Adopted and Filed

Expanded functions; fees, 10.3, 15.8(1), 20.4 to 20.7, ch 23, 25.10(2)“f”

Untitled document

ARC 4676C

DENTAL BOARD[650]

Adopted and Filed

Rule making related to expanded functions for dental assistants and dental hygienists

The Dental Board hereby amends Chapter 10, "General Requirements," Chapter 15, "Fees," and Chapter 20, "Dental Assistants," adopts new Chapter 23, "Expanded Functions," and amends Chapter 25, "Continuing Education," Iowa Administrative Code.

Legal Authority for Rule Making

This rule making is adopted under the authority provided in Iowa Code sections 147.76, 153.33 and 272C.3.

State or Federal Law Implemented

This rule making implements, in whole or in part, Iowa Code sections 153.15, 153.38 and 153.39.

Purpose and Summary

The primary purpose of these amendments is to update the requirements for expanded functions. The amendments move some procedures into the standard scope of practice for dental assistants and dental hygienists and also allow additional procedures to be performed by dental assistants and dental hygienists as new expanded functions. The amendments also include updated terminology to make the rules clearer.

These amendments create a new Chapter 23 for all expanded function requirements. The amendments remove the expanded function requirements currently established in Chapters 10 and 20 and relocate the content into Chapter 23. The intent is to make it easier for dental hygienists and dental assistants to locate the requirements for expanded functions by placing all of the requirements in a single chapter.

These amendments establish clearer requirements for training in expanded functions to ensure that a minimum standard of competency is met at the completion of all expanded function training courses. A review of expanded function training courses to date has shown that there is not a clear minimum training standard. These amendments will resolve this concern.

These amendments also create a process whereby expanded function dental assistants and dental hygienists may document completion of Board-approved training in Level 1 and Level 2 expanded functions.

These amendments also update the fee for a hard copy of a duplicate certificate or proof of renewal.

Public Comment and Changes to Rule Making

Notice of Intended Action for this rule making was published in the Iowa Administrative Bulletin on May 8, 2019, as ARC 4424C.

The public comment period ended on July 1, 2019. The Board received two comments. The Dental Assisting National Board, Inc., recommended that the Board consider requiring candidates to take their third-party examination as a means to assess competency in expanded function procedures. Impact Dental Training, LLC, recommended revisions to language for consistency, asked for clarification on expectations regarding training, expressed concerns regarding implementation of the new rules and made substantive suggestions for changing or recategorizing specific expanded function procedures. In response to these comments, the Board revised language for consistency throughout the rules, clarified expectations regarding new standards, added grandfathering language and reworded some expanded function procedures.

The Board adopted the rule making with the following changes:

The Board made a number of changes following input from interested parties and written comments received. The changes updated the language to be clearer about the procedures and regulations. Following feedback, the option for certification was removed, and alternative regulations were established to verify training.

Adoption of Rule Making

This rule making was adopted by the Board on August 2, 2019.

Fiscal Impact

This rule making has no fiscal impact to the State of Iowa.

Jobs Impact

After analysis and review of this rule making, no impact on jobs has been found.

Waivers

Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the Board for a waiver of the discretionary provisions, if any, pursuant to 650—Chapter 7.

Review by Administrative Rules Review Committee

The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making at its regular monthly meeting or at a special meeting. The Committee's meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).

Effective Date

This rule making will become effective on October 30, 2019.

The following rule-making actions are adopted:

Item 1. Amend subrule 10.3(1) as follows:

10.3(1) "Practice of dental hygiene" as defined in Iowa Code section 153.15 as amended by 2017 Iowa Acts, Senate File 479, means the performance of the following educational, therapeutic, preventive and diagnostic dental hygiene services. Such services, except educational services, shall be delegated by and performed under the supervision of a dentist licensed pursuant to Iowa Code chapter 153.

a. Educational. Assessing the need for, planning, implementing, and evaluating oral health education programs for individual patients and community groups; conducting workshops and in-service training sessions on dental health for nurses, school personnel, institutional staff, community groups and other agencies providing consultation and technical assistance for promotional, preventive and educational services.

