Amended in Assembly March 21, 2013

California Legislature—2013–14 Regular Session

Assembly BillNo. 1174


Introduced by Assembly Member Bocanegra

February 22, 2013


An actbegin insert to amend Sections 1752.4, 1753.5, 1753.6, and 1910 of the Business and Professions Code, and to add Section 14132.726end insertbegin insert to the Welfare and Institution Code,end insert relating to oral health.

LEGISLATIVE COUNSEL’S DIGEST

AB 1174, as amended, Bocanegra. begin deleteOral health: virtual dental homes. end deletebegin insertDental professionals: teledentistry under Medi-Cal.end insert

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Existing

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begin insert(1)end insertbegin insertend insertbegin insertExistingend insert law, the Dental Practice Act, establishes the Dental Board of California. Existing law creates, within the jurisdiction of the board,begin insert a Dental Assisting Council that is responsible for the regulation of dental assistants, registered dental assistants, and registered dental assistants in extended functionsend insertbegin insert andend insert a Dental Hygiene Committee of California, that is responsible forbegin insert theend insert regulation of registered dental hygienists, registered dental hygienists in alternative practice, and registered dental hygienists in extended functions. begin insertExisting law governs the scope of practice for those professionals.end insert

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This bill would authorize a registered dental assistant to determine which radiographs to perform if he or she has completed a specified educational program. The bill would authorize a registered dental assistant in extended functions licensed on or after January 1, 2010 to place interim therapeutic restorations, as defined, pursuant to the order, control, and full professional responsibility of a licensed dentist, as specified. The bill would authorize a registered dental hygienist to operate dental radiography equipment for the purpose of oral radiography, and, after submitting to the committee evidence of satisfactory completion of a course of instruction approved by the committee, determine which radiographs to perform and place interim therapeutic restorations upon the order of a licensed dentist.

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(2) Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including certain dental services, as specified. Existing law provides that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for “teleophthalmology and teledermatology by store and forward,” as defined to mean the asynchronous transmission of medical information to be reviewed at a later time by a licensed physician or optometrist, as specified, at a distant site.

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This bill would enact similar provisions relating to the use of teledentistry, as defined, under the Medi-Cal program. The bill would provide that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient shall not be required under the Medi-Cal program for “teledentistry by store and forward.” The bill would define that term to mean an asynchronous transmission of dental information to be reviewed at a later time by a licensed dentist at a distant site, where the dentist at the distant site reviews the dental information without the patient being present in real time, as defined and as specified. The bill would also provide that dentist participation in services provided at an intermittent clinic, as defined, through the use of telehealth, as defined, shall be considered a billable encounter under Medi-Cal. The bill would also require, on or before January 1, 2017, the department to report to the Legislature the number and type of services provided, and the payments made related to the application of teledentistry, as specified.

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This bill would declare the intent of the Legislature to enact legislation that would incorporate into law the new duties of dental assistants and dental hygienists being tested in a specified pilot project and address barriers to expanding the Virtual Dental Home system of care, as specified, as a cost-effective mechanism to improve the oral health of California’s most underserved and vulnerable citizens.

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Vote: majority. Appropriation: no. Fiscal committee: begin deleteno end deletebegin insertyesend insert. State-mandated local program: no.

The people of the State of California do enact as follows:

P3    1begin insert

begin insertSECTION 1.end insert  

end insert

begin insertSection 1752.4 of the end insertbegin insertBusiness and Professions
2Code
end insert
begin insert is amended to read:end insert

3

1752.4.  

(a) A registered dental assistant may perform all of
4the following duties:

5(1) All duties that a dental assistant is allowed to perform.

6(2) Mouth-mirror inspections of the oral cavity, to include
7charting of obvious lesions, existing restorations, and missing
8teeth.

9(3) Apply and activate bleaching agents using a nonlaser
10light-curing device.

11(4) Use of automated caries detection devices and materials to
12gather information for diagnosis by the dentist.

