ARC 6733C

ARC 6733C

DENTAL BOARD[650]

Adopted and Filed

Rule making related to expanded functions

The Dental Board hereby amends Chapter 10, "General Requirements," and Chapter 23, "Expanded Functions," Iowa Administrative Code.

Legal Authority for Rule Making

This rule making is adopted under the authority provided in Iowa Code section 147.76 and chapter 153.

State or Federal Law Implemented

This rule making implements, in whole or in part, Iowa Code chapter 153.

Purpose and Summary

These amendments update the rules related to expanded functions. The amendments lower the clinical practice requirement following registration for dental assistants to train in expanded functions and provide greater flexibility to train in the functions. The rule making moves some of the Level 2 expanded functions to Level 1 designation for the purposes of training. Additionally, the rule making allows individuals to train in Level 2 expanded functions without the requirement to first complete training in all Level 1 expanded functions. The amendments include one amendment to Chapter 10 to reflect an earlier change to Chapter 23 and Iowa Code section 153.38.

Public Comment and Changes to Rule Making

Notice of Intended Action for this rule making was published in the Iowa Administrative Bulletin on September 7, 2022, as ARC 6515C. The Board accepted written comments through September 30, 2022. The Board received ten written comments. Six of the comments supported the changes that were drafted and in instances commended the Board for attempting to address access to care and staffing needs, particularly in rural areas. Four of the comments expressed concerns with some sections of the proposed rule making. One of the commenters preferred that the rules related to Level 2 expanded functions be left as they were. One of the commenters, who provides expanded function training, offered suggestions for revision to some of the expanded functions, including the number of hours required for training in each area. Additionally, the commenter expressed a preference to eliminate the initial assessment for expanded functions training at the start of a course. The other commenters expressed concern about the reduction in the clinical practice requirement prior to training in expanded functions. This concern arose from the elimination of the minimum training requirement prior to a dental assistance trainee becoming a registered dental assistant, as adopted in ARC 6673C (11/16/22 IAB). The concerns focused on potential risks to the public as a result of the services being performed before the dental assistants are fully prepared.

The following changes from the Notice have been made:

●A revision to Chapter 10 to reflect an earlier change to Chapter 23 and Iowa Code section 153.38 in Item 1. Subsequent items have been renumbered;

●Instead of rescission, an amendment is made to the definition of "provisional restorations" in new Item 3. Subsequent items have been renumbered;

●A reorganization of the orthodontic functions to better meet the needs of orthodontic offices;

●Updates to the minimum training standards based on input from members of the public and the reorganization of some of the Level 1 expanded functions; and

●The grouping of the placement of temporary restorative materials into a single function as opposed to two separate functions.

Adoption of Rule Making

This rule making was adopted by the Board on November 21, 2022.

Fiscal Impact

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

Jobs Impact

After analysis and review of this rule making, there will be a positive impact on jobs in Iowa since the rule making allows licensees and registrants greater flexibility to grow within the profession.

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 rule 650—7.4(17A,147,153).

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 January 18, 2023.

The following rule-making actions are adopted:

Item 1. Amend paragraph 10.3(1)"e" as follows:

e. The following services may only be delegated by a dentist to a dental hygienist: administration of local anesthesia, placement of sealants except as permitted by 650—subrule 23.6(2), and the removal of any plaque, stain, calculus, or hard natural or synthetic material except by toothbrush, floss, or rubber cup coronal polish.

Item 2. Rescind the definitions of "Direct supervision," "General supervision of a dental assistant" and "General supervision of a dental hygienist" in rule 650—23.1(153).

Item 3. Amend rule 650—23.1(153), definition of "Provisional restoration," as follows:

"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 restoration or appliance, which is formed or preformed for temporary purposes, used over a limited period of time.

Item 4. Amend subrules 23.2(2) and 23.2(3) as follows:

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 three months of clinical practice as a registered dental assistant; or

(4)Have at least one year three months 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.

Item 5. Amend rule 650—23.3(153) as follows:

650—23.3(153) Expanded function categories. Dental hygienists and dental assistants must be issued a certificate of completion for the corresponding function in which training has been completed 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 expanded function procedures in which training has been successfully completed.

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. Level 1 expanded functions may be taught by board-approved training providers using curriculum prior-approved by the board.

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) 23.3(2) 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. Training in Level 2 expanded functions must be completed at the University of Iowa College of Dentistry or another accredited school using curriculum approved by the board. Before beginning Level 2 training, dental assistants and dental hygienists must complete all prerequisites established by the accredited school for the Level 2 training to be completed.

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.

