PACHC Memo 09-03 Applicable for: FQHC Management Team Human Resource Department Dental Hygienists Dentists December 14, 2009 TO: Health Center CEOs FROM: Cheri Rinehart, President & CEO SUBJECT: Final Regulations Pennsylvania State Board of Dentistry Summary: As part of the Governor s Prescription for Pennsylvania relating to access to dental care, Act 51 of 2007 was signed into law on July 20, 2007. Final regulations implementing the law were published in the Pennsylvania Bulletin Saturday, December 12, 2009 and became effective on publication. The final regulations: - Implement a new classification of State Board of Dentistry-regulated practitioner, the public health dental hygiene practitioner; - Revise the scope of practice of dental hygienists, to include the addition of the administration of local anesthesia under conditions; and - Revise the supervision requirements for dental hygienists. BACKGROUND: The State Board of Dentistry (Board) has for some time considered expanding the scope of practice of dental hygienists. Board action, however, was preempted by enactment of Act 51 of 2007. This final rulemaking implements Act 51 of 2007, expanding the scope of practice of dental hygienists. Although Pennsylvania s regulatory review process is often quite lengthy from the time a law is written until final implementing regulations are published, the time frame for these regulations was condensed because of the significant work the Board had done prior to passage of Act 51 to seek public comment and direction as well as by the statutory framework established by the law. 1
KEY PROVISIONS: Key New Definitions: Direct supervision for purposes of the administration of local anesthesia, means supervision by a dentist who has examined the patient and authorized the procedure to be performed, is physically present in the dental facility and available during the performance of the procedure, and takes full professional responsibility for the completed procedure. General supervision the definition is amended to extend general supervision to dental hygiene services to be performed within one year of an examination by a dentist, instead of the current standard of 90 days. Local anesthesia the elimination of sensations, especially pain, in one part of the body by regional injection of an anesthetic agent. Public health dental hygiene practitioner - a licensed dental hygienist who is certified by the Board as having met the requirements of section 11.9 of the act (63 P. S. 130j), and who is authorized to perform dental hygiene services in accordance with 33.205b (relating to practice as a public health dental hygiene practitioner) without the authorization, assignment or examination of a dentist. Subgingival agents therapeutic agents, including antimicrobials, antibiotics, antiseptics or anesthetics, placed below the free margin of the gingival by a local delivery system device, including injectable systems for ointments, gels or pastes, and degradable or non-degradable devices, such as fibers, films, strips, slabs, spheres, discs or chips. Permits for Administration of Local Anesthesia by a Dental Hygienist: With publication of the final rulemaking, Pennsylvania joins 41 other states and the District of Columbia in permitting dental hygienists to administer local anesthesia. However, because dental hygienists have not been permitted to do so in the past, most dental hygiene programs located in the Commonwealth do not include the administration of local anesthesia in the curriculum. Therefore, the Board requires dental hygienists to secure a permit prior to administering local anesthesia and requires that: 1. The administration of local anesthesia may only be delegated to those dental hygienists who meet the educational requirements in Section 33.115 of the regulations OR who have been administering local anesthesia lawfully under the laws and regulations of another jurisdiction and are issued a permit by the Board. 2. The administration of local anesthesia may only be performed by a dental hygienist under the direct supervision of a licensed dentist who has examined the patient, has authorized the procedure to be performed, and takes full responsibility for it. 2
3. Dental hygienists who obtain a permit for administration of local anesthesia only use local infiltration anesthesia and intraoral nerve block anesthesia limited to the 2 nd (maxillary) and 3 rd (mandibular) divisions of the trigeminal nerve. The regulations outline three avenues to obtaining a local anesthesia permit, clarify the certification process, and define acceptable documentation. Permits will only be issued to dental hygienists with a Pennsylvania license in good standing who have completed a Basic Life Support (BLS) course. Permits must be renewed every two years. Public Health Dental Hygiene Practitioners By definition, this new category of practitioners provides dental hygiene services in certain public health settings without the authorization, assignment or examination of a dentist. Although the Pennsylvania Academy of General Dentistry expressed concerns about public health dental hygiene practitioners treating patients with severe or life-threatening systemic disease (ASA Class III ASA Class V) without supervision, the final regulations do not include this limitation because exceptions were not provided in the law. These practitioners must: 1. Be licensed dental hygienists 2. Have a certification statement signed by a licensed dentist verifying completion of 3,600 hours of practice as a licensed dental hygienist under that dentist 3. Be covered by professional liability insurance in the minimum amount of $1,000,000 per occurrence and $3,000,000 in the aggregate. 4. Maintain dental records for five years. 5. Refer each patient to a licensed dentist on an annual basis. 6. If planning to use local anesthesia, comply with those requirements as outlined, including obtaining a permit to administer subgingival and local anesthesia. 7. Within 30 days of taking a radiograph, provide to the patient a copy of the radiograph and a referral to a dentist indicating the reason it was taken and any observations noted. These practitioners may: 1. Perform dental hygiene services relating to practice as a dental hygienist without the supervision of a dentist in the following practice settings: schools; correctional facilities; federally qualified health centers (FQHC) or FQHC Look-Alikes; personal care homes; domiciliary facilities; older adult daily living facilities; health care facilities as defined by the Health Care Facilities Act; public or private institutions under the jurisdiction of a federal, state or local agency; and free and reduced-fee nonprofit clinics. (Those working in schools must also be certified by the Department of Education). 2. May perform radiological procedures in any setting without supervision of a dentist. 3
