dental guarantee, which ensures dental coverage will be offered as part of each state CHIP program.

The Dental Access Coalition was also successful in encouraging the inclusion of a dental wrap around benefit in the final version of the reauthorization. A “dental wrap” benefit will enable children of families that meet income and other eligibility requirements for SCHIP and receive medical benefits through an employer-sponsored medical insurance plan to access just dental coverage through SCHIP. This is expected to help reduce the number of children who have some form of medical coverage, but are denied dental coverage.

ADHA also advocated for language that instructs the Government Accountability Office to conduct a study to report on the “feasibility and appropriateness of using qualified mid-level dental health providers, in coordination with dentists, to improve access for children to oral health services and public health overall.” The report will address the potential benefits of mid-level providers, such as the Advanced Dental Hygiene Practitioner (ADHP), in bringing care to those currently disenfranchised from the oral health care system.ADHA President Diann Bomkamp, RDH, BSDH, remarked, “The collective effort within the dental community to advocate for the inclusion of dental benefits in SCHIP demonstrates the strength of collaboration and the positive impact it can have on the patients we serve. Those efforts resulted in dental coverage for millions of low-income children who desperately need access to preventive and other oral health care services.”

A bill has been introduced in Arizona to update the current provisions governing “affiliated’ dental hygiene practice. Currently, affiliated practice dental hygienists may provide services to certain disadvantaged children in limited settings according to “standing orders” established in a written agreement with a dentist. Senate Bill 1400 would extend the allowable settings to include any person residing in a federally designated health professional shortage area. The bill would also remove requirement that services be provided through an entity such as a school authority or a government program. And most significantly, it would remove the restriction that patients be under 18 years.

The Connecticut Dental Hygienists’ Association, working together with the Connecticut Dental Assistants’ Association, introduced a bill to establish an Advanced Dental Hygiene Practitioner and Expanded Function Dental Assistant. House Bill 5630 is currently a shell bill. The complete version of the legislation will be introduced when the Committee on Public Health holds a hearing on the bill.

The Colorado Dental Hygienist’s Association is proposing an update to the practice act that lists additional services to the descriptions of dental hygiene services. The measure, Senate Bill 129, was developed in consultation with Colorado dentists. Some of the services added are already an implicit part of the services dental hygienists are expected to provide—like providing a dental hygiene assessment, diagnosis and treatment planning, as well as appropriate referral to a dentist. This service would be performed with or without supervision. Dental hygienists would be authorized to order fluoride, fluoride varnish and antimicrobial mouth rinses for patients, whether practicing with or without supervision. Currently all dental hygienists must have general supervision to expose X-rays—but this service would be allowed without supervision.

In January, the Maine Dental Hygienists’ Association introduced a number of bills related to the newly established independent practice dental hygienist (IPDH). Legislative Document 13 expands the diagnostic functions of the IPDH by allowing these hygienists to own and operate X-ray equipment. Legislative Document 233 directs the Department of Health and Human Services to adopt rules to directly reimburse IPDHs through the MaineCare program for all procedures covered under the current MaineCare rules. Finally, Legislative Document 234 requires dental and health insurers, as well as health maintenance organizations that include coverage for dental services in their policies, to provide coverage for dental services performed by an independent practice dental hygienist if those services would be covered under the policy or contract and those services are within the lawful scope of practice of the independent practice dental hygienist.

Also introduced in Maine is a bill that directs the Board of Dental Examiners (BDE) to create a new dental hygiene licensing category that will accept alternative education instructional programs. Legislative Document 419 requires the BDE to establish the qualifications and scope of practice for this new licensing category, which must include two years of experience as a dental assistant as well as sponsorship from a licensed Maine dentist.

Massachusetts recently passed a law allowing public health dental hygienists to work in public health settings via a collaborative agreement with a dentist. The bill brings the tally of direct access states up to 29. In order to qualify, a dental hygienist must have at least three years of full-time clinical experience practicing in public health settings and receive appropriate training as determined by the department of public health. Senate Bill 2819 allows public health dental hygienist to bill Medicaid directly for services; however, the Medicaid rules must be amended to reflect this directive from the legislature. Massachusetts is now the 15th state to allow for direct reimbursement of dental hygienists under Medicaid.

