May 23, 2009
Senate Bill 129, the dental hygiene bill, was the source of much apprehension and speculation during the 2009 legislative session. Following are key provisions of SB 129 and information on the bill’s history and impacts.
Dental Hygiene “Diagnosis”
The final version of SB 129 allows dental hygienists to perform a “dental hygiene diagnosis,” which is limited to the identification of an existing oral health problem whose treatment is within a dental hygienist’s authorized scope of practice. Any diagnosis requiring treatment that falls outside the scope of dental hygiene practice must be confirmed by a dentist.
The Colorado Dental Hygienists’ Association (CDHA) introduced SB 129 to address concerns that, under prior law, they were limited to identifying areas of suspicion or concern only in generalized terms. They felt that calling a cavity or related condition by name would risk noncompliance with the dental practice act. Dental hygienists sought to be able to better communicate with patients about specific teeth or conditions that are identified as problematic through “dental hygiene diagnosis.”
From early in the legislative process, the Colorado Dental Association (CDA) expressed strong concern with the term “dental hygiene diagnosis” and explored a number of approaches to address this concern. Initially, in committee, a senator offered an amendment that would have struck the term. The CDA and the American Dental Association (ADA) were supportive of this approach, preferring that the word “diagnosis” be replaced with “assessment.” However, to allow further discussion between interested parties, the committee deferred discussion of the term to the Senate floor. The full Senate elected to define the term rather than strike or replace it. After an engaging Senate floor battle, the definition supported by the CDA was adopted. The CDA later worked to address dental hygienists’ concerns with the Senate-approved definition, agreeing on a slightly modified but still robust definition in the House version of the bill.
The CDA also worked to add a number of limitations around “dental hygiene diagnosis” to ensure that patients are protected. Patients must sign a statement provided by the hygienist recognizing that the diagnosis is only for the purpose of determining necessary dental hygiene services and that the ADA recommends an examination by a dentist twice each year. The bill also requires all licensed dental hygienists to carry professional liability insurance.
Although dental hygienists can now call a cavity by name, treatment for identified conditions remains almost exclusively with a licensed dentist, as most treatments continue to fall outside the dental hygiene scope of practice. The bill clearly states that surgery, irreversible procedures and prescriptive authority may not be assigned to anyone other than a dentist.
Allowances for Unsupervised Dental Hygiene Practice
SB 129 contains some new allowances for unsupervised dental hygienists. It authorizes unsupervised hygienists to take x-rays, prepare study casts, and administer fluoride, fluoride varnish, antimicrobial solutions for mouth rinsing and resorbable antimicrobial agents. Again, the CDA worked to establish appropriate limitations around these provisions to ensure that patients are protected. For example, x-rays may be taken by a dental hygienist but a dentist must read and interpret them. Dental hygienists must continue to work with a dentist to order and obtain many supplies like fluoride. Dental hygienists are allowed to create study casts for only specified, limited purposes. The Colorado State Board of Dental Examiners (SBDE) is required to write rules to govern use of resorbable antimicrobial agents by dental hygienists. By law, dental abnormalities must be immediately referred to a dentist for diagnosis and treatment.
Allowances for Supervised Dental Hygiene Practice
SB 129 changes the supervision requirements for the administration of local anesthesia. In the past, supervised dental hygienists could administer local anesthetic under the direct supervision of a licensed dentist, which requires a dentist to be in the building at the time of administration. SB 129 changed the level of supervision required to “indirect,” which means that a supervised dental hygienist (with appropriate credentials) can administer local anesthetic without a dentist being present on site (for example, if the dentist leaves the office for lunch or prior to the dentist arriving at the office in the morning).
In addition, supervised dental hygienists can perform all activities that unsupervised dental hygienists are permitted to do, including the SB 129 allowances noted in the “unsupervised” section above. Supervised dental hygienists have expanded permissions for many procedures.
Future Implications and Impacts
SB 129 was signed into law by the governor on April 21, 2009. The bill provisions technically went into effect at that time, although rulemaking is still in progress. The SBDE will consider rules to implement SB 129 at its July 9 meeting.
The CDA continually strives to improve the quality, availability, affordability and utilization of oral healthcare services. At a time when many other states are mandating mid-level provider models for oral health, this bill presents a good alternate approach – one that focuses on better utilizing existing resources. The expanded allowances under this bill may allow more dental hygienists to practice in various areas of our state. The collaborative relationship between dentists and unsupervised dental hygienists helps ensure that previously unseen patients will gain access to care through a hygienist as well as receive care from a dentist. SB 129 may serve as a reference for other states when they are faced with access to care issues.
Ultimately, legislation is always the art of compromise. During the summer of 2008, the CDA participated in a series of talks regarding dental hygiene, including participation in a Governor’s Advisory Committee on Scope of Practice and direct talks with the CDHA regarding their desire to update the dental hygiene practice act. A number of the parameters and provisions in the final version of SB 129 reflect consensus reached in these discussions. In addition, the CDA was able to work collaboratively with the CDHA on many occasions during the legislative process.
In the end, the CDA balanced some reasonable expansions to the dental hygiene scope of practice while ensuring appropriate protections for patients. The CDA believes that we made substantial progress and achieved a positive outcome for Colorado’s residents. If you have any questions about this bill, feel free to contact Jennifer Goodrum, Director of Governmental Relations, at 303-996-2847, 800-343-3010 x107 or jennifer@cdaonline.org.
