The regularly scheduled board meeting was proceeded by a meeting of the State Board of Dentistry (SBOD) Regulations Subcommittee. The discussion topic was expanded independent practice sites for Public Health Dental Hygiene Practitioners (PHDHPs). Board counsel noted that the board was still formulating its response to many of the comments that were made during the public comment period. Based on previous discussions by the board, some changes were included in the draft response:
- Birth centers were added.
- Satellite locations of physician’s offices were added.
- Facilities licensed by the Department of Drug and Alcohol Programs were added.
- Language regarding in-home and residential care were removed, with a plan to address these in the future with additional safety measures.
Several board members requested to address physician’s offices as an independent practice site. Dr. Casey noted that many states require collaborative practice agreements with a dentist as a consideration and suggested that this board do the same.
Dr. Cindy Olewine from St. Luke’s was recognized in the audience. She oversees a team of PHDHPs that offers services in a community setting and refers to St. Luke’s as a dental home, primarily for the Medical Assistance (MA) population. She indicated that many locations were easier to include a collaborative practice agreement than others, as some locations that they serve in rural Pennsylvania have few to no dentists participating in MA, making a collaborative agreement difficult.
Morgan Plant, lobbyist for the Pennsylvania Dental Hygienists Association (PDHA), noted that there is currently no requirement for a collaborative agreement in the empowering statute for PHDHPs. When asked about collaborative agreements specifically, Morgan indicated that nurse practitioners, many of which are required to have collaborative practice agreements, consider them a barrier to access in the medical field. She also indicated that there won’t be many PHDHPs practicing independently, most will be working for or partnering with managed care organizations and health systems.
Dr. Lugo asked about sterilization procedures by PHDHPs in mobile settings. He cited a child from Tamaqua that was infected with HIV while living in Florida due to inadequate infection control in a dental van. His concern is that PHDHPs practicing independently and remotely may not have the capability to sterilize properly. Several of the hygienists present noted that all regulated practitioners are required to follow CDC guidelines in regulation, regardless of the setting.
Several board members continued objections about the lack of follow-through on the required referral and noted a newsletter article that indicated only seven percent of patients seen by a PHDHP or independently practicing hygienist follow through with an appointment at a dental home. Ms. Fowler responded that this argument is brought up frequently, and that the provider is only responsible for their own behavior, not their patient’s.
Several board members suggested that as a potential compromise for those with concerns about physicians’ offices, that independent practice in a physician’s office be limited to Dental Health Professional Shortage Areas (DHPSAs), a ratio of provider to population defined by the Department of Health. An informal straw poll of board members indicated that many of the board would be in favor of this.
Board counsel will research the legal ramifications of adding language to the draft regulations tying in DHPSAs to PHDHP practice in physicians’ offices. The scheduled vote on the subject was not held and the board will consider this further at its January meeting.
State Board of Dentistry Meeting
The board introduced incoming board counsel Jackie Lutz. Ms. Lutz has been an attorney for over 30 years and has previously served with other state agencies before being assigned to the Department of State.
Representatives from the Department of State budget office addressed the board. Although the number of licensees increased from 28,273 in 2017/18 to the current level of 29,204, the board is still generating more expenses than revenue. The SBOD has a restricted account, which means that funds cannot be accessed for purposes other than SBOD functioning, but it is part of a larger augmentation account composed of other state boards. This allows the board to borrow from the augmentation account when shortfalls occur. The SBOD has been borrowing from this fund significantly over recent years and these funds will need to be repaid.
The budget office representatives presented the board with two options for an incremental licensing and examination fee increase that would bring the SBOD back to a break-even position in six years. One board member questioned about the across-the-board fee increase package passed in March 2019 by the board. Mr. Johnson indicated that they received resistance from the Independent Regulatory Review Commission about the “sticker shock” of an immediate 40 percent increase, especially when considering the positive financial status of other state boards. They suggested an incremental increase as a compromise.
