CHAPTER 23
EXPANDED FUNCTIONS
650—23.1(153) Definitions. As used in this chapter:
“Accredited school” means a dental, dental hygiene, or dental assisting education program accredited by the Commission on Dental Accreditation (CODA).
“Clinical training” means training which includes patient experiences.
“Didactic training” means educational instruction.
“Fabrication” means the construction or creation of an impression, occlusal registration, provisional restoration or denture, as defined in this chapter.
“Laboratory training” means training that is hands-on, that may include simulation, and that prepares a dental hygienist or dental assistant for patient experiences. Laboratory training can be done as part of an approved course, or obtained through a supervising dentist.
“Observational supervision,” for expanded functions, is for training purposes only and means the dentist is physically present in the treatment room to oversee and direct all services being provided as part of clinical training.
“Patient experiences” are procedures that are performed on a patient, during the course of clinical training, under the observational supervision of a dentist.
“Prosthetic” means any provisional or permanent restoration intended to replace a tooth or teeth.
“Provisional restoration” means a restoration or appliance, which is formed or preformed for temporary purposes, used over a limited period of time.
[ARC 4676C, IAB 9/25/19, effective 10/30/19; ARC 6733C, IAB 12/14/22, effective 1/18/23]
650—23.2(153) Expanded function requirements and eligibility.
	23.2(1) Dental hygienists or dental assistants may only perform expanded function procedures upon successful completion of a board-approved course of training and certification by the board. All expanded function procedures must be delegated by and performed under the direct supervision of a dentist licensed pursuant to Iowa Code chapter 153 unless otherwise specified in this rule. A dental assistant trainee is not eligible to perform or receive training in expanded function procedures. This shall not preclude dental hygienists or dental assistants from practicing expanded function procedures for training purposes while enrolled in a board-approved course of training.
	23.2(2) To be eligible to train in Level 1 expanded function procedures, dental hygienists or dental assistants must comply with one of the following:
	a. 	Hold an active dental hygiene license in Iowa; or
	b. 	Hold an active dental assistant registration, and comply with at least one of the following:
	(1)	Be a graduate of an accredited school; or
	(2)	Be currently certified by the Dental Assisting National Board (DANB); or
	(3)	Have at least three months of clinical practice as a registered dental assistant; or
	(4)	Have at least three months of clinical practice as a dental assistant in a state that does not require registration.
	23.2(3) A dentist who delegates Level 1 or Level 2 expanded function procedures to dental hygienists or dental assistants under direct supervision must examine the patient to review the quality of work prior to the conclusion of the dental appointment. The following expanded function procedures are exempt from this requirement and may be performed under general supervision:
	a. 	Recementation of a provisional restoration.
	b. 	Taking occlusal registrations for purposes other than mounting study casts by dental hygienists only.
[ARC 4676C, IAB 9/25/19, effective 10/30/19; ARC 6733C, IAB 12/14/22, effective 1/18/23]
650—23.3(153) Expanded function categories. Dental hygienists and dental assistants must be issued a certificate of completion for the corresponding function in which training has been completed by a board-approved training program before performing a specific expanded function procedure. A dentist may delegate to dental hygienists or dental assistants only those expanded function procedures in which training has been successfully completed.
	23.3(1)  Level 1. Level 1 expanded functions may be taught by board-approved training providers using curriculum prior-approved by the board.
	23.3(2)  Level 2. Training in Level 2 expanded functions must be completed at the University of Iowa College of Dentistry or another accredited school using curriculum approved by the board. Before beginning Level 2 training, dental assistants and dental hygienists must complete all prerequisites established by the accredited school for the Level 2 training to be completed.
[ARC 4676C, IAB 9/25/19, effective 10/30/19; ARC 6733C, IAB 12/14/22, effective 1/18/23]
650—23.4(153) Level 1 expanded function procedures for dental assistants. Level 1 expanded function procedures for dental assistants include:
	23.4(1) Taking occlusal registrations;
	23.4(2) Placement and removal of gingival retraction material;
	23.4(3) Fabrication, temporary cementation, and removal of provisional restorations following review of the fit and function by the supervising dentist, and temporary recementation of provisional restorations;
	23.4(4) Applying cavity liners and bases and desensitizing agents;
	23.4(5) Applying bonding systems, which may include the placement of the attachments used in clear aligner systems, following review of the fit and function by the supervising dentist;
	23.4(6) Placement, bonding, and removal of provisional orthodontic restorations as follows:
	a. 	Placement or bonding of orthodontic brackets and bands or provisional orthodontic appliances following review of the fit and function by the supervising dentist; and
	b. 	Removal of adhesive, orthodontic brackets and bands, or provisional orthodontic appliances using nonmotorized hand instrumentation;
	23.4(7) Monitoring of patients receiving nitrous oxide inhalation analgesia, which may include increasing oxygen levels as needed, pursuant to the following:
	a. 	A dentist shall induce a patient and establish the maintenance level;
	b. 	A dental assistant may make adjustments that decrease the nitrous oxide concentration during the administration of nitrous oxide;
	c. 	A dental assistant may turn off the oxygen delivery at the completion of the dental procedure;
	23.4(8) Taking final impressions;
	23.4(9) Removal of adhesives using nonmotorized hand instrumentation;
	23.4(10) Placement of temporary restorative materials following preparation of the tooth by a dentist;
	23.4(11) Extraoral adjustment to acrylic dentures without making any adjustments to the prosthetic teeth; and
	23.4(12) Tissue conditioning (soft reline only).