13(5) Obtain intraoral images for computer-aided design (CAD),
14milled restorations.

15(6) Pulp vitality testing and recording of findings.

16(7) Place bases, liners, and bonding agents.

17(8) Chemically prepare teeth for bonding.

18(9) Place, adjust, and finish direct provisional restorations.

19(10) Fabricate, adjust, cement, and remove indirect provisional
20restorations, including stainless steel crowns when used as a
21provisional restoration.

22(11) Place post-extraction dressings after inspection of the
23surgical site by the supervising licensed dentist.

24(12) Place periodontal dressings.

25(13) Dry endodontically treated canals using absorbent paper
26points.

27(14) Adjust dentures extra-orally.

28(15) Remove excess cement from surfaces of teeth with a hand
29instrument.

30(16) Polish coronal surfaces of the teeth.

31(17) Place ligature ties and archwires.

32(18) Remove orthodontic bands.

33(19) All duties that the board may prescribe by regulation.

34(b) A registered dental assistant may only perform the following
35additional duties if he or she has completed a board-approved
36registered dental assistant educational program in those duties, or
37if he or she has provided evidence, satisfactory to the board, of
38having completed a board-approved course in those duties.

P4    1(1) Remove excess cement with an ultrasonic scaler from
2supragingival surfaces of teeth undergoing orthodontic treatment.

3(2) The allowable duties of an orthodontic assistant permitholder
4as specified in Section 1750.3. A registered dental assistant shall
5not be required to complete further instruction in the duties of
6placing ligature ties and archwires, removing orthodontic bands,
7and removing excess cement from tooth surfaces with a hand
8instrument.

9(3) The allowable duties of a dental sedation assistant
10permitholder as specified in Section 1750.5.

11(4) The application of pit and fissure sealants.

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12(5) Determine which radiographs to perform.

end insert

13(c) Except as provided in Section 1777, the supervising licensed
14dentist shall be responsible for determining whether each
15authorized procedure performed by a registered dental assistant
16should be performed under general or direct supervision.

17(d) This section shall become operative on January 1, 2010.

18begin insert

begin insertSEC. end insertbegin insert2.end insert  

end insert

begin insertSection 1753.5 of the end insertbegin insertBusiness and Professions Codeend insert
19begin insert is amended to read:end insert

20

1753.5.  

(a) A registered dental assistant in extended functions
21licensed on or after January 1, 2010, is authorized to perform all
22duties and procedures that a registered dental assistant is authorized
23to perform as specified in and limited by Section 1752.4, and those
24duties that the board may prescribe by regulation.

25(b) A registered dental assistant in extended functions licensed
26on or after January 1, 2010, is authorized to perform the following
27additional procedures under direct supervision and pursuant to the
28order, control, and full professional responsibility of a licensed
29dentist:

30(1) Conduct preliminary evaluation of the patient’s oral health,
31including, but not limited to, charting, intraoral and extra-oral
32evaluation of soft tissue, classifying occlusion, and myofunctional
33evaluation.

34(2) Perform oral health assessments in school-based, community
35health project settings under the direction of a dentist, registered
36dental hygienist, or registered dental hygienist in alternative
37practice.

38(3) Cord retraction of gingiva for impression procedures.

39(4) Size and fit endodontic master points and accessory points.

40(5) Cement endodontic master points and accessory points.

P5    1(6) Take final impressions for permanent indirect restorations.

2(7) Take final impressions for tooth-borne removable prosthesis.

3(8) Polish and contour existing amalgam restorations.

4(9) Place, contour, finish, and adjust all direct restorations.

5(10) Adjust and cement permanent indirect restorations.

6(11) Other procedures authorized by regulations adopted by the
7board.

8(c) All procedures required to be performed under direct
9supervision shall be checked and approved by the supervising
10licensed dentist prior to the patient’s dismissal from the office.

