TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF DENTISTRY

Proposed Regulation

Title of Regulation: 18VAC60-20. Regulations Governing the Practice of Dentistry and Dental Hygiene (amending 18VAC60-20-10, 18VAC60-20-15, 18VAC60-20-16, 18VAC60-20-20, 18VAC60-20-30, 18VAC60-20-50, 18VAC60-20-60, 18VAC60-20-70, 18VAC60-20-105, 18VAC60-20-170, 18VAC60-20-190, 18VAC60-20-200, 18VAC60-20-210, 18VAC60-20-220, 18VAC60-20-230; adding 18VAC60-20-61, 18VAC60-20-72).

Statutory Authority: §§ 54.1-2400 and 54.1-2729.01 of the Code of Virginia.

Public Hearing Information:

January 22, 2010 - 1 p.m. - Perimeter Center, 9960 Mayland Drive, 2nd Floor, Board Room 3, Richmond, VA

Public Comment Deadline: February 19, 2010.

Agency Contact: Sandra Reen, Executive Director, Board of Dentistry, 9960 Mayland Drive, Suite 300, Richmond, VA 23233-1463, telephone (804) 367-4538, 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 specific statutory authority for promulgation of regulations pertaining to dental assistants II (DA II) is found in § 54.1-2729.01 of the Code of Virginia.

Purpose: In its proposed regulatory action, the board has specified the qualifications for registration to practice as a DA II as required by Chapters 84 and 264 of the 2008 Acts of Assembly. Dental assistants will have expanded duties beyond chairside assisting and taking radiographs, which are the typical duties currently delegated to a dental assistant, to include some patient care duties currently performed by a dentist. In conformity with the legislation, a person will be required to hold certification from a national credentialing body, complete an educational program, receive training as prescribed by the board and be registered with the board in order to qualify as a DA II or expanded duty dental assistant.

Dentists have expressed interest in expanded duties for assistants as a means of providing care to a greater number of patients. In some areas of the state, there is a reported shortage of hygienists available for employment in dental offices, so certain aspects of patient care could be delegated to "expanded duty dental assistants," which would enable the dentist to focus on care that necessitates a higher level of knowledge and skill.

To ensure the services can be safely provided by a DA II, the board has set in the regulation the evidence of minimal competency that a dental assistant must demonstrate to be registered and authorized to perform expanded duties. Qualifications include specified hours of didactic education, clinical training and experience, and examination in modules for the performance of specific duties delegated under direct supervision. While the applicant will have to demonstrate clinical knowledge and skills to be registered as a DA II, the dentist will have to be present in the facility, will have to examine the patient both before and after treatment by a DA II and will remain responsible for the care of the patient. Such requirements are necessary to ensure the health and safety of dental patients, while increasing the number of qualified dental personnel and access to care.

Substance:

18VAC60-20-10. Definitions are added for a "dental assistant II," "direct supervision," and "indirect supervision." The definitions of "direction" and "general supervision" are amended.

18VAC60-20-20. The annual renewal fee for a DA II is $50; the inactive registration is $25. Late fees are $20 for an active registration and $10 for inactive registration. The reinstatement fee for a lapsed registration is $125, for a revoked registration is $300, and for a suspended registration is $250.

18VAC60-20-30. The application fee for a DA II is $100. Other miscellaneous fees, which are set at the actual cost to the board, are identical for the DA II as for other regulated professions.

18VAC60-20-50. DA IIs are added to the list of practitioners required to maintain training in basic cardiopulmonary resuscitation.

In subsection F, a requirement is added for a DA II to attest to current DANB certification (or other national accrediting body if approved by the ADA) in order to renew registration.

18VAC60-20-61. Educational requirements for dental assistants II.

Subsection A specifies that a prerequisite for entry into an educational program is current certification as a CDA.

Subsection B establishes the hours and subject areas of training and experience, as follows:

    Subdivision 1 sets 50 hours of didactic coursework in dental anatomy and operative dentistry.

    Subdivision 2 sets the hours of laboratory training required for each of the expanded duties.

    Subdivision 3 sets the hours of clinical experience applying the techniques learned in the preclinical coursework and laboratory that may be completed at a dental office.

    Subdivision 4 establishes the competency examinations required for completion of an education program.

Subsection C requires all treatment of patients by a student to be under the direct and immediate supervision of a dentist, who is responsible for performance of duties. The dentist is required to attest to successful completion and clinical competencies by the student.

18VAC60-20-70. The certification requirement for a DA II is added to this section in subsection C. As required by law, a DA II must have a national credential recognized by the ADA, which is currently a Certified Dental Assistant (CDA) conferred by DANB based on passage of an examination on chairside assisting, radiation health and safety, and infection control.

