02 department of professional and financial regulation 313 board of dental examiners chapter 2: rules relating to dental hygienists summary



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02 DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
313 BOARD OF DENTAL EXAMINERS
Chapter 2: RULES RELATING TO DENTAL HYGIENISTS

Summary: This Chapter establishes the duties a dentist may delegate to dental hygienists. A dentist may not permit a dental hygienist to perform any act not specifically provided for in this chapter.


Section I. GENERAL SUPERVISION OF DENTAL HYGIENISTS
Dental hygienists may perform the following duties under the general supervision of a dentist:
A. Apply cavity varnish;
B. Apply desensitizing agents to teeth;
C. Apply fluoride to control caries;
D. Apply liquids, pastes, or gel topical anesthetics;
E. Apply sealants, provided that a licensed dentist first makes the determination and diagnosis as to the surfaces on which the sealants shall be applied;
In Public health or school sealant programs only, determination, and diagnosis of the sealant site by a dentist need not occur;
F. Cement pontics and facings outside the mouth;
G. Change/replace dry socket packets after diagnosed and treatment planned by a dentist;
H. Deliver, but not condense or pack, amalgam or composite restoration material;
I. Expose and process radiographs, permitted pursuant to Title 32 M.R.S.A. §1100-J(3)(A);
J. Fabricate temporary crowns and bridges, limiting handpiece rotary instrumentation used in the fabrication only to extraoral use, so long as the dentist checks the occlusion and fit prior to releasing the patient;
K. For instruction purposes, a dental hygienist may demonstrate to a patient how the patient should place and remove removable prostheses, appliances, or retainers;
L. For the purpose of eliminating pain or discomfort, remove loose, broken, or irritating orthodontic appliances;
M. Give oral health instruction;
N. Interview patients and record complete medical and dental histories;
O. Irrigate and aspirate the oral cavity;
P. Isolate operative fields;
Q. Obtain bacterial sampling when treatment is planned by the dentist;
R. Perform all procedures necessary for a complete prophylaxis, including root planing;
S. Perform cold vitality testing with confirmation by the dentist;
T. Perform complete periodontal and dental restorative charting;
U. Perform dietary analyses for dental disease control;
V. Perform electronic vitality scanning with confirmation by the dentist;
W. Perform oral inspections, recording all conditions that should be called to the attention of the dentist;
X. Perform post-operative irrigation of surgical sites;
Y. Perform preliminary selection and fitting of orthodontic bands, but final placement and cementing in the patient’s mouth shall be done by the dentist;
Z. Place and recement temporary crowns with temporary cement;
AA. Place and recement with temporary cement an existing crown that has fallen out;
BB. Place and remove gingival retraction cord without vasoconstrictor;
CC. Place and remove matrix bands;
DD. Place and remove periodontal dressing;
EE. Place and remove rubber dams;
FF. Place and remove wedges;
GG. Place elastics and/or instruct in their use;
HH. Place, hold or remove celluloid and other plastic strips prior to or subsequent to the placement of a filling by the dentist;
II. Place localized delivery of chemotherapeutic agents when treatment is planned by the dentist;
JJ. Place or remove temporary separating devices;
KK. Place wires, pins, and elastic ligatures to tie in orthodontic arch wires that have been fitted and approved by the dentist at the time of insertion;
LL. Place temporary restorations as an emergency procedure, provided that the patient is informed of the temporary nature of the restoration;
MM. Pour and trim dental models;
NN. Prepare tooth sites and surfaces with a rubber cup and pumice for banding or bonding of orthodontic brackets. This procedure shall not be intended or interpreted as a preparation for restorative material;
OO. Reapply, on an emergency basis only, orthodontic brackets;
PP. Remove composite material using slow speed instrumentation for de-bonding brackets, as long as the dentist conducts a final check prior to release of the patient;
QQ. Remove excess cement from the supragingival surfaces of teeth;
RR. Remove orthodontic arch wires and tension devices and any loose bands or bonds, but only as directed by the dentist;
SS. Remove sutures;
TT. Retract lips, cheek, tongue, and other tissue parts;
UU. Select and try in stainless steel or other preformed crowns for insertion by the dentist;
VV. Smooth and polish amalgam restorations;
WW. Take and record the vital signs of blood pressure, pulse, and temperature;
XX. Take and pour impressions for study casts, athletic mouth guards, custom trays, bleaching trays, fluoride trays, opposing models, retainers, and stents;
YY. Take dental plaque smears for microscopic inspection and patient education;
ZZ. Take intra-oral measurements and make preliminary selection of arch wires and intra and extra-oral appliances, including head gear; and
AAA. Take intra-oral photographs.

