SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE January 17, 1996 9:03 a.m. MEMBERS PRESENT Senator Lyda Green, Chairman Senator Loren Leman, Vice-Chairman Senator Mike Miller Senator Johnny Ellis Senator Judy Salo MEMBERS ABSENT All members present. COMMITTEE CALENDAR SENATE BILL NO. 212 "An Act relating to the grounds for revoking or suspending a dental license and for the imposition of other disciplinary sanctions by the Board of Dental Examiners; and providing for an effective date." SENATE BILL NO. 165 "An Act relating to psychologists and psychological associates." PREVIOUS SENATE COMMITTEE ACTION SB 212 - No previous action to record. SB 165 - No previous action to record. WITNESS REGISTER Mike Tibbles, Staff Senator Green State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Presented the sponsor statements of SB 212 and SB 165. Scott Crowther 1726 Bellevue Loop Anchorage, Alaska 99515 POSITION STATEMENT: Supported SB 212. Dr. Burton Miller, Licensed Dentist 2600 Denali Street Anchorage, Alaska 99517 POSITION STATEMENT: Supported SB 212. Dr. Michael Ziff, Executive Director International Academy of Oral Medicine and Toxicology Orlando, Florida POSITION STATEMENT: Discussed the need for the public to be informed of potentially dangerous dental materials. Dr. Roger Eichman, Dentist Box 20765 Juneau, Alaska 99802 POSITION STATEMENT: Viewed SB 212 as a means of opening communication. Elmer Lindstrom, Special Assistant Department of Health & Social Services PO Box 110601 Juneau, Alaska 99811-0601 POSITION STATEMENT: The Section of Epidemiology determined that that amalgam fillings were not a public health issue or risk. The Division of Public Health suggested that the issue of amalgam fillings be stated in SB 212. Catherine Reardon, Director Division of Occupational Licensing Department of Commerce & Economic Development PO Box 110806 Juneau, Alaska 99811-0806 POSITION STATEMENT: Suggested that SB 212 be limited to amalgam fillings. Sam Kito Alaska Dental Society PO Box 210575 Anchorage, Alaska 99517 POSITION STATEMENT: Suggested that dentists mediate amongst themselves. Jennifer Jones, Co-Chair Licensing Equity Committee Alaska Psychological Association 2453 W 27th Anchorage, Alaska 99517 POSITION STATEMENT: Discussed the reasons for SB 165. Stated support for SB 165 by the Alaska Psychological Association. Kathryn Carssow 1335 O Street Anchorage, Alaska 99501 POSITION STATEMENT: Supported SB 165. Christie Brown 101 E 9th, Suite 14B Anchorage, Alaska 99504 POSITION STATEMENT: Create a fair and equitable environment for psychological associates. Kathy Pontius, Graduate Student HC 34 Box 2068 Wasilla, Alaska 99654 POSITION STATEMENT: Supported SB 165. Roy White, Licensed Marital Family Therapists PO Box 105 Palmer, Alaska 99645 POSITION STATEMENT: Supported SB 165. ACTION NARRATIVE TAPE 96-1, SIDE A SHES - 1/17/96  SB 212 DISCIPLINARY SANCTIONS FOR DENTISTS  Number 001 CHAIRMAN GREEN called the Senate Health, Education and Social Services (HESS) Committee to order at 9:03 a.m. and introduced SB 212 as the first order of business before the committee. MIKE TIBBLES, Staff to Senator Green, read the sponsor statement which outlines the two main concerns that lead to SB 212. "First, it insures the rights of dentists to practice the safe dentistry method of their choice and secondly, by insuring this right, the bill provides dentists the same level of protection against board sanctions physicians currently receive under the law." SB 212 would allow dentists to inform patients of safe, alternative procedures without the concern of sanctions. SENATOR LEMAN asked if Mr. Tibbles was aware of any challenges caued by the 1990 law, the State Medical Board--Grounds for imposition of disciplinary sanctions which is a portion of HB 146. MIKE TIBBLES was unaware of any such cases. SENATOR ELLIS asked who had requested the legislation. MIKE TIBBLES said that an individual had brought the legislation forward. Number 065 SCOTT CROWTHER informed the committee that a reform movement had been initiated in dentistry in 1984 which has resulted in the documentation by medical scientists of the many health risks associated with mercury. Mercury leaks out of dental amalgam. Due to this documentation countries in Western Europe and Canada are now phasing out the use of mercury based amalgam. Mr. Crowther believed that a more economical medical and dental system could be obtained if amalgams were not used. Furthermore, individuals could reach a higher quality of life and health if amalgams were removed. In order to achieve these two goals more mercury-free dentists are needed in Alaska. Mr. Crowther explained that mercury-free dentists would not knowingly install a mercury-based product in a patient's teeth. Mercury-free dentists informe patients of the health risks of amalgams. Mr. Crowther pointed out that Sweden's socialized medical and dental system was setting an international standard. In Sweden, amalgams are not installed and if the patient wishes to remove any amalgam it is done at the government's expense. Number 103 Mr. Crowther explained that he was a patient that had experienced severe health problems due to the leakage of mercury from dental amalgam. If his amalgams had not been removed four years ago he doubted his ability to be present at this meeting. Due to mercury detoxification and body system rebuilding with dietary supplements, he has experienced many health improvements. He emphasized that other patients