Legislature(1995 - 1996)
03/02/1995 02:37 PM House HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HHES - 03/02/95 HB 182 - DELEGATION OF DUTIES TO DENTAL ASSISTANTS CO-CHAIR CYNTHIA TOOHEY introduced HB 182 and asked her fellow HESS Committee members to consider it. This is legislation to allow Alaska's dentists to delegate certain specific duties to their dental assistants. According to an Attorney General's interpretation of Alaska statute, dental assistants are not allowed to perform three procedures: Applying topical preventive agents, applying prophylactic agents, and applying pit and fissure sealants. CO-CHAIR TOOHEY explained that these are nonevasive treatments. She introduced HB 182 when she became aware of problems which were arising from the fact that in rural Alaska, it is especially difficult for a dentist to do his or her job without help. It is more likely that this help will come from a dental assistant than from another dentist or from a dental hygienist. CO-CHAIR TOOHEY said the dentist is responsible for all that happens in his or her practice, and therefore, must train assistants to do whatever procedures they are to perform. CO-CHAIR TOOHEY explained an oversight in the initial drafting of this bill left out dentists who are not licensed by Chapter 36 of Title 8. She asked the committee to consider the amendment included in the bill packets, so that the ability to delegate these three tasks to assistants is given to dentists who work for a branch of the federal government, as well as to the rest of Alaska's dentists. Number 207 CO-CHAIR TOOHEY said that in order to enable dentists to do their jobs in rural Alaska and across the rest of the state, HESS Committee members should support the amendment and HB 182 as amended and vote for its passage. CO-CHAIR BUNDE entertained a motion to adopt the amendment. Co- Chair Toohey moved that the amendment be adopted. REPRESENTATIVE TOM BRICE objected for purposes of discussion. Number 284 CO-CHAIR TOOHEY said the original bill contained a glitch. The dentists that work for the public health service, the Indian Health Service (IHS) and the federal government do not need an Alaskan license. As long as they are licensed by every other state, they qualify to practice dentistry in the state of Alaska. The amendment on page 1, line 6, inserts, "or by a dentist exempt from licensure under AS 08.36.350(a)(2)". Number 330 REPRESENTATIVE AL VEZEY asked if it was Co-Chair Toohey's contention that the wording in the current bill specifically excludes those individuals who are authorized to practice under AS 08.36 that are not specifically licensed by the state. CO-CHAIR TOOHEY said those dentists can practice in the state. REPRESENTATIVE VEZEY asked if Co-Chair Toohey was maintaining that the existing wording specifically excludes those people that will be included by the amendment. CO-CHAIR TOOHEY said yes. The amendment is including those people because they are the ones that normally use dental assistants in the bush. This amendment will include them into the statute. Number 410 REPRESENTATIVE VEZEY said he had not read the entire statute. He would question if these dentists are authorized to practice under another section in AS 08.36, which they are, if it would not be redundant to reference certain other subsections of AS 08.36. CO-CHAIR TOOHEY said apparently, it is not redundant. They are allowed to practice within the state, as long as they are licensed in another state in the Union. This is because they are a federal or IHS employee. REPRESENTATIVE VEZEY said that is the root of his question. If they are authorized to practice by virtue of being a federal officer (because a member of the public health service is an official officer of the federal government), he wondered if it is really necessary to include these dentists specifically. Number 482 CO-CHAIR BUNDE asked on whose advice was the amendment proposed. CO-CHAIR TOOHEY answered the amendment was proposed because of a discovery by her staff. She said that a witness in the room would be able to answer this question. Number 508 BEN BROWN, legislative aide for Co-Chair Toohey, said the request to include persons exempted by Section 350 of Chapter 36 came from the Tanana Chiefs Conference Health Department. Dentists practicing in rural Alaska are a heterogeneous group. Some of them are private dentists who are licensed by the state of Alaska under Chapter 36. Others are employees of the public health service, the IHS or another agency of the federal government. MR. BROWN continued that the Tanana Chiefs Conference Health Department said the bill would not meet their needs as much as they would like unless the amendment was adopted. This was to make sure that those exempt from licensure under this chapter were included. CO-CHAIR BUNDE asked if people employed by the federal government are not licensed by the state. MR. BROWN said they were exempt from licensure by the state. Number 560 CO-CHAIR BUNDE said the question was, is that exemption granted in Chapter 36. MR. BROWN said that exemption is granted under the subsection of Chapter 36 that is cited by this amendment. Number 590 DR. TOM BORNSTEIN, dentist with the Southeast Alaska Regional Health Consortium (SEARHC) and director of dental services, said that dentists who work for the public health service are exempt from licensure in the state. However, many of those dentists do have state licenses. The problem is that these dentists are dealing with the delegation of duties to people who are licensed in this state. DR. BORNSTEIN said that in other words, there would be no problem with a federal dentist delegating authority to perform the duties in question to a federal dental assistant. The question that Mr. Brown has tried to clarify is that a dentist who is not under the purview of the state (not licensed by the state but licensed by the federal government), delegating responsibility to a dental assistant who is regulated by the state.... CO-CHAIR BUNDE politely interrupted and said the original question concerned the ability to practice without being licensed by the state. He asked if that ability was recognized in