In addition to the public health hygienist, SB 2819 would create a full-time state dental director to lead the Office of Oral Health and to oversee and implement public oral health prevention and education programs. This legislation would also establish a full-time dental director of dental services in the office of Medicaid to oversee the MassHealth dental program and collaborate with the Department of Public Health’s dental director on public health programs to improve access to oral health care.

The Minnesota Department of Health published the final recommendations from the Oral Health Practitioner (OHP) Workgroup as well as legislation further defining the OHP in state statute. This information, along with a letter from the state’s Commissioner of Health, is available at http://www.health.state.mn.us/healthreform/oralhealth/index.html. The recommendations include guidance on practice settings, recommended levels of supervision for various OHP services, licensure requirements, collaborative management agreement requirements and guidelines for evaluating outcomes of OHP practice. The report also acknowledges plans for the ADHP master’s program at Metropolitan State as well as the University of Minnesota’s bachelor’s and master’s programs in dental therapy. The Minnesota Dental Hygienists’ Association and state Safety Net Coalition, both of which were represented on the Workgroup, support the workgroup’s recommendations.

Senate Bill 64, a bill to establish a board of dental hygienists separate from the board of dental examiners, was introduced in New Hampshire. The nine-member board will have the power to grant licensure, establish license fees, undertake disciplinary actions against licensees when necessary and make rules regarding supervision for dental hygiene services.

This is a sunset year for the New Mexico Board of Dental Health Care and the associated Dental Hygienists Committee (which regulates dental hygiene). Sunset is a periodic review of state agencies in place in a number of states. In these states, agencies must be periodically renewed by the legislature to continue to exist, and prior to the reauthorization, there is a review to evaluate the activities of the agency and the underlying statute (the practice act for dental boards) that the agency administers.

So far, three bills related to the sunset review have been introduced. One of them makes no changes but merely reauthorizes the board and committee until 2015. A second (Senate Bill 302) would allow a dental hygienist or dental assistant to qualify as an expanded function dental auxiliary (EFDA) for restorative services. The third (House Bill 676), upon which dentists and dental hygienists collaborated, also includes a provision for a restorative EFDA, but adds a number of additional “access” related provisions.

HB 676 would recognize that a dentist may provide diagnostic and treatment planning services via teledentistry. It expands the dental hygiene scope of practice by adding assessment for dental sealants, the performance of a “dental hygiene focused examination” and some fluoride and antimicrobial prescriptive authority. Experienced dental hygienists could qualify to administer local anesthesia under general supervision. Certified dental assistants could qualify as “community dental health coordinators” following board-approved education. They would work under the supervision of dentists or dental hygienists in certain alternative settings to provide “educational, preventive and limited palliative and assessment services.” Like dental assistants, CDHCs could not perform services within the dental hygiene scope unless by a formal recommendation of dental hygiene committee.

Senate Bill 5455/House Bill 1309 prevents the expiration of two significant unsupervised practice provisions in Washington State in 2009. Senior centers (entities providing health, social, nutritional, educational or recreational services for persons over 50) will be permanently added as a setting where hygienists may practice according to a written practice plan arrangement with a dentist. In addition, a two-year-old program that permits unsupervised dental hygienists working in community-based school sealant programs to also provide cleanings will continue.

The Maine State Legislature is considering a bill to expand the diagnostic function of the newly created independent practice dental hygienist. Legislative Document 13 would allow these hygienists to perform X-rays and to own X-ray equipment. The bill was referred to the Committee on Business, Research and Economic Development.

Maine is also considering a bill that expands the health screening in schools to include oral health screening. Legislative Document 100 requires oral health screening for students prior to entering kindergarten and for new students to a school district entering grades 1-6. The bill awaits a hearing in the Committee on Education and Cultural Affairs.

On January 6, 2009, the Massachusetts State Legislature passed a bill that would create a public health hygienist who could work in public health settings via a collaborative agreement with a dentist. In order to qualify, a dental hygienist must have at least three years of full-time clinical experience practicing in public health settings and receive appropriate training as determined by the department of public health. This hygienist also would be allowed to bill Medicaid directly for services.