should not repeat his experience. He informed the committee that one hundred other patients had signed a petition supporting SB 212. Mr. Crowther pointed out that mercury-free dentists who have removed amalgams face the threat of board review since mercury-free dentists are not following conventional beliefs. He believed that the passage of SB 212 would protect existing mercury-free dentists from board review and mercury-free dentistry would grow in Alaska. Patients would benefit the most from the removal of amalgams. Number 134 SENATOR LEMAN asked if the protection sought was for cases in which the removal and replacement of amalgams were performed when no detrimental health challenges were known. Can dentists currently remove and replace amalgams that are identified as causing health challenges? SCOTT CROWTHER explained that, according to the American Dentists Association Code of Ethics, dentists can remove and replace amalgams if a physician issues a statement to that effect. Few physicians have the background and training necessary to identify mercury poisoning. DR. BURTON MILLER, a licensed dentist in Anchorage, was in favor of SB 212. He emphasized that SB 212 would not allow disciplinary actions to be imposed solely on the grounds that a practice is unconventional or experimental unless the board could demonstrate physical harm to the patient. Dr. Miller informed the committee that he had experienced censorship action due to his philosophy and practice that noxious and poisonous substances are such. Therefore, his practice is considered unconventional and experimental. Dr. Miller was appointed by Governor Hickel to the Board of Dental Examiners in May 1993 and served 11 months. He explained that the Alaska State Dental Society, of which the Board of Dental Examiners comprises the majority, considered his dental philosophy experimental, unconventional, dangerous, costly and harmful. The Alaska State Dental Society invested much time and effort to portray his practice as such without interviewing him or mentioning his Dental Board work ethics. Therefore, he was penalized for his unconventional and experimental practice philosophy. He pointed out that Roger Eichman of Juneau also faced the same treatment by the Dental Board of Examiners. Other dentists with similar philosophies in the lower 48 are being reprimanded and censored as well as disciplinary action and even license revocation. Number 209 In an article last year, The Journal of the American Medical Association stated that 40 percent of the population is seeking alternative medical care. Dr. Miller said that the same information that pushed 40 percent of the population towards alternative medical care is the same information that the American Dental Association (ADA) does not circulate to its members. Information regarding the issue of mercury vapor from mercury amalgam can be found in reputable, prestigious scientific journals. Due to this information many dentists are practicing mercury-free, biological dentistry in secret. Dr. Miller said that SB 212 would encourage health centered dentistry without the fear of reprisal. Dr. Miller supported the passage of SB 212. SENATOR LEMAN asked if the examination or training to become and continue to remain a dentist included the capability of installing mercury amalgam filling. DR. BURTON MILLER was fairly sure that mercury amalgam filling was still part of the curriculum as when he attended school. Dr. Miller added that when he attended school the toxicity of mercury was not mentioned. Today mercury is known to be more toxic than lead cadmium or arsenic. Number 250 DR. MICHAEL ZIFF, Executive Director of the International Academy of Oral Medicine and Toxicology (IAOMT), stated that the scientific evidence against the use of mercury amalgam has compelled many governments to end the use of mercury amalgam. In 1994, the United States' Public Health Service stated that mercury exposure from amalgam dental fillings exceeded the minimum risk level therefore, creating a potential health risk to patients. Even so, the dental profession declares that mercury exposure from dental amalgam is not harmful to patients merely because dental amalgams have been used for over 150 years. Dr. Ziff informed the committee that the ADA amended its Code of Ethics in 1986 in order to state that the removal of dental amalgams was unethical while encouraging boards of dentistry to discipline dentists who performed the removal of dental amalgams. Following the amendment, four dentists in the United States have lost their license for this. This is a restriction on trade as well as a disservice to the public health. Dr. Ziff emphasized that state board's must inform their citizens of dental procedures that prevent risk to the patient. The IAOMT has informed the Alaska Board of Dentistry of their duty to inform the public of the potential risk of dental amalgam. Furthermore, the IAOMT informed the Alaska Board of Dentistry to end the disciplinary actions against those fulfilling their obligation to public health. In response to Senator Salo, Dr. Ziff explained that he had been in dentistry for 35 years and currently practiced one half day a week. Dr. Ziff sold his practice in 1988 in order to dedicate his time to scientific investigation. Number 298 SENATOR SALO asked if there had been any successful litigations against dentists regarding amalgam fillings. DR. MICHAEL ZIFF was unaware of any such cases. He informed the committee of