statute. He asked Representative Vezey if that was what he wanted to know. Number 711 REPRESENTATIVE VEZEY said the state of Alaska cannot regulate the federal government. The state has medical officers serving in the public health service and serving in the uniformed services. These people are not licensed by the state of Alaska. The state cannot deny them the right to practice. The Alaska statutes may or may not mention that fact, but it does not change the fact that the state of Alaska cannot regulate their practice. He asked if we, as a state, have the right to regulate the public health service in anything they do. DR. BORNSTEIN answered that the Native corporations, in many instances, have hired what are called "direct hire personnel." There are people that come under the state's laws and specifically, the health corporations can hire employees who would be under state statutes but not under federal statutes. In other words, all of the folks that SEARHC hires that are not federally employed are under the state's regulation. The amendment is an attempt to avoid a situation in which a dentist who is not regulated by the state, (and Representative Vezey is correct, it is irrelevant), is delegating tasks to a dental assistant who is regulated by the state. That is the problem. DR. BORNSTEIN said the amendment is trying to avoid the situation in which the dentist does not have the authority to delegate this responsibility even though a private dentist would. Number 828 REPRESENTATIVE BRICE attempted to clarify Dr. Bornstein's remarks. He said that currently, private dentists can have dental assistants apply topical preventive or prophylactic agents. DR. BORNSTEIN said that if HB 182 passes, that will be the case. If HB 182 passes without including a provision for the federal dentists to have those same delegation authorities, a grey area would exist. The amendment is an attempt to avoid this grey area. Number 843 REPRESENTATIVE BRICE asked if the amendment is expanding the bill, not narrowing the bill down. Co-Chair Toohey said yes, somewhat. The amendment is to allow the federal government to have the same powers as the private dentist. CO-CHAIR BUNDE asked if the objection to the motion to adopt the amendment was still maintained. Representative Brice said no, and the amendment was passed. The Committee Substitute (CS) for HB 182 was now adopted. The discussion was now open to public testimony. Number 914 DR. BORNSTEIN spoke in support of HB 182. Dentistry, as well as medicine, is coming to the realization that prevention of disease is more humane and cost-effective than treatment of an already existing condition. This is especially true in regard to dental caries (tooth decay). Everyone would rather see it prevented. Among the most cost-effective tools for the prevention of dental caries is the use of pit and fissure sealants, which is a plastic coating that goes over the biting surfaces of back teeth; and topical preventive agents that are applied to teeth, such as topical fluorides and newly approved fluoride varnishes. Number 965 DR. BORNSTEIN said that dental sealant use has been a tool of the dental industry for quite some time. It is a major element of dental disease prevention. This practice has been in widespread use for about the last 15 years. SEARHC has had formal sealant programs for the last several years in conjunction with the schools in many villages and in the main clinics. DR. BORNSTEIN said these programs are in place throughout Southeast Alaska. This is the responsibility of SEARHC and many of the other Native corporations. These organizations go into the villages and perform similar sealant programs. SEARHC has a ten-year track record of providing these types of intensive sealant programs. During this time, dental assistants have been heavily relied upon to apply these sealants. DR. BORNSTEIN said the glitch in the system came when the state rendered an opinion that SEARHC's direct hire dental assistants came under the Alaska Dental Practice Act. Up until that time, it was the widely held assumption that the dental assistants were not covered by that Act in that they were working in a quasi-federal system. DR. BORNSTEIN said that also, it is held by the state that the federally hired dental assistants are not covered. Therefore, the situation exists in which a federally hired dental assistant can work side-by-side with a direct-hire dental assistant and the federally hired assistant can perform duties that the direct hire assistant, with the same level of training, cannot. Number 1075 DR. BORNSTEIN explained that sealants are a safe and relatively simple procedure. He is not aware, in the ten years that SEARHC has provided intensive sealant programs utilizing dental assistants, that there has been any untoward events. He is not aware of any problems associated with dental assistants applying the sealants. DR. BORNSTEIN said the application of dental sealants does not involve any diagnosis, removal of tooth structure, tooth grinding or the use of anesthetics or medications on the part of the dental assistant. In fact, currently the recommendations for teeth that have incipient carious lesions, which are the very beginnings of tooth decay, is to seal those lesions over. Microbiological data suggests that those lesions basically become quiescent and do not progress because they are cut off from their nutrient source. Number 1138 DR. BORNSTEIN said these are very effective means of preventing dental caries. This is a procedure that has been shown to be cost effective and safe. It is something that the dental assistants are more than adequately capable of doing. This is also something that can be done without decreasing the quality of the care that is provided. DR. BORNSTEIN has become aware of some of the concerns that have been raised in regards to allowing dental assistants to apply sealants. Some information Dr. Bornstein saw circulated characterized dental assistants as untrained and inexperienced. Yesterday afternoon, Dr. Bornstein called the other dental clinics maintained by SEARHC in Juneau, Sitka and Ketchikan. Each of those clinics employ four dental