In addition to the public health hygienist, Senate Bill 2819 would create a full-time dental director to lead the Office of Oral Health and to oversee and implement public oral health prevention and education programs. This legislation would also establish a full-time dental director of dental services in the office of Medicaid to oversee the MassHealth dental program and collaborate with the Department of Public Health’s dental director on public health programs to improve access to oral health care.

The bill is currently awaiting the governor’s signature.

The Oral Health Practitioner (OHP) Workgroup in Minnesota held its final meeting on October 5, 2008. The workgroup, which consists of 13 stakeholders, was created as a result of the OHP compromise legislation and were tasked with making recommendations defining the scope, supervision and education of the provider. The Minnesota Department of Health drafted a report based upon the Workgroup’s recommendations and will submit draft legislation reflecting the recommendations to the state legislature by January 15, 2009. For more information on the workgroup and its recommendations, please visit the OHP Web site at www.health.state.mn.us/healthreform/oralhealth/index.html.

Earlier this year, the New Hampshire State Legislature passed a bill establishing a committee to study the ADHP and other ways to increase access to care. The committee, composed of three members from the state House and one member from the state Senate, met over seven times during a period of three months and heard testimony from the New Hampshire Dental Hygienists’ Association, the New Hampshire Dental Society and other stakeholders. The committee’s recommendation is for further discussion at the stakeholder level before taking legislative action. However, the committee stated that inaction at the stakeholder level would result in legislative action. The New Hampshire Dental Hygienists’ Association is submitting a bill to establish an ADHP taskforce composed of representatives from the various stakeholders.

Although national and state elections seem barely behind us, preliminary activity has already started in some state legislatures for the 2009 session. Bills of interest to the dental hygiene community have been prefiled in at least two states—Montana and Texas. Prefiling, allowed in the vast majority of states, means the sponsor of the legislation has authorized printed copies of a proposed bill to be made available for public review before the legislature officially convenes. Typically, this means the bill may be heard in committee and discussed early in the session.

The Texas measure (Senate Bill 97) amends the access to care provision that currently allows dental hygienists to provide one-time delegated services to some patients who have not been examined by a dentist. Currently, these patients must be seen in nursing homes or school-based clinics. The proposed law would add Head Start programs and community health centers to the approved settings. It would also allow dental hygienists to continue to provide services for up to one year before a dentist would need to examine the patient to authorize any additional procedures.

According to the Texas Dental Hygienists’ Association, these minor changes would have a big impact on improving access to care for the underserved. Currently there are 82 counties in Texas that are designated as Dental Health Professional Shortage Areas by the Department of State Health Services. In 2007, only 50% of Medicaid eligible children received dental treatment services.

A separate measure (House Bill 168) would allow a dentist to delegate the administration of block and infiltration local anesthesia to a dental hygienist. The dental hygienist would need to complete a board-approved course and administer under direct supervision.

The Montana proposal (Legislative Concept 302) would transfer the regulation of denturists from the board of dentistry to the existing board of hearing aid dispensers. The combined board of hearing aid dispensers and denturists would have seven members, three of whom would be denturists.

The independent practice of denturitry is allowed in Arizona, Colorado, Idaho, Maine, Montana, Oregon and Washington. In four of these, the dental board oversees the regulation of denturists. However, in Idaho, Oregon and Washington, denturists are self-regulating under a denturitry board.

Bills Relating to Dental Hygiene Signed into Law, July 2007 through September 2008.

This bill creates collaborative practice for dental hygienists, adds restorative services for both dental hygienists and dental assistants and allows a dental hygienist to administer local anesthesia under general supervision.

California SB 853     Signed 6/13/08

This bill creates a self-regulating dental hygiene committee in conjunction with the Department of Consumer Affairs. The committee will consist of four dental hygienists, four public members and one dentist appointed by the governor.

Colorado HB 1134     Signed 3/20/08

This bill exempts community health centers, state agencies and, for a period of one year, legal heirs from the requirement that only a dentist may own a dental practice and only a dentist or dental hygienist may own a dental hygiene practice.