a case in progress in which the ADA's attorneys declared that the ADA did not have any responsibility to protect the public from allegedly dangerous materials in dentistry. DR. ROGER EICHMAN, 25 year Dentist, noted that he had replaced Dr. Miller on the Alaska Board of Dentistry until he too was not confirmed. He said that he was one of the pioneers in composite fillings in the United States. Composite fillings have improved from a material point of view such that there is no reason to use an amalgam filling. Amalgam fillings expand, break teeth, give out electrical action and are toxic. Dr. Eichman informed the committee that he is the president of the Juneau Mining District and is very well versed in field geology. There is a field geology test for mercury which illustrates how mercury vaporizes off of the silver amalgam. This happens every time a person with such a filling chews or polishes a tooth not to mention when an amalgam is placed or replaced. An amalgam filling contains 50 percent mercury when placed in the tooth however when assayed after 10 years, only half of the mercury remains. Dr. Eichman said that the mercury is absorbed. After 20-30 years, an allergy to the metal is developed which leads to a discussion of symptoms such as multiple sclerosis, lupus, and other debilitating diseases. He acknowledged that mercury has not been said to cause these diseases, but in order to receive treatment for these disorders it seems necessary to remove the mercury load from the body. Number 366 Dr. Eichman said that it would be unethical for him to recommend amalgam removal or to influence the patient in any manner. It is not unethical if a patient requests, unprompted, the replacement of their amalgam fillings. He emphasized that he could not determine if a patient with an amalgam filling had a problem or would later on. Furthermore, Dr. Eichman did not know anyone who could diagnose this problem with any assuridty, moreover the tests used are expensive. Removing the amalgam is the cheapest manner in which to deal with this issue. He noted that merely this discussion with the committee could put his practice in jeopardy although, he expressed more concern for the upcoming generation of dentists with regard to the debate over amalgams versus composites. Discussion of this debate and the related cases is necessary in order to learn and treat future cases. CHAIRMAN GREEN asked Dr. Eichman if SB 212 addresses the concerns. In response to Chairman Green, DR. EICHMAN said that the bill moves toward helping. Dr. Eichman did not believe that SB 212 placed anyone in a position of harm. SB 212 opens communication, but does not change practice. Number 415 SENATOR ELLIS inquired as to the average cost of the removal of an amalgam filling and the replacement with the composite filling. DR. EICHMAN estimated that such a procedure would cost $80-$125 a filling depending upon the size of the filling. The cost of amalgam fillings in Juneau are higher than the above estimate. ELMER LINDSTROM, Special Assistant in the Department of Health & Social Services (DHSS), explained that early this year Dr. Crowther had offered to provide the department with information regarding amalgam fillings and mercury toxicity. Mr. Lindstrom provided the information to the Division of Public Health in order to receive the division's opinion on this issue. The Section of Epidemiology in the Division of Public Health reported that the scientific literature did not support the suggestion that these fillings were a public health issue or a public health risk. The position by the Section of Epidemiology remains the same. The Division of Public Health identified SB 212 as related to the amalgam filling issue although, the bill does not mention this issue. Mr. Lindstrom related the Division of Public Health's concern that SB 212 goes beyond that issue and could include other unconventional or experimental practices in the future. The Division of Public Health suggested that the issue of amalgam fillings should be stated in SB 212 to eliminate the broadness of this statute. This statute would limit the ability of the board. Mr. Lindstrom said that the interest of the Division of Public Health is the impact on the consumer. In conclusion, Mr. Lindstrom proposed the question: is the removal of amalgam fillings necessary in the instance when there is no demonstrable physical harm from the removal of the fillings? According to the Division of Public Health's perspective on the scientific literature, the removal of amalgam fillings is not necessary and can be an expensive procedure. Number 466 SENATOR LEMAN pointed out that comparable wording to that in SB 212 is used in statutes referring to medical doctors; this language has been in place for approximately six years. In response to Senator Leman, ELMER LINDSTROM was unaware of any problems related to the medical statutes. Mr. Lindstrom speculated that the Division of Public Health would have had the same testimony on the medical bill as today. CATHERINE REARDON, Director of the Division of Occupational Licensing in the Department of Commerce & Economic Development, explained that the division issues dental licenses and interacts with the board in disciplining dentists and dental hygienists who prove to be incompetent or unethical in their practice. She reiterated the concern that SB 212 encompasses more than amalgam fillings. Ms. Reardon expressed concern with the effect of the medical statutes, which