assistants. DR. BORNSTEIN asked the dental assistants for their number of years of experience in their current occupation. In Juneau, the numbers were 10 years, 15 years, 13 years and 3 years. In Sitka, the experience levels were 16 years, 32 years, 10 years and 2 years. In Ketchikan, the numbers were 18 years, 12 years, 1 year and 15 years. This is a random survey taken the day before the HESS Committee meeting. Some of the newer dental assistants have replaced people who also worked for a very long time. Number 1230 DR. BORNSTEIN said these are not folks that are unfamiliar with dental procedures. In addition, this was not a stacked survey. Dr. Bornstein asked about every dental assistant in the SEARHC organization. DR. BORNSTEIN thinks that many of the corporations and established dental practices are in the same range as SEARHC. It may be somewhat of a tainted characterization to say that dental assistants lack experience. DR. BORNSTEIN said the nature of the procedure is that it is relatively easy to perform. The body of knowledge that is required to go along with the application of dental sealants is really what the dental assistants are trained for. They know about infection control and universal precautions, Occupational Safety and Health Administration (OSHA) regulations, material safety data sheets, patient safety and instrument use. DR. BORNSTEIN said that dental assistants learn all those things, it is their job. Adding the additional responsibility of dental sealants is a very minor addition to their training. Number 1297 DR. BORNSTEIN said there also may be some confusion as to whether the bill addresses the polishing of teeth. Dr. Bornstein does not see where it addresses the polishing of teeth, and is not sure where this concern comes from. It does not appear to him that the bill addresses the polishing of teeth. DR. BORNSTEIN continued that there is also concern that allowing the dental assistants to perform this procedure will devalue the services of the dental hygienists. He feels that is an unfair assumption. The dental hygienists, as any dentist will attest, undergo extensive training. They are very deserving to be a profession in their own right. DR. BORNSTEIN said their main focus is periodontal therapy and prevention of dental disease. As the practice of dentistry moves in the direction of the prevention of dental disease, Dr. Bornstein thinks that the value of dental hygienists will only increase. He does not think this concern is valid, though he has heard it expressed. Number 1366 DR. BORNSTEIN said the issue of certification of dental assistants to perform these duties has also arisen. He tried to find out whether certification was feasible and if the process exists for dental assistants to be able to be certified. He called the Academy for General Dentistry and reviewed the education materials put out by the American Dental Association. He called the IHS in Albuquerque, New Mexico to ascertain whether or not there was a certification process. DR. BORNSTEIN explained that in 1991, the Navajo area had planned to certify dental assistants. They found it was "overkill." They had gone through the same situation and realized that what they were netting by coming up with a formal certification process was not valuable. Essentially, before they are allowed to perform certain duties, dental assistants receive on-the-job training that involves inservices in the dental practice, and a certain number of contact hours with patients. That is how the Navajo area has proceeded. Number 1430 CO-CHAIR BUNDE said Dr. Bornstein would be available to answer questions and announced the order in which comments would be taken from teleconference sites. Number 1461 REPRESENTATIVE VEZEY attempted to summarized Dr. Bornstein's testimony. He said that dental assistants are capable of being qualified or are qualified to administer prophylactic treatments. He asked if Mr. Bornstein could make that statement without reservations. DR. BORNSTEIN said he has no reservations whatsoever. The dental assistants have been performing these duties for ten years already. This is not something that the dental industry in Alaska is asking to embark on. This is something that has been done already. REPRESENTATIVE VEZEY commented that Dr. Bornstein did not address the advantages of using a dental assistant over a dental hygienist. Representative Vezey said he was just going to assume that using dental assistants allows the industry to provide health care service at lower cost. Number 1509 DR. BORNSTEIN said the dental assistant's salary is generally lower than the dental hygienist's salary. In addition, it allows for more efficient staffing configurations. It is better to have a dentist provide services only they can provide rather than tying them up with services that a dental assistant could be providing. REPRESENTATIVE VEZEY thinks the issue that is before the HESS Committee is providing health care to the public at the lowest cost without compromising quality. He asked if Dr. Bornstein thought HB 182 would provide this. Dr. Bornstein said absolutely. Number 1550 CO-CHAIR BUNDE, for the edification of the committee, asked if it would be fair to say that in level of training, responsibility and cost, the scale goes dentist, hygienist, assistant. Dr. Bornstein said yes. REPRESENTATIVE BRICE asked if Dr. Bornstein said that dental assistants have been performing the duties in question for the past ten years. DR. BORNSTEIN explained that in the programs that the Native health corporations inherited from the federal government, there was essentially a grey area as to what was regulated and what was not. The federal dental assistants were not regulated under the state. DR. BORNSTEIN said as the corporations accumulated non-federally hired dental assistants, they were viewed largely by the Native health corporations to be under the same guidelines that the other dental assistants were. Therefore, those dental assistants have been applying dental sealants for years. It is in those programs that dental assistants have been providing those services. CO-CHAIR BUNDE announced that Representative Davis joined the