TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING
Titles of Regulations: 18VAC60-21. Regulations
Governing the Practice of Dentistry (amending 18VAC60-21-10, 18VAC60-21-30,
18VAC60-21-40, 18VAC60-21-90, 18VAC60-21-130, 18VAC60-21-240, 18VAC60-21-250,
18VAC60-21-260, 18VAC60-21-290, 18VAC60-21-291).
18VAC60-25. Regulations Governing the Practice of Dental
Hygiene (amending 18VAC60-25-40, 18VAC60-25-190).
18VAC60-30. Regulations Governing the Practice of Dental
Assistants (amending 18VAC60-30-50).
Statutory Authority: § 54.1-2400 and 54.1-2709.5 of the
Code of Virginia.
Public Hearing Information:
January 26, 2018 - 8:50 a.m. - Department of Health
Professions, Perimeter Building, 9960 Mayland Drive, 2nd Floor, Board Room 4,
Henrico, VA 23233
Public Comment Deadline: February 23, 2018.
Agency Contact: Sandra Reen, Executive Director, Board
of Dentistry, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone
(804) 367-4437, FAX (804) 527-4428, or email sandra.reen@dhp.virginia.gov.
Basis: Section 54.1-2400 of the Code of Virginia
provides the Board of Dentistry the authority to promulgate regulations to
administer the regulatory system.
The statutory authority for the Board of Dentistry to
promulgate regulations to determine required equipment standards for safe
administration and monitoring of sedation and anesthesia is found in Chapter 27
(§ 54.1-2700 et seq.) of Title 54.1 of the Code of Virginia. Section
54.1-2709.5 of the Code of Virginia addresses permits for sedation and anesthesia
required.
Purpose: As stated in the American Dental Association
(ADA) Guidelines for Teaching Pain Control and Sedation to Dentists and Dental
Students, "because sedation and general anesthesia are a continuum, it is
not always possible to predict how an individual patient will respond. Hence,
practitioners intending to produce a given level of sedation should be able to
diagnose and manage the physiologic consequences (rescue) for patients whose
level of sedation becomes deeper than initially intended." Therefore, the
guidelines no longer specify a lesser amount of training for dentists who only
intend to administer by the enteral route. The guidelines now specify training
in moderate sedation adequate to prepare a dentist for an unintended loss of
consciousness or greater alteration of the state of consciousness than is the
intent of the dentist. Accordingly, regulations of the Board of Dentistry are
amended to ensure the same level of training and experience as specified in the
ADA guidelines that are necessary to protect the health and safety of patients
in the Commonwealth.
Substance: For consistency with the revised Guidelines
for Teaching Pain Control and Sedation to Dentists and Dental Students (October
2016), the board has (i) amended the use of the term conscious/moderate
sedation throughout the chapters to refer to moderate sedation; (ii) changed
the name of the guidelines consistent with the 2016 title; and (iii) eliminated
the training for dentists to administer moderate sedation by the enteral method
only as the guidelines no longer make a distinction for enteral administration
and specify the same training for all who administer moderate sedation.
Issues: The primary advantage to the public is the
greater protection for the citizens of the Commonwealth who receive moderate
sedation in dental offices. Adequate training for dentists who administer or
supervise administration of moderate sedation is essential for health and
safety of patients. There are no disadvantages.
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 (Board) proposes to amend its regulations governing dentistry and
dental hygiene in response to changed and retitled American Dental
Association's (ADA) guidelines for teaching sedation.1 Specifically
and substantively, the Board proposes to remove training and experience
requirements for the Board's permit for enteral administration2 only
sedation as the ADA now recommends that all dentists who will be using conscious
or moderate sedation be required to complete the training for moderate
sedation.
Result of Analysis. There is insufficient information to
ascertain whether benefits will outweigh costs for this proposed regulatory
action.
Estimated Economic Impact. Current regulation allows dentists
to apply for and receive either a permit for conscious/moderate sedation by any
method or a permit for conscious/moderate sedation by enteral administration
only. The permit requirements for conscious/moderate sedation by any method
include 60 hours of didactic training. The permit requirements for
conscious/moderate sedation by enteral administration only include 18 hours of
didactic training. The Board's dentistry regulation also currently requires
that the course content for any didactic training that will qualify dentists
for permitting "be consistent with the ADA's Guidelines for Teaching the
Comprehensive Control of Anxiety and Pain in Dentistry in effect at the time
the training occurred." The Board now proposes to eliminate its permit of
conscious/moderate sedation by enteral administration only and require all
dentists seeking permits in the future to complete the training for moderate
sedation by any method. The Board also proposes to update the title of the ADA's
guidelines because the title of the ADA's guidance document was also changed.
Board staff reports that the elimination of enteral administration only permits
will not affect dentists who currently hold such permits but will affect future
applicants.
Board staff reports that they are amending these regulations in
response to changes in ADA guidelines for teaching sedation. The ADA states
that they changed their guidelines to eliminate enteral administration only
training because, "sedation and general anesthesia are a continuum, it is
not always possible to predict how an individual patient will respond. Hence,
practitioners intending to produce a given level of sedation should be able to
diagnose and manage the physiologic consequences (rescue) for patients whose
level of sedation becomes deeper than initially intended." Board staff
reports that they do not have specific data that would indicate dentists with
enteral administration only permits are inadequately trained to handle
emergencies or deeper levels of sedation that may arise with individual
patients. To the extent that enteral administration only training might be
inadequate, patients would likely benefit from requiring more training. Any
benefit that may arise would need to be weighed against the costs that will
accrue to affected dentists.
Dentists who may wish to obtain an enteral administration only
permit in Virginia going forward will have to, instead, incur fees and time
costs for the longer training for moderate sedation permitting. Board staff
reports that a weekend course (18 hours of training) that prepares a dentist
for enteral administration only permitting costs $2,800 plus travel and
lodging; board staff did an internet search and found costs for 60-hour
moderate sedation courses ranging between $3,750 to $14,495 (plus travel and
lodging). Given these numbers, the cost of moderate sedation training will
likely be $950 to $11,695 higher fee costs than enteral administration only
training. Additionally, using Bureau of Labor Statistics data3 for
the mean hourly wage of general dentists in Virginia ($85 per hour)4,
affected dentists will likely incur $3,570 in additional time costs for
completing the additional 42 hours of training required for a moderate sedation
permit.
Businesses and Entities Affected. This proposed regulation will
affect all dentists who seek to obtain a moderate sedation permit in the
future. This proposed regulation will not affect any dentists who obtained an
enteral only permit in the past.
Localities Particularly Affected. No localities will be
particularly affected by this proposed change.
Projected Impact on Employment. Increasing required hours of
training for individuals who previously would have chosen to apply for an
enteral administration only permit, but who will have to meet requirements for
a moderate sedation permit instead, may increase employment for individuals who
provide such training in the Commonwealth.
Effects on the Use and Value of Private Property. This proposed
regulatory change is unlikely to affect the use or value of private property in
the Commonwealth.
Real Estate Development Costs. These proposed regulatory
changes are unlikely to affect real estate development costs in the
Commonwealth.
