Understanding the New Rules Allowing Local Anesthesia Administration for Adults Under General Supervision
It is important for dental hygienists in Washington State to understand when the new rule applies to patients and in which practice settings it is allowed. Your Washington Dental Hygienists’ Association (WDHA) has worked hard for more than two years to move this change forward and make it a reality for Washington State dental hygienists.
The existing rules (WAC 246-817-550 & 560) that specify what dental hygienists who work in supervised settings (not direct access settings) can do under general or under close supervision have been updated and went into effect as of January 13, 2017. The updated rules move the following procedures from the requirement of close supervision to the list of procedures allowed under general supervision:
1. Head and neck examination
2. Administer local anesthetic agents and adjunctive procedures if certain conditions are met.
- Adjunctive procedures include local anesthesia reversal agents and buffered anesthetic.
- The conditions for administration of local anesthesia under general supervision are:
- The patient is at least 18 years of age
- The patient has been examined by the delegating dentist within the previous twelve (12) months
- There has been no change in the patient’s medical history since the last examination. If there has been a change in the patient’s medical history within that time, the dental hygienist must consult with the dentist before administering local anesthetics.
- The delegating dentist who performed the examination has approved the patient for the administration of local anesthetics by a dental hygienist under general supervision and documented this approval in the patient’s record.
3. Deliver oral antibiotic prophylaxis as prescribed by a dentist
4. Take impressions, bite registration, or digital scans of the teeth and jaws for:
- Diagnostic and opposing models
- Fixed and removable orthodontic appliances, occlusal guards, bleaching trays, and fluoride trays
- Temporary indirect restorations such as temporary crowns
Dental hygienists in supervised settings continue to be allowed to administer local anesthesia to patients less than 18 years of age as long as it is under close supervision and they may use adjunctive procedures including local anesthetic reversal agents and buffered anesthetic. WAC 246-817-560, which is the rule that allows dental hygienists to administer nitrous oxide analgesia and place antimicrobials under close supervision, clarifies this.
The rules for dental hygienists when practicing in unsupervised settings have NOT changed. These direct access settings as specified in RCW 18.29.056 (certain health care facilities and senior centers) and RCW 18.29.220 (community-based sealant programs) have a very limited scope of practice and the procedures allowed have not changed and do not include any of the procedures listed above in points 1 to 4.
To be clear, these new rules apply to dental hygienists when working in supervised settings. The dentist supervisor will now be able to determine/delegate when it is appropriate for a dental hygienist to administer local anesthesia under general supervision and to which adult patients. In making this delegation of duties, the dentist will need to provide documentation in the patient’s chart. Hygienists will want to work with their dentists to determine how and when this will be implemented to improve their patients’ care.
The two-year effort to bring about this change in the delegation of duties allowed under general supervision was the combined work of WDHA, the Dental Hygiene Examining Committee (DHEC) of the Department of Health, and the Dental Collaboration Committee established by the Dental Quality Assurance Commission (DQAC). In 2014 WDHA approached DHEC about making a request to DQAC to clarify that dental hygienists could perform head and neck examinations under general supervision. DHEC took the opportunity to request additional procedures be moved to general supervision, including local anesthesia, delivering antibiotic prophylaxis, and eventually included impression taking in the request.
At that time, DQAC had just recently established the Dental Collaboration Committee with two commission members and was requesting representation from DHEC and the Board of Denturists to create a forum for discussion of matters before DQAC that also relate to dental hygienists and denturists. DHEC appointed two of its members to the committee and, along with a denturist board representative, this committee began the process of deliberating the change from close to general supervision for these procedures during lunch hour conference calls every couple of months. WDHA always had several participants on these calls and took a very active part in providing information to the committee members regarding the education and training of dental hygienists in local anesthesia administration and medical emergency management by recruiting dental hygiene educators with expertise in these areas.
Kathy Bassett, WDHA member and lead author of the textbook, Local Anesthesia for Dental Professionals, can be credited with guiding the language used for the wording, “Administer local anesthetic agents and adjunctive procedures.” You will note that it does not include the word injection so that dental hygienists are not limited to that form of administration. Instead it will allow dental hygienists to use new and evolving forms of local anesthetic administration as those are developed and this includes adjunctive procedures as they are realized, with buffered anesthetic and reversal agents serving as examples.
The Dental Collaboration Committee took their recommendations to support these changes back to DQAC. WDHA members were always in attendance at DQAC meetings to understand and respond to any concerns raised. After another year in which DQAC continued to raise concerns and requests for information, and the Collaboration Committee and WDHA responded, DQAC voted to schedule the new rules for a public hearing at the DQAC meeting on October 28, 2016. The meeting began with the rules public hearing at 8 am and minutes later the hearing had been closed with a unanimous vote by DQAC to approve the new rules. The rules went into effect on January 13, 2017 following the Department of Health filing and can be found at this LINK.