meeting at 3:05 p.m. Representative Rokeberg also joined the meeting. Number 1658 JOELLEN TATE RINKER, Legislative Chairperson of the Alaska State Dental Hygienists Association, testified from Anchorage via teleconference. She said dental hygienists are health care providers committed to quality care in public service. In order to provide this care, they are tested, trained and licensed. The way HB 182 is written, they feel that the quality of care in the state of Alaska could be compromised. This would mainly impede the private sector. MS. TATE RINKER said the Dental Hygienist Association is opposed to this bill the way it is written. They are not opposed to assistants placing sealants or applying topical fluoride. They do feel that the type of preventative or prophylactic agents is not well defined in this bill. In addition, in the state of Alaska, there is no examination for dental assistants. There is no required certification. This could mean that anyone could be hired off the street, as a dental assistant, and the next day they could be applying pit and fissure sealants. MS. TATE RINKER said she realizes she may be speaking of an extreme case, however, passing the law as it is written would make that situation possible. She asked if that is the kind of professional, quality care that HESS Committee members would want their families to receive. Number 1715 MS. TATE RINKER said the big issue that her association has with the bill is that there are no provisions for any formal implications regarding procedures which are sensitive and can be performed on the public. The public is paying for and expecting quality, professional care from their health care provider. When this bill insures the public that they are receiving or increasing quality care, it will be supported. She asked, isn't it important for all assistants to have a comprehensive training program so the public can be assured of the professional care it deserves. MS. TATE RINKER understands that the bill was introduced on behalf of the Native corporations for their sealant and topical fluoride programs. These are important programs. MS. TATE RINKER said she is employed by a Native corporation. She understands the issue of training and thinks it needs to be in the bill. She said she is willing to work with the Native corporations, the Dental Society and the Dental Hygienists Society to place the language into the statutes that would place an educational element into the bill. Number 1773 CO-CHAIR BUNDE asked Ms. Tate Rinker if it would raise her comfort level with the bill if the bill listed these topical agents specifically. MS. TATE RINKER said that would help, but she would still have a problem with the fact that there are no education requirements for people who are working in the mouth. REPRESENTATIVE CAREN ROBINSON said she understands that in the past, dental hygienists have requested language that basically says, "...if certified by the board, and under the general supervision of the licensed dentist." MS. TATE RINKER said that language was drafted in 1991, and asked Representative Robinson to notice that language also refers to other persons. At this point Ms. Tate Rinker thinks that to define dental assistants would be much more appropriate. She still feels that we can develop language. It would be important for the three associations to get together to discuss language and also to confer with the state on what would be appropriate language that all three associations would be comfortable with, yet still get the Native corporations programs that they need. Number 1838 LISA HODSON-SMITH, dental hygienist and former adjunct clinical professor at the University of Alaska, also testified from Anchorage. She said her focus and conviction has been on the prevention of diseases of Alaska residents to prevent epidemics such as hepatitis B and AIDS. Anyone who works on a patient providing care of any kind must have formal training in disease prevention and microbiology. MS. HODSON-SMITH believes that competency tests have to be given. It just takes one virus to spread AIDS. Each individual is responsible. It may have been tolerated in the past ten years, but she does not think untrained individuals should be tolerated or accepted. She thinks that, in fact, hiring people who have no background in disease transmission through improper cleansing of themselves and tools will actually promote serious diseases in Alaska. MS. HODSON-SMITH said these people need the clinical skills on sealants, but they also need more formal training in disease transmission. It will benefit all Alaskans if dental assistants have that training. Number 1909 CO-CHAIR BUNDE said he assumes from her testimony that she does not feel that a dentist who hires a dental assistant necessarily gives a person the training of which she spoke. MS. HODSON-SMITH said no. She has observed this many times, and has worked in many offices in different states. She has seen dental assistants who do not have training. She has seen improper dental practices and has had to dismiss herself from the office in which the improper practices were taking place. She said that dental assistant training should involve much more than just the basic skills of sealant placing. She said that she is referring to the transmission of diseases such as hepatitis B and AIDS. Number 1945 DR. KEN CROOKS, chief of Dental Services, Bristol Bay Area Health Corporation; and president of the Coastal District Dental Society, testified via teleconference from Dillingham. He spoke for his fellow society members from Dillingham to Barrow. He said that all in the bush feel that this legislation is vitally important. The bush has some of the highest instance of dental disease in the country, and they need to make the best use they can of their health care resources. He thinks Dr. Bornstein accurately portrayed the situation. He would try not to repeat Dr. Bornstein. DR. CROOKS pointed out that in his area, historically they have dealt with thousands of dental sealants. Statewide, if you count the times that topical fluoride programs have been administered by adults without formal training or even by school