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. Small businesses dentists who may wish
to obtain an enteral administration only permit in Virginia going forward will
have to, instead, incur fees and time costs for the longer training for
moderate sedation permitting. Board staff reports that a weekend course (18
hours of training) that prepares a dentist for enteral administration only
permitting costs $2,800 plus travel and lodging; board staff did an internet
search and found costs for 60-hour moderate sedation courses ranging between
$3,750 to $14,495 (plus travel and lodging). Given these numbers, the cost of
moderate sedation training will likely be $950 to $11,695 higher fee costs than
enteral administration only training. Additionally, using Bureau of Labor
Statistics data for the mean hourly wage of general dentists in Virginia ($85
per hour), affected dentists will likely incur $3,570 in additional time costs
for completing the additional 42 hours of training required for a moderate
sedation permit. As of first quarter 2016, there were 3,201 private dental
practices in Virginia.5 All of these practices would qualify as
small businesses.
Alternative Method that Minimizes Adverse Impact. In the
absence of direct evidence that enteral administration only training does not
adequately prepare dentists to respond to deepening levels of sedation that may
occur when treating patients, small business dentists may benefit from being
allowed enteral administration only permits with training requirements in
current regulation.6
Adverse Impacts:
Businesses. Dentists who may wish to obtain an enteral
administration only permit in Virginia going forward will have to, instead,
incur fees and time costs for the longer training for moderate sedation
permitting. Board staff reports that a weekend course (18 hours of training)
that prepares a dentist for enteral administration only permitting costs $2,800
plus travel and lodging; board staff did an internet search and found costs for
60-hour moderate sedation courses ranging between $3,750 to $14,495 (plus
travel and lodging). Given these numbers, the cost of moderate sedation
training will likely be $950 to $11,695 higher fee costs than enteral
administration only training. Additionally, using Bureau of Labor Statistics
data for the mean hourly wage of general dentists ($85 per hour), affected
dentists will likely incur $3,570 in additional time costs for completing the
additional 42 hours of training required for a moderate sedation permit.
Localities. No locality is likely to suffer adverse impacts on
account of this proposed regulatory change.
Other Entities. No other entities are likely to suffer adverse
impacts on account of this proposed regulatory change.
______________________________
1Prior to October 2016, as referenced in the Board's Regulations
Governing the Practice of Dentistry, guidelines for teaching sedation were
titled Guidelines for Teaching the Comprehensive Control of Anxiety and Pain in
Dentistry. The guidelines for teaching sedation approved by the ADA in October
2016 are titled Guidelines for Teaching Pain Control and Sedation to Dentists
and Dental Students.
2"Enteral" is defined in these regulations as
"any technique of administration in which the agent is absorbed through
the gastrointestinal tract or the oral mucosa (i.e., oral, rectal,
sublingual)."
3https://www.bls.gov/oes/2016/may/oes_va.htm
4This calculation assumes dentists will value their time
what roughly their mean earnings for that time would be if they were working.
Individuals may place a greater or lesser value on their own time.
5Source: Virginia Employment Commission
6The ADA's pre-2016 guidelines could likely serve as a
guide for these training requirements.
Agency's Response to Economic Impact Analysis: The Board
of Dentistry does not concur with the result of the economic impact analysis
(EIA) by the Department of Planning and Budget (DPB) for the proposed
regulation, 18VAC60-21, Regulations Governing the Practice of Dentistry,
relating to regulations for moderate sedation permits.
The EIA noted that the change will affect future applicants for
such permits. In fact, staff reported to DPB that the revised American Dental
Association (ADA) for Teaching the Comprehensive Control of Anxiety and Pain in
Dentistry have been enforced since they were changed in October of 2016.
Regulations currently state that training must be consistent with ADA
guidelines, so applicants for moderate permits have already been required to
complete the 60-hour training requirement for more than a year. Proposed
amendments clarify the current requirement and are consistent with the current
guidelines. Therefore, since the revised ADA standard is already in effect, it
is incorrect to state that "this proposed regulation will affect all
dentists who seek to obtain a moderate sedation permit in the future."
Staff of the board also reported to DPB that the number of
hours of training required for an enteral permit has actually been 24 rather
than 18 hours because that is the number that was specified by ADA guidelines
in 2007. Although the board did not amend its regulations at that time, it has
enforced the hourly requirement as stated in the guidelines, and continuing
education providers adopted the 24-hour standard. As stated above, the
requirement for a moderate sedation permit is and always has been completion of
training as specified in the guidelines. The ADA guidelines are the only
national standard for sedation and anesthesia in the dental profession.
Therefore, the EIA is incorrect in stating that an additional 42 hours of
training is required; in fact, the revised ADA guidelines require an additional
36 hours.
Summary:
The proposed regulatory action (i) amends the term
"conscious/moderate sedation" throughout the chapter to refer to
"moderate sedation," (ii) changes the name of the American Dental
Association Guidelines for Teaching Pain Control and Sedation to Dentists and
Dental Students for consistency with the revised 2016 title, and (iii)
eliminates the training for dentists to administer moderate sedation by the
enteral method only.
Part I
General Provisions
18VAC60-21-10. Definitions.
A. The following words and terms when used in this chapter
shall have the meanings ascribed to them in § 54.1-2700 of the Code of
Virginia:
"Board"
"Dental hygiene"
"Dental hygienist"
"Dentist"
"Dentistry"
"License"
"Maxillofacial"
"Oral and maxillofacial surgeon"
B. The following words and terms when used in this chapter
shall have the following meanings unless the context clearly indicates otherwise:
"AAOMS" means the American Association of Oral and
Maxillofacial Surgeons.
"ADA" means the American Dental Association.
"Advertising" means a representation or other notice
given to the public or members thereof, directly or indirectly, by a dentist on
behalf of himself, his facility, his partner or associate, or any dentist
affiliated with the dentist or his facility by any means or method for the
purpose of inducing purchase, sale, or use of dental methods, services,
treatments, operations, procedures, or products, or to promote continued or
increased use of such dental methods, treatments, operations, procedures, or
products.
"CODA" means the Commission on Dental Accreditation
of the American Dental Association.
"Code" means the Code of Virginia.
"Dental assistant I" means 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 chapter but shall
not include an individual serving in purely an administrative, secretarial, or
clerical capacity.
"Dental assistant II" means a person under the
direction and direct supervision of a dentist who is registered by the board to
perform reversible, intraoral procedures as specified in 18VAC60-21-150 and
18VAC60-21-160.
"Mobile dental facility" means a self-contained unit
in which dentistry is practiced that is not confined to a single building and
can be transported from one location to another.
"Nonsurgical laser" means a laser that is not
capable of cutting or removing hard tissue, soft tissue, or tooth structure.
"Portable dental operation" means a nonfacility in
which dental equipment used in the practice of dentistry is transported to and
utilized on a temporary basis at an out-of-office location, including patients'
homes, schools, nursing homes, or other institutions.
"Radiographs" means intraoral and extraoral
radiographic images of hard and soft tissues used for purposes of diagnosis.
C. The following words and terms relating to supervision as used
in this chapter shall have the following meanings unless the context clearly
indicates otherwise:
"Direct supervision" means that the dentist examines
the patient and records diagnostic findings prior to delegating restorative or
prosthetic treatment and related services to a dental assistant II for
completion the same day or at a later date. The dentist prepares the tooth or
teeth to be restored and remains immediately available in the office to the
dental assistant II for guidance or assistance during the delivery of treatment
and related services. The dentist examines the patient to evaluate the
treatment and services before the patient is dismissed.
"Direction" means the level of supervision (i.e.,
immediate, direct, indirect, or general) that a dentist is required to exercise
with a dental hygienist, a dental assistant I, or a dental assistant II or that
a dental hygienist is required to exercise with a dental assistant to direct
and oversee the delivery of treatment and related services.
