State Board of Dentistry Report – September 13, 2019

Regulations Subcommittee

The regular board meeting was proceeded by a meeting of the SBOD Regulations Subcommittee. Board counsel reported on the proposed regulatory package that added independent practice sites for Public Health Dental Hygiene Practitioners (PHDHPs).

The draft annex that was on the agenda amended the original regulations to cross-reference sections concerning satellite locations for physicians’ offices and break up some sections for formatting reasons. The section allowing for PHDHP independent practice in places of residence was removed.

A board member noted the scope of practice for a PHDHP practicing independently allowed them to take radiographs but did not allow them to read radiographs for diagnostic purposes. It was suggested that a PHDHP could refer to a dentist for radiograph interpretation.

Another board member had serious concerns with a PHDHP continuing to treat patients that failed to follow through on a referral. She noted that other states require documentation that a patient had seen a dentist before allowing for continued independent hygiene treatment. She also expressed concern that the regulation did not include language indicating a PHDHP should practice in a public health setting and could “open up a free for all” and create opportunities for abuse through excessive billing. The topic generated discussion among the board members, but it was noted that this line of discussion exceeded the purpose of what the board was there to accomplish, which was to consider additional practice sites.

The question was raised whether a PHDHP could bill insurance for services. It was later noted that via a MA bulletin in August 2017, PHDHPs can bill MA insurance plans and three HealthChoices plans had taken steps to implement fee schedules and procedures for PHDHP care.

Helen Hawkey of the Pennsylvania Oral Health Coalition was asked to testify. She made note of the MA plans that were establishing billing protocols and described some of the PHDHP programs that were currently operating in the state. She provided statistical evidence of the follow-through rates for referrals, but many board members felt that this was a small sample size from specific programs and would not represent the entirety of the PHDHP system.

Ms. Hawkey drew responses from several board members with an assertion that if someone did not follow through on a referral to a dental home, there was no harm in having someone clean their teeth without an exam. Several board members responded with oral pathology diagnoses that would make cleaning without an exam potentially hazardous. She also noted that a PHDHP has never been cited by the board for disciplinary reasons, which some board members refuted as not applicable to their qualifications to practice independently.

Dr. Bernie Dishler from PDA presented a history of the addition of physicians’ offices as independent practice sites. He noted that, as more people went to physicians than dentists, physicians were encouraged to learn to do preliminary oral health screenings and fluoride varnishes. Many physicians wished to implement this but asked if a hygienist could be brought on staff to complete it. Dr. Dishler recommended limiting the practice to pediatric physicians’ offices, but that was disparaged by some board members.

Dr. Angel Stout of the Pennsylvania Chapter of the American Academy of Pediatric Dentistry was called to testify. She reported that without statistics, it is impossible to know how effective PHDHP treatment is, and it should never have entered serious consideration without this evidence. She provided the board with a breakdown of where PHDHPs are located, along with dental offices and pediatric dental offices. She noted that in many rural locations of Central Pennsylvania, there are few practitioners of any type, leading to the concern that this regulation will add little relief to rural access issues.

A board member asked a representative from the Pennsylvania Dental Hygienists’ Association what other states served as a model for the proposed independent practice in Pennsylvania. PDHA representatives noted California, Washington, and New Mexico as suggested state models.

Mr. Steve Neidlinger from PAGD requested to address the board. He asked if HealthChoices MCOs could reimburse for PHDHP services, could they also track data to see if referrals to a dental home were being completed. He also encouraged all involved to address a financially viable MA system that provided restorative care for adults. The board noted that they were prohibited from taking an advocacy position, but Mr. Neidlinger encouraged advocacy organizations in the audience to collaborate to prioritize this in the future.

Subcommittee Chair Dr. Ivan Lugo indicated that there would be one more subcommittee meeting before the November 15 meeting and the board would likely vote on the amended regulatory package then.

State Board of Dentistry Meeting

Board Chair Dr. Jack Erhard began the meeting by requesting the board to remember the victims of Hurricane Dorian. He thanked all that attended the previous Regulations Subcommittee meeting.

There were several edits to the minutes from the previous meeting. The minutes were approved with amendments.

Prosecutorial Report

  • The first case involved infection control violations, including instrument corrosion and preloaded syringes. The entire staff has completed remediation and was compliant with investigators. The dentists involved received a $1,500 penalty for each, $1,000 in costs, and a 15-month probationary period.
  • The second case involved a dentist who was cited for failing to keep adequate dental records and subsequently billed for unfinished procedures. It was noted that this is a new licensee in Pennsylvania. They received a civil penalty of $2,500, costs of $849, and a requirement to complete 15 CE hours on recordkeeping, restorative, and endo.
  • The third case was a follow-up from a case decided in January 2019. A dentist surrendered their license after failing to follow infection control protocols, such as no spore testing and failing to wear gloves or masks. The associate in the practice was noted for their cooperation and for their attempt to “do the right thing” by cooperating and encouraging staff to do the same. The associate received a civil penalty, cost of prosecution, and probation for two years.
  • The fourth case involved a dentist that exceeded the scope of their anesthesia permit by stacking triazolam with nitrous despite only having a Permit II for nitrous. It was noted that the dentist was licensed and properly permitted elsewhere, and had the adequate training to offer triazolam, just not the proper permit. They received a $3,500 civil penalty, $2,998.31 in costs, and a cease and desist order on offering anesthesia.
  • The fifth case involved a dentist who offered nitrous after allowing their Permit II to lapse. They received a $3,500 civil penalty and a public reprimand.

Report of Board Counsel

Board Counsel reported on the proceedings from the Regulations Subcommittee meeting. She noted that private residences were removed as an independent practice site for PHDHPs, with the intention that it would be addressed by the board in a separate regulation. The full language of the regulatory change would be made available to the board at its November meeting.

A board member asked if a vote was forthcoming regarding physicians’ offices as an independent practice site. Dr. Erhard asked that all votes be postponed until the next board meeting.

The board discussed the recently passed legislation, Act 41 of 2019, which would require board to create a path for provisional licensure for out-of-state licensees. A subcommittee composed by Dr. Erhard, Ms. Theresa Groody, and Ms. Donna Murphy was formed. The board discussed the equivalencies of both out-of-state licensee categories, as well as foreign education. It was decided that the board would require case-by-case consideration for EFDAs and foreign-trained dentists and hygienists, and a combination of CODA-accredited school graduation, two years for clinical practice, and exam passage for US educated dentists and hygienists for Act 41 provisional license approval.

Report of the Chair

Dr. Erhard inquired into where the board stood in its motion to limit licensure to passage of American Board of Dental Examiners (ADEX) testing. He noted that ADEX was working to make administration of the test more convenient and has developed models that are much more like real teeth. He encouraged the board to follow the courage of its convictions regarding ADEX.

Report of the Commissioner

BPOA Commissioner Kalonji Johnson requested that the board refer any questions regarding licensure status to the PALS system. SBOD offices should be contacted with other questions regarding a licensee’s standing. He noted that the office of the SBOD is committed to maintaining customer service as a priority, likely in response to press reports of other state boards which have been reported as rude or negligent.

A letter asking for clarification on the use of lasers by hygienists was referred to the Scope of Practice Subcommittee. The SBOD retired to Executive Session at approximately 12:40 p.m.