personnel, Dr. Crooks can count hundreds of thousands of procedures that have been performed successfully. Nationally, when studying states with statutes that permit the application of sealants, more than a million of these procedures have been performed. The successful track record for these procedures is undeniable. DR. CROOKS said he understands people will be concerned, but in his opinion they are overreacting. It has been demonstrated that the skill level that is required to perform these services is the same level of skills or less than many of the other procedures the dental assistants perform. DR. CROOKS said the issue of infection control has been brought up. That is one that the dental profession can point to with pride. There has been one office with a documented transmission of AIDS in the country. That was under very unusual circumstances that are still not clear. Dr. Crooks said these same dental assistants who are accomplishing this level of quality are the people we are speaking of in terms of applying dental sealants and topical prophylactic agents. DR. CROOKS said that Ms. Rinker brought up polishing agents as being prophylactic agents. He would refer her back to the statute. He said to look carefully at Paragraph 1. Clearly, paragraph 1 describes all portions of administering a cleaning of teeth. This remains unchanged by this legislation and totally in the domain of dental hygienists. He would offer his reassurance and opinion that there is no way this will lead to any kind of teeth cleaning by dental assistants. Number 2077 REPRESENTATIVE ROBINSON asked if Dr. Crooks had any problem with working with the Dental Hygienists Association to come up with some language that either requires some level of training or certification for dental assistants. DR. CROOKS said he thought that language would be necessarily very broad and vague. He said that a dental assistant can be trained to perform these procedures excellently in less than two hours. If we were to take the other aspects of dental assistants' jobs, which require similar levels of training, we could develop a process of certifying dozens and dozens of procedures that would all have to strain validity for having a certification. Number 2121 ROBIN STRATTON, federally employed dental hygienist, Bristol Bay Area Health Corporation (BBAHC), also testified via teleconference from Dillingham. She said her practice in Dillingham is somewhat different than that of the hygienists that have previously spoken. She wanted to speak about her involvement in the dental disease program in Bristol Bay. MS. STRATTON said the oral disease prevention program is compliant of the dental program in Bristol Bay and others like it throughout the state. Sealant and topical fluoride application performed by dental assistants has been a tremendous asset to patients there in the past. The delegation of these duties is an important part of the coordinated effort to prevent oral disease. MS. STRATTON thinks that legislation of this nature will serve the patient population by increasing the availability of these services. She also believes it is critical to have trained dental assistants and that those performance standards are monitored by their employers. Given the amount of training that dental assistants in the BBAHC receive, and the benefits this legislation will have to the people that the BBAHC serves, Ms. Stratton supports HB 182. Number 2180 REPRESENTATIVE ROBINSON asked how Ms. Stratton is assured that performance standards are maintained. MS. STRATTON said they have extensive training programs, inservices and supervision in the clinic. Number 2199 DR. DAN PITTS, Soldotna Dental Clinic, testified from Soldotna. He has practiced in Alaska for the last 20 years, 17 of those 20 years in Soldotna. He is the past president of the Alaska Dental Society and currently a council member of the American Dental Association. For six years, earlier in his practice, he traveled to the villages of Tetlin, Tok and Northway. He can attest to the fact that dental decay is in epidemic proportions in the rural areas. Number 2229 DR. PITTS said that other than a toothbrush, fluorides and pit and fissure sealants are our best tools to fight this epidemic. He applauded Representative Toohey for proposing this bill, and he supports the bill also. Speaking for the Alaska Dental Society, he wants to assure the HESS Committee members that proper training through the state OSHA laws are already in the guidelines necessary for the avoidance of disease transmission. The state OSHA laws require this. DR. PITTS added that performance standards are under the direct supervision of a dentist. The dentist is the one that diagnoses the need for sealants, and the dentist authorizes either the assistant or the dental hygienist to place them. The dentist is the one responsible if they are not done right. This is the way it should be. DR. PITTS said that it is all done under the auspices and general supervision of the dentist. Assistants have previously been able to place sealants legally in Alaska. It was not until the hygiene statutes were amended to include sealants that a problem arose. However, when asked for an intent of legislation, it was shown that it was not the intent of the legislation which put sealants into the hygiene statutes to disallow the dental assistants. Number 2286 DR. PITTS said this has become a point of contention between the Attorney General and the legislature. Dr. Pitts said he would stay out of that argument. But he is in favor of HB 182. It is another line of defense against tooth decay. Dentists in both private and public practice are both fully qualified to supervise and train the dental assistants to provide this service. TAPE 95-13, SIDE B Number 000 DR. E.L. WHEELER, Tanana Chiefs Conference, testified via teleconference from Fairbanks. He is presently a commissioned officer in the public health service. He has served in the public health service for six years. He is in support of HB 182. He feels that with the travel that is done to the bush area and other remote Alaskan areas, it is very important to meet the needs of patients out in the