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11(d) (1) A registered dental assistant in extended functions
12licensed on or after January 1, 2010, is authorized to place interim
13therapeutic restorations, defined as the removal of carries using
14hand instruments and placement of an adhesive restorative
15material, upon the order of the supervising dentist under general
16supervision, except as authorized pursuant to paragraph (2), and
17pursuant to the order, control, and full professional responsibility
18of a licensed dentist.

end insert
begin insert

19(2) The supervising licensed dentist shall be responsible for
20determining whether the functions authorized pursuant to
21paragraph (1) may be performed under general or direct
22supervision.

end insert
23begin insert

begin insertSEC. end insertbegin insert3.end insert  

end insert

begin insertSection 1753.6 of the end insertbegin insertBusiness and Professions Codeend insert
24begin insert is amended to read:end insert

25

1753.6.  

(a) Each person who holds a license as a registered
26dental assistant in extended functions on the operative date of this
27section may only perform those procedures that a registered dental
28assistant is allowed to perform as specified in and limited by
29Section 1752.4, and the procedures specified in paragraphs (1) to
30(6), inclusive, until he or she provides evidence of having
31completed a board-approved course in the additional procedures
32specified in paragraphs (1), (2), (5), and (7) to (11), inclusive, of
33subdivision (b)begin insert, and paragraph (1) of subdiend insertbegin insertvision (d),end insert of Section
34 1753.5, and an examination as specified in Section 1753.4:

35(1) Cord retraction of gingiva for impression procedures.

36(2) Take final impressions for permanent indirect restorations.

37(3) Formulate indirect patterns for endodontic post and core
38castings.

39(4) Fit trial endodontic filling points.

40(5) Apply pit and fissure sealants.

P6    1(6) Remove excess cement from subgingival tooth surfaces with
2a hand instrument.

3(b) This section shall become operative on January 1, 2010.

4begin insert

begin insertSEC. end insertbegin insert4.end insert  

end insert

begin insertSection 1910 of the end insertbegin insertBusiness and Professions Codeend insertbegin insert is
5amended to read:end insert

6

1910.  

A registered dental hygienist is authorized to perform
7the following procedures under general supervision:

8(a) Preventive and therapeutic interventions, including oral
9prophylaxis, scaling, and root planing.

10(b) Application of topical, therapeutic, and subgingival agents
11used for the control of caries and periodontal disease.

12(c) The taking of impressions for bleaching trays and application
13and activation of agents with nonlaser, light-curing devices.

14(d) The taking of impressions for bleaching trays and placements
15of in-office, tooth-whitening devices.

begin insert

16(e) Operate dental radiography equipment for the purpose of
17oral radiography.

end insert
begin insert

18(f) After submitting to the committee evidence of satisfactory
19completion of a course of instruction approved by the committee,
20the following:

end insert
begin insert

21(1) Determine which radiographs to perform.

end insert
begin insert

22(2) Place interim therapeutic restorations, defined as the
23removal of carries using hand instruments and placement of an
24adhesive restorative material, upon the order of a licensed dentist.

end insert
25begin insert

begin insertSEC. 5.end insert  

end insert

begin insertSection 14132.726 is added to the end insertbegin insertWelfare and
26Institutions Code
end insert
begin insert, to read:end insert

begin insert
27

begin insert14132.726.end insert  

(a) To the extent that federal financial participation
28is available, face-to-face contact between a health care provider
29and a patient shall not be required under the Medi-Cal program
30for teledentistry by store and forward. Services appropriately
31provided through the store and forward process are subject to
32billing and reimbursement policies developed by the department.

33(b) A patient receiving teledentistry by store and forward shall
34be notified of the right to receive interactive communication with
35the distant dentist, and shall receive an interactive communication
36with the distant dentist, upon request. If requested, communication
37with the distant dentist may occur either at the time of the
38consultation, or within 30 days of the patient’s notification of the
39results of the consultation.