b. Therapeutic. Identifying and evaluating factors which indicate the need for and performing (1) oral prophylaxis, which includes supragingival and subgingival debridement of plaque, and detection and removal of calculus with instruments or any other devices; (2) periodontal scaling and root planing; (3) removing and polishing hardened excess restorative material; (4) administering local anesthesia with the proper permit; (5) administering nitrous oxide inhalation analgesia in accordance with 650—subrules 29.6(4) and 29.6(5); (6) applying or administering medicaments prescribed by a dentist, including chemotherapeutic agents and medicaments or therapies for the treatment of periodontal disease and caries; (7) removal of adhesives.

c. Preventive. Applying pit and fissure sealants and other medications or methods for caries and periodontal disease control; organizing and administering fluoride rinse or sealant programs.

d. Diagnostic. Reviewing medical and dental health histories; performing oral inspection; indexing dental and periodontal disease; preliminary charting of existing dental restorations and teeth; making occlusal registrations for mounting study casts; testing pulp vitality; testing glucose levels; analyzing dietary surveys.

e. The following services may only be delegated by a dentist to a dental hygienist: administration of local anesthesia, placement of sealants, and the removal of any plaque, stain, calculus, or hard natural or synthetic material except by toothbrush, floss, or rubber cup coronal polish.

f. Phlebotomy.

g. Expanded function procedures in accordance with 650—Chapter 23.

Item 2. Rescind subrules 10.3(8) and 10.3(9).

Item 3. Amend subrule 15.8(1) as follows:

15.8(1) Duplicates. The fee for issuance of a hard-copy duplicate license, permit or registration certificate or current renewal is $25. Electronic copies are provided at no cost.

Item 4. Amend rule 650—20.4(153) as follows:

650—20.4(153) Scope of practice.

20.4(1) In all instances, a dentist assumes responsibility for determining, on the basis of diagnosis, the specific treatment patients will receive and which aspects of treatment may be delegated to qualified personnel as authorized in these rules.

20.4(2) A licensed dentist may delegate to a dental assistant those procedures for which the dental assistant has received training. This delegation shall be based on the best interests of the patient. Such services shall be delegated by and performed under the supervision of a licensed dentist and may include:

a. Placement and removal of dry socket medication;

b. Placement of periodontal dressings;

c. Testing pulp vitality;

d. Preliminary charting of existing dental restorations and teeth;

e. Glucose testing;

f. Phlebotomy; and

g. Expanded function procedures in accordance with 650—Chapter 23.

20.4(2) 20.4(3) The dentist shall exercise supervision and shall be fully responsible for all acts performed by a dental assistant. A dentist may not delegate to a dental assistant any of the following, unless allowed pursuant to 650—Chapter 23:

a. Diagnosis, examination, treatment planning, or prescription, including prescription for drugs and medicaments or authorization for restorative, prosthodontic or orthodontic appliances.

b. Surgical procedures on hard and soft tissues within the oral cavity and any other intraoral procedure that contributes to or results in an irreversible alteration to the oral anatomy.

c. Administration of local anesthesia.

d. Placement of sealants.

e. Removal of any plaque, stain, or hard natural or synthetic material except by toothbrush, floss, or rubber cup coronal polish, or removal of any calculus.

f. Dental radiography, unless the assistant is qualified pursuant to 650—Chapter 22.

g. Those procedures that require the professional judgment and skill of a dentist.

20.4(3) 20.4(4) A dental assistant may perform duties consistent with these rules under the supervision of a licensed dentist. The specific duties dental assistants may perform are based upon:

a. The education of the dental assistant.

b. The experience of the dental assistant.

Item 5. Rescind rule 650—20.5(153).

Item 6. Renumber rules 650—20.6(153) and 650—20.7(153) as 650—20.5(153) and 650—20.6(153).

Item 7. Amend renumbered rules 650—20.5(153) and 650—20.6(153) as follows:

650—20.5(153) Categories of dental assistants: dental assistant trainee, registered dental assistant. There are two categories of dental assistants. Both the supervising dentist and the registered dental assistant or dental assistant trainee are responsible for maintaining documentation of training. Such documentation must be maintained in the office of practice and shall be provided to the board upon request.