bush that are unable to walk around the corner to the dental office. DR. WHEELER said the public health service has training programs for the dental assistants and sealant placing and other procedures that help the dentist. Presently, his office has federally-hired dental assistants who are placing sealants. These assistants are trained by the IHS. Also trained are tribal-hire dental assistants who are paid by the tribe. DR. WHEELER said the only difference between the federal dental assistants and the tribal-hired assistants is that they are paid by different organizations. They are both trained by the IHS, and the dental assistants do an excellent job and take pride in their work. Number 128 DR. WHEELER added that, especially with the IHS and the Tanana Chiefs, allowing the dental assistants to place sealants when out in the villages lets the assistants that are from those small village to help their own people. They take pride in this, and do a high quality job. REPRESENTATIVE VEZEY asked Dr. Wheeler if, as a commissioned officer of the public health service, his understanding of the federal premise is such that the state can regulate him or his practice, regardless of who Dr. Wheeler uses to help in that practice. Number 199 DR. WHEELER answered that as a member of the public health service, it is basically the same as if he was in the Air Force or Army. He is not under state jurisdiction. In fact, he does not even need an Alaska state license to practice for the public health service in Alaska. He does, however, have an Alaska license and that is why he is testifying. DR. WHEELER said that was the point he was trying to make about the federal employees, as far as federally-hired dental assistants versus tribal-hired assistants. REPRESENTATIVE VEZEY asked if the state can regulate those who assist Dr. Wheeler if they are hired by a non-federal agency. DR. WHEELER said yes, that was correct. Number 262 PHYLLIS CAVANAUGH, dental clinic supervisor, Public Health Service, testified from Fairbanks via teleconference. She has worked for the Tanana Chiefs Conference for 22 years, and has been an employee of the United States public health service for 34 years. She has been working with sealants since their inception. There is training in the application of these sealants. Also, from her experience, a trained dental assistant should be applying sealants. This benefits both the doctor and the patient. The doctor is free to perform more pressing tasks, and the patients benefit because they require less visits. MS. CAVANAUGH explained that sealants applied now can last up to four years. Therefore, both the state and the individual see a savings. It is best to do this for children immediately during their cavity-prone years, instead of putting it off for a year until a hygienist can come to the village. In this time, large cavities can develop. MS. CAVANAUGH said it was proven through a study of Alaska that the application of sealants is effective. Dental assistants would like to continue to apply these sealants. Number 397 CECELIA PREZIOSE, dental hygienist, testified from Anchorage. She has worked both in the private and public sectors. She does not think there is anyone in the dental profession that does not agree that the more educated a dental assistant is the more beneficial it is to both dentist and patient. No one would dispute that. The problem lies with the wording of the bill itself. MS. PREZIOSE said a panel of dentists, hygienists and assistants should meet and come up with wording that would protect the public. It would also secure the licenses that are needed for health care professionals to perform these duties. The problem is the wording of the bill. It is vague, people will be taking advantage of it, and people who are not trained will be doing work without proper knowledge. The bottom line is that the public will suffer. Number 483 CO-CHAIR TOOHEY read Section 1(d) of HB 182. "This section does not prohibit a dental assistant from applying topical preventative or prophylactic agents or pit and fissure sealants when those duties have been delegated to the assistant by a dentist licensed under AS 08.36." She asked Ms. Preziose what she found confusing. MS. PREZIOSE answered that the confusion lies in that the bill does not specify what qualifications the dental assistant has to have. Number 617 CAROL STOLPE, registered dental hygienist, also testified from Anchorage. She said it sounds like everyone is in agreement that a change would be beneficial to those individuals in the bush and rural areas that are working with the federal government employees. These people have a training program, and they are not, as she understands it, constrained by the laws of the state of Alaska. MS. STOLPE said that training is the issue, and perhaps some kind of registration or licensing following that training would solve the problem. It seems to Ms. Stolpe that it would be wise to postpone the passage of this bill until the affected parties, including, of course, the consumer, as well as the dental hygienist and assistant associations meet to reword the change so it more directly reflects the intent of the parties involved. MS. STOLPE concluded by saying that the individual who said the consumer could have the reassurance that these assistants applying the agents will be well-trained. She says that is a nice thought, but that is not necessarily good enough to protect the consumer. The language in the law should be more clear. Number 671 JULIE BLEIER, testifying from Anchorage, said that for eight years she performed as an on-the-job trained dental assistant. Her training came from various dentists with different teaching skills and values. The training taught her how to do a specific duty, but she never fully understood the "why" of performed procedures. Also, she never fully realized the degree to which some patients' health was jeopardized. MS. BLEIER said that when she would ask "why," the answers varied from, "This is the way I do things," to "This is the way I was trained." Ms. Bleier provided some examples of health and safety deviations she witnessed. She once passed an etching material