P7    1(c) Dentist participation in services provided at an intermittent
2clinic, as defined in Section 1206 of the Health and Safety Code,
3through the use of telehealth, as defined in Section 2290.5 of the
4Business and Professions Code, shall be considered a billable
5encounter under Medi-Cal.

6(d) Notwithstanding Chapter 3.5 (commencing with Section
711340) of Part 1 of Division 3 of Title 2 of the Government Code,
8the department may implement, interpret, and make specific this
9section by means of all-county letters, provider bulletins, and
10similar instructions.

11(e) On or before January 1, 2017, the department shall report
12to the Legislature the number and type of services provided, and
13the payments made related to the application of store and forward
14teledentistry as provided, under this section as a Medi-Cal benefit.

15(f) For purposes of this section, the following definitions apply:

16(1) “Asynchronous store and forward” means the transmission
17of a patient’s dental information from an originating site to the
18health care provider at a distant site without the presence of the
19patient.

20(2) “Distant site” means a site where a health care provider
21who provides health care services is located while providing these
22services via a telecommunications system.

23(3) “Health care provider” means a person who is licensed
24under Chapter 4 (commencing with Section 1600) of Division 2
25of the Business and Professions Code.

26(4) “Originating site” means a site where a patient is located
27at the time health care services are provided via a
28telecommunications system or where the asynchronous store and
29forward service originates.

30(5) “Synchronous interaction” means a real-time interaction
31between a patient and a health care provider located at a distant
32site.

33(6) “Teledentistry” means the mode of delivering dental health
34care services and public dental health via information and
35communication technologies to facilitate the diagnosis,
36consultation, treatment, education, care management, and
37self-management of a patient’s dental health care while the patient
38is at the originating site and the dental health care provider is at
39a distant site. Teledentistry includes synchronous interactions and
40asynchronous store and forward transfers.

P8    1(7) “Teledentistry by store and forward” means an
2 asynchronous transmission of dental information to be reviewed
3at a later time by a licensed dentist at a distant site, where the
4dentist at the distant site reviews the dental information without
5the patient being present in real time.

end insert
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6

SECTION 1.  

(a) The Legislature finds and declares the
7following:

8(1) Significant portions of California’s population suffer from
9significant oral health disparities. Untreated dental disease can
10have serious consequences for overall health and the ability to be
11a productive member of society.

12(2) Reports from the United States Surgeon General and the
13Institute of Medicine of the National Academics indicate that these
14oral health disparities tend to be concentrated in people with low
15incomes, disadvantaged children, individuals with disabilities and
16chronic medical conditions, dependent older adults, and people
17living in rural areas.

18(3) Approximately one-fourth of all children in California have
19never visited a dental office and two-thirds of all children in the
20state suffer from poor oral health by the time they reach the 3rd
21grade.

22(4) Low-income adults no longer have coverage under the state’s
23Denti-Cal program for other than emergency services and too many
24of them are stigmatized by having missing teeth, miss work because
25of dental infections, or end up in hospital emergency departments.

26(5) A new model of delivering oral health services, called the
27Virtual Dental Home, has been demonstrating a community-based,
28prevention-focused, telehealth-facilitated system of care in
29California, supported by the Health Workforce Pilot Project No.
30172, administered by the Office of Statewide Health Planning and
31Development.

32(6) The Virtual Dental Home system of care brings care to
33community locations where the most underserved and vulnerable
34children and adults receive educational, social, and general health
35services. It emphasizes prevention and early intervention and
36targets those at highest risk for developing dental disease. This
37system delivers oral health at a very low cost per child or adult
38and has the potential to save the state overall oral health expenses.

39(b) It is the intent of the Legislature to enact legislation to
40incorporate the new duties of dental assistants and dental hygienists
P9    1being tested in the Health Workforce Pilot Project No. 172 into
2law and to address barriers to expanding the Virtual Dental Home
3system of care as a cost-effective mechanism to improve the oral
4health of California’s most underserved and vulnerable citizens.

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