Section II. DIRECT SUPERVISION OF DENTAL HYGIENISTS
A dental hygienist may perform the following duties only when under the direct supervision of a dentist:
A. Administer local anesthesia, but only after being issued a permit from the Board.


  1. Permit Requirements. In order to qualify for a permit to administer local anesthesia, a dental hygienist must meet the following minimum requirements:

(a) Required Course of Study. An applicant must successfully complete with a passing grade a course of study of at least 40 hours of instruction in a formal program in administration of local anesthesia sponsored by an institutional program accredited by the Commission on Dental Accreditation of the American Dental Association. A certificate of course completion and a copy of the syllabus must be provided to the Board for approval. The course must include didactic studies and clinical experience in the administration of block and infiltration anesthesia. A minimum of 30 satisfactorily performed injections is required.


The curriculum for required study must include but is not necessarily limited to:
i. Medical history evaluation procedures;
ii. Understanding pharmacology of local anesthesia and vasoconstrictors;
iii. Anatomy of head, neck, and oral cavity as it relates to administering local anesthetic agents;
iv. Indications and contraindications for administration of local anesthesia;
v. Selection and preparation of the armamentaria and record keeping for administering various local anesthetic agents;
vi. Medical and legal management of complications;
vii. Recognition and management of post-injection complications and management of reactions to injections;
viii. Proper infection control techniques with regard to local anesthesia and proper disposal of sharps;
ix. Methods of administering local anesthetic agents with emphasis on:
(1) Technique
(a) aspiration
(b) slow injection
(2) Minimum effective dosage
(b) Examination. Upon satisfactory completion of the application process, including submission of a copy of a valid CPR certification, the applicant must pass a Board administered examination in the administration of local anesthesia, or a national, regional, or state examination in the administration of local anesthesia as approved by the Board.
A dental hygienist who has been licensed and trained to administer local anesthesia in another state may qualify, at the discretion of the Board, to take the examination by presenting written documentation of such licensure and training to the Board, along with documentation of at least two years experience within the past five years and by gaining approval of the Board through the interview process.
(c) Application. All applicants must complete an application provided by the Board.
(d) Fee. All applicants must submit an application fee as provided by Chapter 7.
(2) Permit by Endorsement. The Board may issue a permit to administer local anesthesia to a licensed dental hygienist who is licensed in another state or Canadian province and has:
(a) successfully completed the examination administered by the Board or a national, regional, or state administered examination;
(b) provided the Board with documentation of training equivalent to or greater than that required by these rules;
(c) agreed to limit the administration of local anesthesia as provided by these rules;
(d) completed an application provided by the Board; and
(e) submitted an application fee as provided by Chapter 7 of these rules.
(3) Duration of Anesthesia Permit. A permit to administer local anesthesia shall be effective for a period of five (5) years from the date of issuance.
B. Administer nitrous oxide pursuant to this rule, but only after being issued a permit by the Board. A dental hygienist who has not obtained a permit to administer nitrous oxide from the Board may, during nitrous oxide administration by the dentist, observe the gauges and advise the dentist of any changes in gauge indices or readings but shall not in any way or under any circumstances adjust, manipulate or control the nitrous oxide apparatus or equipment.
(1) Permit Requirements. In order to qualify for a permit to nitrous oxide, a dental hygienist must meet the following minimum requirements:


  1. Required Course of Study. An applicant must successfully complete a nitrous oxide course in a CODA-approved dental or dental hygiene program or other Board-approved course. The nitrous oxide course must be at least 8 hours in length and include didactic and clinical components and an exit examination. The hygienist must receive both a minimum of 75% on the exit examination and course grade in order to meet satisfactory completion requirements.




  1. Application. All applicants must complete an application provided by the Board.

(c) Fee. All applicants must submit an application fee as provided by Chapter 7.




  1. Permit by Endorsement. The Board may issue a permit to administer nitrous oxide to a licensed dental hygienist who is licensed in another state or Canadian province and has:




  1. successfully completed a nitrous oxide course within a CODA- approved dental or dental hygiene program;




  1. been licensed, permitted or certified to administer nitrous oxide in another state;




  1. administered nitrous oxide within the last 2 years;




  1. completed an application provided by the Board; and




  1. submitted an application fee as provided in Chapter 7 of these rules.

