Title of Regulation: 18VAC60-30. Regulations Governing the Practice of Dental Assistants (amending 18VAC60-30-60, 18VAC60-30-120; adding 18VAC60-30-116).

Statutory Authority: § 54.1-2400 of the Code of Virginia.

Public Hearing Information:

February 28, 2020 - 9 a.m. - Department of Health Professions, Perimeter Center, 9960 Mayland Drive, 2nd Floor, Board Room 4, Henrico, VA 23233

Public Comment Deadline: March 20, 2020.

Agency Contact: Sandra Reen, Executive Director, Board of Dentistry, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone (804) 367-4437, or email sandra.reen@dhp.virginia.gov.

Basis: Regulations are promulgated under the general authority of Chapter 24 of Title 54.1 of the Code of Virginia. Section 54.1-2400 provides the Board of Dentistry the authority to promulgate regulations to administer the regulatory system. Specific authority for regulation of the profession of dental assisting is found in § 54.1-2729.01 of the Code of Virginia.

Purpose: The proposed regulatory action amends the educational requirements to become a dental assistant II (DAII) from a program based on completion of required hours to a competency-based program based on satisfactory completion of didactic coursework and clinical experiences. The expanded duties permitted for practice by a DAII in Virginia are outside the scope of practice for dental assistants in most other states. However, the current qualifications for a DAII appear to be more burdensome and costly than most dental assistants can afford. Therefore, the board is proposing to modify the qualifications to a competency-based model that would allow a well-trained assistant to complete the coursework and clinical training in fewer hours. To ensure some standardization in the determination of competency by supervising dentists, the dentists will be required to undergo a calibration of the procedures in which they are training. The combination of didactic hours, competency determination in specific procedures, and both written and clinical examination should provide evidence of competency to protect the public health and safety.

Substance: Following recommendations from the Regulatory Advisory Panel, the board amended the educational requirements to become a dental assistant II from a program based on completion of required hours to a competency-based program based on satisfactory completion of didactic coursework and clinical experiences.

A new section (18VAC60-30-116) specifies the requirements for educational programs training people for registration as dental assistants II to include requirements for the programs (i) to be accredited by the Commission on Dental Accreditation of the American Dental Association; (ii) to have a program coordinator who is registered in Virginia as a dental assistant II or licensed in Virginia as a dental hygienist or dentist; (iii) to have a clinical practice advisor who is a licensed dentist in Virginia; (iv) to have a registered dental assistant II who assists in teaching the laboratory training component of the program with a minimum of two years of experience in performing clinical dental assisting; and (v) to have a participation agreement with any dentist who has successfully completed a calibration exercise on evaluating the clinical skills of a student and who agrees to supervise clinical experience.

The clinical experience component with live patients must be under the direct and immediate supervision of a licensed dentist who is responsible for the performance of duties by the student. The dentist has to attest to successful completion of the clinical competencies and restorative experiences.

18VAC60-30-120 is amended to delete a certain number of hours in the didactic portion to a competency-based program that includes basic histology, understanding of the periodontium and temporal mandibular joint, pulp tissue and nerve innervation, occlusion and function, muscles of mastication, and any other item related to the restorative dental process. A written examination is required at the conclusion of didactic coursework.

The laboratory training hours are also reduced but specified to be completed on a manikin simulator to competency. Clinical experience applying the techniques learned in the preclinical coursework and laboratory training may be completed in a dental office on a live patient in the three modules with specified components. A clinical competency exam is also required.

Issues: The primary advantage to the public is the possibility of more access to affordable dental care through greater utilization of expanded duty dental assistant. If dental assistants are appropriately trained in the laboratory on a manikin simulator and then have clinical experience with a calibrated dentist, there should be no disadvantages to the changes.

There are no advantages or disadvantages to the agency or the Commonwealth.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The Board of Dentistry proposes to amend the educational requirements to become a dental assistant II from a program based on completion of required hours to a competency-based program.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. "Dental assistant I" is defined in the Regulations Governing the Practice of Dental Assistants as any unlicensed person under the direction of a dentist or a dental hygienist who renders assistance for services provided to the patient as authorized under this regulation but shall not include an individual serving in purely an administrative, secretarial, or clerical capacity. Individuals who become qualified and are registered as a dental assistant II may, under the direction and direct supervision of a dentist, perform intraoral procedures that are not permitted for a dental assistant I. Those intraoral procedures are: 1) performing pulp capping procedures, 2) packing and carving of amalgam restorations, 3) placing and shaping composite resin restorations with a slow speed handpiece, 4) taking final impressions, 5) use of a non-epinephrine retraction cord, and 6) final cementation of crowns and bridges after adjustment and fitting by the dentist.

Registration of dental assistants II became effective in 2011, yet only 26 persons are currently registered as a dental assistant II.² For several years, the Board has discussed the need to re-examine the requirements to determine whether they could be made less burdensome. In this action, the Board proposes amendments in order to reduce the burden of becoming a dental assistant II in order to encourage more participation, while ensuring that registrants are qualified to provide the associated services.