18VAC60-20-72. Requirements for registration by endorsement include (i) current national certification, (ii) current authorization to perform expanded duties in another state, and (iii) qualifications substantially equivalent to the education and training in specific duties required in Virginia or documented experience in the restorative and prosthetic expanded duties for at least 24 of the past 48 months preceding application.

18VAC60-20-105. The requirements for obtaining an inactive registration and for reactivating back to active status are added in subsection C, which provides that current national certification is required for reactivation.

18VAC60-20-190. The duties that may be delegated to a registered DA II are set out in subsection C of 18VAC60-20-230. Since those duties are currently listed in 18VAC60-20-190 as "non-delegable" and may only be performed by a licensed dentist, this section is amended to allow for delegation to a DA II.

18VAC60-20-200. The current ratio is no more than two hygienists per dentists at any one time. With the registration of DA IIs, the ratio has been expanded to allow a total of four dental hygienists or DA IIs in any combination.

18VAC60-20-210 and 18VAC60-20-220. Since the definition of "direction" has been amended to include the level of supervision that a dentist is required to exercise in delegating to a dental hygienist, the provisions of 18VAC60-20-210, specifying the duties of a dental hygienist, are amended to differentiate between those that may be under indirect supervision and those that may be under general supervision. Subsection C in 18VAC60-20-210 is deleted because the amended definition of direction refers to a level of supervision required for the services provided, which is set out in 18VAC60-20-220.

18VAC60-20-230. Subsection C is added to specify the duties that are delegable to a DA II who has qualified by education, training, and examination must be under direction and direct supervision (as defined in 18VAC60-20-10). Those duties are:

  1. Placing, packing, carving, and polishing of amalgam restorations;

  2. Placing and shaping composite resin restorations;

  3. Taking final impressions and use of a non-epinephrine retraction cord; and

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

Issues: The primary advantage of this proposal to the public is more accessibility for dental care by persons who are qualified by education, training, and examination to perform certain restorative and prosthetic dental functions. The ability of dental practices to provide services to populations of patients is enhanced with expanded duty dental assistants and with an increase in the ratio of dentists to dental hygienists or DA IIs from two per dentist to four per dentist. To the extent dental assistants acquire the additional qualifications and credentials for expanded functions as a DA II, the regulation has the potential to improve accessibility and reduce costs. If a DA II is appropriately trained and clinically competent, and if the dentist provides direct supervision as specified in regulation, there should be no disadvantages.

There are no disadvantages of these provisions to the agency or the Commonwealth. More specificity about direction and the levels of supervision should allow board staff to direct persons with questions about those issues to the regulations.

The Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. Chapters 84 and 264 of the 2008 Acts of the Assembly created the new professional registration called dental assistant II (DA II). Pursuant to this legislation the Board of Dentistry (Board) proposes to specify requirements for registration and the scope of practice for a DA II. Further, the Board proposes to permit dentists to: 1) utilize a total of four dental hygienists or DA II in any combination practicing under direction or general supervision at one and the same time, and 2) delegate some duties to dental hygienists under general supervision with or without the dentist being present.

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

Estimated Economic Impact. Chapters 84 and 264 of the 2008 Acts of the Assembly created Code of Virginia § 54.1-2729.01.B which states that:

A person who (i) has met the educational and training requirements prescribed by the Board; (ii) holds a certification from a credentialing organization recognized by the American Dental Association; and (iii) has met any other qualifications for registration as prescribed in regulations promulgated by the Board may practice as a dental assistant II. A dental assistant II may perform duties not otherwise restricted to the practice of a dentist or dental hygienist under the direction of a licensed dentist that are reversible, intraoral procedures specified in regulations promulgated by the Board.

The Board proposes to permit a DA II to perform the following procedures under the direction and direct supervision of a dentist which under current regulations may only be performed by a dentist: 1) performing pulp capping procedures, 2) packing and carving of amalgam restorations, 3) placing and shaping composite resin restorations, 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. The DA II would need to have successfully completed the extensive coursework, laboratory training, clinical experience and examinations specified in the proposed regulations prior to performing these procedures.

In both the current and proposed regulations a dental assistant is defined as "any unlicensed person under the supervision of a dentist who renders assistance for services provided to the patient as authorized under this chapter but shall not include an individual serving in purely a secretarial or clerical capacity." The proposed amendments to these regulations do not change requirements or opportunities for dental assistants. The proposed amendments and the enabling legislation essentially create a new registered profession called "dental assistant II" which is permitted to perform a subset of duties which can now only be performed by dentists.  Given the required extensive training and supervision by dentists, public safety is unlikely to be compromised by permitting the practice of the DA II. To the extent that that individuals pursue and obtain DA II registration, and dentists choose to hire such individuals to perform these procedures, access to dental care for the public may increase for the public. Thus, this proposal produces a net benefit.