Florida HB 923     Signed 5/28/08

This bill allows dentists in practice for five years who are licensed in another state to obtain a Florida “health access” dental license without taking the clinical exam. Practice is limited to “health access” settings such as community health centers and head start centers.

Indiana HB 1172     Signed 3/24/08

This bill allows dental hygienists to administer local anesthesia under direct supervision and expands the current law to allow prescriptive supervision in hospitals, clinics, fixed charitable institutions, public health settings and correctional institutions. Under prescriptive supervision, the physical presence of a dentist is not required, but the dentist must have examined the patient and prescribed the patient care within the previous 45 days.

Kansas HB 2781     Signed 3/28/08

This bill removes the prohibition against dentists owning satellite offices in rural counties with less than 10,000 people.

Louisiana SB 312     Signed 7/8/08

This bill requires water fluoridation for public water systems statewide with at least 5,000 connections. Communities can vote to opt out if 15 percent of registered voters sign a petition.

Maine LD 2277     Signed 4/15/08

This bill creates an independent practice dental hygienist. An independent practice dental hygienist must possess a bachelor’s degree from a CODA-accredited dental hygiene program and have 2,000 hours of clinical practice in a private dental practice, or possess an associate degree from a CODA-accredited dental hygiene program and have 6,000 hours of clinical practice in a private dental practice. A referral plan must exist for patients in need of additional care.

Maryland HB 1280     Signed 4/24/08

This bill allows a 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 and Head Start programs.

Minnesota SB 2942     Signed 5/12/08

This bill establishes an Oral Health Practitioner (OHP) – formerly the Advanced Dental Hygiene Practitioner (ADHP) – in statute and convenes a workgroup to make recommendations and propose legislation that defines the scope of practice, supervision, education and regulation of the provider.

New Hampshire HB 1487     Signed 6/18/08

This bill establishes a committee to study the ADHP and models proposed by the American Dental Hygienists’ Association, the American Dental Association and other national and state groups to increase access to oral health care.

New York SB 1239     Signed 7/18/07

This bill requires that students entering pre-kindergarten, kindergarten or the first grade present a dental health certificate.

Pennsylvania SB 455     Signed 7/20/07

This bill allows a public health dental hygiene practitioner to provide preventive health care to individuals in a variety of public health settings without dental supervision.

Utah SB 174      Signed 3/17/08

This bill removes a provision that allowed for licensure of foreign-trained dentists and dental hygienists.

West Virginia HB 4129     Signed 3/31/08

This bill establishes a special volunteer dental hygienist license for retired dental hygienists who wish to donate their expertise for the care and treatment of indigent and needy patients.

West Virginia SB 13     Signed 3/20/08

This bill authorizes the board of dental examiners to promulgate rules allowing a dental hygienist to practice in public health settings under different degrees of supervision.

Rules

New Jersey Adopted N.J.A.C. 13:30-1A.3

This bill permits a dental hygienist to administer local anesthesia under direct supervision. The rule requires passage of the Northeast Regional Board of Dental Examiners’ written examination in the administration of local anesthesia, and completion of a board-approved course in local anesthesia that is at least 20 hours of didactic instruction and 12 hours of clinical training.

Tennessee Final Rule 0460-3-.12.
This bill permits a dental hygienist to administer local anesthesia under direct supervision. The rule requires completion of a board-approved course that is at least 32 hours in length, 24 hours of which must be didactic.

Virginia Final 4/16/08

This bill establishes guidelines, criteria and regulations to enable licensed dental 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.

Vermont Approved 5/13/08

The board of dental examiners approved proposed rules that allow dental hygienists to provide hygiene services in public health settings under the supervision of a dentist via a general supervision agreement. The agreement authorizes the dental hygienist to provide services agreed to between the dentist and the dental hygienist, including sealants, fluoride varnish and prophylaxis. The agreement does not require physical presence of the dentist, but it stipulates that the supervising dentist review all patient records.