Item 6. Amend rule 650—23.4(153) as follows:

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 following review of the fit and function by the supervising dentist, and temporary recementation of provisional restorations;

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

23.4(5) Applying bonding systems, which may include the placement of the attachments used in clear aligner systems, following review of the fit and function by the supervising dentist;

23.4(6) Placement, bonding, and removal of provisional orthodontic restorations as follows:

a. Placement or bonding of orthodontic brackets and bands or provisional orthodontic appliances following review of the fit and function by the supervising dentist; and

b. Removal of adhesive, orthodontic brackets and bands, or provisional orthodontic appliances using nonmotorized hand instrumentation;

23.4(5) 23.4(7) 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) 23.4(8) Taking final impressions;

23.4(7) 23.4(9) Removal of adhesives using nonmotorized hand instrumentation;

23.4(8) 23.4(10) Placement of Class 1 temporary filling restorative materials following preparation of the tooth by a dentist; and

23.4(9) Recementation of provisional restorations.

23.4(11) Extraoral adjustment to acrylic dentures without making any adjustments to the prosthetic teeth; and

23.4(12) Tissue conditioning (soft reline only).

Item 7. Amend rule 650—23.5(153) as follows:

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 following review of the fit and function by the supervising dentist, and temporary recementation 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) Applying bonding systems, which may include the placement of the attachments used in clear aligner systems, following review of the fit and function by the supervising dentist;

23.5(5) 23.5(6) Taking final impressions;

23.5(7) Placement, bonding, and removal of provisional orthodontic appliances as follows:

a. Placement or bonding of orthodontic brackets and bands or provisional orthodontic appliances following review of fit and function by the supervising dentist; and

b. Removal of adhesive, orthodontic brackets and bands, or provisional orthodontic appliances;

23.5(6) 23.5(8) Placement of Class 1 temporary filling restorative materials following preparation of the tooth by a dentist; and

23.5(7) Recementation of provisional restorations.

23.5(9) Extraoral adjustment to acrylic dentures without making any adjustments to the prosthetic teeth; and

23.5(10) Tissue conditioning (soft reline only).

Item 8. Amend rule 650—23.6(153) as follows:

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; and

d. Fitting of stainless steel crowns on primary posterior teeth, and cementation after fit verification by a 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) Level 2 expanded function procedures for dental assistants include the placement of sealants. The placement of sealants is included in the scope of practice for dental hygienists and is not considered an expanded function for dental hygienists.

23.6(3) These Level 2 expanded function procedures refer to both primary and permanent teeth except as otherwise noted. Training in Level 2 expanded functions may be separated between application of the services on primary or permanent teeth as determined by the accredited training provider.

Item 9. Amend rule 650—23.7(153) as follows:

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, temporary recementation, and removal of provisional restorations:

Goal: To replicate the anatomy and function of the natural tooth, prior to the final restoration, and 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: 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 ; and 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 to apply appropriate medicaments to minimize sensitivity to existing tooth structure.

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

Minimum training requirement: Two hours One hour 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 five patient experiences in each one of these areas (for a total of 15 patient experiences under observational supervision) the functions under observational supervision.

(5)Applying bonding systems, which may include the placement of the attachments used in clear aligner systems, following review of the fit and function by the supervising dentist:

Goal: To apply appropriate material and systems that adhere to the existing tooth structure.

Standard: Manipulate and apply appropriate material and systems 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 five patient experiences under observational supervision.

(6)Placement, bonding, and removal of orthodontic brackets and bands or provisional orthodontic appliances pursuant to subrules 23.4(5) and 23.5(7):

Goal: To place on and remove from the existing tooth structure orthodontic brackets and bands or provisional orthodontic appliances.

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

Minimum training requirement: For each function, 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 five patient experiences under observational supervision.

(5) (7)Monitoring of patients receiving nitrous oxide inhalation analgesia, pursuant to subrule 23.4(5) 23.4(7):

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) (8)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) (9)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) (10)Placement of Class 1 temporary filling restorative materials following preparation of the tooth by the dentist:

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

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

Minimum training requirement: One hour 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 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.

(11)Extraoral adjustment to acrylic dentures without making any adjustments to the prosthetic teeth:

Goal: To make adjustments to dentures.

Standard: Identify how and where to make extraoral adjustments to dentures.

Minimum training requirement: One hour 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 five patient experiences under observational supervision.

(12)Tissue conditioning (soft reline only):

Goal: To apply appropriate material to dentures.

Standard: Identify how and where to apply appropriate material to dentures.

Minimum training requirement: One hour 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 five patient experiences under observational supervision.

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.

[Filed 11/22/22, effective 1/18/23]

[Published 12/14/22]

Editor's Note: For replacement pages for IAC, see IAC Supplement 12/14/22.