TO: OHIO LICENSED DENTISTS AND DENTAL HYGIENISTS FROM: THE OHIO STATE DENTAL BOARD Lili C. Kaczmarek, Esq., Executive Director RE: Administrative Rules 4715-9-01 and 4715-9-05 regarding Dental Hygiene Practice when the Dentist is not Physically Present, pursuant to Ohio Rev. Code 4715.22. DATE: JULY 9, 1999   The administrative rules, 4715-9-01 and 4715-9-05, regarding dental hygiene practice when the dentist is not physically present, are now in effect. [1] These rules can be reviewed on the Board's website by clicking on the "Laws, Rules, Policies" menu option, selecting the "Ohio Administrative Code" and clicking on the specific rule number. DENTAL HYGIENE PRACTICE WHEN THE DENTIST IS NOT PHYSICALLY PRESENT (Ohio Administrative Code Rule 4715-9-05) Despite the fact that the rules are in effect, pursuant to the rules, the following criteria must be met before a dental hygienist can practice without the supervising dentist being physically present: The dental hygienist must have at least two (2) years and a minimum of three thousand (3,000) hours of experience in the practice of dental hygiene before being eligible to practice without the dentist being physically present. This information must be verified on a form approved by the Board, with all supporting documentation attached. [2] The dental hygienist must successfully complete a course approved by the Board in the identification and prevention of medical emergencies before being eligible to practice without the dentist being physically present. [3] The rule requires that this course be taken from a permanent sponsor, that it be at least four (4) hours in duration, and that it cover, at a minimum, the following topics: (a) Medical history, (b) Recognition of common medical emergency situations, (c) Office emergency protocols, (d) Basic airway management, (e) Prevention of emergency situations during dental appointments, (f) Symptoms, first aid treatment and possible outcomes for patients who exhibit bleeding injuries, cardiovascular disease, insulin reaction, diabetic coma, shock, syncope, epileptic seizures and allergic reactions. This information must be verified on a form approved by the Board, with all supporting documentation attached. [4] The Board has determined that it will approve these courses retroactive to March 1, 1999. However, ALL sponsors must submit an Application for Dental Hygiene Medical Emergency Recognition Course in Ohio to the Board for approval. Retroactive approval of courses will be permitted until the last Board meeting of this calendar year, which is December 1-2, 1999. After that date, all courses will need to be approved by the Board prior to the course being offered. The dental hygienist must be currently certified in cardiopulmonary resuscitation (CPR) at all times while treating patients when the dentist is not physically present. This information must be verified on a form approved by the Board, with all supporting documentation attached. [5] The supervising dentist must have evaluated the dental hygienist's skills and made a determination that the hygienist is competent to treat patients while the dentist is not physically present. This information must be verified on a form approved by the Board. The supervising dentist must be licensed in the state of Ohio, and the dental hygienist must be an employee of, or under contract with, the supervising dentist, or a dentist who is the employer of the supervising dentist or a partner in the supervising dentist's association or corporation, or be an employee of, or under contract with, a government entity that employs the dental hygienist to provide dental hygiene services in a public school or in connection with other programs the government entity administers. THE FORM The Board has created and approved a form that the dentist must maintain in each facility where the dental hygienist will practice that attests that these requirements have been met by the particular dental hygienist. This form can be accessed through our website by clicking on the "Forms" menu option, and selecting the form for "Approval Form for a Dental Hygienist Practicing When the Dentist is not Physically Present". The dentist must attach all necessary documentation to the form which verifies that the requirements have been met, and this form must be made available immediately upon the request of the Board or an agent of the Board. Once the above requirements have been met [6] and the form has been completed by the supervising dentist, eligible dental hygienists may practice dental hygiene on patients when the supervising dentist is not physically present, provided that the following mandates are adhered to: At all times the dental hygienist is under the supervision, order, control and full responsibility of the licensed supervising dentist. The supervising dentist must have completed and evaluated a medical and dental history of the patient not more than one (1) year prior to the date the dental hygienist provides dental hygiene services to the patient. The supervising dentist must have examined the patient not more than seven (7) months prior to the date the dental hygienist provides dental hygiene services to the patient. The dental hygienist may only practice dental hygiene when the dentist is not physically present for up to fifteen (15) consecutive business days or no more than three consecutive weeks, whichever occurs first. In advance of the dental hygiene appointment, the patient must be notified that the supervising dentist will not be present and that the dental hygienist cannot diagnose the patient's dental health care status. This notice must be documented in the patient record. The dental hygienist must comply with all written protocols for emergencies established by the supervising dentist, and must also comply with written protocols/standing orders that the supervising dentist establishes. The dental hygienist shall not treat a patient when the dentist is not physically present, if there has