The current regulations state that "No dentist shall have more than two dental hygienists practicing under direction or general supervision at one and the same time …" The Board proposes to amend the language to state that "A dentist may utilize up to a total of four dental hygienists or dental assistants II in any combination practicing under direction or general supervision at one and the same time …" This proposed change may moderately increase employment and increase access to dental care for the public and is unlikely to create significant health risk for the public.

The Board also proposes to specify that the dental hygienist may perform certain duties under general supervision with or without the dentist being present. Currently, the regulations specify that general supervision is only possible "without the dentist present."  Allowing the hygienist to perform duties that meet the criteria for practice under general supervision when the dentist is present will allow the hygienist to see certain patients under general supervision but not require the dentist to see the patient at any point during the appointment (as is required under indirect supervision).  This will enable dental staff to use their time more efficiently and should not create public health risk. Thus the proposal creates benefit without apparent cost.

Businesses and Entities Affected. The proposed amendments potentially affect dental practices. There are 5,850 active licensed dentists in Virginia.¹ Potentially providers of training for the DA II are affected as well. Potential training entities include universities, community colleges, and proprietary schools.

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

Projected Impact on Employment. The current regulations state that "No dentist shall have more than two dental hygienists practicing under direction or general supervision at one and the same time …" The Board proposes to amend the language to state that "A dentist may utilize up to a total of four dental hygienists or dental assistants II in any combination practicing under direction or general supervision at one and the same time …" This proposed change may moderately increase employment.

Effects on the Use and Value of Private Property. The creation of the DA II registration will allow individuals with such registration to perform some procedures under the supervision of a dentist that may now only be performed by dentists. To the extent that individuals pursue and obtain DA II registration, and dentists choose to hire such individuals to perform these procedures, some dental practices will change and potentially increase in value. The proposal to allow dentists to delegate certain duties to dental hygienists under general supervision that under the current regulations may only be performed by dental hygienists when the dentist is not present in the office may enable dental staff to use their time more efficiently and thus may moderately increase the value of some dental practices.

Small Businesses: Costs and Other Effects. The proposed amendments will not increase costs for small businesses.

Small Businesses: Alternative Method that Minimizes Adverse Impact. The proposed amendments are unlikely to adversely affect small businesses.

Real Estate Development Costs. The proposed amendments are unlikely to significantly affect real estate development costs.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 36 (06). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB's best estimate of these economic impacts.

_________________________

¹ Source: Department of Health Professions

Agency's Response to the Department of Planning and Budget's Economic Impact Analysis: The Board of Dentistry concurs with the analysis of the Department of Planning and Budget for the proposed regulation, 18VAC60-20, Regulations Governing the Practice of Dentistry and Dental Hygiene, relating to registration and practice of dental assistants II.

Summary:

The Board of Dentistry has amended its regulations to specify requirements for the registration and the scope of practice of a dental assistant II (DA II) in accordance with Chapters 84 and 264 of the 2008 Acts of Assembly. The regulations establish (i) definitions for supervision, (ii) fees for registration and renewal, (iii) qualifications (including education, clinical training, examination and national certification), (iv) continuing competency requirements, and (v) duties that may be delegated to a DA II.

CHAPTER 20
REGULATIONS GOVERNING THE DENTAL PRACTICE OF DENTISTRY AND DENTAL HYGIENE

Part I
General Provisions

18VAC60-20-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"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.

"Analgesia" means the diminution or elimination of pain in the conscious patient.

"Anxiolysis" means the diminution or elimination of anxiety through the use of pharmacological agents in a dosage that does not cause depression of consciousness.

"Conscious sedation" means a minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal commands, produced by pharmacological or nonpharmacological methods, including inhalation, parenteral, transdermal or enteral, or a combination thereof.

"Deep sedation/general anesthesia" means an induced state of depressed consciousness or unconsciousness accompanied by a complete or partial loss of protective reflexes, including the inability to continually maintain an airway independently and/or respond purposefully to physical stimulation or verbal command and is produced by a pharmacological or nonpharmacological method or a combination thereof.

"Dental assistant" means any unlicensed person under the supervision of a dentist who renders assistance for services provided to the patient as authorized under this chapter but shall not include an individual serving in purely a secretarial or clerical capacity.