Under both the current and proposed regulations, there are three types of required training: 1) didactic course work, 2) laboratory training, and 3) clinical experience. The current regulation requires at least 50 hours of didactic course work on dental anatomy and operative dentistry. The proposed regulation does not specify number of hours; instead, topics to be covered within dental anatomy and operative dentistry are listed. Education programs may cover these topics in significantly fewer than 50 hours.

There are three separate modules within laboratory training for both the current and proposed regulations. The Board proposes greatly reduced minimum number of hours for all three modules, while adding specific demonstrations of competency on a manikin in each module.³ Clinical experience has the same three modules. The Board again proposes greatly reduced minimum number of hours for all three modules. Here the Board proposes to add specific demonstrations of competency on a live patient for each module.⁴ In this way, students who are quick learners or who come into the program with some relevant skills may complete laboratory training and clinical experience much more quickly and potentially at lower cost.

There is currently only one active dental assistant II program in the Commonwealth, which is at Germanna Community College. Under the requirements of the current regulation, there are four courses with the following costs:

Oral Anatomy and Operative Dentistry	$750.00
Module 1: Amalgam Restorations: Placing, Packing, Carving, & Polishing (includes lab & clinical)	$491.25
Module 2: Composite Resin Restorations: Placing & Shaping (includes lab & clinical)	$491.25
Module 3: Indirect Restoration Techniques (includes lab & clinical)	$491.25

Oral Anatomy and Operative Dentistry is mandatory for all students. Students can choose between taking one or two of the modules, or all three. Once registered, they would only be permitted to perform procedures in the modules that they have successfully completed and demonstrated competency.

According to DHP, Germanna and other educational institutions that have indicated interest in starting a dental assistant II program have indicated that they could offer the program at lower cost than under the proposed regulation. Demonstrations of competency would likely produce at least as much assurance of patient safety as greater required hours of training without such specific demonstrations of competency. Thus, the proposed amendments would likely produce net benefits for the Commonwealth.

Businesses and Entities Affected. The proposed amendments potentially affect the one community college that currently has a dental assistant II program (Germanna Community College), and other educational institutions that may wish to establish dental assistant II programs. According to DHP, Fortis College, J. Sargeant Reynolds Community College, and ECPI University have all expressed interest. The proposed amendments also potentially affect the 3,260 dental offices⁵ in the Commonwealth, as well as dental assistants and other staff in those offices.

Localities Particularly Affected. The proposed amendments do not disproportionately affect particular localities.

Projected Impact on Employment. The proposed amendments may encourage more individuals to seek to become trained and employed as a dental assistant II. This potential increase in demand may lead to the establishment of dental assistant II education programs, with commensurate increase in employed staff.

Effects on the Use and Value of Private Property. The proposed amendments are unlikely to significantly affect the use and value of private property.

Real Estate Development Costs. The proposed amendments do not affect real estate development costs.

Small Businesses:

Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

Costs and Other Effects. The proposed amendments are unlikely to significantly affect costs for small businesses.

Alternative Method that Minimizes Adverse Impact. The proposed amendments do not adversely affect small businesses.

Adverse Impacts:

Businesses. The proposed amendments do not adversely affect businesses.

Localities. The proposed amendments do not adversely affect localities.

Other Entities. The proposed amendments do not adversely affect other entities.

___________________________

²Source: Department of Health Professions

³See 18VAC60-30-120 B 3 in the proposed regulation for the specific changes: https://townhall.virginia.gov/l/ViewXML.cfm?textid=13137

⁴See 18VAC60-30-120 B 4 in the proposed regulation for the specific changes: https://townhall.virginia.gov/l/ViewXML.cfm?textid=13137

⁵Data source: Virginia Employment Commission

Agency's Response to Economic Impact Analysis: The Board of Dentistry concurs with the economic impact analysis of the Department of Planning and Budget.

Summary:

The proposed action changes the qualifications for registration as a dental assistant II from a program of completion of required hours to a competency-based program of didactic coursework and clinical experience.

18VAC60-30-60. Delegation to dental assistants II.

The following duties Duties may only be delegated under the direction and direct supervision of a dentist to a dental assistant II who has completed the coursework, corresponding module of laboratory training, corresponding module of clinical experience, and examinations specified in 18VAC60-30-120:.

1. Performing pulp capping procedures;

2. Packing and carving of amalgam restorations;

3. Placing and shaping composite resin restorations with a slow speed handpiece;

4. Taking final impressions;

5. Use of a non-epinephrine retraction cord; and

6. Final cementation of crowns and bridges after adjustment and fitting by the dentist.

18VAC60-30-116. Requirements for educational programs.