been a significant change in the patient's medical history since the last appointment with the dentist. The supervising dentist shall have no more than three dental hygienists treating patients when the dentist is not physically present. The following procedures shall not be performed by any dental hygienist when the supervising dentist is not physically present: Procedures while the patient is anesthetized. Definitive root planing. Definitive subgingival curettage. Sulcular placement of prescribed materials Selection of shade for fabrication of appliances or restorations. Pulp testing. Application of periodontal dressings (packs). Suture removal. Placement of a rubber dam over preplaced clamp, and removal of clamp and rubber dam. Application of cavity varnish. Placement of surgical dressings. The following orthodontic procedures: (a) Preliminary selection and sizing of orthodontic bands and arch wires. (b) Checking for and removal of loosened orthodontic bands and arch wires. (c) Placement and removal of orthodontic arch wires, auxiliary arch wires, and ligation of same to orthodontic bands and/or brackets. (d) Placement and removal of orthodontic separators and ties (steel or elastomeric). The following endodontic procedures: (a) Irrigation and drying of canals during endodontic procedures. (b) Placement of medication in pulp chamber of teeth with non-vital pulp or instrumented root canals. The following restorative procedures: (a) Construction of provisional (temporary) crowns (metal or plastic). (b) Preliminary selection and sizing of stainless steel crowns. (c) Polymerization of light-activated restorative or bonding materials. The preparation of materials, drugs and medications for use in dental procedures, including, but not limited to: (a) Palliative materials; (b) Restorative materials. All non-invasive supportive services normally utilized in conjunction with the treatment by the dentist of fascia pain or TMJ syndrome. All advanced remedial intra-oral dental tasks and procedures (4715-3-01(F)). Monitoring nitrous oxide-oxygen. The rule also provides that certain additional requirements be met if the dental hygienist is providing dental hygiene services to patients in a health care facility. A health care facility means either a "hospital" registered under section 3701.07 of the Ohio Revise Code, or a "home" as defined in section 3721.01 of the Ohio Revised Code. If dental hygiene services are being provided in a health care facility, an Ohio licensed physician, or an Ohio licensed nurse must be physically present in the health care facility when dental hygiene services are rendered. PERMISSIBLE PRACTICES OF A DENTAL HYGIENIST (Ohio Administrative Code Rule 4715-9-01) It is important to note that these amended rules do not give additional duties to dental hygienists that did not exist previously. These rules simply allow that certain duties which could be done when the dentist is physically present, may now be dome when the dentist is not physically present. The dental hygienist must still practice under the "supervision, order, control and full responsibility" of the supervising dentist (R.C. 4715.22), except that the dentist need not always be physically present, subject to the terms and restrictions out lines in the statute and rules, as discussed herein. The Board amended this rule to clearly state what can and cannot be done by the dental hygienist when the dentist is not physically present. Duties that can be done when the supervising dentist is not physically present must be done pursuant to the written order of the dentist. Section (A)(1) (polishing), (2)(removal of calcareous deposits/accretions) and (3)(periodontal scaling) are duties that can be done when the dentist is not physically present. [7] Further, Sections (B)(sealants) and , and (C)(radiographs) are also duties that can be performed when the dentist is not physically present. Again, these duties must be performed pursuant to the supervising dentist's written order. Section (D) of the rule lists the specific basic remedial intra-oral dental tasks and procedures which may now be performed when the dentist is not physically present, so long as the other requirements which have just been discussed above are adhered to. Section (E) regarding advanced remedial restorative intra-oral dental tasks and procedures states that the dental hygienist performing them is subject to the rules regulating expanded function dental auxiliaries, which is direct supervision. Therefore, any duties relating to section (E) can not be performed by the dental hygienist when the dentist is not physically present. Section (F) also requires direct supervision for the monitoring of nitrous oxide-oxygen by a dental hygienist. The Board hopes this memorandum is helpful to you in determining how to implement these new rules in your practice. If you have additional questions, please contact us at the Dental Board office. 1Effective Date June 17, 1999 2This information can include W2 forms and statements from employers verifying employment. 3A list of the initial Board approved course will appear on the website after the Board's July 28-29, 1999 Board meeting. Additional courses will appear following each of the Board meetings. 4The course completion documents will suffice for this purpose. 5The course completion documents, which must include a copy of the course registration card that indicates expiration dates, will suffice for this purpose. 6These eligibility requirements do not apply to dental hygienists who practice in Board approved special needs programs, so long as the requirements outlined in section (B) of the rule are followed. 7Section (4)(soft tissue curettage), (5)(root planing) and (6)(sulcular placement of prescribed materials, are duties which cannot be performed when the dentist is not physically present, as indicated in the statute, R.C. 4715.22(4) and the rule, 4751-9-05(E). http://www.dental.ohio.gov/infmemo799.htm This page updated July 14, 1999