18VAC60-20-81. Administration of local anesthesia and/or nitrous oxide by dental hygienists.

A. A dental hygienist who meets the qualifications set forth in this section and who is under the direction of a dentist may administer nitrous oxide/inhalation analgesia or, to patients 18 years of age or older, local anesthesia. Local anesthesia shall not include topical Schedule VI medicinal agents that may be administered under general supervision pursuant to 18VAC60-20-220 B.

B. To be eligible to administer only nitrous oxide/inhalation analgesia, a dental hygienist shall:

1. Successfully complete a didactic and clinical course leading to certification in administration of nitrous oxide offered by a dental or dental hygiene program accredited by the Commission on Dental Accreditation of the American Dental Association, which includes a minimum of eight hours in didactic and clinical in the following topics:

a. Patient physical and psychological assessment;

b. Medical history evaluation;

c. Equipment and techniques used for administration of nitrous oxide;

d. Neurophysiology of nitrous oxide administration;

e. Pharmacology of nitrous oxide;

f. Recordkeeping, medical and legal aspects of nitrous oxide;

g. Adjunctive uses of nitrous oxide for dental patients; and

h. Clinical experiences in administering nitrous oxide, including training with live patients.

2. Successfully complete an examination with a minimum score of 75% in the administration of nitrous oxide/inhalation analgesia given by the accredited program.

C. To be eligible to administer both local anesthesia and nitrous oxide/inhalation analgesia, a dental hygienist shall:

1. Successfully complete a didactic and clinical course leading to certification in administration of local anesthesia and nitrous oxide/inhalation analgesia that is offered by a dental or dental hygiene program accredited by the Commission on Dental Accreditation of the American Dental Association, which includes a minimum of 36 didactic and clinical hours in the following topics:

a. Patient physical and psychological assessment;

b. Medical history evaluation and recordkeeping;

c. Neurophysiology of local anesthesia;

d. Pharmacology of local anesthetics and vasoconstrictors;

e. Anatomical considerations for local anesthesia;

f. Techniques for maxillary infiltration and block anesthesia;

g. Techniques for mandibular infiltration and block anesthesia;

h. Local and systemic anesthetic complications;

i. Management of medical emergencies;

j. Clinical experiences in maxillary and mandibular infiltration and block injections;

k. Pharmacology of nitrous oxide;

l. Adjunctive uses of nitrous oxide for dental patients; and

m. Clinical experiences in administering nitrous oxide and local anesthesia injections on patients.

2. Successfully complete an examination with a minimum score of 75% in the administration of nitrous oxide/inhalation analgesia and local anesthesia given by the accredited program.

D. A dental hygienist who holds a certificate or credential issued by the licensing board of another U.S. jurisdiction that authorizes the administration of nitrous oxide/inhalation analgesia or local anesthesia may be authorized for such administration in Virginia if:

1. The qualifications on which the credential or certificate was issued were substantially equivalent in hours of instruction and course content to those set forth in subsections B and C of this section; or

2. If the certificate or credential issued by another jurisdiction was not substantially equivalent, the hygienist can document experience in such administration for at least 24 of the past 48 months preceding application for licensure in Virginia.

E. A dentist who provides direction for the administration of nitrous oxide/inhalation analgesia or local anesthesia shall ensure that the dental hygienist has met the qualifications for such administration as set forth in this section.

Statutory Authority

§54.1-2400 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 14, eff. April 16, 2008.

18VAC60-20-108. Administration of anxiolysis or inhalation analgesia.

A. Education and training requirements. A dentist who utilizes anxiolysis or inhalation analgesia shall have training in and knowledge of:

1. Medications used, the appropriate dosages and the potential complications of administration.

2. Physiological effects of nitrous oxide and potential complications of administration.

B. Equipment requirements. A dentist who utilizes anxiolysis or inhalation analgesia or who directs the administration of inhalation analgesia by a dental hygienist shall maintain the following equipment in his office and be trained in its use:

1. Blood pressure monitoring equipment.

2. Positive pressure oxygen.

3. Mechanical (hand) respiratory bag.

C. Monitoring requirements.

1. The treatment team for anxiolysis shall consist of the dentist and a second person in the operatory with the patient to assist, monitor and observe the patient. [ One member of the team shall be in the operatory monitoring the patient at all times once the administration has begun. A dentist who utilizes anxiolysis shall ensure that there is continuous visual monitoring of the patient to determine the level of consciousness.  Once the administration of anxiolysis has begun, the dentist shall ensure that a person qualified in accordance with 18VAC60-20-135 is present with the patient at all times to determine the level of consciousness by continuous visual monitoring of the patient. ]

2. A dentist who utilizes anxiolysis or inhalation analgesia shall ensure that there is continuous visual monitoring of the patient to determine the level of consciousness or a dental hygienist who utilizes inhalation analgesia shall ensure that there is continuous visual monitoring of the patient to determine the level of consciousness.