20.5(1) Registered dental assistant. Registered dental assistants are individuals who have met the requirements for registration and have been issued a certificate of registration. A registered dental assistant may, under general supervision, perform dental radiography, intraoral suctioning, use of a curing light and intraoral camera, and all extraoral duties that are assigned by the dentist and are consistent with these rules. During intraoral procedures, the registered dental assistant may, under direct supervision, assist the dentist in performing duties assigned by the dentist that are consistent with these rules. The registered dental assistant may take radiographs if qualified pursuant to 650—Chapter 22.

20.5(2) Dental assistant trainee. Dental assistant trainees are all individuals who are engaging in on-the-job training to meet the requirements for registration and who are learning the necessary skills under the personal supervision of a licensed dentist. Trainees may also engage in on-the-job training in dental radiography pursuant to rule 650—22.3(136C,153).

a. No change.

b. Trainee restart.

(1)Reapplying for trainee status. A trainee may "start over" as a dental assistant trainee provided the trainee submits an application in compliance with subrule 20.7(1) 20.6(1).

(2) to (4) No change.

c. No change.

650—20.6(153) Registration requirements after July 1, 2001. Effective July 2, 2001, dental assistants must meet the following requirements for registration:

20.6(1) Dental assistant trainee.

a. to c. No change.

d. Prior to the trainee status expiration date, the dental assistant trainee's supervising dentist must ensure that the trainee has received a certificate of registration or has been issued start-over trainee status in accordance with rule 650—20.6(153) 650—20.5(153) before performing any further dental assisting duties.

20.6(2) Registered dental assistant.

a. No change.

b. Applications for registration as a registered dental assistant must be filed on official board forms and include the following:

(1)No change.

(2)Evidence of meeting the requirements specified in 20.7(2)"a." 20.6(2)"a."

(3) to (9) No change.

20.6(3) Rescinded IAB 9/17/03, effective 10/22/03.

20.6(4) 20.6(3) All applications must be signed and verified by the applicant as to the truth of the documents and statements contained therein.

20.6(5) Review of applications. The board shall follow the procedures specified in 650—11.8(147,153) in reviewing applications for registration and qualification.

Item 8. Adopt the following new rule 650—20.7(153):

650—20.7(153) Review of applications. The board shall follow the procedures specified in rule 650—11.8(147,153) in reviewing applications for registration and qualification.

Item 9. Adopt the following new 650—Chapter 23:

CHAPTER 23

EXPANDED FUNCTIONS

650—23.1(153) Definitions. As used in this chapter:

"Accredited school" means a dental, dental hygiene, or dental assisting education program accredited by the Commission on Dental Accreditation (CODA).

"Clinical training" means training which includes patient experiences.

"Didactic training" means educational instruction.

"Direct supervision" means that the dentist is present in the treatment facility, but it is not required that the dentist be physically present in the treatment room.

"Fabrication" means the construction or creation of an impression, occlusal registration, provisional restoration or denture, as defined in this chapter.

"General supervision of a dental assistant" means that a dentist has examined the patient and has delegated the services to be provided by a registered dental assistant, which are limited to all extraoral duties, dental radiography, intraoral suctioning, use of a curing light, intraoral camera, and recementation of a provisional restoration. The dentist need not be present in the facility while these services are being provided.

"General supervision of a dental hygienist" means that a dentist has examined the patient and has prescribed authorized services to be provided by a dental hygienist. The dentist need not be present in the facility while these services are being provided. If a dentist will not be present, the following requirements shall be met:

1.Patients or their legal guardians must be informed prior to the appointment that no dentist will be present and therefore no examination will be conducted at that appointment.

2.The hygienist must consent to the arrangement.

3.Basic emergency procedures must be established and in place, and the hygienist must be capable of implementing these procedures.

4.The treatment to be provided must be prior prescribed by a licensed dentist and must be entered in writing in the patient record.