"Dental assistant II" means a person under the direction of a dentist who is registered to perform reversible, intraoral procedures as specified in this chapter.

"Direct supervision" means that the dentist examines the patient and records diagnostic findings prior to delegating restorative or prosthetic treatment and related services to 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 in the operatory or an area immediately adjacent to the operatory in order to be immediately available 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 dentist examines the patient and is present for observation, advice, and control over the performance of dental services the level of supervision that a dentist is required to exercise with a dental hygienist and with a dental assistant or that a dental hygienist is required to exercise with a dental assistant to direct and oversee the delivery of treatment and related services.

"Enteral" is any technique of administration in which the agent is absorbed through the gastrointestinal tract or oral mucosa (i.e., oral, rectal, sublingual).

"General supervision" means that the dentist has examined the patient and issued a written order for the specific, authorized services to be provided by a dental hygienist when the dentist is not present in the facility while the services are being provided 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. The order may authorize the dental hygienist to supervise a dental assistant who prepares the patient for treatment and prepares the patient for dismissal following 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 dental hygienist, or (iii) preparing the patient for dismissal following treatment.

"Inhalation" is 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 sensibility to pain without the loss of consciousness.

"Local anesthesia" means the loss of sensation or pain in the oral cavity or the maxillofacial or adjacent and associated structures generally produced by a topically applied or injected agent without depressing the level of consciousness.

"Parenteral" means a technique of administration in which the drug bypasses the gastrointestinal tract (i.e., intramuscular, intravenous, intranasal, submucosal, subcutaneous, or intraocular).

"Radiographs" means intraoral and extraoral x-rays of hard and soft tissues to be used for purposes of diagnosis.

18VAC60-20-15. Recordkeeping.

A dentist shall maintain patient records for not less than three years from the most recent date of service for purposes of review by the board to include the following:

1. Patient's name and date of treatment;

2. Updated health history;

3. Diagnosis and treatment rendered;

4. List of drugs prescribed, administered, dispensed and the quantity;

5. Radiographs;

6. Patient financial records;

7. Name of the dentist and the dental hygienist or the dental assistant II providing service; and

8. Laboratory work orders which meet the requirements of § 54.1-2719 of the Code of Virginia.

18VAC60-20-16. Address of record; posting of licenses or registrations.

A. Address of record. At all times, each licensed dentist and, dental hygienist, and dental assistant II shall provide the board with a current address of record. All required notices mailed by the board to any such licensee or registrant shall be validly given when mailed to the latest address of record given by the licensee. All changes in the address of record or in the public address, if different from the address of record, shall be furnished to the board in writing within 30 days of such changes.

B. Posting of license or registration. A copy of the registration of a dental assistant II shall either be posted in an operatory in which the person is providing services to the public or in the patient reception area where it is clearly visible to patients and accessible for reading.

Part II
Licensure Renewal and Fees

18VAC60-20-20. License renewal Renewal and reinstatement.

A. Renewal fees. Every person holding an active or inactive license or a dental assistant II registration or a full-time faculty license shall, on or before March 31, renew his license or registration. Every person holding a teacher's license, temporary resident's license, a restricted volunteer license to practice dentistry or dental hygiene, or a temporary permit to practice dentistry or dental hygiene shall, on or before June 30, request renewal of his license.

1. The fee for renewal of an active license or permit to practice or teach dentistry shall be $285, and the fee for renewal of an active license or permit to practice or teach dental hygiene shall be $75. The fee for renewal of registration as a dental assistant II shall be $50.

2. The fee for renewal of an inactive license shall be $145 for dentists and $40 for dental hygienists. The fee for renewal of an inactive registration as a dental assistant II shall be $25.

3. The fee for renewal of a restricted volunteer license shall be $15.

4. The application fee for temporary resident's license shall be $60. The annual renewal fee shall be $35 a year. An additional fee for late renewal of licensure shall be $15.

B. Late fees. Any person who does not return the completed form and fee by the deadline required in subsection A of this section shall be required to pay an additional late fee of $100 for dentists with an active license and, $25 for dental hygienists with an active license, and $20 for a dental assistant II with active registration. The late fee shall be $50 for dentists with an inactive license and, $15 for dental hygienists with an inactive license, and $10 for a dental assistant II with an inactive registration. The board shall renew a license or dental assistant II registration if the renewal form, renewal fee, and late fee are received within one year of the deadline required in subsection A of this section.

C. Reinstatement fees and procedures. The license or registration of any person who does not return the completed renewal form and fees by the deadline required in subsection A of this section shall automatically expire and become invalid and his practice of dentistry/dental hygiene as a dentist, dental hygienist, or dental assistant II shall be illegal.

