ARC 2028C
DENTAL BOARD[650]
Adopted and Filed
Pursuant to the authority of Iowa Code sections 147.76 and 272C.2, the Dental Board adopts amendments to Chapter 20, “Dental Assistants,” Iowa Administrative Code.
The amendments clarify general supervision requirements for dental assistants, add to the list of permissible services a dental assistant may perform under general supervision, increase the number of expanded function procedures which may be delegated to a registered dental assistant and set the education and training requirements for those procedures, and permit registered dental assistants to work under public health supervision in certain settings.
The amendments increase the number of services a dentist may delegate to a dental assistant under general supervision by adding the use of a curing light and intraoral camera.
The amendments increase the number of expanded function procedures from 9 procedures to 16 procedures, define the supervision requirements for the performing of all expanded function procedures, and set the education and training requirements.
The amendments authorize an Iowa-licensed dentist to provide public health supervision to a registered dental assistant if the services are provided in a public or private school, public health agencies, hospitals, or the armed forces.
Notice of Intended Action was published in the Iowa Administrative Bulletin on April 1, 2015, as ARC 1940C. A public hearing was held on April 21, 2015, at 2 p.m.	at the office of the Dental Board. There was one attendee, Tom Cope, representing the Iowa Dental Hygienists Association, who read the Association’s previously submitted written comments.
There were 18 written comments received. All written comments supported the general intent of the amendments. Several commenters asked for changes to be made to reduce duplicative paperwork and reporting requirements that may also be performed by dental hygienists; several requested that the three years of clinical practice experience required to become eligible to work under public health supervision be reduced to one year of clinical practice experience; several requested that some of the duties be changed or removed; and one requested that there be a limit to the number of dental assistants that a dentist can supervise while expanded function procedures are performed and a limit to the number of dental assistants that a dentist can supervise under public health supervision.
The Board reviewed and discussed the public comments during its April 23, 2015, open session Board meeting and allowed additional comments from the public. Based on the review and comments, several changes have been made to the amendments published under Notice of Intended Action. In paragraph “4” of Item 2, definition of “public health supervision,” the minimum clinical practice experience requirement was changed from three years to one year. In Item 6, paragraph 20.4(4)“c”(2)“5,” the phrase “where denture is not relieved or modified” has been deleted. In Item 12, subparagraphs 20.16(2)“b”(3) to (5) have been revised grammatically for consistency in terminology and parallel structure. Also in Item 12, the name of the Bureau of Oral and Health Delivery Systems has been corrected in subrules 20.16(2) and 20.16(3).
These amendments were adopted by the Board on May 15, 2015.
After analysis and review of this rule making, a positive impact on jobs has been found for dental assistants, who will now be able to perform more procedures and work in more settings.
These amendments are intended to implement Iowa Code sections 153.38 and 153.39.
These amendments will become effective on July 15, 2015.
The following amendments are adopted.
	Item 1. Amend rule 650—20.2(153), definition of “General supervision,” as follows:
“General supervision” means that a dentist has examined the patient and has delegated the services to be provided by a registered dental assistant, which are limited to all extraoral duties, dental radiography, intraoral suctioning, and use of a curing light and intraoral camera. The dentist need not be present in the facility while these services are being provided.
	Item 2. Adopt the following new definition of “Public health supervision” in rule 650—20.2(153):
“Public health supervision” means all of the following:
	1.	The dentist authorizes and delegates the services provided by a registered dental assistant to a patient in a public health setting, with the exception that services may be rendered without the patient’s first being examined by a licensed dentist;
	2.	The dentist is not required to provide future dental treatment to patients served under public health supervision;
	3.	The dentist and the registered dental assistant have entered into a written supervision agreement that details the responsibilities of each licensee/registrant, as specified in subrule 20.16(2); and
	4.	The registered dental assistant has an active Iowa registration and a minimum of one year of clinical practice experience.
	Item 3. Rescind subrule 20.3(3).
	Item 4. Renumber subrule 20.3(4) as 20.3(3).
	Item 5. Renumber rules 650—20.4(153) to 650—20.14(153) as 650—20.5(153) to 650—20.15(153).
	Item 6. Adopt the following new rule 650—20.4(153):
650—20.4(153) Expanded function requirements.
	20.4(1) Supervision requirements. Registered dental assistants may only perform expanded function procedures which are delegated by and performed under the direct supervision of a dentist licensed pursuant to Iowa Code chapter 153. Dental assistant trainees are not eligible to perform expanded function procedures.