ADHA Exhibits at the National Conference of State Legislatures Annual Legislative Summit

For the fourth consecutive year, ADHA participated in the National Conference of State Legislatures’ (NCSL) Annual Legislative Summit. NCSL, a bipartisan organization that serves as a resource to state legislators and their staff, hosts the annual meeting, which attracts legislators and staff from all over the country. The Summit, held in New Orleans this year, is an opportunity for policymakers to examine a host of policy issues.

ADHA hosted a booth in the NCSL exhibit hall alongside hundreds of other national organizations and interests, including nearly every major health care organization. This year, the conference drew over 6,000 registrants. ADHA’s booth provides an opportunity to talk face-to-face with attendees to teach them more about the association and the role the dental hygienist plays on the oral health care team.

ADHA staff was fortunate to have several members from Louisiana volunteer their time in the booth to meet and greet attendees. Two Louisiana State University (LSU) faculty members, Jennifer Hew, RDH, MSHCM, and Geri Waguespack, RDH, MS, as well as Rebecca Cascio, RDH, and former District VII Trustee Catherine Ellington, RDH, BS, manned the booth over the three-day span of the conference. Louisiana Dental Hygienists’ Association lobbyist Jane Burgin also spent time meeting and networking with legislators and staff at the ADHA booth.

ADHA was fortunate to have toothbrushes, toothpaste and dental floss donated by Sunstar Butler to give away to NSCL attendees. The giveaways, which also included basic information about dental hygienists and their impact on access to oral health care services, are instrumental in attracting visitors to the booth and open the door to conversations about oral health and the importance of preventive care. LSU’s Waguespack noted, “It was great to talk with attendees, many of whom have great relationships with their dental hygienists and understand how policies that relate to oral health impact individuals’ total health.”

Jennifer Hew, RDH, MSHCM, added, “NCSL was an opportunity for me to talk with my own legislators directly and highlight specific types of policy changes that could improve patient access to preventive care in the state.”

Throughout the course of the conference, many legislators stopped by to offer their own personal experience and insights into oral health care issues.  Representative Gerald Green from Georgia noted that he was planning to give the oral health care supplies provided to him at the booth to a group of underprivileged children that he was accompanying on a trip. A group of legislators who spearheaded recent policy changes in Maryland, including Delegate Nathaniel Oaks, also stopped by to learn more about dental hygiene practice in other states.

In addition to the contact with policymakers, NCSL also affords ADHA the chance to network with other stakeholder organizations. As noted, nearly every major health care organization is present at NCSL, including the American Dental Association and specialty dental organizations, the American Medical Association, and a host of nursing groups. ADHA’s presence at NCSL affords the association higher visibility and opens up additional partnership opportunities, a key component of ADHA’s strategic plan.

NCSL’s Annual Legislative Summit was a well orchestrated event that offered great exposure for ADHA and dental hygiene issues. In coming months, ADHA staff will be working with state leaders to carry out the necessary follow-up with legislators and staff who visited the ADHA booth. ADHA looks forward to exhibiting at NCSL in 2009 when the Summit will move to Philadelphia.

State News

On July 8, Louisiana Governor Bobby Jindal signed into law a water fluoridation bill supported by the LDHA and the Louisiana Dental Association. Senate Bill 312 mandates that public water systems statewide with at least 5,000 connections provide cost estimates to the state for implementing fluoridation by March 2009. The state will then work with each system to find grants and state budget funds to implement fluoridation community by community. Communities can vote to opt out if 15 percent of registered voters sign a petition.
On August 6, the New Jersey State Board of Dentistry approved rules permitting licensed dental hygienists who meet certain educational and training requirements to administer local anesthesia under direct supervision. The rules stipulate that the supervising dentist must assess the patient and determine which anesthetic agent (infiltration or block) the hygienist may administer.

In order to qualify for the permit, dental hygienists must have passed the NERB written local anesthesia exam and have completed a board-approved course in local anesthesia administration. The required course must consist of 20 hours of didactic and 12 hours of clinical instruction, including a minimum of 20 hours of monitored administrations of local. Additionally, licensed dental hygienists who hold a local permit must complete four hours of continuing education in the administration of local anesthesia every other biennial renewal period. This does not increase the total CE requirement, which is currently 20 hours.