3. If inhalation analgesia is used, monitoring shall include making the proper adjustments of nitrous oxide machines at the request of or by the dentist or a dental hygienist qualified in accordance with requirements of 18VAC60-20-81 to administer nitrous oxide during administration of the sedation and observing the patient's vital signs.

D. Discharge requirement. The dentist shall ensure that the patient is not discharged to his own care until he exhibits normal responses.

Statutory Authority

§54.1-2400 of the Code of Virginia.

Historical Notes

Former 18VAC60-20-107 derived from Virginia Register Volume 21, Issue 19, eff. June 29, 2005; adopted as 18VAC60-20-108, Errata 21:22 VA.R. 3119 July 11, 2005; amended, Virginia Register Volume 22, Issue 26, eff. November 18, 2006; Volume 24, Issue 14, eff. April 16, 2008.

18VAC60-20-190. Nondelegable duties; dentists.

Only licensed dentists shall perform the following duties:

1. Final diagnosis and treatment planning;

2. Performing surgical or cutting procedures on hard or soft tissue;

3. Prescribing or parenterally administering drugs or medicaments;

4. Authorization of work orders for any appliance or prosthetic device or restoration to be inserted into a patient's mouth;

5. Operation of high speed rotary instruments in the mouth;

6. Performing pulp capping procedures;

7. Administering and monitoring general anesthetics and conscious sedation except as provided for in §54.1-2701 of the Code of Virginia and 18VAC60-20-108 C, 18VAC60-20-110 F, and 18VAC60-20-120 F;

8. Administering nitrous oxide or oxygen inhalation analgesia;

9. 8. Condensing, contouring or adjusting any final, fixed or removable prosthodontic appliance or restoration in the mouth;

10. 9. Final positioning and attachment of orthodontic bonds and bands;

11. 10. Taking impressions for master casts to be used for prosthetic restoration of teeth or oral structures;

12. 11. Final cementation of crowns and bridges; and

13. 12. Placement of retraction cord.

Statutory Authority

§54.1-2400 and Chapter 27 (§54.1-2700 et seq.) of Title 54.1 of the Code of Virginia.

Historical Notes

Derived from VR255-01-1 §4.5, eff. September 1, 1987; amended, Virginia Register Volume 5, Issue 7, eff. February 1, 1989; Volume 7, Issue 19, eff. July 17, 1991; Volume 9, Issue 19, eff. July 15, 1993; Volume 10, Issue 19, eff. July 13, 1994; Volume 11, Issue 3, eff. April 6, 1995; Volume 11, Issue 9, eff. April 6, 1995; Volume 15, Issue 5, eff. December 23, 1998; Volume 21, Issue 19, eff. June 29, 2005; Volume 24, Issue 14, eff. April 16, 2008.

18VAC60-20-220. Dental hygienists.

A. The following duties shall only be delegated to dental hygienists under direction with the dentist being present:

1. Scaling and root planing of natural and restored teeth using hand instruments, rotary instruments and ultrasonic devices under anesthesia administered by the dentist.

2. Performing an initial examination of teeth and surrounding tissues including the charting of carious lesions, periodontal pockets or other abnormal conditions for assisting the dentist in the diagnosis.

3. Administering nitrous oxide or local anesthesia by dental hygienists qualified in accordance with the requirements of 18VAC60-20-81.

B. The following duties shall only be delegated to dental hygienists and may be delegated by written order in accordance with §54.1-3408 of the Code of Virginia to be performed under general supervision without the dentist being present:

1. Scaling and root planing of natural and restored teeth using hand instruments, rotary instruments and ultrasonic devices.

2. Polishing of natural and restored teeth using air polishers.

3. Performing a clinical examination of teeth and surrounding tissues including the charting of carious lesions, periodontal pockets or other abnormal conditions for further evaluation and diagnosis by the dentist.

4. Subgingival irrigation or subgingival application of topical Schedule VI medicinal agents.

5. Duties appropriate to the education and experience of the dental hygienist and the practice of the supervising dentist, with the exception of those listed in subsection A of this section and those listed as nondelegable in 18VAC60-20-190.

C. Nothing in this section shall be interpreted so as to prevent a licensed dental hygienist from providing educational services, assessment, screening or data collection for the preparation of preliminary written records for evaluation by a licensed dentist.

Statutory Authority

§54.1-2400 of the Code of Virginia.

Historical Notes

Derived from VR255-01-1 §5.3, eff. September 1, 1987; amended, Virginia Register Volume 5, Issue 7, eff. February 1, 1989; Volume 7, Issue 19, eff. July 17, 1991; Volume 9, Issue 19, eff. July 15, 1993; Volume 10, Issue 19, eff. July 13, 1994; Volume 11, Issue 3, eff. April 6, 1995; Volume 11, Issue 9, eff. April 6, 1995; Volume 15, Issue 5, eff. December 23, 1998; Volume 19, Issue 20, eff. July 16, 2003; Volume 24, Issue 14, eff. April 16, 2008.