[ARC 4676C, IAB 9/25/19, effective 10/30/19; ARC 6733C, IAB 12/14/22, effective 1/18/23]
650—23.5(153) Level 1 expanded function procedures for dental hygienists. Level 1 expanded function procedures for dental hygienists include:
	23.5(1) Taking occlusal registrations;
	23.5(2) Placement and removal of gingival retraction material;
	23.5(3) Fabrication, temporary cementation, and removal of provisional restorations following review of the fit and function by the supervising dentist, and temporary recementation of provisional restorations;
	23.5(4) Applying cavity liners and bases;
	23.5(5) Applying bonding systems, which may include the placement of the attachments used in clear aligner systems, following review of the fit and function by the supervising dentist;
	23.5(6) Taking final impressions;
	23.5(7) Placement, bonding, and removal of provisional orthodontic appliances as follows:
	a. 	Placement or bonding of orthodontic brackets and bands or provisional orthodontic appliances following review of fit and function by the supervising dentist; and
	b. 	Removal of adhesive, orthodontic brackets and bands, or provisional orthodontic appliances;
	23.5(8) Placement of temporary restorative materials following preparation of the tooth by a dentist;
	23.5(9) Extraoral adjustment to acrylic dentures without making any adjustments to the prosthetic teeth; and
	23.5(10) Tissue conditioning (soft reline only).
[ARC 4676C, IAB 9/25/19, effective 10/30/19; ARC 6733C, IAB 12/14/22, effective 1/18/23]
650—23.6(153) Level 2 expanded function procedures for dental hygienists and dental assistants.
	23.6(1) Level 2 expanded function procedures for dental hygienists and dental assistants include:
	a. 	Placement and shaping of amalgam following preparation of a tooth by a dentist;
	b. 	Placement and shaping of adhesive restorative materials following preparation of a tooth by a dentist;
	c. 	Polishing of adhesive restorative material using a slow-speed handpiece; and
	d. 	Fitting of stainless steel crowns on primary posterior teeth, and cementation after fit verification by a dentist.
	23.6(2) Level 2 expanded function procedures for dental assistants include the placement of sealants. The placement of sealants is included in the scope of practice for dental hygienists and is not considered an expanded function for dental hygienists.
	23.6(3) These Level 2 expanded function procedures refer to both primary and permanent teeth except as otherwise noted. Training in Level 2 expanded functions may be separated between application of the services on primary or permanent teeth as determined by the accredited training provider.
[ARC 4676C, IAB 9/25/19, effective 10/30/19; ARC 5748C, IAB 7/14/21, effective 8/18/21; ARC 6733C, IAB 12/14/22, effective 1/18/23]
650—23.7(153) Expanded function training.
	23.7(1) Approved expanded function training programs. Training programs for Level 1 and Level 2 expanded function procedures must be board-approved. Training programs for Level 2 expanded function procedures shall be eligible for board approval if the training is offered through the University of Iowa College of Dentistry or another accredited school.
	23.7(2) Certificates of completion. All board-approved training programs are authorized and required to issue certificates to dental hygienists and dental assistants who successfully complete expanded function training. A certificate shall be issued for one or more of the listed expanded function procedures completed. Dental hygienists and dental assistants shall prominently display the expanded functions certificate in each dental facility where services are provided.
	23.7(3) Training requirements. Training may be completed in one or more of the listed expanded function procedures. Clinical training in expanded function procedures must be completed under observational supervision. Level 1 expanded function training must consist of the following:
	a. 	An initial assessment to determine the base entry level of all participants in the program;
	b. 	Completion of a training program that meets the following minimum standards for each function:
	(1)	Taking occlusal registrations:
Goal: To reproduce the patient’s jaw relationship accurately.
Standard: Demonstrate an accurate occlusal registration confirmed by a supervising dentist.
Minimum training requirement: One hour of didactic training, and clinical training that includes a minimum of five patient experiences under observational supervision.
	(2)	Placement and removal of gingival retraction material:
Goal: To expose the margins of a crown by displacing tissue from the tooth.
Standard: Perform the procedural steps to place and remove retraction material and recognize oral conditions and techniques that may compromise tissue displacement or patient health.
Minimum training requirement: Two hours of didactic training, the equivalent of one hour of laboratory training that includes a minimum of three experiences, and clinical training that includes a minimum of five patient experiences under observational supervision.
	(3)	Fabrication, temporary cementation, temporary recementation, and removal of provisional restorations:
Goal: To replicate the anatomy and function of the natural tooth, prior to the final restoration, and secure the provisional restoration to a previously prepared tooth after the provisional restoration has become loose or dislodged.
Standard: Use various methods to fabricate and temporarily cement single-unit and multiunit provisional restorations.