	20.4(2) Expanded function training required. A registered dental assistant shall not perform any expanded function procedures listed in this chapter unless the assistant has successfully met the education and training requirements and is in compliance with the requirements of this chapter.
	20.4(3) Education and training requirements. All expanded function training must be prior-approved by the board. The supervising dentist and the registered dental assistant shall be responsible for maintaining in each office of practice documentation of successful completion of the board-approved training.
	a. 	Expanded function training for Level 1 procedures shall be eligible for board approval if the training is offered through a program accredited by the Commission on Dental Accreditation of the American Dental Association (ADA) or another program, which may include on-the-job training offered by a dentist licensed in Iowa. Training must consist of the following:
	(1)	An initial assessment to determine the base entry level of all participants in the program. At a minimum, all participants must meet at least one of the following requirements before beginning expanded function training:
	1.	Be a graduate of an ADA-accredited dental assistant program; or
	2.	Be currently certified by the Dental Assisting National Board (DANB); or
	3.	Have at least one year of clinical practice as a registered dental assistant; or
	4.	Have at least one year of clinical practice as a dental assistant in a state that does not require registration;
	(2)	A didactic component;
	(3)	A laboratory component, if necessary;
	(4)	A clinical component, which may be obtained under the personal supervision of the participant’s supervising dentist while the participant is concurrently enrolled in the training program; and
	(5)	A postcourse competency assessment at the conclusion of the training program.
	b. 	Expanded function training for Level 2 procedures shall be eligible for board approval if the training is offered through the University of Iowa College of Dentistry or a program accredited by the Commission on Dental Accreditation of the American Dental Association.
	20.4(4) Expanded function providers.
	a. 	Basic expanded function provider. Registered dental assistants who do not wish to become certified as a Level 1 or Level 2 provider may perform select Level 1 expanded function procedures provided they have met the education and training requirements for those procedures. A dentist may delegate to a registered dental assistant only those Level 1 procedures for which the assistant has received the required expanded function training.
	b. 	Certified Level 1 provider. Registered dental assistants must successfully complete training for all Level 1 expanded function procedures before becoming a certified Level 1 provider.
	(1)	A dentist may delegate any of the Level 1 expanded function procedures to dental assistants who are certified Level 1 providers.
	(2)	Level 1 procedures include:
	1.	Taking occlusal registrations;
	2.	Placement and removal of gingival retraction;
	3.	Fabrication and removal of provisional restorations;
	4.	Applying cavity liners and bases, desensitizing agents, and bonding systems;
	5.	Placement and removal of dry socket medication;
	6.	Placement of periodontal dressings;
	7.	Testing pulp vitality;
	8.	Monitoring of nitrous oxide inhalation analgesia;
	9.	Taking final impressions;
	10.	Removal of adhesives (hand instrumentation only); and
	11.	Preliminary charting of existing dental restorations and teeth.
	c. 	Certified Level 2 provider. A registered dental assistant must become a certified Level 1 provider and successfully pass a board-approved entrance examination with a score of at least 75 percent before beginning training as a certified Level 2 provider. Registered dental assistants must successfully complete training for all Level 2 expanded function procedures before becoming certified Level 2 providers.
	(1)	A dentist may delegate any of the Level 1 or Level 2 expanded function procedures to a registered dental assistant who is a certified Level 2 provider.
	(2)	Level 2 procedures include:
	1.	Placement and shaping of amalgam following preparation of a tooth by a dentist;
	2.	Placement and shaping of composite following preparation of a tooth by a dentist;
	3.	Forming and placement of stainless steel crowns;
	4.	Taking records for the fabrication of dentures and partial dentures; and
	5.	Tissue conditioning (soft reline only).
These procedures refer to both primary and permanent teeth.
	(3)	Notwithstanding 650—paragraph 10.3(1)“e” and paragraph 20.3(2)“e,” for the purposes of this chapter, the removal of adhesives by hand instrumentation does not constitute the removal of “hard natural or synthetic material.”
	Item 7. Amend renumbered subparagraphs 20.5(1)“b”(1) and (2) as follows:
	(1)	Reapplying for trainee status. A trainee may “start over” as a dental assistant trainee provided the trainee submits an application in compliance with subrule 20.6(1) 20.7(1).