Once the approved regulations are published, New Jersey will be the 42nd state, including the District of Columbia, to allow dental hygienists to administer local anesthesia.

New Jersey Dental Hygienists’ Association (NJDHA) President Winnie Furnari RDH, MS, FAADH, noted, “The longstanding work by the leaders and members of the NJDHA is highly commendable. We thank ADHA, all the dental hygienists, dentists and members of the public who gave their support. As a result, the vote was a unanimous one. We wish the remaining states all success in this endeavor by working with the boards of dentistry in achieving this benefit for our patients.”

A bill to establish the Community Dental Health Coordinator (CDHC) provider was introduced in the Michigan state legislature. Senate Bill 1400 would establish a CDHC pilot program to allow CDHCs to practice in areas designated as “dentally underserved” by the state board of dentistry. The pilot program would be four years in length but it could be extended.

The proposed bill would enable CDHCs to take radiographs, apply fluorides, polish coronally, place temporary restorative materials and scale Type I gingivitis patients, among other services. The bill directs the CDHC to work under the supervision of a dentist, although the level of supervision is not articulated. The provider would not be licensed by the state and would be required to complete a training program accredited by the “American Dental Association’s Workforce Models National Coordinating and Development Committee” and the ADA’s “Curriculum Committee.”

The legislation is pending in the Senate Committee on Families and Human Services. To date, no hearing date has been set. Neither the Michigan Dental Hygienists’ Association (MDHA) nor the Michigan Board of Dentistry endorses or approves of this CDHC concept as written. MDHA is opposed to any scope of practice being included in this workforce model.

The California Dental Hygienists’ Association (CDHA) looks forward to January 1, 2009, as the beginning of a new era for dental hygienists. On that landmark date, dental hygienists will take on the authority to create and implement regulations related to licensure and education, evaluate dental hygiene education programs, and oversee disciplinary actions for the dental hygiene profession through the new Dental Hygiene Committee of California (DHCC). The committee will consist of four consumers, one general practice or public health dentist, and four dental hygienists (one dental hygienist who is an educator and one registered dental hygienist in alternative practice). The DHCC will fall under the umbrella of the Department of Consumer Affairs.

“This is true regulatory autonomy. Regulatory autonomy is an important hallmark of a profession,” says CDHA President Noel Kelsch, RDHAP. She continues, “The DHCC and the regulatory autonomy it creates are very important because these put the profession of dental hygiene in a position to prioritize the dental hygiene legislative agenda in California, as well as allow the profession to determine how to maximize consumer utilization of dental hygiene services.”

Kelsch notes that “autonomy means self-government, not freedom from all supervision.” Creation of the DHCC does not change dental hygiene settings or supervision levels, which are in the state statute. The DHCC can pursue changes in the dental hygiene scope of practice.

Kelsch describes the effort to create the Committee as a six-year, sometimes challenging, “legislative journey.” Between 2002 and 2006, CDHA introduced two self-regulation bills that passed through the California Legislature, only to see them vetoed by the Governor. However, Kelsch concluded, “So many dental hygienists continued to contribute their time, expertise and efforts to this cause that it ultimately led to a third bill’s success. Passage of this bill will give us a stronger voice in the future of access to care, allowing hygienists to meet the needs of the citizens of California.”

As of July 1, a new Oklahoma rule allows dentists and dental hygienists continuing education (CE) credit for unpaid volunteer service to indigent patients through entities approved by the board. One hour of service will be counted as one hour of CE. Dentists may count ten hours and hygienists five hours of service as CE during each reporting cycle.

There is also a new Oklahoma CE requirement that both dentists and dental hygienists complete a course in ethics every three years The hours may be obtained through a formal course, seminar, meeting or self-study.

For the third time in as many years, a bill for dental hygiene-self regulation has made its way through the California legislature. This year, Governor Schwarzenegger signed it into law — on Friday, June 13.

The earlier bills, one for a dental hygiene “bureau” in the Department of Consumer Affairs, and the other for a dental hygiene committee of the dental board, passed out of the legislature and then were vetoed by the governor.