"General supervision" means that a dentist completes
a periodic comprehensive examination of the patient and issues a written order
for hygiene treatment that states the specific services to be provided by a
dental hygienist during one or more subsequent appointments when the dentist
may or may not be present. Issuance of the order authorizes the dental
hygienist to supervise a dental assistant performing duties delegable to dental
assistants I.
"Immediate supervision" means the dentist is in the
operatory to supervise the administration of sedation or provision of
treatment.
"Indirect supervision" means the dentist examines
the patient at some point during the appointment and is continuously present in
the office to advise and assist a dental hygienist or a dental assistant who is
(i) delivering hygiene treatment, (ii) preparing the patient for examination or
treatment by the dentist, or (iii) preparing the patient for dismissal
following treatment.
"Remote supervision" means that a supervising
dentist is accessible and available for communication and consultation with a
dental hygienist during the delivery of dental hygiene services but such
dentist may not have conducted an initial examination of the patients who are
to be seen and treated by the dental hygienist and may not be present with the
dental hygienist when dental hygiene services are being provided. For the
purpose of practice by a public health dental hygienist, "remote
supervision" means that a public health dentist has regular, periodic communications
with a public health dental hygienist regarding patient treatment, but such
dentist may not have conducted an initial examination of the patients who are
to be seen and treated by the dental hygienist and may not be present with the
dental hygienist when dental hygiene services are being provided.
D. The following words and terms relating to sedation or
anesthesia as used in this chapter shall have the following meanings unless the
context clearly indicates otherwise:
"Analgesia" means the diminution or elimination of
pain.
"Conscious/moderate sedation" or "moderate
sedation" means a drug-induced depression of consciousness, during which
patients respond purposefully to verbal commands, either alone or accompanied
by light tactile stimulation. Reflex withdrawal from a painful stimulus is not
considered a purposeful response. No interventions are required to maintain a
patent airway, and spontaneous ventilation is adequate. Cardiovascular function
is usually maintained.
"Deep sedation" means a drug-induced depression of
consciousness during which patients cannot be easily aroused but respond
purposefully following repeated or painful stimulation. Reflex withdrawal from
a painful stimulus is not considered a purposeful response. The ability to
independently maintain ventilatory function may be impaired. Patients may
require assistance in maintaining a patent airway, and spontaneous ventilation
may be inadequate. Cardiovascular function is usually maintained.
"Enteral" means any technique of administration
in which the agent is absorbed through the gastrointestinal tract or oral
mucosa (i.e., oral, rectal, sublingual).
"General anesthesia" means a drug-induced loss of
consciousness during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilator function is often
impaired. Patients often require assistance in maintaining a patent airway, and
positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular function.
Cardiovascular function may be impaired.
"Inhalation" means a technique of administration in
which a gaseous or volatile agent, including nitrous oxide, is introduced into
the pulmonary tree and whose primary effect is due to absorption through the
pulmonary bed.
"Inhalation analgesia" means the inhalation of
nitrous oxide and oxygen to produce a state of reduced sensation of pain with
minimal alteration of consciousness.
"Local anesthesia" means the elimination of
sensation, especially pain, in one part of the body by the topical application
or regional injection of a drug.
"Minimal sedation" means a drug-induced state during
which patients respond normally to verbal commands. Although cognitive function
and physical coordination may be impaired, airway reflexes, and ventilator and
cardiovascular functions are unaffected. Minimal sedation includes
"anxiolysis" (the diminution or elimination of anxiety through the
use of pharmacological agents in a dosage that does not cause depression of
consciousness) and includes "inhalation analgesia" when used in
combination with any anxiolytic agent administered prior to or during a
procedure.
"Moderate sedation" (see the definition of
conscious/moderate sedation) means a drug-induced depression of
consciousness, during which patients respond purposefully to verbal commands,
either alone or accompanied by light tactile stimulation. Reflex withdrawal
from a painful stimulus is not considered a purposeful response. No
interventions are required to maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular function is usually maintained.
"Monitoring" means to observe, interpret, assess,
and record appropriate physiologic functions of the body during sedative
procedures and general anesthesia appropriate to the level of sedation as
provided in Part VI (18VAC60-21-260 et seq.) of this chapter.
"Parenteral" means a technique of administration in
which the drug bypasses the gastrointestinal tract (i.e., intramuscular,
intravenous, intranasal, submucosal, subcutaneous, or intraocular).
"Titration" means the incremental increase in drug
dosage to a level that provides the optimal therapeutic effect of sedation.
"Topical oral anesthetic" means any drug, available
in creams, ointments, aerosols, sprays, lotions, or jellies, that can be used
orally for the purpose of rendering the oral cavity insensitive to pain without
affecting consciousness.
18VAC60-21-30. Posting requirements.
A. A dentist who is practicing under a firm name or who is practicing
as an employee of another dentist is required by § 54.1-2720 of the Code
to conspicuously display his name at the entrance of the office. The employing
dentist, firm, or company must enable compliance by designating a space at the
entrance of the office for the name to be displayed.
B. In accordance with § 54.1-2721 of the Code a dentist
shall display his dental license where it is conspicuous and readable by
patients in each dental practice setting. If a licensee practices in more than
one office, a duplicate license obtained from the board may be displayed.
C. A dentist who administers, prescribes, or dispenses
Schedules II through V controlled substances shall maintain a copy of his
current registration with the federal Drug Enforcement Administration in a
readily retrievable manner at each practice location.
D. A dentist who administers conscious/moderate moderate
sedation, deep sedation, or general anesthesia in a dental office shall display
his sedation or anesthesia permit issued by the board or certificate issued by
AAOMS.
18VAC60-21-40. Required fees.
A. Application/registration fees.
1. Dental license by examination
|
$400
|
2. Dental license by credentials
|
$500
|
3. Dental restricted teaching license
|
$285
|
|
|
4. Dental faculty license
|
$400
|
5. Dental temporary resident's license
|
$60
|
6. Restricted volunteer license
|
$25
|
7. Volunteer exemption registration
|
$10
|
8. Oral maxillofacial surgeon registration
|
$175
|
9. Cosmetic procedures certification
|
$225
|
10. Mobile clinic/portable operation
|
$250
|
11. Conscious/moderate Moderate sedation permit
|
$100
|
12. Deep sedation/general anesthesia permit
|
$100
|
B. Renewal fees.
1. Dental license - active
|
$285
|
2. Dental license - inactive
|
$145
|
3. Dental temporary resident's license
|
$35
|
4. Restricted volunteer license
|
$15
|
5. Oral maxillofacial surgeon registration
|
$175
|
6. Cosmetic procedures certification
|
$100
|
7. Conscious/moderate Moderate sedation permit
|
$100
|
8. Deep sedation/general anesthesia permit
|
$100
|
C. Late fees.
1. Dental license - active
|
$100
|
2. Dental license - inactive
|
$50
|
3. Dental temporary resident's license
|
$15
|
4. Oral maxillofacial surgeon registration
|
$55
|
5. Cosmetic procedures certification
|
$35
|
6. Conscious/moderate Moderate sedation permit
|
$35
|
7. Deep sedation/general anesthesia permit
|
$35
|
D. Reinstatement fees.
1. Dental license - expired
|
$500
|
2. Dental license - suspended
|
$750
|
3. Dental license - revoked
|
$1000
|
4. Oral maxillofacial surgeon registration
|
$350
|
5. Cosmetic procedures certification
|
$225
|
E. Document fees.
1. Duplicate wall certificate
|
$60
|
2. Duplicate license
|
$20
|
3. License certification
|
$35
|
F. Other fees.
1. Returned check fee
|
$35
|
2. Practice inspection fee
|
$350
|
G. No fee will be refunded or applied for any purpose other
than the purpose for which the fee is submitted.