"Laboratory training" means training that is hands-on, that may include simulation, and that prepares a dental hygienist or dental assistant for patient experiences. Laboratory training can be done as part of an approved course, or obtained through a supervising dentist.

"Observational supervision," for expanded functions, is for training purposes only and means the dentist is physically present in the treatment room to oversee and direct all services being provided as part of clinical training.

"Patient experiences" are procedures that are performed on a patient, during the course of clinical training, under the observational supervision of a dentist.

"Prosthetic" means any provisional or permanent restoration intended to replace a tooth or teeth.

"Provisional restoration" means a crown or bridge placed with the intention of being replaced with a permanent crown or bridge at a later date, or a permanent crown provisionally recemented to be replaced or recemented at a later date.

650—23.2(153) Expanded function requirements and eligibility.

23.2(1) Dental hygienists or dental assistants may only perform expanded function procedures upon successful completion of a board-approved course of training and certification by the board. All expanded function procedures must be delegated by and performed under the direct supervision of a dentist licensed pursuant to Iowa Code chapter 153 unless otherwise specified in this rule. A dental assistant trainee is not eligible to perform or receive training in expanded function procedures. This shall not preclude dental hygienists or dental assistants from practicing expanded function procedures for training purposes while enrolled in a board-approved course of training.

23.2(2) To be eligible to train in Level 1 expanded function procedures, dental hygienists or dental assistants must comply with one of the following:

a. Hold an active dental hygiene license in Iowa; or

b. Hold an active dental assistant registration, and comply with at least one of the following:

(1)Be a graduate of an accredited school; or

(2)Be currently certified by the Dental Assisting National Board (DANB); or

(3)Have at least one year of clinical practice as a registered dental assistant; or

(4)Have at least one year of clinical practice as a dental assistant in a state that does not require registration.

23.2(3) A dentist who delegates Level 1 or Level 2 expanded function procedures to dental hygienists or dental assistants under direct supervision must examine the patient to review the quality of work prior to the conclusion of the dental appointment. The following expanded function procedures are exempt from this requirement and may be performed under general supervision:

a. Recementation of a provisional restoration.

b. Taking occlusal registrations for purposes other than mounting study casts by Level 1 or Level 2 dental hygienists only.

650—23.3(153) Expanded function categories.

23.3(1) Basic Level 1. Dental hygienists or dental assistants who train in some, but not all, Level 1 expanded function procedures are deemed to be basic expanded function dental hygienists or dental assistants. Dental hygienists and dental assistants must be issued a certificate of completion for the corresponding function by a board-approved training program before performing a specific expanded function procedure. A dentist may delegate to dental hygienists or dental assistants only those Level 1 expanded function procedures for which training has been successfully completed.

23.3(2) Certified Level 1. Expanded function dental hygienists or dental assistants who have successfully completed training for all Level 1 expanded function procedures and have been issued a certificate of completion by a board-approved training program are deemed to be certified Level 1 dental hygienists or dental assistants.

23.3(3) Certified Level 2. Before beginning Level 2 training to become certified in Level 2, expanded function dental hygienists or dental assistants must have a minimum of one year of clinical practice as a certified Level 1 dental hygienist or dental assistant and pass an entrance examination administered by the Level 2 training program.

a. Dental hygienists or dental assistants who have successfully completed training in Level 2 expanded function procedures and have been issued a certificate of completion by a board-approved training program are deemed to be certified Level 2 dental hygienists or dental assistants.

b. A dentist may delegate any Level 1 or Level 2 expanded function procedures to dental hygienists or dental assistants who are certified Level 2.