California, like a number of states, has a sunset provision for agencies, which requires that the legislature reinstate the agencies periodically to keep them in existence. The veto of the 2007 bill not only prevented the dental hygiene committee from coming into existence, but also permitted sunset of the dental board to occur, with shutdown beginning this month as board duties are transferred to staff in the Department of Consumer Affairs.

The current bill, Senate Bill 853, is ready to go to the governor, supported by both the dental hygienists’ association and the dental association. It would reestablish the board of dentistry to regulate dentistry and also create separate nine-member dental hygiene committee, appointed by the governor.

This new committee would have its own rulemaking power concerning the education, licensure, discipline and overall practice of dental hygienists, registered dental hygienists in extended function (RDHEF) and registered dental hygienists in alternative practice (RDHAP). It would make specific recommendations to the dental board concerning scope of practice issues; however, the current dental hygiene scope is extensively described in statute.

Four members of the committee would be public representatives, four would be dental hygienists, and one would be a general practice or public health dentist. Of the dental hygiene members, one would need to be either an RDHEF or RDHAP and another, a dental hygiene educator.

Pointing out that the bill had the “unanimous support of both houses of the state legislature, the California Dental Association, the California Dental Hygienists’ Association, and was co-authored by Senator Emmerson, a dentist,” a spokesperson for the California Dental Hygienists’ Association indicated that “the consumers of California as well as all dental hygiene professionals will benefit from the self-regulation of dental hygiene issues.”

The Missouri proposal to allow dental assistants to scale died with no action taken in May. The measure, House Bill 1976, which had no senate companion, received a committee hearing, but the committee chose not to vote. At 10:30 the night before the end of the legislative session, an amendment to the bill was proposed, but it was ruled out of order and never made it any further.

On May 12, Minnesota made history by becoming the first state in the country to establish an Oral Health Practitioner (OHP) – formerly the Advanced Dental Hygiene Practitioner (ADHP) - in statute. The OHP bill underwent a number of changes, including the name change, as it moved through the legislative process. The final language, which was signed into law, is the result of a compromise between the various stakeholders, including the Minnesota Dental Hygienist’s Association (MDHA) and the Minnesota Dental Association. The language establishes an OHP in statute as a licensed, educated provider who works under the supervision of a dentist via a collaborative management agreement. The language stipulates that OHPs must work in underserved areas and cannot begin lawful practice prior to 2011. A workgroup composed of the various stakeholders will convene this fall to make recommendations and propose legislation that defines the scope of practice, supervision, education and regulation of the provider. These recommendations will be presented to the 2009 legislature. This is an important step toward increasing oral health services to the underserved.

“This legislation is a major achievement to help improve oral health care access and treatment for those in need. The Minnesota Dental Hygienists’ Association thanks those individuals and groups who have worked so hard, despite resistance, throughout this worthwhile initiative, from its inception through now. The tremendous support from those who understand why this is important has been incredible. Special thanks to the Safety Net Coalition, Metropolitan State University, chief author Senator Ann Lynch, Senator Sandra Pappas and Senator Lawrence Pogemiller for their tireless efforts,” said Mary Beth Kensek, MDHA president.

The New Hampshire State Senate passed an amended bill establishing a committee to study practice by advanced dental hygiene practitioners and various models currently being proposed by the American Dental Hygienists’ Association, the American Dental Association, and other national and state groups to increase access to oral health care. The committee will ascertain the fiscal and programmatic impacts on New Hampshire Medicaid dental programs. The bill is enrolled and awaits the governor’s signature.

The Vermont Board of Dental Examiners approved proposed rules that would allow dental hygienists to provide hygiene services in public health settings under the supervision of a dentist via a general supervision agreement. The agreement authorizes the hygienist to provide services agreed to between the dentist and the dental hygienist including sealants, fluoride varnish and prophylaxis. The agreement does not require physical presence of the dentist, but it does stipulate that the supervising dentist review all patient records. The Legislative Committee on Administrative Rules will meet in June to confirm that the amended rules comply with the legislative intent.

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.