1. Any person whose license or dental assistant II registration has expired for more than one year and who wishes to reinstate such license or registration shall submit to the board a reinstatement application and the reinstatement fee of $500 for dentists and, $200 for dental hygienists or $125 for dental assistants II.

2. With the exception of practice with a restricted volunteer license as provided in §§ 54.1-2712.1 and 54.1-2726.1 of the Code of Virginia, practicing in Virginia with an expired license or registration may subject the licensee to disciplinary action by the board.

3. The executive director may reinstate such expired license or registration provided that the applicant can demonstrate continuing competence, that no grounds exist pursuant to § 54.1-2706 of the Code of Virginia and 18VAC60-20-170 to deny said reinstatement, and that the applicant has paid the unpaid reinstatement fee and any fines or assessments. Evidence of continuing competence shall include hours of continuing education as required by subsection H of 18VAC60-20-50 and may also include evidence of active practice in another state or in federal service or current specialty board certification.

D. Reinstatement of a license or dental assistant II registration previously revoked or indefinitely suspended. Any person whose license or registration has been revoked shall submit to the board for its approval a reinstatement application and fee of $1,000 for dentists and, $500 for dental hygienists and $300 for dental assistants II. Any person whose license or registration has been indefinitely suspended shall submit to the board for its approval a reinstatement application and fee of $750 for dentists and, $400 for dental hygienists, and $250 for dental assistants II.

18VAC60-20-30. Other fees.

A. Dental licensure application fees. The application fee for a dental license by examination, a license to teach dentistry, a full-time faculty license, or a temporary permit as a dentist shall be $400. The application fee for dental license by credentials shall be $500.

B. Dental hygiene licensure application fees. The application fee for a dental hygiene license by examination, a license to teach dental hygiene, or a temporary permit as a dental hygienist shall be $175. The application fee for dental hygienist license by endorsement shall be $275.

C. Dental assistant II registration application fee. The application fee for registration as a dental assistant II shall be $100.

C. Duplicate wall D. Wall certificate. Licensees desiring a duplicate wall certificate or a dental assistant II desiring a wall certificate shall submit a request in writing stating the necessity for such duplicate a wall certificate, accompanied by a fee of $60.

D. E. Duplicate license or registration. Licensees or registrants desiring a duplicate license or registration shall submit a request in writing stating the necessity for such duplicate license, accompanied by a fee of $20. If a licensee or registrant maintains more than one office, a notarized photocopy of a license or registration may be used.

E. F. Licensure or registration certification. Licensees or registrants requesting endorsement or certification by this board shall pay a fee of $35 for each endorsement or certification.

F. G. Restricted license. Restricted license issued in accordance with § 54.1-2714 of the Code of Virginia shall be at a fee of $285.

G. H. Restricted volunteer license. The application fee for licensure as a restricted volunteer dentist or dental hygienist issued in accordance with § 54.1-2712.1 or § 54.1-2726.1 of the Code of Virginia shall be $25.

H. I. Returned check. The fee for a returned check shall be $35.

I. J. Inspection fee. The fee for an inspection of a dental office shall be $350.

18VAC60-20-50. Requirements for continuing education.

A. After April 1, 1995, a A dentist or a dental hygienist shall be required to have completed a minimum of 15 hours of approved continuing education for each annual renewal of licensure. A dental assistant II shall be required to maintain current certification from the Dental Assisting National Board or another national credentialing organization recognized by the American Dental Association.

1. Effective June 29, 2006, a A dentist, or a dental hygienist, or a dental assistant II shall be required to maintain evidence of successful completion of training in basic cardiopulmonary resuscitation.

2. Effective June 29, 2006, a A dentist who administers or a dental hygienist who monitors patients under general anesthesia, deep sedation or conscious sedation shall complete four hours every two years of approved continuing education directly related to administration or monitoring of such anesthesia or sedation as part of the hours required for licensure renewal.

3. 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.

B. An approved continuing dental education program shall be relevant to the treatment and care of patients and shall be:

1. Clinical courses in dentistry and dental hygiene dental practice; 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, stress management). 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 courses, to include audio and video presentations, which meet the requirements in subdivision B 1 of this section and which are given by one of the following sponsors:

1. American Dental Association and National Dental Association, their constituent and component/branch associations;

2. American Dental Hygienists' Association and National Dental Hygienists Association, their constituent and component/branch associations;

3. American Dental Assisting Association, its constituent and component/branch associations;

4. American Dental Association specialty organizations, their constituent and component/branch associations;

5. American Medical Association and National Medical Association, their specialty organizations, constituent, and component/branch associations;

6. Academy of General Dentistry, 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 Health Care 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 which is 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 and Research Foundation;

14. The Dental Assisting National Board; or

15. A regional testing agency (i.e., Central Regional Dental Testing Service, Northeast Regional Board of Dental Examiners, Southern Regional Testing Agency, or Western Regional Examining Board) when serving as an examiner.