650—23.4(153) Level 1 expanded function procedures for dental assistants. Level 1 expanded function procedures for dental assistants include:

23.4(1) Taking occlusal registrations;

23.4(2) Placement and removal of gingival retraction material;

23.4(3) Fabrication, temporary cementation, and removal of provisional restorations;

23.4(4) Applying cavity liners and bases; desensitizing agents; and bonding systems, to include the placement of orthodontic brackets, following the determination of location by the supervising dentist;

23.4(5) Monitoring of patients receiving nitrous oxide inhalation analgesia, which may include increasing oxygen levels as needed, pursuant to the following:

a. A dentist shall induce a patient and establish the maintenance level;

b. A dental assistant may make adjustments that decrease the nitrous oxide concentration during the administration of nitrous oxide;

c. A dental assistant may turn off the oxygen delivery at the completion of the dental procedure;

23.4(6) Taking final impressions;

23.4(7) Removal of adhesives using nonmotorized hand instrumentation;

23.4(8) Placement of Class 1 temporary filling materials; and

23.4(9) Recementation of provisional restorations.

650—23.5(153) Level 1 expanded function procedures for dental hygienists. Level 1 expanded function procedures for dental hygienists include:

23.5(1) Taking occlusal registrations;

23.5(2) Placement and removal of gingival retraction material;

23.5(3) Fabrication, temporary cementation, and removal of provisional restorations;

23.5(4) Applying cavity liners and bases and applying bonding systems for restorative purposes, including the placement of orthodontic brackets, following the determination of location by the supervising dentist;

23.5(5) Taking final impressions;

23.5(6) Placement of Class 1 temporary filling materials; and

23.5(7) Recementation of provisional restorations.

650—23.6(153) Level 2 expanded function procedures for dental hygienists and dental assistants.

23.6(1) Level 2 expanded function procedures for dental hygienists and dental assistants include:

a. Placement and shaping of amalgam following preparation of a tooth by a dentist;

b. Placement and shaping of adhesive restorative materials following preparation of a tooth by a dentist;

c. Polishing of adhesive restorative material using a slow-speed handpiece;

d. Fitting of stainless steel crowns on primary posterior teeth, and cementation after fit verification by the dentist;

e. Tissue conditioning (soft reline only);

f. Extraoral adjustment to acrylic dentures without making any adjustments to the prosthetic teeth; and

g. Placement of intracoronal temporary fillings following preparation of a tooth by a dentist.

23.6(2) These Level 2 expanded function procedures refer to both primary and permanent teeth except as otherwise noted.

650—23.7(153) Expanded function training.

23.7(1) Approved expanded function training programs. Training programs for Level 1 and Level 2 expanded function procedures must be board-approved. Training programs for Level 2 expanded function procedures shall be eligible for board approval if the training is offered through the University of Iowa College of Dentistry or another accredited school.

23.7(2) Certificates of completion. All board-approved training programs are authorized and required to issue certificates to dental hygienists and dental assistants who successfully complete expanded function training. A certificate shall be issued for one or more of the listed expanded function procedures completed as Basic Level 1, or a certificate shall be issued for Certified Level 1 or Certified Level 2. Dental hygienists and dental assistants shall prominently display the expanded functions certificate in each dental facility where services are provided.

23.7(3) Training requirements. Training may be completed in one or more of the listed expanded function procedures. Clinical training in expanded function procedures must be completed under observational supervision. Beginning January 1, 2020, Level 1 expanded function training must consist of the following:

a. An initial assessment to determine the base entry level of all participants in the program;

b. Completion of a training program that meets the following minimum standards for each function:

(1)Taking occlusal registrations:

Goal: To reproduce the patient's jaw relationship accurately.

Standard: Demonstrate an accurate occlusal registration confirmed by a supervising dentist.

Minimum training requirement: One hour of didactic training, and clinical training that includes a minimum of five patient experiences under observational supervision.

(2)Placement and removal of gingival retraction material:

Goal: To expose the margins of a crown by displacing tissue from the tooth.

Standard: Perform the procedural steps to place and remove retraction material and recognize oral conditions and techniques that may compromise tissue displacement or patient health.

Minimum training requirement: Two hours of didactic training, the equivalent of one hour of laboratory training that includes a minimum of three experiences, and clinical training that includes a minimum of five patient experiences under observational supervision.

(3)Fabrication, temporary cementation and removal of provisional restorations:

Goal: To replicate the anatomy and function of the natural tooth, prior to the final restoration.