The board moved to accept the first option that increased license renewal fees by 18 percent over the next three renewal cycles, or six years. The motion passed unanimously.
- The first case involved two consent agreements including the principal/owner and associate of a practice, and both involving the same patient. The patient was accepted in 2015 after developing problems with a flipper. After two years with the associate, the principal assumed care. During that period, the patient developed significant periodontal disease before being referred to a periodontist for treatment. Both dentists were cited for limited diagnosis and poor record keeping, and received civil penalties, public reprimands, and ordered to attend remedial education.
- The second case involved a dentist that received previous discipline for employing someone that was not licensed to take radiographs, and for violations of disease control guidelines. Subsequently, the dentist was cited in a case for poor record keeping that failed to meet the standard of care. The respondent claims that this resulted in no harm to the patient. The dentist was also cited for accepting a patient that was recommended for five extractions, and instead performed four root canals. The patient did not understand why the change was made, and experts testified that the teeth were beyond saving and should have been extracted. The respondent claims that no harm ultimately came to the patient as a result, and a financial settlement was accepted by the patient. As the provider was already on probation for the previous violations, they received a 30-day suspension, during which they must undertake 50 hours of varied education and an additional probationary period of two years.
- The third case involved a practitioner who entered the 3-year voluntary recovery program due to alcoholism.
In addition to the prosecutorial report, Attorney Paul Jarabeck provided the board with follow-up regarding a case involving an unlicensed EFDA. Since the board had no jurisdiction to provide much punitively to an unlicensed practitioner, the Department of State brought the case to Commonwealth Court, where the unlicensed practitioner was ordered to cease and desist practice until the proper education and credentialing was attained.
Report of the Chair
The chair allowed Dr. Funari to address the board as part of his report. Dr. Jim Robbins, who oversees anesthesia inspections for the SBOD on behalf of the Pennsylvania Society or Oral Maxillofacial Surgeons (PSOMS), would like to address the board. He will likely be included on the agenda for the January 2020 meeting based on availability. Dr. Funari also noted that the American Society of Oral Maxillofacial Surgeons (ASOMS) has developed a leadership program for oral surgeons on state dentistry boards, and Dr. Funari would like to participate. It was recommended that he submit the application to offset some of his expenditures for participating.
Dr. Erhard reviewed the progress of the Act 41 work group, which was formulated to develop implementation guidelines for qualified practitioners to receive provisional licensure and fill gaps in the dental workforce. The work group includes Dr. Erhard, Ms. Murray, and Ms. Groody. The guidelines will delineate that anyone applying for a provisional license will receive an approve/deny vote from the workgroup. If a denial is received, the entire board can then review and overrule if appropriate. This process will have priority for regulatory review and will likely be fast-tracked due to the statutory mandate of Act 41.
Ms. Groody asked about the implementation of the board’s motion to draft regulation requiring a clinical exam for EFDA certification. Ms. Groody also noted that she asks this every meeting, and no response is ever given. No progress was noted at this meeting either, but it was noted that the regulations could be included as a part of the Act 41 provisional licensure process.
PDA President Dr. Charles Incalcaterra sent correspondence to the board expressing concerns about teledentistry and DIY dentistry and requesting regulatory change to address it by adapting the definition of general supervision be clarified by ensuring that preliminary examinations are done in person. Marisa Swarney of PDA cited a specific large employer in Southeastern Pennsylvania who had a hygiene day for its employees with only general supervision of a telephonic out-of-state dentist. A board member asked about the status of legislation authorizing telemedicine. The bill is currently in the last stage of legislative approval, but has been stalled in previous sessions in this stage. The board is under no obligation to rule in this case, but will consider PDA’s request in the future.
The board reelected Dr. Erhard as chair for 2020, and Ms. Hart Hughes as Secretary. The SBOD retired to Executive Session at approximately 12:05 p.m.