Legislature(1995 - 1996)

03/02/1995 02:37 PM HES

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
txt
 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.                                              
                                                                               

Document Name Date/Time Subjects