(3) Dentist Responsibilities: A licensed dentist, who is providing the direct supervision of the administration of nitrous oxide must:




  1. decide which patient will receive nitrous oxide and should document this decision by note or prescription in the patient dental record;




  1. note in the patient dental record the condition of the patient’s recovery prior to the patient’s discharge; and




  1. ensure that nitrous oxide equipment is calibrated every three years in order to ensure that it is functioning correctly.

(4) Concentration of Nitrous Oxide. A dental hygienist issued a permit by the Board to administer nitrous oxide may administer nitrous oxide, utilizing induction via titration and not to exceed 50% concentration.


C. Irrigate and dry root canals;
D. Record readings with a digital caries detector and report them to the dentist for interpretation and evaluation;
E. Remove socket dressings;
F. Take cytological smears, as requested by the dentist; and
G. Take impressions for nightguards and occlusal splints as long as the dentist takes all measurements and bite registrations.

Section III. PUBLIC HEALTH SUPERVISION STATUS
A. Public Health Supervision Status. Upon notification to the Board, as set forth below, hygienists may provide services pursuant to "Public Health Supervision" status as defined in Section 1(C).
B. Roles and Responsibilities. When working together in a Public Health Supervision relationship, dentists, and dental hygienists shall enter into a Public Health Supervision Agreement based on the following roles and responsibilities:


  1. The dentist providing Public Health Supervision must:




    1. Be available to provide an appropriate level of contact, communication, collaboration, and consultation with the dental hygienist;




    1. Have specific standing orders or policy guidelines for procedures which are to be carried out for each location or program, although the dentist need not be present when the procedures are being performed;




    1. Help provide for the patient’s additional needed care in collaboration with the dental hygienist, although the dentist has no responsibility for providing treatment.

(2) A dental hygienist providing services under Public Health Supervision may perform only those duties within the accepted scope of practice of dental hygiene, as follows:


a. Apply cavity varnish;
b. Apply desensitizing agents to teeth;
c. Apply fluoride to control caries;
d. Apply liquids, pastes, or gel topical anesthetics;
e. Apply sealants;
f. Apply topical antimicrobials (excluding antibiotics), including fluoride for the purposes of bacterial reduction, caries control and desensitization in the oral cavity. The practitioner must follow current manufacturer’s instructions in the use of these medicaments. For the purposes of this section, “topical” includes superficial and intrasulcular application.
g. Cement pontics and facings outside the mouth;
h. Expose and process radiographs upon written standing prescription orders from a dentist who will be available to interpret all dental radiographs within 21 days and completes and signs a radiographic review and findings form;
i. For instruction purposes, a dental hygienist may demonstrate to a patient how the patient should place and remove removable prostheses, appliances or retainers;


  1. For the purposes of eliminating pain or discomfort, remove loose, broken or irritating orthodontic appliances;




  1. Give oral health instruction;

l. Interview patients and record complete medical and dental histories;




  1. Irrigate and aspirate the oral cavity;

n. Isolate operative fields;


o. Perform all procedures necessary for a complete prophylaxis, including root planing;
p. Perform complete periodontal and dental restorative charting;


  1. Perform dietary analyses for dental disease control;

r. Perform oral inspections, recording all conditions that should be called to the attention of the dentist;


s. Perform pulp tests pursuant to the direction of a dentist;
t. Place and remove gingival retraction cord without vasoconstrictor;
u. Place and remove matrix bands for purposes of fabricating and/or placing temporary restorations;
v. Place and remove rubber dams;
w. Place and remove wedges for purposes of fabricating and/or placing temporary restorations;
x. Place temporary restorations in compliance with the protocol adopted by the Board and attached to this rule as Appendix 1;
y. Remove excess cement from the supragingival surfaces of teeth;
z. Retract lips, cheek, tongue and other tissue parts;
aa. Smooth and polish restorations, limited to slow speed application only;
bb. Take and record the vital signs of blood pressure, pulse, and temperature;
cc. Take dental plaque smears for microscopic inspection and patient education;
dd. Take impressions for and deliver athletic mouth guards, and custom fluoride trays;
ee. Take intra-oral photographs;
(3) A dental hygienist providing services under Public Health Supervision must perform the following duties:


    1. Provide to the patient, parent or guardian a written plan for referral or an agreement for follow-up, recording all conditions that should be called to the attention of a dentist;




    1. Have each patient sign a permission slip or consent form that informs them that the service to be received does not take the place of regular dental checkups at a dental office and is meant for people who otherwise would not have access to the service;