H. For the renewal of licenses, registrations,
certifications, and permits in 2016, the following fees shall be in effect:
1. Dentist - active
|
$210
|
2. Dentist - inactive
|
$105
|
3. Dental full-time faculty
|
$210
|
4. Temporary resident
|
$25
|
5. Dental restricted volunteer
|
$10
|
6. Oral/maxillofacial surgeon registration
|
$130
|
7. Cosmetic procedure certification
|
$75
|
8. Conscious/moderate Moderate sedation
certification
|
$75
|
9. Deep sedation/general anesthesia
|
$75
|
10. Mobile clinic/portable operation
|
$110
|
18VAC60-21-90. Patient information and records.
A. A dentist shall maintain complete, legible, and accurate
patient records for not less than six years from the last date of service for
purposes of review by the board with the following exceptions:
1. Records of a minor child shall be maintained until the
child reaches the age of 18 years or becomes emancipated, with a minimum time
for record retention of six years from the last patient encounter regardless of
the age of the child;
2. Records that have previously been transferred to another
practitioner or health care provider or provided to the patient or his personal
representative pursuant to § 54.1-2405 of the Code; or
3. Records that are required by contractual obligation or
federal law may need to be maintained for a longer period of time.
B. Every patient record shall include the following:
1. Patient's name on each page in the patient record;
2. A health history taken at the initial appointment that is
updated (i) when analgesia, sedation, or anesthesia is to be administered; (ii)
when medically indicated; and (iii) at least annually;
3. Diagnosis and options discussed, including the risks and
benefits of treatment or nontreatment and the estimated cost of treatment
options;
4. Consent for treatment obtained and treatment rendered;
5. List of drugs prescribed, administered, or dispensed and
the route of administration, quantity, dose, and strength;
6. Radiographs, digital images, and photographs clearly
labeled with patient name, date taken, and teeth identified;
7. Notation of each treatment rendered, the date of treatment
and of the dentist, dental hygienist, and dental assistant II providing
service;
8. Duplicate laboratory work orders that meet the requirements
of § 54.1-2719 of the Code including the address and signature of the
dentist;
9. Itemized patient financial records as required by
§ 54.1-2404 of the Code;
10. A notation or documentation of an order required for
treatment of a patient by a dental hygienist practicing under general
supervision as required in 18VAC60-21-140 B; and
11. The information required for the administration of conscious/moderate
moderate sedation, deep sedation, and general anesthesia required in
18VAC60-21-260 D.
C. A licensee shall comply with the patient record
confidentiality, release, and disclosure provisions of § 32.1-127.1:03 of
the Code and shall only release patient information as authorized by law.
D. Records shall not be withheld because the patient has an
outstanding financial obligation.
E. A reasonable cost-based fee may be charged for copying
patient records to include the cost of supplies and labor for copying
documents, duplication of radiographs and images, and postage if mailing is
requested as authorized by § 32.1-127.1:03 of the Code. The charges
specified in § 8.01-413 of the Code are permitted when records are
subpoenaed as evidence for purposes of civil litigation.
F. When closing, selling, or relocating a practice, the
licensee shall meet the requirements of § 54.1-2405 of the Code for giving
notice and providing records.
G. Records shall not be abandoned or otherwise left in the
care of someone who is not licensed by the board except that, upon the death of
a licensee, a trustee or executor of the estate may safeguard the records until
they are transferred to a licensed dentist, are sent to the patients of record,
or are destroyed.
H. Patient confidentiality must be preserved when records are
destroyed.
18VAC60-21-130. Nondelegable duties; dentists.
Only licensed dentists shall perform the following duties:
1. Final diagnosis and treatment planning;
2. Performing surgical or cutting procedures on hard or soft
tissue except a dental hygienist performing gingival curettage as provided in
18VAC60-21-140;
3. Prescribing or parenterally administering drugs or
medicaments, except a dental hygienist, who meets the requirements of
18VAC60-25-100, may parenterally administer Schedule VI local anesthesia to
patients 18 years of age or older;
4. Authorization of work orders for any appliance or
prosthetic device or restoration that is to be inserted into a patient's mouth;
5. Operation of high speed rotary instruments in the mouth;
6. Administering and monitoring conscious/moderate moderate
sedation, deep sedation, or general anesthetics except as provided for in
§ 54.1-2701 of the Code and Part VI (18VAC60-21-260 et seq.) of this
chapter;
7. Condensing, contouring, or adjusting any final, fixed, or
removable prosthodontic appliance or restoration in the mouth with the
exception of packing and carving amalgam and placing and shaping composite
resins by dental assistants II with advanced training as specified in
18VAC60-30-120;
8. Final positioning and attachment of orthodontic bonds and
bands; and
9. Final adjustment and fitting of crowns and bridges in
preparation for final cementation.
Part V
Licensure Renewal
18VAC60-21-240. License renewal and reinstatement.
A. The license or permit of any person who does not return
the completed renewal form and fees by the deadline shall automatically expire
and become invalid, and his practice of dentistry shall be illegal. With the
exception of practice with a current, restricted volunteer license as provided
in § 54.1-2712.1 of the Code practicing in Virginia with an expired
license or permit may subject the licensee to disciplinary action by the board.
B. Every person holding an active or inactive license and
those holding a permit to administer conscious/moderate moderate
sedation, deep sedation, or general anesthesia shall annually, on or before
March 31, renew his license or permit. Every person holding a faculty license,
temporary resident's license, a restricted volunteer license, or a temporary
permit shall, on or before June 30, request renewal of his license.
C. Any person who does not return the completed form and fee
by the deadline required in subsection B of this section shall be required to
pay an additional late fee.
D. The board shall renew a license or permit if the renewal
form, renewal fee, and late fee are received within one year of the deadline
required in subsection B of this section provided that no grounds exist to deny
said renewal pursuant to § 54.1-2706 of the Code and Part II
(18VAC60-21-50 et seq.) of this chapter.
E. Reinstatement procedures.
1. Any person whose license or permit has expired for more
than one year or whose license or permit has been revoked or suspended and who
wishes to reinstate such license or permit shall submit a reinstatement
application and the reinstatement fee. The application must include evidence of
continuing competence.
2. To evaluate continuing competence, the board shall consider
(i) hours of continuing education that meet the requirements of subsection H of
18VAC60-21-250; (ii) evidence of active practice in another state or in federal
service; (iii) current specialty board certification; (iv) recent passage of a
clinical competency examination accepted by the board; or (v) a refresher
program offered by a program accredited by the Commission on Dental Accreditation
of the American Dental Association.
3. The executive director may reinstate such expired license
or permit provided that the applicant can demonstrate continuing competence,
the applicant has paid the reinstatement fee and any fines or assessments, and
no grounds exist to deny said reinstatement pursuant to § 54.1-2706 of the
Code and Part II (18VAC60-21-50 et seq.) of this chapter.
18VAC60-21-250. Requirements for continuing education.
A. A dentist shall complete a minimum of 15 hours of
continuing education, which meets the requirements for content, sponsorship,
and documentation set out in this section, for each annual renewal of licensure
except for the first renewal following initial licensure and for any renewal of
a restricted volunteer license.
1. All renewal applicants shall attest that they have read and
understand and will remain current with the laws and regulations governing the
practice of dentistry and dental hygiene in Virginia.