Dental Hygienists Scope of Professional Practice: - Placement of subgingival agents - Periodontal probing, scaling, root planing, polishing or another procedure required to remove calculus deposits, accretions, excess or flash restorative materials and stains from the exposed surfaces of the teeth and beneath the gingiva. - Administration of local anesthesia by regional injection with proper certification. - Perform radiologic procedures under general supervision of a licensed dentist. Supervision: - The placement of subgingival agents, some of which require a prescription by a dentist, would be permitted only under direct supervision unless the dentist has reviewed the patient s dental records and medical history and has written a prescription or given an order for the placement of subgingival agents in which case general supervision is required. - For scaling, root planing, polishing and the like, a dental hygienist may provide the professional services under general supervision when the patient is free of systemic disease or suffers from mild systemic disease as determined by the dentist with input from the dental hygienist and upon review of the patient s medical history. Direct supervision when the patient is suffering from systemic disease which is severe, incapacitating or life threatening. - For administration of local anesthesia by regional injection, only under the direct supervision of the dentist. For administration of local anesthesia, direct supervision means supervision by a dentist who has examined the patient and authorized the procedure to be performed, is physically present in the dental facility and available during the performance of the procedure, and takes full responsibility for the completed procedure. - For professional services not identified above the dentist shall compare the listed services and the supervision required with the unlisted service and utilize appropriate supervision. Supervision for non-comparable services shall be determined by the Board on a modality basis. Performance of Radiologic Procedures Public health dental hygiene practitioners may perform radiologic procedures in those public health settings defined in the regulations under section 33.205b(c) without the supervision of a dentist. Within 30 days of taking a radiograph, the public health dental hygiene practitioner must provide to the patient a copy of the radiograph and a referral to a dentist indicating the reason the radiograph was taken and any observations noted. Dental hygienists may perform radiologic procedures in any setting under the general supervision of a licensed dentist. For the purpose of this subsection, ''general supervision'' means supervision by a dentist who examines the patient, develops a dental treatment plan, authorizes 4
the performance of the radiologic services to be performed within 1 year of the examination, and takes full professional responsibility for performance of the dental hygienist. Auxiliary personnel. The regulations establish the Radiation Health and Safety examination administered by the Dental Assisting National Board (DANB) as the required examination for auxiliary personnel who wish to administer ionizing radiation in a dental office. Auxiliary personnel who have passed the examination may perform radiologic procedures on the premises of a dentist under the direct supervision of a dentist. The dentist must be on the premises when a radiologic procedure is performed, but is not required to personally observe performance of the procedure. Continuing Education: Required credit hours must be in subjects which contribute directly to the maintenance of clinical competence of a dentist, dental hygienist, public health dental hygiene practitioner or expanded function dental assistant. The regulations provide examples of approved subject areas. Dental hygienists with a permit to administer local anesthesia. A minimum of 3 hours of the required 20 hours of continuing education biennially must be in continuing education in courses related to the administration of local anesthesia, including pharmacology. Public health dental hygiene practitioner. Must complete 5 of the required 20 hours of continuing education in public health-related courses. Dental hygienist May complete no more than 3 of the required 20 hours of continuing education in courses relating to communication skills. RECOMMENDED HEALTH CENTER ACTION: 1. Evaluate whether your health center would benefit from employing public health dental practitioner(s). 2. Ensure that patients are provided a copy of any radiograph taken by a public health dental hygiene practitioner within 30 days along with a referral to a dentist to determine the presence or absence of diagnosable conditions. 3. Ensure that dental hygienists with local anesthesia permits complete at least 3 hours of continuing education in courses related to the administration of local anesthesia, including pharmacology. 4. Ensure that dental records are maintained for a minimum of 5 years from the date of the last treatment entry for all patients seen by a public health dental hygiene practitioner. 5. Ensure documentation of the annual referral to a dentist. 5
PACHC ACTION: PACHC, in addition to providing this summary of the final regulations for you, has reached out to the State Board of Dentistry to see if they will work with us to offer an audioconference on the regulations as an opportunity for you to have questions answered. PACHC is researching potential payment implications for FQHCs of the regulatory changes. The final rule in its entirety can be downloaded from http://www.pabulletin.com/secure/data/vol39/39-50/2275.html. FOR MORE INFORMATION: Questions may be directed to Cheryl Bumgardner, Clinical Coordinator, PACHC at (717) 761-6443, ext. 208 or Cheryl@pachc.com. 6