    1. Ensure her/his proprietary forms meet the content requirements of this rule;




    1. If a patient has been seen by an IPDH or a dentist within the preceding twelve (12) months, the PHS entity/dental hygienist shall contact the IPDH or dentist prior to providing any dental hygiene services to the patient. If it has been more than twelve (12) months since the patient was last seen then it is not necessary for the PHS entity/dental hygienist to contact the IPDH or dentist. This does not preclude a PHS hygienist from providing preventive dental hygiene treatment to a patient within that twelve month period;




    1. Inform the Board in writing of any changes in or termination of the Public Health Supervision Agreement; and




    1. Maintain an appropriate level of contact and communication with the Maine licensed dentist providing Public Health Supervision.

C. Criteria. Hygienists providing services pursuant to Public Health Supervision status shall meet the following criteria:


(1) The proposal fills a need not currently being met. To ensure that the proposal involves the treatment of patients who are not otherwise under the treatment of a dental provider, the Board requires that:


  1. All PHS proprietary forms include the following language:




  1. “If your child is being seen every six (6) months for an exam by a dentist or a dental cleaning and fillings (if needed) do not fill out this form as she/he does not qualify for the service.”




  1. “Patient was last seen by ____________________________.




  1. “Patient was last seen ____________________ (month and year).”




  1. “Permission Statement: I give permission for my child

to receive dental hygiene services by a Public Health Dental Hygienist.”


  1. “I understand that the services provided today do not take the place of a complete dental exam by a dentist.”



  1. All PHS proprietary forms shall include the following information:




  1. Demographics to include: child’s name, responsible party, MaineCare number, and date of birth;

(ii) Identification of the dental provider that last provided care to the patient;


(iii) Dental concerns of the responsible party/patient;
(iv) Patient’s Medical/Health History;
(vi) Information regarding HIPAA.
(2) The particular proposed practice setting(s), including the proposed supervisor, will be adequate to accomplish the goal;
(3) Appropriate public health guidelines can be followed in the proposed setting(s);
(4) Adequate parameters of care can be maintained in the proposed practice setting(s);
(5) A dentist is available to provide Public Health Supervision to the dental hygienist and specific standing orders are submitted to the Board. If criteria (1) – (4) are met, but a dentist is not readily available under (5), the Board shall assist the dental hygienist in finding a dentist to provide Public Health Supervision; and
(6) Effective October 1, 2012, the particular proposed PHS practice setting is not a “traditional dental setting.”


  1. Traditional Dental Setting. For the purposes of this rule, a “traditional dental setting” is defined as a fixed, office-based location where a dentist, IPDH, or denturist provides dental services to the public.




  1. Nontraditional Dental Setting. For the purposes of this rule, a “nontraditional dental setting” is any setting that is not defined as a “traditional dental setting,” including but not limited to schools, community centers, nursing homes, and mobile clinics.

D. Notification Process. A dental hygienist wishing to practice under Public Health Supervision must notify the Board on a notification form specified by the Board, providing such information as the Board may deem necessary, including the signature of the supervising dentist. The dental hygienist shall list all known locations at which he or she expects to practice. Upon filing of the written notification to the Board, the dental hygienist may practice under Public Health Supervision for a specified period not to exceed three years. If, during the specified period, the dental hygienist finds that he or she will be providing services at locations other than those described in the notification form, he or she shall notify the Board in writing about each of these locations, in the manner specified by the Board. Any notification for a specified period may be amended, upon written submission by the dental hygienist to the supervising dentist and the Board. The Board may revoke Public Health Supervision status if a program does not continue to meet the criteria specified in section III.C.


E. Reporting Requirements. Each dental hygienist 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 must be completed in the manner specified by the Board, including information about each location where the dental hygienist has rendered these services. The dental hygienist must submit the form to the dentist providing Public Health Supervision for his or her signature, before sending it to the Board.
F. Reimbursement. Dental hygienists providing services under Public Health Supervision may be compensated for their work by salary, honoraria, and other mechanisms by the employing or sponsoring entity. Nothing in this rule shall preclude the entity that employs or sponsors a dental hygienist from seeking payment, reimbursement, or other source of funding for the services provided.

STATUTORY AUTHORITY: 32 M.R.S.A. §§ 1073(2), 1079(2), 1095, 1098-E, 1100-A


EFFECTIVE DATE:

May 22, 2007 – filing 2007-193


AMENDED:

February 11, 2009 – filing 2009-55


REPEAL AND REPLACE:

September 9, 2012 – filing 2012-246, including attachment





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