2. A dentist shall maintain current training certification in
basic cardiopulmonary resuscitation with hands-on airway training for health
care providers or basic life support unless he is required by 18VAC60-21-290 or
18VAC60-21-300 to hold current certification in advanced life support with
hands-on simulated airway and megacode training for health care providers.
3. A dentist who administers or monitors patients under
general anesthesia, deep sedation, or conscious/moderate moderate
sedation shall complete four hours every two years of approved continuing
education directly related to administration and monitoring of such anesthesia
or sedation as part of the hours required for licensure renewal.
4. Continuing education hours in excess of the number required
for renewal may be transferred or credited to the next renewal year for a total
of not more than 15 hours.
5. Up to two hours of the 15 hours required for annual renewal
may be satisfied through delivery of dental services, without compensation, to
low-income individuals receiving health services through a local health
department or a free clinic organized in whole or primarily for the delivery of
those services. One hour of continuing education may be credited for three
hours of providing such volunteer services, as documented by the health
department or free clinic.
B. To be accepted for license renewal, continuing education
programs shall be directly relevant to the treatment and care of patients and
shall be:
1. Clinical courses in dentistry and dental hygiene; or
2. Nonclinical subjects that relate to the skills necessary to
provide dental or dental hygiene services and are supportive of clinical
services (i.e., patient management, legal and ethical responsibilities, and
stress management). Courses not acceptable for the purpose of this subsection
include, but are not limited to, estate planning, financial planning,
investments, business management, marketing, and personal health.
C. Continuing education credit may be earned for verifiable
attendance at or participation in any course, to include audio and video
presentations, that meets the requirements in subsection B of this section and
is given by one of the following sponsors:
1. The American Dental Association and the National Dental
Association, their constituent and component/branch associations, and approved
continuing education providers;
2. The American Dental Hygienists' Association and the
National Dental Hygienists Association, and their constituent and
component/branch associations;
3. The American Dental Assisting Association and its
constituent and component/branch associations;
4. The American Dental Association specialty organizations and
their constituent and component/branch associations;
5. A provider accredited by the Accreditation Council for
Continuing Medical Education for Category 1 credits;
6. The Academy of General Dentistry, its constituent and
component/branch associations, and approved continuing education providers;
7. A college or university that is accredited by an
accrediting agency approved by the U.S. Department of Education or a hospital
or health care institution accredited by the Joint Commission on Accreditation
of Healthcare Organizations;
8. The American Heart Association, the American Red Cross, the
American Safety and Health Institute, and the American Cancer Society;
9. A medical school accredited by the American Medical
Association's Liaison Committee for Medical Education;
10. A dental, dental hygiene, or dental assisting program or
advanced dental education program accredited by the Commission on Dental
Accreditation of the American Dental Association;
11. State or federal government agencies (i.e., military
dental division, Veteran's Administration, etc.);
12. The Commonwealth Dental Hygienists' Society;
13. The MCV Orthodontic Education and Research Foundation;
14. The Dental Assisting National Board and its affiliate, the
Dental Auxiliary Learning and Education Foundation; or
15. A regional testing agency (i.e., Central Regional Dental
Testing Service, Northeast Regional Board of Dental Examiners, Southern
Regional Testing Agency, Council of Interstate Testing Agencies, or Western
Regional Examining Board) when serving as an examiner.
D. The board may grant an exemption for all or part of the
continuing education requirements due to circumstances beyond the control of
the licensee, such as temporary disability, mandatory military service, or
officially declared disasters. A written request with supporting documents must
be submitted prior to renewal of the license.
E. The board may grant an extension for up to one year for
completion of continuing education upon written request with an explanation to
the board prior to the renewal date.
F. A licensee is required to verify compliance with the continuing
education requirements in his annual license renewal. Following the renewal
period, the board may conduct an audit of licensees to verify compliance.
Licensees selected for audit must provide original documents certifying that
they have fulfilled their continuing education requirements by the deadline
date as specified by the board.
G. All licensees are required to maintain original documents
verifying the date and subject of the program or activity, the sponsor, and the
amount of time earned. Documentation shall be maintained for a period of four
years following renewal.
H. A licensee who has allowed his license to lapse, or who
has had his license suspended or revoked, shall submit evidence of completion
of continuing education equal to the requirements for the number of years in
which his license has not been active, not to exceed a total of 45 hours. Of
the required hours, at least 15 must be earned in the most recent 12 months and
the remainder within the 36 months preceding an application for reinstatement.
I. Continuing education hours required by board order
shall not be used to satisfy the continuing education requirement for license
renewal or reinstatement.
J. Failure to comply with continuing education requirements
may subject the licensee to disciplinary action by the board.
Part VI
Controlled Substances, Sedation, and Anesthesia
18VAC60-21-260. General provisions.
A. Application of Part VI. This part applies to prescribing,
dispensing, and administering controlled substances in dental offices, mobile
dental facilities, and portable dental operations and shall not apply to
administration by a dentist practicing in (i) a licensed hospital as defined in
§ 32.1-123 of the Code, (ii) a state-operated hospital, or (iii) a
facility directly maintained or operated by the federal government.
B. Registration required. Any dentist who prescribes,
administers, or dispenses Schedules II through V controlled drugs must hold a
current registration with the federal Drug Enforcement Administration.
C. Patient evaluation required.
1. The decision to administer controlled drugs for dental
treatment must be based on a documented evaluation of the health history and
current medical condition of the patient in accordance with the Class I through
V risk category classifications of the American Society of Anesthesiologists
(ASA) in effect at the time of treatment. The findings of the evaluation, the
ASA risk assessment class assigned, and any special considerations must be
recorded in the patient's record.
2. Any level of sedation and general anesthesia may be
provided for a patient who is ASA Class I and Class II.
3. A patient in ASA Class III shall only be provided minimal
sedation, conscious/moderate moderate sedation, deep sedation, or
general anesthesia by:
a. A dentist after he has documented a consultation with the
patient's primary care physician or other medical specialist regarding
potential risks and special monitoring requirements that may be necessary;
b. An oral and maxillofacial surgeon who has performed a
physical evaluation and documented the findings and the ASA risk assessment
category of the patient and any special monitoring requirements that may be
necessary; or
c. A person licensed under Chapter 29 (§ 54.1-2900 et
seq.) of Title 54.1 of the Code who has a specialty in anesthesia.
4. Minimal sedation may only be provided for a patient who is
in ASA Class IV by:
a. A dentist after he has documented a consultation with the
patient's primary care physician or other medical specialist regarding potential
risks and special monitoring requirements that may be necessary; or
b. An oral and maxillofacial surgeon who has performed a
physical evaluation and documented the findings and the ASA risk assessment
category of the patient and any special monitoring requirements that may be
necessary.
5. Conscious/moderate Moderate sedation, deep
sedation, or general anesthesia shall not be provided in a dental office for
patients in ASA Class IV and Class V.
D. Additional requirements for patient information and
records. In addition to the record requirements in 18VAC60-21-90, when conscious/moderate
moderate sedation, deep sedation, or general anesthesia is administered,
the patient record shall also include:
1. Notation of the patient's American Society of Anesthesiologists
classification;
2. Review of medical history and current conditions, including
the patient's weight and height or, if appropriate, the body mass index;
3. Written informed consent for administration of sedation and
anesthesia and for the dental procedure to be performed;
4. Preoperative vital signs;
5. A record of the name, dose, and strength of drugs and route
of administration including the administration of local anesthetics with
notations of the time sedation and anesthesia were administered;
6. Monitoring records of all required vital signs and
physiological measures recorded every five minutes; and
7. A list of staff participating in the administration,
treatment, and monitoring including name, position, and assigned duties.