which is used in pit and fissure sealants over the patient's face. Some of the material dropped on the patient's forehead. The material was not wiped off until after the procedure was completed, about 45 minutes later. If Ms. Bleier had known that the material contained phosphoric acid, she would never have passed it over the patient's face. MS. BLEIER has witnessed dental assistants, whose on-the-job training did not stress the importance of isolating a completely dry area to apply sealant material, applying pit and fissure sealants. Patients are paying good money for sealants to last at least five years, and the sealants that Ms. Bleier has seen could not last long enough for the patient to walk out of the office. MS. BLEIER said that these are very basic, fundamental procedures that many dentists take for granted, and don't stress to dental assistants. These fundamentals require formal and professional education to establish a firm foundation for proper patient care, and to insure consistency within the dental assistant profession. MS. BLEIER said that on-the-job training is not the answer. Dentists simply do not have the time to provide adequate comprehensive dental assistant training. Time is money, and training will suffer. Without question, if Ms. Bleier had to "do it all over," she would have gone to school to be a certified dental assistant. Due to the high cost of dental care, the patient expects a high level of competence from the entire dental staff. She asked the HESS Committee members to please consider these consequences when making their decision. She asked them to remember that they are also dental patients. Number 808 CO-CHAIR TOOHEY asked Ms. Bleier if she knew of a dental assistant school. MS. BLEIER answered there is a dental assistant school at the University of Alaska in Anchorage. CO-CHAIR TOOHEY asked how long that schooling takes. MS. BLEIER answered that it takes eight months. Number 873 BARBARA O'DONNELL testified from Anchorage. She is currently working toward a degree as a registered dental hygienist. She testified via teleconference from Anchorage that she has spent two years in training toward her dental hygienist degree. She has often engaged in a debate about the histology, the enamel structure and how pit and fissure sealants and etching materials are applied, and materials data analysis. This debate has been with many clinical instructors in classrooms. MS. O'DONNELL has also received quite a bit of training in how to apply those agents and the liability and responsibility involved with that application. She does not see HB 182, as it is proposed right now, as addressing any of the training that she feels is required to perform these applications. Number 951 MS. O'DONNELL will take a national board examination in one month. She will be questioned on the issues of enamel structure and materials used in the process of applying these sealants and other agents. She has spent many hours studying these topics, and she does not see the provision in HB 128 for any type of training that covers not only the application but also histology and understanding of tooth structure and safety considerations. MS. O'DONNELL said there were also issues of liability. Most dental hygienists are faced with purchasing liability insurance, and they assume liability for the procedures that are offered to the public. She does not know if dental assistants take on this level of liability for the procedures they perform right now. She would like to know who is going to assume the responsibility of the liability of performing these applications. CO-CHAIR BUNDE said that he would assume that the liability would fall upon the dentist. Number 1049 KATHLEEN WILLIAMSON, registered dental hygienist, was educated in Alaska and took both her national and state board exams. She has been working mostly in a private clinical setting for 11 years now. She has been trying to remember exactly how many hours of her training was dedicated to pit and fissure sealants, and she cannot. This has already been covered, but it is true that although the main tools used are an explorer and a mirror, there are a lot of other things that happen. MS. WILLIAMSON said that in her experience, anyone can be taught to do a number of things. What an education does is teach you what can go wrong with those things, so you can make decisions about how, why, and when a procedure takes place. She also took a separate course that licenses her to administer local anesthetic. A dentist could teach her how to do this, but she does not know that he would teach her all the things that could go wrong if she did it wrong. Number 1102 MS. WILLIAMSON thought that was the crux of the contention, that the bill allows the dentist to teach the assistant how to perform duties. Therefore, the wording is just not there that tells exactly what the dentist is going to teach the assistant. MS. WILLIAMSON wondered if dental assistants are aware that polishing agents are coded according to color. The color tells you if the agent is coarse or finer. There are many little things that she went to school to learn, and the dentist did too. She thinks some sort of formal education should be a requirement. MS. WILLIAMSON said she has also worked for SEARHC in the bush. She said that one of the limitations that exist in the bush is that there is typically only one chair. If there is only one chair, she would assume the dentist is present. If the dentist is there, then he can do these procedures. He probably does not want to be present during lunch, so is that the time when the assistant will place the sealants? Number 1166 MS. WILLIAMSON asked if the assistant would go to the bush on a different day, when the dentist is not present because the assistant lives in that village. When Ms. Williamson worked in the bush, there was only one chair, and she was the hygienist. Therefore, she went and performed, under general supervision, those duties that the law allowed her to do. MS. WILLIAMSON asked if there is already two chairs, would there be a dentist working in one chair, and a dental assistant working the other chair, but no dental hygienist. She asked