	(2)	Examination scores valid for three years. A “repeat” trainee is not required to retake an examination (jurisprudence, infection control/hazardous materials, radiography) if the trainee has successfully passed the examination within three years of the date of application. If a trainee has failed two or more examinations, the trainee must satisfy the remedial education requirements in subrule 20.10(1) 20.11(1). The trainee status application will not be approved until the trainee successfully completes any required remedial education.
	Item 8. Amend renumbered subrule 20.5(2) as follows:
	20.5(2) Registered dental assistant. A registered dental assistant may perform under general supervision dental radiography, intraoral suctioning, use of a curing light and intraoral camera, and all extraoral duties that are assigned by the dentist and are consistent with these rules. During intraoral procedures, the registered dental assistant may, under direct supervision, assist the dentist in performing duties assigned by the dentist that are consistent with these rules. The registered dental assistant may take radiographs if qualified pursuant to 650—Chapter 22.
	Item 9. Amend renumbered subparagraph 20.7(2)“b”(2) as follows:
	(2)	Evidence of meeting the requirements specified in 20.6(2)“a.” 20.7(2)“a.”
	Item 10. Amend renumbered paragraph 20.11(1)“b” as follows:
	b. 	A dental assistant who fails the second examination will be required to complete the remedial education requirements set forth in subrule 20.10(2) 20.11(2).
	Item 11. Rescind rule 650—20.15(153).
	Item 12. Adopt the following new rule 650—20.16(153):
650—20.16(153) Public health supervision allowed. A dentist may provide public health supervision to a registered dental assistant if the dentist has an active Iowa license and the services are provided in a public or private school, public health agencies, hospitals, or the armed forces.
	20.16(1) Public health agencies defined. For the purposes of this rule, public health agencies include programs operated by federal, state, or local public health departments.
	20.16(2) Responsibilities. When working together in a public health supervision relationship, a dentist and registered dental assistant shall enter into a written agreement that specifies the following responsibilities.
	a. 	The dentist providing public health supervision must:
	(1)	Be available to provide communication and consultation with the registered dental assistant;
	(2)	Have age- and procedure-specific standing orders for the performance of services. Those standing orders must include consideration for medically compromised patients and medical conditions for which a dental evaluation must occur prior to the provision of services;
	(3)	Specify a period of time in which an examination by a dentist must occur prior to providing further services;
	(4)	Specify the location or locations where the services will be provided under public health supervision.
	b. 	A registered dental assistant providing services under public health supervision may only provide services which are limited to all extraoral duties, dental radiography, intraoral suctioning, and use of a curing light and intraoral camera and must:
	(1)	Maintain contact and communication with the dentist providing public health supervision;
	(2)	Practice according to age- and procedure-specific standing orders as directed by the supervising dentist, unless otherwise directed by the dentist for a specific patient;
	(3)	Ensure that the patient, parent, or guardian receives a written plan for referral to a dentist;
	(4)	Ensure that each patient, parent, or guardian signs a consent form that notifies the patient that the services that will be received do not take the place of regular dental checkups at a dental office and are meant for people who otherwise would not have access to services; and
	(5)	Ensure that a procedure is in place for creating and maintaining dental records for the patients who are treated, including where these records are to be located.
	c. 	The written agreement for public health supervision must be maintained by the dentist and the registered dental assistant and a copy filed with the board office within 30 days of the date on which the dentist and the registered dental assistant entered into the agreement. The dentist and registered dental assistant must review the agreement at least biennially.
	d. 	The registered dental assistant shall file annually with the supervising dentist and the bureau of oral and health delivery systems a report detailing the number of patients seen, the services provided to patients and the infection control protocols followed at each practice location.
	e. 	A copy of the written agreement for public health supervision shall be filed with the Bureau of Oral and Health Delivery Systems, Iowa Department of Public Health, Lucas State Office Building, 321 E. 12th Street, Des Moines, Iowa 50319.
	20.16(3) Reporting requirements. Each registered dental assistant who has rendered services under public health supervision must complete a summary report at the completion of a program or, in the case of an ongoing program, at least annually. The report shall be filed with the bureau of oral and health delivery systems of the Iowa department of public health on forms provided by the department and shall include information related to the number of patients seen and services provided so that the department may assess the impact of the program. The department will provide summary reports to the board on an annual basis.
[Filed 5/18/15, effective 7/15/15]
[Published 6/10/15]
Editor’s Note: For replacement pages for IAC, see IAC Supplement 6/10/15.