E. Pediatric patients. No sedating medication shall be
prescribed for or administered to a patient 12 years of age or younger prior to
his arrival at the dentist office or treatment facility.
F. Informed written consent. Prior to administration of any
level of sedation or general anesthesia, the dentist shall discuss the nature
and objectives of the planned level of sedation or general anesthesia along
with the risks, benefits, and alternatives and shall obtain informed, written
consent from the patient or other responsible party for the administration and
for the treatment to be provided. The written consent must be maintained in the
patient record.
G. Level of sedation. The determinant for the application of
the rules for any level of sedation or for general anesthesia shall be the
degree of sedation or consciousness level of a patient that should reasonably
be expected to result from the type, strength, and dosage of medication, the
method of administration, and the individual characteristics of the patient as
documented in the patient's record. The drugs and techniques used must carry a
margin of safety wide enough to render the unintended reduction of or loss of
consciousness unlikely, factoring in titration and the patient's age, weight,
and ability to metabolize drugs.
H. Emergency management.
1. If a patient enters a deeper level of sedation than the
dentist is qualified and prepared to provide, the dentist shall stop the dental
procedure until the patient returns to and is stable at the intended level of sedation.
2. A dentist in whose office sedation or anesthesia is
administered shall have written basic emergency procedures established and
staff trained to carry out such procedures.
I. Ancillary personnel. Dentists who employ unlicensed,
ancillary personnel to assist in the administration and monitoring of any form
of minimal sedation, conscious/moderate moderate sedation, deep
sedation, or general anesthesia shall maintain documentation that such
personnel have:
1. Training and hold current certification in basic
resuscitation techniques with hands-on airway training for health care
providers, such as Basic Cardiac Life Support for Health Professionals or a
clinically oriented course devoted primarily to responding to clinical
emergencies offered by an approved provider of continuing education as set
forth in 18VAC60-21-250 C; or
2. Current certification as a certified anesthesia assistant
(CAA) by the American Association of Oral and Maxillofacial Surgeons or the
American Dental Society of Anesthesiology (ADSA).
J. Assisting in administration. A dentist, consistent with
the planned level of administration (i.e., local anesthesia, minimal sedation, conscious/moderate
moderate sedation, deep sedation, or general anesthesia) and appropriate
to his education, training, and experience, may utilize the services of a
dentist, anesthesiologist, certified registered nurse anesthetist, dental
hygienist, dental assistant, or nurse to perform functions appropriate to such
practitioner's education, training, and experience and consistent with that
practitioner's respective scope of practice.
K. Patient monitoring.
1. A dentist may delegate monitoring of a patient to a dental
hygienist, dental assistant, or nurse who is under his direction or to another
dentist, anesthesiologist, or certified registered nurse anesthetist. The
person assigned to monitor the patient shall be continuously in the presence of
the patient in the office, operatory, and recovery area (i) before
administration is initiated or immediately upon arrival if the patient
self-administered a sedative agent, (ii) throughout the administration of
drugs, (iii) throughout the treatment of the patient, and (iv) throughout
recovery until the patient is discharged by the dentist.
2. The person monitoring the patient shall:
a. Have the patient's entire body in sight;
b. Be in close proximity so as to speak with the patient;
c. Converse with the patient to assess the patient's ability
to respond in order to determine the patient's level of sedation;
d. Closely observe the patient for coloring, breathing, level
of physical activity, facial expressions, eye movement, and bodily gestures in
order to immediately recognize and bring any changes in the patient's condition
to the attention of the treating dentist; and
e. Read, report, and record the patient's vital signs and
physiological measures.
L. A dentist who allows the administration of general
anesthesia, deep sedation, or conscious/moderate moderate
sedation in his dental office is responsible for assuring that:
1. The equipment for administration and monitoring, as
required in subsection B of 18VAC60-21-291 or subsection C of 18VAC60-21-301,
is readily available and in good working order prior to performing dental
treatment with anesthesia or sedation. The equipment shall either be maintained
by the dentist in his office or provided by the anesthesia or sedation
provider; and
2. The person administering the anesthesia or sedation is
appropriately licensed and the staff monitoring the patient is qualified.
18VAC60-21-290. Requirements for a conscious/moderate moderate
sedation permit.
A. After March 31, 2013, no No dentist may
employ or use conscious/moderate moderate sedation in a dental
office unless he has been issued a permit by the board. The requirement for a
permit shall not apply to an oral and maxillofacial surgeon who maintains
membership in the American Association of Oral and Maxillofacial Surgeons
(AAOMS) and who provides the board with reports that result from the periodic
office examinations required by AAOMS. Such an oral and maxillofacial surgeon
shall be required to post a certificate issued by AAOMS.
B. Automatic qualification. Dentists who hold a current
permit to administer deep sedation and general anesthesia may administer conscious/moderate
moderate sedation.
C. To determine eligibility for a conscious/moderate moderate
sedation permit, a dentist shall submit the following:
1. A completed application form indicating one of the
following permits for which the applicant is qualified:
a. Conscious/moderate sedation by any method;
b. Conscious/moderate sedation by enteral administration
only; or
c. Temporary conscious/moderate sedation permit (may be
renewed one time);
2. The application fee as specified in 18VAC60-21-40;
3. A copy of a transcript, certification, or other
documentation of training content that meets the educational and training
qualifications as specified in subsection D of this section, as applicable;
and
4. A copy of current certification in advanced cardiac life
support (ACLS) or pediatric advanced life support (PALS) as required in
subsection E of this section.
D. Education requirements for a permit to administer conscious/moderate
moderate sedation. 1. Administration by any method. A dentist may
be issued a conscious/moderate moderate sedation permit to
administer by any method by meeting one of the following criteria:
a. 1. Completion of training for this treatment
modality according to the ADA's Guidelines for Teaching the Comprehensive
Pain Control of Anxiety and Pain in Dentistry Sedation
to Dentists and Dental Students in effect at the time the training
occurred, while enrolled in an accredited dental program or while enrolled in a
post-doctoral university or teaching hospital program; or
b. 2. Completion of a continuing education
course that meets the requirements of 18VAC60-21-250 and consists of (i) 60
hours of didactic instruction plus the management of at least 20 patients per
participant, (ii) demonstration of competency and clinical experience in conscious/moderate
moderate sedation, and (iii) management of a compromised airway. The
course content shall be consistent with the ADA's Guidelines for Teaching the
Comprehensive Pain Control of Anxiety and Pain in
Dentistry Sedation to Dentists and Dental Students in effect at the
time the training occurred.
2. Enteral administration only. A dentist may be issued a
conscious/moderate sedation permit to administer only by an enteral method if
he has completed a continuing education program that meets the requirements of
18VAC60-21-250 and consists of not less than 18 hours of didactic
instruction plus 20 clinically oriented experiences in enteral or a combination
of enteral and nitrous oxide/oxygen conscious/moderate sedation techniques. The
course content shall be consistent with the ADA's Guidelines for Teaching the
Comprehensive Control of Anxiety and Pain in Dentistry in effect at the time
the training occurred. The certificate of completion and a detailed description
of the course content must be maintained.
3. A dentist who self-certified his qualifications in
anesthesia and moderate sedation prior to January 1989 may be issued a
temporary conscious/moderate sedation permit to continue to administer only
conscious/moderate sedation until May 7, 2015. After May 7, 2015, a dentist
shall meet the requirements for and obtain a conscious/moderate sedation permit
to administer by any method or by enteral administration only.
