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.
“Direct supervision” means that the dentist is present in the treatment facility, but it is not required that the dentist be physically present in the treatment room.
“Fabrication” means the construction or creation of an impression, occlusal registration, provisional restoration or denture, as defined in this chapter.
“General supervision of a dental assistant” 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, use of a curing light, intraoral camera, and recementation of a provisional restoration. The dentist need not be present in the facility while these services are being provided.
“General supervision of a dental hygienist” means that a dentist has examined the patient and has prescribed authorized services to be provided by a dental hygienist. The dentist need not be present in the facility while these services are being provided. If a dentist will not be present, the following requirements shall be met:
	1.	Patients or their legal guardians must be informed prior to the appointment that no dentist will be present and therefore no examination will be conducted at that appointment.
	2.	The hygienist must consent to the arrangement.
	3.	Basic emergency procedures must be established and in place, and the hygienist must be capable of implementing these procedures.
	4.	The treatment to be provided must be prior prescribed by a licensed dentist and must be entered in writing in the patient record.
“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 crown or bridge placed with the intention of being replaced with a permanent crown or bridge at a later date, or a permanent crown provisionally recemented to be replaced or recemented at a later date.
[ARC 4676C, IAB 9/25/19, effective 10/30/19]
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 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.
	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 Level 1 or Level 2 dental hygienists only.
[ARC 4676C, IAB 9/25/19, effective 10/30/19]
650—23.3(153) Expanded function categories.
	23.3(1) Basic Level 1. Dental hygienists or dental assistants who train in some, but not all, Level 1 expanded function procedures are deemed to be basic expanded function dental hygienists or dental assistants. Dental hygienists and dental assistants must be issued a certificate of completion for the corresponding function 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 Level 1 expanded function procedures for which training has been successfully completed.
	23.3(2) Certified Level 1. Expanded function dental hygienists or dental assistants who have successfully completed training for all Level 1 expanded function procedures and have been issued a certificate of completion by a board-approved training program are deemed to be certified Level 1 dental hygienists or dental assistants.
	23.3(3) Certified Level 2. Before beginning Level 2 training to become certified in Level 2, expanded function dental hygienists or dental assistants must have a minimum of one year of clinical practice as a certified Level 1 dental hygienist or dental assistant and pass an entrance examination administered by the Level 2 training program.
	a. 	Dental hygienists or dental assistants who have successfully completed training in Level 2 expanded function procedures and have been issued a certificate of completion by a board-approved training program are deemed to be certified Level 2 dental hygienists or dental assistants.
	b. 	A dentist may delegate any Level 1 or Level 2 expanded function procedures to dental hygienists or dental assistants who are certified Level 2.
[ARC 4676C, IAB 9/25/19, effective 10/30/19]
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;
	23.4(4) Applying cavity liners and bases; desensitizing agents; and bonding systems, to include the placement of orthodontic brackets, following the determination of location by the supervising dentist;
	23.4(5) 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(6) Taking final impressions;
	23.4(7) Removal of adhesives using nonmotorized hand instrumentation;
	23.4(8) Placement of Class 1 temporary filling materials; and
	23.4(9) Recementation of provisional restorations.
[ARC 4676C, IAB 9/25/19, effective 10/30/19]
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;
	23.5(4) Applying cavity liners and bases and applying bonding systems for restorative purposes, including the placement of orthodontic brackets, following the determination of location by the supervising dentist;
	23.5(5) Taking final impressions;
	23.5(6) Placement of Class 1 temporary filling materials; and
	23.5(7) Recementation of provisional restorations.
[ARC 4676C, IAB 9/25/19, effective 10/30/19]
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;
	d. 	Fitting of stainless steel crowns on primary posterior teeth, and cementation after fit verification by a dentist;
	e. 	Tissue conditioning (soft reline only);
	f. 	Extraoral adjustment to acrylic dentures without making any adjustments to the prosthetic teeth; and
	g. 	Placement of intracoronal temporary fillings following preparation of a tooth 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.
[ARC 4676C, IAB 9/25/19, effective 10/30/19; ARC 5748C, IAB 7/14/21, effective 8/18/21]
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 as Basic Level 1, or a certificate shall be issued for Certified Level 1 or Certified Level 2. 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. Beginning January 1, 2020, 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 and removal of provisional restorations:
Goal: To replicate the anatomy and function of the natural tooth, prior to the final restoration.
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; desensitizing agents; and bonding systems, to include the placement of orthodontic brackets, following the determination of location by the supervising dentist:
Goal: To apply appropriate material that protects existing tooth structure and adheres existing tooth structure to restorative materials.
Standard: Manipulate and apply appropriate material 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 5 patient experiences in each one of these areas (for a total of 15 patient experiences under observational supervision).
	(5)	Monitoring of patients receiving nitrous oxide inhalation analgesia, pursuant to subrule 23.4(5):
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.
	(6)	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.
	(7)	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.
	(8)	Placement of Class 1 temporary filling materials:
Goal: Place Class 1 temporary filling materials following preparation of a tooth by a dentist.
Standard: Identify how, when and where to place Class 1 temporary filling materials.
Minimum training requirement: One hour of didactic training, and clinical training that includes a minimum of five patient experiences under observational supervision.
	(9)	Recementation of provisional restorations:
Goal: 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: If this training is completed in conjunction with training in fabrication, temporary cementation and removal of provisional crown and bridge restorations, the training requirements may be combined since the procedures are related. If this training is being completed separately, the same training requirements for fabrication, temporary cementation and removal of provisional restorations applies.
	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]
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]