In order to train persons for registration as a dental assistant II, an educational program shall meet the following requirements:

1. The program shall be provided by an educational institution that maintains a program accredited by the Commission on Dental Accreditation of the American Dental Association.

2. The program shall have a program coordinator who is registered in Virginia as a dental assistant II or is licensed in Virginia as a dental hygienist or dentist. The program coordinator shall have administrative responsibility and accountability for operation of the program.

3. The program shall have a clinical practice advisor who is a licensed dentist in Virginia and who may also serve as the program coordinator. The clinical practice advisor shall assist in the laboratory training component of the program and conduct the program's calibration exercise for dentists who supervise the student's clinical experience.

4. A dental assistant II, registered in Virginia, who assists in teaching the laboratory training component of the program shall have a minimum of two years of clinical experience in performing duties delegable to a dental assistant II.

5. The program shall enter into a participation agreement with any dentist who agrees to supervise clinical experience. The dentist shall successfully complete the program's calibration exercise on evaluating the clinical skills of a student. The dentist supervisor may be the employer of the student.

6. Each program shall enroll practice sites for clinical experience, which may be a dental office, a nonprofit dental clinic, or an educational institution clinic.

7. All treatment of patients shall be under the immediate supervision of a licensed dentist who is responsible for the performance of duties by the student. The dentist shall attest to the successful completion of the clinical competencies and restorative experiences.

18VAC60-30-120. Educational requirements for dental assistants II.

A. A prerequisite for entry into an educational program preparing a person for registration as a dental assistant II shall be current certification as a Certified Dental Assistant (CDA) conferred by the Dental Assisting National Board.

B. To be registered as a dental assistant II, a person shall complete the following requirements a competency-based program from an educational institution that maintains a program in dental assisting, dental hygiene or dentistry accredited by CODA meets the requirements of 18VAC60-30-116 and includes all of the following:

1. At least 50 hours of didactic course work Didactic coursework in dental anatomy and operative dentistry that may be completed online that includes basic histology, understanding of the periodontium and temporal mandibular joint, pulp tissue and nerve innervation, occlusion and function, muscles of mastication, and any other item related to the restorative dental process.

2. Didactic coursework in operative dentistry to include materials used in direct and indirect restorative techniques, economy of motion, fulcrum techniques, tooth preparations, etch and bonding techniques and systems, and luting agents.

3. Laboratory training that may to be completed in the following modules with no more than 20% of the specified instruction to be completed as homework in a dental office:

a. At least 40 No less than 15 hours of placing, packing, carving, and polishing of amalgam restorations, placement of a non-epinephrine retraction cord, and pulp capping procedures and no less than six class I and six class II restorations completed on a manikin simulator to competency;

b. At least 60 No less than 40 hours of placing and shaping composite resin restorations, placement of a non-epinephrine retraction cord, and pulp capping procedures,and no less than 12 class I, 12 class II, five class III, five class IV, and five class V restorations completed on a manikin simulator to competency; and

c. At least 20 10 hours of taking making final impressions and use, placement of a non-epinephrine retraction cord; and, final cementation of crowns and bridges after preparation, and adjustment and fitting by the dentist, and no less than four crown impressions, two placements of retraction cord, five crown cementations, and two bridge cementations on a manikin simulator to competency.

d. At least 30 hours of final cementation of crowns and bridges after adjustment and fitting by the dentist.

3. 4. Clinical experience applying the techniques learned in the preclinical coursework and laboratory training that may be completed in a dental office, in the following modules:

a. At least 80 30 hours of placing, packing, carving, and polishing of amalgam restorations, placement of a non-epinephrine retraction cord, and no less than six class I and six class II restorations completed on a live patient to competency;

b. At least 120 60 hours of placing and shaping composite resin restorations, placement of a non-epinephrine retraction cord, and no less than six class I, six class II, five class III, three class IV, and five class V restorations completed on a live patient to competency; and

c. At least 40 30 hours of taking making final impressions and use; placement of a non-epinephrine retraction cord; and final cementation of crowns and bridges after preparation, adjustment, and fitting by the dentist; and no less than four crown impressions, two placements of retraction cord, five crown cementations, and two bridge cementations on a live patient to competency.

d. At least 60 hours of final cementation of crowns and bridges after adjustment and fitting by the dentist.

4. 5. Successful completion of the following competency examinations given by the accredited educational programs:

a. A written examination at the conclusion of the 50 hours of didactic coursework; and

b. A practical examination at the conclusion of each module of laboratory training; and

c. A comprehensive written examination at the conclusion of all required coursework, training, and experience for each of the corresponding modules clinical competency exam.

C. All treatment of patients shall be under the direct and immediate supervision of a licensed dentist who is responsible for the performance of duties by the student. The dentist shall attest to successful completion of the clinical competencies and restorative experiences. An applicant may be registered as a dental assistant II with specified competencies set forth in subdivision a, b, or c of subdivisions B 3 and B 4 of this section.