E. Additional training required. Dentists who administer conscious/moderate
moderate sedation shall:
1. Hold current certification in advanced resuscitation
techniques with hands-on simulated airway and megacode training for health care
providers, such as ACLS or PALS as evidenced by a certificate of completion
posted with the dental license; and
2. Have current training in the use and maintenance of the
equipment required in 18VAC60-21-291.
18VAC60-21-291. Requirements for administration of conscious/moderate
moderate sedation.
A. Delegation of administration.
1. A dentist who does not hold a permit to administer conscious/moderate
moderate sedation shall only use the services of a qualified dentist or
an anesthesiologist to administer such sedation in a dental office. In a
licensed outpatient surgery center, a dentist who does not hold a permit to
administer conscious/moderate moderate sedation shall use a
qualified dentist, an anesthesiologist, or a certified registered nurse
anesthetist to administer such sedation.
2. A dentist who holds a permit may administer or use the
services of the following personnel to administer conscious/moderate moderate
sedation:
a. A dentist with the training required by 18VAC60-21-290 D
2 to administer by an enteral method;
b. A dentist with the training required by
18VAC60-21-290 D 1 to administer by any method and who holds a
moderate sedation permit;
c. b. An anesthesiologist;
d. c. A certified registered nurse anesthetist
under the medical direction and indirect supervision of a dentist who meets the
training requirements of 18VAC60-21-290 D 1 and holds a moderate sedation
permit; or
e. d. A registered nurse upon his direct
instruction and under the immediate supervision of a dentist who meets the
training requirements of 18VAC60-21-290 D 1 and holds a moderate
sedation permit.
3. If minimal sedation is self-administered by or to a patient
13 years of age or older before arrival at the dental office, the dentist may
only use the personnel listed in subdivision 2 of this subsection to administer
local anesthesia. No sedating medication shall be prescribed for or administered
to a patient 12 years of age or younger prior to his arrival at the dentist
office or treatment facility.
4. Preceding the administration of conscious/moderate moderate
sedation, a permitted dentist may use the services of the following personnel
under indirect supervision to administer local anesthesia to anesthetize the
injection or treatment site:
a. A dental hygienist with the training required by
18VAC60-25-100 C to parenterally administer Schedule VI local anesthesia to
persons 18 years of age or older; or
b. A dental hygienist, dental assistant, registered nurse, or
licensed practical nurse to administer Schedule VI topical oral anesthetics.
5. A dentist who delegates administration of conscious/moderate
moderate sedation shall ensure that:
a. All equipment required in subsection B of this section is
present, in good working order, and immediately available to the areas where
patients will be sedated and treated and will recover; and
b. Qualified staff is on site to monitor patients in accordance
with requirements of subsection D of this section.
B. Equipment requirements. A dentist who administers conscious/moderate
moderate sedation shall have available the following equipment in sizes
for adults or children as appropriate for the patient being treated and shall
maintain it in working order and immediately available to the areas where
patients will be sedated and treated and will recover:
1. Full face mask or masks;
2. Oral and nasopharyngeal airway management adjuncts;
3. Endotracheal tubes with appropriate connectors or other
appropriate airway management adjunct such as a laryngeal mask airway;
4. A laryngoscope with reserve batteries and bulbs and
appropriately sized laryngoscope blades;
5. Pulse oximetry;
6. Blood pressure monitoring equipment;
7. Pharmacologic antagonist agents;
8. Source of delivery of oxygen under controlled positive
pressure;
9. Mechanical (hand) respiratory bag;
10. Appropriate emergency drugs for patient resuscitation;
11. Electrocardiographic monitor if a patient is receiving
parenteral administration of sedation or if the dentist is using titration;
12. Defibrillator;
13. Suction apparatus;
14. Temperature measuring device;
15. Throat pack;
16. Precordial or pretracheal stethoscope; and
17. An end-tidal carbon dioxide monitor (capnograph).
C. Required staffing. At a minimum, there shall be a
two-person treatment team for conscious/moderate moderate
sedation. The team shall include the operating dentist and a second person to
monitor the patient as provided in 18VAC60-21-260 K and assist the operating
dentist as provided in 18VAC60-21-260 J, both of whom shall be in the operatory
with the patient throughout the dental procedure. If the second person is a
dentist, an anesthesiologist, or a certified registered nurse anesthetist who
administers the drugs as permitted in 18VAC60-21-291 subsection A
of this section, such person may monitor the patient.
D. Monitoring requirements.
1. Baseline vital signs shall be taken and recorded prior to
administration of any controlled drug at the facility and prior to discharge.
2. Blood pressure, oxygen saturation, end-tidal carbon
dioxide, and pulse shall be monitored continually during the administration and
recorded every five minutes.
3. Monitoring of the patient under conscious/moderate moderate
sedation is to begin prior to administration of sedation or, if pre-medication
is self-administered by the patient, immediately upon the patient's arrival at
the dental facility and shall take place continuously during the dental
procedure and recovery from sedation. The person who administers the sedation
or another licensed practitioner qualified to administer the same level of
sedation must remain on the premises of the dental facility until the patient
is evaluated and is discharged.
E. Discharge requirements.
1. The patient shall not be discharged until the responsible
licensed practitioner determines that the patient's level of consciousness,
oxygenation, ventilation, and circulation are satisfactory for discharge and
vital signs have been taken and recorded.
2. Post-operative instructions shall be given verbally and in
writing. The written instructions shall include a 24-hour emergency telephone
number.
3. The patient shall be discharged with a responsible
individual who has been instructed with regard to the patient's care.
F. Emergency management. The dentist shall be proficient in
handling emergencies and complications related to pain control procedures,
including the maintenance of respiration and circulation, immediate establishment
of an airway, and cardiopulmonary resuscitation.
Part II
Practice of Dental Hygiene
18VAC60-25-40. Scope of practice.
A. Pursuant to § 54.1-2722 of the Code, a licensed
dental hygienist may perform services that are educational, diagnostic,
therapeutic, or preventive under the direction and indirect or general
supervision of a licensed dentist.
B. The following duties of a dentist shall not be delegated:
1. Final diagnosis and treatment planning;
2. Performing surgical or cutting procedures on hard or soft
tissue, except as may be permitted by subdivisions C 1 and D 1 of this section;
3. Prescribing or parenterally administering drugs or
medicaments, except a dental hygienist who meets the requirements of
18VAC60-25-100 C may parenterally administer Schedule VI local anesthesia to
patients 18 years of age or older;
4. Authorization of work orders for any appliance or
prosthetic device or restoration that is to be inserted into a patient's mouth;
5. Operation of high speed rotary instruments in the mouth;
6. Administration of deep sedation or general anesthesia and conscious/moderate
moderate sedation;
7. Condensing, contouring, or adjusting any final, fixed, or
removable prosthodontic appliance or restoration in the mouth with the
exception of packing and carving amalgam and placing and shaping composite
resins by dental assistants II with advanced training as specified in
18VAC60-30-120;
8. Final positioning and attachment of orthodontic bonds and
bands; and
9. Final adjustment and fitting of crowns and bridges in
preparation for final cementation.
C. The following duties shall only be delegated to dental
hygienists under direction and may only be performed under indirect
supervision:
1. Scaling, root planing, or gingival curettage of natural and
restored teeth using hand instruments, slow-speed rotary instruments,
ultrasonic devices, and nonsurgical lasers with any sedation or anesthesia
administered.
2. Performing an initial examination of teeth and surrounding
tissues including the charting of carious lesions, periodontal pockets, or
other abnormal conditions for assisting the dentist in the diagnosis.