contain language similar to that in SB 212, have had on investigations and enforcement. Ms. Reardon suggested that SB 212 be limited to the amalgam issue. She discussed the investigative procedure in which demonstrable harm must be determined and classified in order to move forward with the allegations. CHAIRMAN GREEN did not believe that SB 212 repealed or took any powers from the division. SB 212 does not have any correlation to any unprofessional conduct. SENATOR ELLIS commented that the bill changed the standard. Number 528 CATHERINE REARDON explained that under SB 212, the division would be required to prove that a dental practice was not only unconventional practice, but that the practice also harms the person. The harm would also have to be well documented. Ms. Reardon said that this creates the concern regarding the broadness of SB 212. Limiting SB 212 to the amalgam fillings would narrow the conditions under which the division would investigate accusations against a practitioner. SENATOR SALO expressed concern that if SB 212 specifically addresses amalgam fillings, the division may be left protecting mainstream dentistry if amalgam is later found to be harmful. CATHERINE REARDON acknowledged Senator Salo's concern, but feared that the language limited the board's ability to outline what is considered a safe practice. She felt that if metal fillings were found to be harmful under the amalgam language, the division would also have problems because that practice would then be considered unconventional or experimental. SENATOR SALO preferred protection from those practices that illustrated demonstrable harm or useless economic waste over making the language specific to amalgams. CATHERINE REARDON mentioned that the Dental Board had adopted the 1995 ADA Code of Ethics through regulation. The 1995 ADA Code of Ethics refers to amalgams only in general terms regarding the quality of care. TAPE 96-1, SIDE B According to the investigative unit, no one has been disciplined nor could the unit recall any complaint investigations which were based on amalgams versus composites. SENATOR MILLER asked if composite fillings conformed to the minimum standards of professional dentistry. In response, CATHERINE REARDON said that he had hit on the issue - there is not a book of dos and don'ts. SENATOR MILLER inquired as to what portion of the statutes were being used to justify that composites cannot be used if the composites do in fact conform to the minimum standards. CATHERINE REARDON stated that the board and the division are not disciplining dentists who use composite fillings. Ms. Reardon further clarified that there is a debate within the dental community regarding whether composite fillings are part of the standard. There was discussion about Dr. Miller's testimony which Senator Miller had understood that Dr. Miller had received disciplinary action for using composites. SENATOR LEMAN clarified that Dr. Miller was referring to his not being confirmed on the board as his disciplinary action. Senator Leman recalled that during the confirmation hearings for Dr. Miller his use of composites was brought forth. Number 544 DR. EICHMAN said that the entire dental community is moving toward composite fillings. The problem rises when a dentist recommends composites to a patient; the dentist is considered unethical. However, it would not be unethical for a dentist to place composites, if a patient requested so with no suggestions from the dentist. Dr. Eichman pointed out that this is a communication problem. He further noted that a dentist could be censored if they spoke out against the ADA, moreover the dentist could be placed before the board. The ADA considers it unethical to speak out about a dental problem. SAM KITO, Alaska Dental Society, explained that the amalgam debate surfaced after the legislature and the administration had passed the Dental Practices Act. The Dental Practices Act allows the Dental Board to be able to discipline themselves. The board determines whether a dentist is performing up to a certain standard. He said that the debate is over a dentist recommending composites to a patient that has amalgam filling. Mr. Kito did not believe there would be any argument that amalgam lasts longer than composites. The argument is about the presence of scientific proof that amalgam is safe. The studies indicate to the Dental Association and the majority of Alaskan dentists that amalgam is not harmful. If amalgam was harmful a determination would have been made; there has not been a determination. Number 495 Mr. Kito passed out the ADA's Code of Ethics and Professional Conduct. He agreed that this was an internal argument. He explained that the Dental Board and the Dental Association had difficulties in the past regarding whether the Division of Occupational Licensing would take an issue disciplining a dentist. The division indicated that there was much work involved and the standards were not set at that level. Mr. Kito suggested that dentists mediating amongst themselves would be a better option. He informed the committee that the Attorney General would not get involved unless a crime had been committed. The Dental Association of Alaska has indicated that they would like to work with the process that has been put in place. SENATOR SALO asked if the Dental Association would agree that they are moving toward composites. SAM KITO replied, no. That issue should be debated within the professional ranks and is being debated. The