if this was the plan to save money. The other chair will be operating, but the operator will not have to be paid as much. Number 1198 CO-CHAIR TOOHEY asked about the average salary for a dental hygienist. MS. WILLIAMSON said the average was about $200 per day, or $30 to $35 per hour. CO-CHAIR TOOHEY asked how much the salary of a dental assistant is. Dr. Bornstein answered that dental assistants probably make, depending on experience, between $12 and $20 per hour. Co-Chair Toohey stated she thinks that is probably one of the major reasons for the delegation. MS. WILLIAMSON said she thinks that bush dentists and public health service dentists are trying to push this bill through, but the one who will most benefit is the urban dentist. The procedures in question are commonly done. Counting fluoride treatments and cleaning, these account for probably 20 procedures every day in a regular office. MS. WILLIAMSON said that probably what will happen is the regular dentist will be scheduling these treatments and applications, and the child will walk out with sealants and the process will be over in no time at all. CO-CHAIR TOOHEY said that will happen anyway, whether they are licensed or not. If they are licensed that will still happen. Co- Chair Toohey said that she is a nurse. They are now training nursing assistants because nurses have become so well-recognized with a high pay scale that has become a problem. Whatever happens, the cost of treatment must be lowered. We are obliged to lower the cost of treatment in this country. Whether they are licensed or not, they will still be doing whatever it takes to keep those cavities from coming. The job of the dental hygienist will never be excluded, but some of the jobs may be usurped. Number 1309 MS. WILLIAMSON said that was fine. As a matter of fact, that is why dental hygienists were created in the first place, because dentists don't want to do what hygienists do. Dentists are trained to perform those duties, but they don't want to do them. MS. WILLIAMSON said however, the hygienists went to school to learn their trade and what could go wrong and what might not be a good idea to do. Number 1329 REPRESENTATIVE DAVIS said it has been indicated there is a dental assistant school. He asked how many dental assistants currently in the field have gone to school. He asked if someone could be hired without going to school; and if someone could be hired, trained, and called a dental assistant. MS. WILLIAMSON said that someone could be trained on the job and called a dental assistant. She said that was where the contention was. In Alaska, no formal education is needed for a dental assistant position. Some states require this formal education, but Alaska and some other states do not. There is a dental assistant school in Alaska, but it is not required that a person attend that school in order to be a dental assistant. Many dental assistants are trained on the job. This is not to say that they do not do a good job, but it depends on what the dentist said was important. CO-CHAIR BUNDE announced the end of public testimony, and opened discussion for the committee. Number 1396 REPRESENTATIVE ROBINSON said she was strongly in favor of this approach to dental care across the state, and wants to see this bill passed. She wondered if the issue could be placed into a subcommittee. It appears that everyone seems to be in favor of the essence of the bill. She has not heard that the dental hygienists are adamantly opposed to the bill, but the contention lies in the semantics of whether or not the bill clearly has the necessary safeguards. REPRESENTATIVE ROBINSON said everyone wants to make sure that every child in all areas of the state receives appropriate and quality dental care. She asked if the sponsor of the bill would be willing to form a subcommittee. Representative Robinson said she would be happy to work with the sponsor of the bill (Representative Toohey), dental hygienists and dentists to see if a solution can be found. REPRESENTATIVE ROBINSON said a solution may not be possible. However, it would benefit everyone to try and find language that assures quality control. This bill does not have another committee to go to, so this is the committee to take on that responsibility. Number 1465 CO-CHAIR TOOHEY said the bill was amenable, and said if Dr. Bornstein would be willing to work with herself and Representative Robinson, a solution may be possible. REPRESENTATIVE VEZEY said he would be opposed to trying to add verbiage to this statute. He thought if Title 8 was studied, it would be found that dentists are licensed by the dental licensing board. They are charged with maintaining the standards of the American Dental Association or the Alaska Dental Association. There is an extremely high standard that is already enacted in the statute. It is not enacted verbatim, it is adopted from professional standards. REPRESENTATIVE VEZEY continued that by virtue of the fact that this is the dentist's practice, the dentist is obligated to maintain these standards in order to keep his license. Not to mention the fact that the dentist is required to maintain the malpractice insurance and has full liability. Representative Vezey thought that no matter how hard the HESS Committee members try, they cannot codify good dental practice. It is simply beyond the means of this legislature to do so. That is why there is a dental board. Number 1530 REPRESENTATIVE ROKEBERG said he was looking at the statute under Title 8. The statute which would be amended by the bill is the dental hygienists statute, not the dentist's statute. The dental hygienist statute is nine pages long. From listening to testimony and Representative Robinson, he believes that if we are looking toward the certification of dental assistants, another nine pages will have to be drafted. CO-CHAIR BUNDE said that, as chair, he would make a command decision. He said the bill would be held and asked that Representatives Toohey, Vezey and Robinson bring the bill back to the committee next week, either in its original form, or whatever their research may come up with.
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