3. Administering nitrous oxide or local anesthesia by dental
hygienists qualified in accordance with the requirements of 18VAC60-25-100.
D. The following duties shall only be delegated to dental
hygienists and may be performed under indirect supervision or may be delegated
by written order in accordance with § 54.1-2722 D of the Code to be
performed under general supervision:
1. Scaling, root planning, or gingival curettage of natural
and restored teeth using hand instruments, slow-speed rotary instruments,
ultrasonic devices, and nonsurgical lasers with or without topical oral
anesthetics.
2. Polishing of natural and restored teeth using air
polishers.
3. Performing a clinical examination of teeth and surrounding
tissues including the charting of carious lesions, periodontal pockets, or
other abnormal conditions for further evaluation and diagnosis by the dentist.
4. Subgingival irrigation or subgingival and gingival application
of topical Schedule VI medicinal agents pursuant to § 54.1-3408 J of the
Code.
5. Duties appropriate to the education and experience of the
dental hygienist and the practice of the supervising dentist, with the
exception of those listed as nondelegable in subsection B of this section and
those restricted to indirect supervision in subsection C of this section.
E. The following duties may only be delegated under the
direction and direct supervision of a dentist to a dental assistant II:
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.
F. A dental hygienist employed by the Virginia Department of
Health may provide educational and preventative dental care under remote
supervision, as defined in § 54.1-2722 D of the Code, of a dentist employed by
the Virginia Department of Health and in accordance with the protocol adopted
by the Commissioner of Health for Dental Hygienists to Practice in an Expanded
Capacity under Remote Supervision by Public Health Dentists, September 2012, which
is hereby incorporated by reference.
18VAC60-25-190. Requirements for continuing education.
A. In order to renew an active license, a dental hygienist
shall complete a minimum of 15 hours of approved continuing education.
Continuing education hours in excess of the number required for renewal may be
transferred or credited to the next renewal year for a total of not more than
15 hours.
1. A dental hygienist shall be required to maintain evidence
of successful completion of a current hands-on course in basic cardiopulmonary
resuscitation for health care providers.
2. A dental hygienist who monitors patients under general
anesthesia, deep sedation, or conscious/moderate moderate
sedation shall complete four hours every two years of approved continuing education
directly related to monitoring of such anesthesia or sedation as part of the
hours required for licensure renewal.
3. Up to two hours of the 15 hours required for annual renewal
may be satisfied through delivery of dental hygiene services, without compensation,
to low-income individuals receiving health services through a local health
department or a free clinic organized in whole or primarily for the delivery of
those services. One hour of continuing education may be credited for three
hours of providing such volunteer services, as documented by the health
department or free clinic.
B. An approved continuing education program shall be relevant
to the treatment and care of patients and shall be:
1. Clinical courses in dental or dental hygiene practice; or
2. Nonclinical subjects that relate to the skills necessary to
provide dental hygiene services and are supportive of clinical services (i.e.,
patient management, legal and ethical responsibilities, risk management, and
recordkeeping). Courses not acceptable for the purpose of this subsection
include, but are not limited to, estate planning, financial planning,
investments, and personal health.
C. Continuing education credit may be earned for verifiable
attendance at or participation in any course, to include audio and video
presentations, that meets the requirements in subdivision B 1 of this section
and is given by one of the following sponsors:
1. The American Dental Association and the National Dental
Association and their constituent and component/branch associations;
2. The American Dental Hygienists' Association and the
National Dental Hygienists Association and their constituent and
component/branch associations;
3. The American Dental Assisting Association and its
constituent and component/branch associations;
4. The American Dental Association specialty organizations and
their constituent and component/branch associations;
5. A provider accredited by the Accreditation Council for
Continuing Medical Education for Category 1 credits;
6. The Academy of General Dentistry and its constituent and
component/branch associations;
7. Community colleges with an accredited dental hygiene
program if offered under the auspices of the dental hygienist program;
8. A college or university that is accredited by an
accrediting agency approved by the U.S. Department of Education or a hospital
or health care institution accredited by the Joint Commission on Accreditation
of Healthcare Organizations;
9. The American Heart Association, the American Red Cross, the
American Safety and Health Institute, and the American Cancer Society;
10. A medical school accredited by the American Medical
Association's Liaison Committee for Medical Education or a dental school or
dental specialty residency program accredited by the Commission on Dental
Accreditation of the American Dental Association;
11. State or federal government agencies (i.e., military
dental division, Veteran's Administration, etc.);
12. The Commonwealth Dental Hygienists' Society;
13. The MCV Orthodontic Education and Research Foundation;
14. The Dental Assisting National Board and its affiliate, the
Dental Auxiliary Learning and Education Foundation;
15. The American Academy of Dental Hygiene, its constituent
and component/branch associations; or
16. A regional testing agency (i.e., Central Regional Dental
Testing Service, Northeast Regional Board of Dental Examiners, Southern
Regional Testing Agency, Council of Interstate Testing Agencies, or Western
Regional Examining Board) when serving as an examiner.
D. Verification of compliance.
1. All licensees are required to verify compliance with
continuing education requirements at the time of annual license renewal.
2. Following the renewal period, the board may conduct an
audit of licensees to verify compliance.
3. Licensees selected for audit shall provide original
documents certifying that they have fulfilled their continuing education
requirements by the deadline date as specified by the board.
4. Licensees are required to maintain original documents
verifying the date and the subject of the program or activity, the sponsor, and
the amount of time earned. Documentation shall be maintained for a period of
four years following renewal.
5. Failure to comply with continuing education requirements
may subject the licensee to disciplinary action by the board.
E. Exemptions.
1. A licensee is exempt from completing continuing education
requirements and considered in compliance on the first renewal date following
the licensee's initial licensure.
2. The board may grant an exemption for all or part of the
continuing education requirements due to circumstances beyond the control of
the licensee, such as temporary disability, mandatory military service, or
officially declared disasters. A written request with supporting documents must
be submitted at least 30 days prior to the deadline for renewal.
F. The board may grant an extension for up to one year for
completion of continuing education upon written request with an explanation to
the board prior to the renewal date.
G. Continuing education hours required by board order shall
not be used to satisfy the continuing education requirement for license renewal
or reinstatement.
18VAC60-30-50. Nondelegable duties; dentists.
Only licensed dentists shall perform the following duties:
1. Final diagnosis and treatment planning;
2. Performing surgical or cutting procedures on hard or soft
tissue except a dental hygienist performing gingival curettage as provided in
18VAC60-21-140;
3. Prescribing or parenterally administering drugs or medicaments,
except a dental hygienist who meets the requirements of 18VAC60-25-100 may
parenterally administer Schedule VI local anesthesia to patients 18 years of
age or older;
4. Authorization of work orders for any appliance or
prosthetic device or restoration that is to be inserted into a patient's mouth;
5. Operation of high speed rotary instruments in the mouth;
6. Administering and monitoring conscious/moderate moderate
sedation, deep sedation, or general anesthetics except as provided for in
§ 54.1-2701 of the Code and subsections J and K of 18VAC60-21-260;
7. Condensing, contouring, or adjusting any final, fixed, or
removable prosthodontic appliance or restoration in the mouth with the
exception of packing and carving amalgam and placing and shaping composite
resins by dental assistants II with advanced training as specified in
18VAC60-30-120;
8. Final positioning and attachment of orthodontic bonds and
bands; and
9. Final adjustment and fitting of crowns and bridges in
preparation for final cementation.
VA.R. Doc. No. R17-4975; Filed December 4, 2017, 3:50 p.m.