majority of dentists believe that dental amalgam is not harmful. Mr. Kito reiterated Ms. Reardon's point that the Division of Occupational Licensing is not charging, prosecuting, or reviewing any dentist that installs composites. Mr. Kito said that it is a matter of the conduct in the movement from amalgams to composites. CHAIRMAN GREEN asked for the pleasure of the committee. SENATOR LEMAN moved that SB 212 be moved out of committee with individual recommendations. Hearing no objection, it was so ordered. SHES - 1/17/96 SB 165 PSYCHOLOGISTS & PSYCHOLOGICAL ASSOCIATES  Number 448 CHAIRMAN GREEN introduced SB 165 as the next order of business before the committee. SENATOR MILLER moved that the committee adopt the Lauterbach F version of SB 165 as the HESS Committee Substitute(CS). MIKE TIBBLES, Staff to Senator Green, reviewed the changes that the CS made. Changes Made By the CS (1) Page 1, line 6 after "evidence" the language "sufficient to conclude" was added in order to tighten the language. (2) Page 2, line 22 changed "doctoral degree" to "master's degree" due to a drafting error. (3) Page 4, line 30 - page 5, line 4 tightened the language regarding the definition of "sexual misconduct". CHAIRMAN GREEN noted that the change in definition of "sexual misconduct" was at the request of the Association of Psychologists. Without objection the CS was adopted as a working draft. MIKE TIBLLES read the sponsor statement which indicated that the provisions surrounding the licensure of psychological associates are too inhibiting. SB 165 would bring the psychological associates into conformity with other masters-level programs. Number 406 JENNIFER JONES, Co-Chair of the Licensing Equity Committee of the Alaska Psychological Association, identified the primary reason for this legislation as being the small number of licensed professionals in Alaska at the masters-level. She reiterated that the process of licensure is burdensome and prohibitive. The committee wants to encourage masters degree clinicians to obtain a license. The rural population would be greatly affected because in rural areas there are no Ph. Ds to do weekly supervision. This legislation would establish greated equity amongst mental health professionals who deal with the same populations as psychologists. Ms. Jones indicated that there seems to be more of a need to create standards for providing health care. Third-party payers are more interested in reimbursing licensed professionals. Therefore masters level psychology individuals without licenses are less likely to be reimbursed for services. Individuals in such situations are not able to practice in the state. SB 165 is a step towards meeting the changes in the entire health care field. Ms. Jones suggested the option of temporary licenses for masters-level people with oversight during the time they are practicing before receiving their full license. Ms. Jones noted that the previous sexual conduct language was ambiguous which lead to the tighter language in the CS. The language in the CS would strengthen the boards ability to initiate investigations of complaints. CHAIRMAN GREEN asked if this legislation had wide support from Ms. Jones constituents. JENNIFER JONES replied yes. The Alaska Psychological Association does support this legislation. KATHRYN CARSSOW, 20 year Alaskan resident, explained how she came to pursue a masters degree in Clinical Psychology or social work and family therapy. She supported SB 165 and noted that she had helped in its drafting. Masters degree professionals should be able to practice on their own in rural areas in a reasonable time frame, which should conform to the time frame requirements of marital and family therapists. This draft legislation would allow more mental health professionals to practice across the state. Number 322 CHRISTIE BROWN informed the committee that she had practiced at an undergraduate level for 10 years and is currently pursuing her masters degree. This bill would bring about fair and equitable changes for psychological associates. SB 165 would allow masters level people to practice in areas where there are no professionals available. KATHY PONTIUS, graduate student in Clinical Psychology, noted the difference in the supervisory requirements for licensure of those in social work, marital and family therapists as opposed to those in psychology. She informed the committee that there is not a masters degree program in marital and family therapy in Alaska. The masters degree program for social work began this fall at the University of Alaska-Anchorage, although the program is not accredited. Ms. Pontius pointed out that the unfairness of the current statute have forced many possible clinical psychologist majors to move out of state to obtain their degree. Therefore, Alaska loses possible therapists. In conclusion, Ms. Pontius supported SB 165. ROY WHITE, licensed Marital and Family Therapist, supported SB 165. He reiterated the concern of the movement of psychological professionals out of the state under the current licensure requirements. Number 244 SENATOR MILLER moved that CS SB 165(HES) be moved out of committee with individual recommendations. Hearing no objections, it was so ordered. CHAIRMAN GREEN announced the Joint HESS meeting for 1-18-96. The joint committee will have EO 97 and an overview of the Mental Health Program and Planning before them. There being no further business before the committee, the meeting was adjourned at 10:21 a.m.