D. A licensee is exempt from completing continuing education requirements and considered in compliance on the first renewal date following the licensee's initial licensure.

E. 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.

F. A licensee is required to provide information on compliance with continuing education requirements in his annual license renewal. A dental assistant II is required to attest to current certification by the Dental Assisting National Board or another national credentialing organization recognized by the American Dental Association. Following the renewal period, the board may conduct an audit of licensees or registrants to verify compliance. Licensees or registrants 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 or registrants are required to maintain original documents verifying the date and subject of the program or activity. Documentation must 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, must 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. A dental assistant II who has allowed his registration to lapse or who has had his registration suspended or revoked must submit evidence of current certification from a credentialing organization recognized by the American Dental Association to reinstate his registration.

I. Continuing education hours required by board order shall not be used to satisfy the continuing education requirement for license or registration renewal or reinstatement.

J. Failure to comply with continuing education requirements or current certification requirements may subject the licensee or registrant to disciplinary action by the board.

Part III
Entry and Licensure Requirements

18VAC60-20-60. Education Educational requirements for dentists and dental hygienists.

A. Dental licensure. An applicant for dental licensure shall be a graduate and a holder of a diploma or a certificate from a dental program accredited by the Commission on Dental Accreditation of the American Dental Association, which consists of either a pre-doctoral dental education program or at least a 12-month post-doctoral advanced general dentistry program or a post-doctoral dental education program in any other specialty.

B. Dental hygiene licensure. An applicant for dental hygiene licensure shall have graduated from or have been issued a certificate by a program of dental hygiene accredited by the Commission on Dental Accreditation of the American Dental Association.

18VAC60-20-61. 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 from an educational program accredited by the Commission on Dental Accreditation of the American Dental Association:

1. At least 50 hours of didactic course work in dental anatomy and operative dentistry that may be completed on-line.

2. Laboratory training that may 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 hours of placing, packing, carving, and polishing of amalgam restorations;

b. At least 60 hours of placing and shaping composite resin restorations;

c. At least 20 hours of taking final impressions and use of a non-epinephrine retraction cord; and

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

3. 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 hours of placing, packing, carving, and polishing of amalgam restorations;

b. At least 120 hours of placing and shaping composite resin restorations;

c. At least 40 hours of taking final impressions and use of a non-epinephrine retraction cord; and

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

4. 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;

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.

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.

18VAC60-20-70. Licensure examinations; registration certification.

A. Dental examinations.

1. All applicants shall have successfully completed Part I and Part II of the examinations of the Joint Commission on National Dental Examinations prior to making application to this board.

2. All applicants to practice dentistry shall satisfactorily pass the complete board-approved examinations in dentistry. Applicants who successfully completed the board-approved examinations five or more years prior to the date of receipt of their applications for licensure by this board may be required to retake the examinations or take board-approved continuing education unless they demonstrate that they have maintained clinical, ethical and legal practice for 48 of the past 60 months immediately prior to submission of an application for licensure.

3. If the candidate has failed any section of a board-approved examination three times, the candidate shall complete a minimum of 14 hours of additional clinical training in each section of the examination to be retested in order to be approved by the board to sit for the examination a fourth time.

B. Dental hygiene examinations.

1. All applicants are required to successfully complete the dental hygiene examination of the Joint Commission on National Dental Examinations prior to making application to this board for licensure.

2. All applicants to practice dental hygiene shall successfully complete the board-approved examinations in dental hygiene, except those persons eligible for licensure pursuant to 18VAC60-20-80.

3. If the candidate has failed any section of a board-approved examination three times, the candidate shall complete a minimum of seven hours of additional clinical training in each section of the examination to be retested in order to be approved by the board to sit for the examination a fourth time.

C. Dental assistant II certification. All applicants for registration as a dental assistant II shall provide evidence of a current credential as a Certified Dental Assistant (CDA) conferred by the Dental Assisting National Board or another certification from a credentialing organization recognized by the American Dental Association and acceptable to the board, which was granted following passage of an examination on general chairside assisting, radiation health and safety, and infection control.

C. D. All applicants who successfully complete the board-approved examinations five or more years prior to the date of receipt of their applications for licensure or registration by this board may be required to retake the board-approved examinations or take board-approved continuing education unless they demonstrate that they have maintained clinical, ethical, and legal practice for 48 of the past 60 months immediately prior to submission of an application for licensure or registration.