Standard: Use various methods to fabricate and temporarily cement single-unit and multiunit provisional restorations.

Minimum training requirement: Four hours of didactic training, the equivalent of four hours of laboratory training that includes a minimum of five experiences, and clinical training that includes a minimum of ten patient experiences under observational supervision.

(4)Applying cavity liners and bases; desensitizing agents; and bonding systems, to include the placement of orthodontic brackets, following the determination of location by the supervising dentist:

Goal: To apply appropriate material that protects existing tooth structure and adheres existing tooth structure to restorative materials.

Standard: Manipulate and apply appropriate material to meet clinical competency.

Minimum training requirement: Two hours of didactic training, the equivalent of one hour of laboratory training that includes a minimum of two experiences, and clinical training that includes a minimum of 5 patient experiences in each one of these areas (for a total of 15 patient experiences under observational supervision).

(5)Monitoring of patients receiving nitrous oxide inhalation analgesia, pursuant to subrule 23.4(5):

Goal: Understand the equipment, recognize the signs of patient distress or adverse reaction, and know when to call for help.

Standard: Exercise the ability to maintain patient safety while nitrous oxide is used.

Minimum training requirement: Two hours of didactic training, one hour of laboratory training in the office where the dental hygienist or dental assistant is employed, and five patient experiences under observational supervision.

(6)Taking final impressions:

Goal: Reproduce soft and hard oral tissues, digitally or with impression materials.

Standard: Complete the procedural steps to obtain a clinically acceptable final impression.

Minimum training requirement: Three hours of didactic training, and the equivalent of clinical training that includes a minimum of six patient experiences under observational supervision.

(7)Removal of adhesives using nonmotorized hand instrumentation:

Goal: Remove excess adhesives and bonding materials to eliminate soft tissue irritation.

Standard: Identify how, when and where to remove excessive bonding or adhesive material.

Minimum training requirement: One hour of didactic training, and clinical training that includes a minimum of five patient experiences under observational supervision.

(8)Placement of Class 1 temporary filling materials:

Goal: Place Class 1 temporary filling materials following preparation of a tooth by a dentist.

Standard: Identify how, when and where to place Class 1 temporary filling materials.

Minimum training requirement: One hour of didactic training, and clinical training that includes a minimum of five patient experiences under observational supervision.

(9)Recementation of provisional restorations:

Goal: Secure the provisional restoration to a previously prepared tooth after the provisional restoration has become loose or dislodged.

Standard: Use various methods to fabricate and temporarily cement single-unit and multiunit provisional restorations.

Minimum training requirement: If this training is completed in conjunction with training in fabrication, temporary cementation and removal of provisional crown and bridge restorations, the training requirements may be combined since the procedures are related. If this training is being completed separately, the same training requirements for fabrication, temporary cementation and removal of provisional restorations applies.

c. A postcourse written examination at the conclusion of the training program, with a minimum of ten questions per function, must be administered. Participants must obtain a score of 75 percent or higher on each examination administered.

23.7(4) Grandfathering. Any dental hygienist or dental assistant who has completed expanded function training prior to January 1, 2020, can continue to perform expanded function procedures for which training has been completed. For any expanded function procedures that are new, in whole or in part, additional training to satisfy the standard and minimum training requirement is required of the dental hygienist or dental assistant prior to performing the new expanded function procedure.

These rules are intended to implement Iowa Code chapter 153.

Item 10. Amend paragraph 25.10(2)"f" as follows:

f. For dental assistants registered pursuant to rule 650—20.7(153) 650—20.6(153), the current biennium renewal period, or portion thereof, following original issuance of the registration.

[Filed 8/22/19, effective 10/30/19]

[Published 9/25/19]

Editor's Note: For replacement pages for IAC, see IAC Supplement 9/25/19.

Dental Board


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Official Document

  • Expanded functions; fees, 10.3, 15.8(1), 20.4 to 20.7, ch 23, 25.10(2)“f”
  • Published on 9/25/2019
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  • Adopted and Filed

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Iowa Code References

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Iowa Code 153 Iowa Code 153.15
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