Minimum training requirement: Four hours of didactic training, the equivalent of four hours of laboratory training that includes a minimum of five experiences, and clinical training that includes a minimum of ten patient experiences under observational supervision.
	(4)	Applying cavity liners and bases and desensitizing agents:
Goal: To apply appropriate material that protects existing tooth structure and to apply appropriate medicaments to minimize sensitivity to existing tooth structure.
Standard: Manipulate and apply appropriate material and apply appropriate medicaments to meet clinical competency.
Minimum training requirement: One hour of didactic training, the equivalent of one hour of laboratory training that includes a minimum of two experiences, and clinical training that includes a minimum of five patient experiences in each one of the functions under observational supervision.
	(5)	Applying bonding systems, which may include the placement of the attachments used in clear aligner systems, following review of the fit and function by the supervising dentist:
Goal: To apply appropriate material and systems that adhere to the existing tooth structure.
Standard: Manipulate and apply appropriate material and systems to meet clinical competency.
Minimum training requirement: Two hours of didactic training, the equivalent of one hour of laboratory training that includes a minimum of two experiences, and clinical training that includes a minimum of five patient experiences under observational supervision.
	(6)	Placement, bonding, and removal of orthodontic brackets and bands or provisional orthodontic appliances pursuant to subrules 23.4(5) and 23.5(7):
Goal: To place on and remove from the existing tooth structure orthodontic brackets and bands or provisional orthodontic appliances.
Standard: Manipulate and apply appropriate material and appliances to meet clinical competency.
Minimum training requirement: For each function, two hours of didactic training, the equivalent of one hour of laboratory training that includes a minimum of two experiences, and clinical training that includes a minimum of five patient experiences under observational supervision.
	(7)	Monitoring of patients receiving nitrous oxide inhalation analgesia, pursuant to subrule 23.4(7):
Goal: Understand the equipment, recognize the signs of patient distress or adverse reaction, and know when to call for help.
Standard: Exercise the ability to maintain patient safety while nitrous oxide is used.
Minimum training requirement: Two hours of didactic training, one hour of laboratory training in the office where the dental hygienist or dental assistant is employed, and five patient experiences under observational supervision.
	(8)	Taking final impressions:
Goal: Reproduce soft and hard oral tissues, digitally or with impression materials.
Standard: Complete the procedural steps to obtain a clinically acceptable final impression.
Minimum training requirement: Three hours of didactic training, and the equivalent of clinical training that includes a minimum of six patient experiences under observational supervision.
	(9)	Removal of adhesives using nonmotorized hand instrumentation:
Goal: Remove excess adhesives and bonding materials to eliminate soft tissue irritation.
Standard: Identify how, when and where to remove excessive bonding or adhesive material.
Minimum training requirement: One hour of didactic training, and clinical training that includes a minimum of five patient experiences under observational supervision.
	(10)	Placement of temporary restorative materials following preparation of the tooth by the dentist:
Goal: Place temporary restorative materials following preparation of a tooth by a dentist.
Standard: Identify how, when and where to place temporary restorative materials.
Minimum training requirement: Two hours of didactic training, the equivalent of one hour of laboratory training that includes a minimum of two experiences, and clinical training that includes a minimum of five patient experiences under observational supervision.
	(11)	Extraoral adjustment to acrylic dentures without making any adjustments to the prosthetic teeth:
Goal: To make adjustments to dentures.
Standard: Identify how and where to make extraoral adjustments to dentures.
Minimum training requirement: One hour of didactic training, the equivalent of one hour of laboratory training that includes a minimum of two experiences, and clinical training that includes a minimum of five patient experiences under observational supervision.
	(12)	Tissue conditioning (soft reline only):
Goal: To apply appropriate material to dentures.
Standard: Identify how and where to apply appropriate material to dentures.
Minimum training requirement: One hour of didactic training, the equivalent of one hour of laboratory training that includes a minimum of two experiences, and clinical training that includes a minimum of five patient experiences under observational supervision.
	c. 	A postcourse written examination at the conclusion of the training program, with a minimum of ten questions per function, must be administered. Participants must obtain a score of 75 percent or higher on each examination administered.
	23.7(4) Grandfathering. Any dental hygienist or dental assistant who has completed expanded function training prior to January 1, 2020, can continue to perform expanded function procedures for which training has been completed. For any expanded function procedures that are new, in whole or in part, additional training to satisfy the standard and minimum training requirement is required of the dental hygienist or dental assistant prior to performing the new expanded function procedure.
[ARC 4676C, IAB 9/25/19, effective 10/30/19; ARC 6733C, IAB 12/14/22, effective 1/18/23]
These rules are intended to implement Iowa Code chapter 153.
[Filed ARC 4676C (Notice ARC 4424C, IAB 5/8/19), IAB 9/25/19, effective 10/30/19]
[Filed ARC 5748C (Notice ARC 5381C, IAB 1/13/21), IAB 7/14/21, effective 8/18/21]
[Filed ARC 6733C (Notice ARC 6515C, IAB 9/7/22), IAB 12/14/22, effective 1/18/23]