D. E. All applicants for licensure by examination or registration as a dental assistant II shall be required to attest that they have read and understand and will remain current with the applicable Virginia dental and dental hygiene laws and the regulations of this board.

18VAC60-20-72. Registration by endorsement as a dental assistant II.

A. An applicant for registration by endorsement as a dental assistant II shall provide evidence of the following:

1. Hold current certification as a Certified Dental Assistant (CDA) conferred by the Dental Assisting National Board or another national credentialing organization recognized by the American Dental Association;

2. Be currently authorized to perform expanded duties as a dental assistant in another state, territory, District of Columbia, or possession of the United States;

3. Hold a credential, registration, or certificate with qualifications substantially equivalent in hours of instruction and course content to those set forth in 18VAC60-20-61 or if the qualifications were not substantially equivalent the dental assistant can document experience in the restorative and prosthetic expanded duties set forth in 18VAC60-20-230 for at least 24 of the past 48 months preceding application for registration in Virginia.

B. An applicant shall also:

1. Be certified to be in good standing from each state in which he is currently registered, certified, or credentialed or in which he has ever held a registration, certificate, or credential;

2. Be of good moral character;

3. Not have committed any act that would constitute a violation of § 54.1-2706 of the Code of Virginia; and

4. Attest to having read and understand and to remain current with the laws and the regulations governing dental practice in Virginia.

18VAC60-20-105. Inactive license or registration.

A. Any dentist or dental hygienist who holds a current, unrestricted license in Virginia may, upon a request on the renewal application and submission of the required fee, be issued an inactive license. With the exception of practice with a restricted volunteer license as provided in §§ 54.1-2712.1 and 54.1-2726.1 of the Code of Virginia, the holder of an inactive license shall not be entitled to perform any act requiring a license to practice dentistry or dental hygiene in Virginia.

B. An inactive license may be reactivated upon submission of the required application, payment of the current renewal fee, and documentation of having completed continuing education hours equal to the requirement for the number of years in which the license has been inactive, 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 immediately preceding the application for activation. The board reserves the right to deny a request for reactivation to any licensee who has been determined to have committed an act in violation of § 54.1-2706 of the Code of Virginia.

C. Any dental assistant II who holds a current, unrestricted registration in Virginia may upon a request on the renewal application and submission of the required fee be issued an inactive registration. The holder of an inactive registration shall not be entitled to perform any act requiring registration to practice as a dental assistant II in Virginia. An inactive registration may be reactivated upon submission of evidence of current certification from the national credentialing organization recognized by the American Dental Association. The board reserves the right to deny a request for reactivation to any registrant who has been determined to have committed an act in violation of § 54.1-2706 of the Code of Virginia.

Part V
Unprofessional Conduct

18VAC60-20-170. Acts constituting unprofessional conduct.

The following practices shall constitute unprofessional conduct within the meaning of § 54.1-2706 of the Code of Virginia:

1. Fraudulently obtaining, attempting to obtain or cooperating with others in obtaining payment for services;

2. Performing services for a patient under terms or conditions which are unconscionable. The board shall not consider terms unconscionable where there has been a full and fair disclosure of all terms and where the patient entered the agreement without fraud or duress;

3. Misrepresenting to a patient and the public the materials or methods and techniques the licensee uses or intends to use;

4. Committing any act in violation of the Code of Virginia reasonably related to the practice of dentistry and dental hygiene;

5. Delegating any service or operation which requires the professional competence of a dentist or, dental hygienist, or dental assistant II to any person who is not a dentist or, dental hygienist, or dental assistant II as authorized by this chapter;

6. Certifying completion of a dental procedure that has not actually been completed;

7. Knowingly or negligently violating any applicable statute or regulation governing ionizing radiation in the Commonwealth of Virginia, including, but not limited to, current regulations promulgated by the Virginia Department of Health; and

8. Permitting or condoning the placement or exposure of dental x-ray film by an unlicensed person, except where the unlicensed person has complied with 18VAC60-20-195.

Part VI
Direction and Delegation of Duties

18VAC60-20-190. 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;

3. Prescribing or parenterally administering drugs or medicaments, except a dental hygienist, who meets the requirements of 18VAC60-20-81, 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 to be inserted into a patient's mouth;

5. Operation of high speed rotary instruments in the mouth;

6. Performing pulp capping procedures;

7. 6. Administering and monitoring general anesthetics and conscious sedation except as provided for in § 54.1-2701 of the Code of Virginia and 18VAC60-20-108 C, 18VAC60-20-110 F, and 18VAC60-20-120 F;

8. 7. Condensing, contouring or adjusting any final, fixed or removable prosthodontic appliance or restoration in the mouth with the exception of placing, packing, and carving amalgam and composite resins by dental assistants II with advanced training as specified in 18VAC60-20-61 B;

9. 8. Final positioning and attachment of orthodontic bonds and bands; and

10. Taking impressions for master casts to be used for prosthetic restoration of teeth or oral structures;

11. 9. Final cementation adjustment and fitting of crowns and bridges; and in preparation for final cementation.

12. Placement of retraction cord.

18VAC60-20-200. Utilization of dental hygienists and dental assistants II.

No dentist shall have more than two A dentist may utilize up to a total of four dental hygienists or dental assistants II in any combination practicing under direction or general supervision at one and the same time, with the exception that a dentist may issue written orders for services to be provided by dental hygienists under general supervision in a free clinic, a public health program, or on a voluntary basis.

18VAC60-20-210. Requirements for direction and general supervision.

A. In all instances and on the basis of his diagnosis, a licensed dentist assumes ultimate responsibility for determining, on the basis of his diagnosis, the specific treatment the patient will receive and, which aspects of treatment will be delegated to qualified personnel, and the direction required for such treatment, in accordance with this chapter and the Code of Virginia.

B. Dental hygienists shall engage in their respective duties only while in the employment of a licensed dentist or governmental agency or when volunteering services as provided in 18VAC60-20-200. Persons acting within the scope of a license issued to them by the board under § 54.1-2725 of the Code of Virginia to teach dental hygiene and those persons licensed pursuant to § 54.1-2722 of the Code of Virginia providing oral health education and preliminary dental screenings in any setting are exempt from this section.

C. Duties delegated to a dental hygienist under direction shall only be performed when the dentist is present in the facility and examines the patient during the time services are being provided.

D. C. Duties that are delegated to a dental hygienist under general supervision shall only be performed if the following requirements are met:

1. The treatment to be provided shall be ordered by a dentist licensed in Virginia and shall be entered in writing in the record. The services noted on the original order shall be rendered within a specific time period, not to exceed 10 months from the date the dentist last examined the patient. Upon expiration of the order, the dentist shall have examined the patient before writing a new order for treatment.

2. The dental hygienist shall consent in writing to providing services under general supervision.

3. The patient or a responsible adult shall be informed prior to the appointment that no a dentist will may not be present, that no anesthesia can be administered, and that only those services prescribed by the dentist will be provided.

4. Written basic emergency procedures shall be established and in place, and the hygienist shall be capable of implementing those procedures.

E. D. General supervision shall not preclude the use of direction when, in the professional judgment of the dentist, such direction is necessary to meet the individual needs of the patient.

18VAC60-20-220. Dental hygienists.

A. The following duties shall only be delegated to dental hygienists under direction with the dentist being present and may be performed under indirect supervision:

1. Scaling and/or root planing of natural and restored teeth using hand instruments, rotary instruments and ultrasonic devices under anesthesia administered by the dentist.

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 18VAC60-20-81.

B. The following duties shall only be delegated to dental hygienists and may be delegated by written order in accordance with § 54.1-3408 of the Code of Virginia to be performed under general supervision without when the dentist being may not be present:

1. Scaling and/or root planing of natural and restored teeth using hand instruments, rotary instruments and ultrasonic devices.

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 application of topical Schedule VI medicinal agents.

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 in subsection A of this section and those listed as nondelegable in 18VAC60-20-190.

C. Nothing in this section shall be interpreted so as to prevent a licensed dental hygienist from providing educational services, assessment, screening or data collection for the preparation of preliminary written records for evaluation by a licensed dentist.

18VAC60-20-230. Delegation to dental assistants.

A. Duties appropriate to the training and experience of the dental assistant and the practice of the supervising dentist may be delegated to a dental assistant under the direction or under general supervision required in 18VAC60-20-210, with the exception of those listed as nondelegable in 18VAC60-20-190 and those which may only be delegated to dental hygienists as listed in 18VAC60-20-220.

B. Duties delegated to a dental assistant under general supervision shall be under the direction of the dental hygienist who supervises the implementation of the dentist's orders by examining the patient, observing the services rendered by an assistant and being available for consultation on patient care.

C. The following 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 18VAC60-20-61:

1. Performing pulp capping procedures;

2. Packing and carving of amalgam restorations;

3. Placing and shaping composite resin restorations;

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.

VA.R. Doc. No. R09-1526; Filed December 2, 2009, 10:25 a.m.