We write on behalf of the American Association of Orthodontists (AAO) and Virginia Association of Orthodontists (VAO) in response to the 2022 reproposed regulations published in the Virginia Register on May 19, 2025, to take regulatory action regarding the training and supervision of digital scan technicians. We appreciate the opportunity to submit public comments on these important issues for patient health and safety. The AAO is the nation’s largest dental specialty organization and represents more than 19,000 orthodontists in the United States and abroad, including over 400 members who are residents of, or licensed to practice dentistry in, the Commonwealth of Virginia and are members of the Virginia Association of Orthodontists (VAO). 

As you know, HB 165 and SB122 of the 2020 General Assembly defined a digital scan technician, as used in teledentistry, and required the Board to promulgate regulations for training technicians to practice under the supervision of a dentist licensed in Virginia.

We support the Board’s ongoing efforts to develop rules governing the training and supervision of digital scan technicians in a manner that prioritizes the health and safety of patients in Virginia. As the Board works to establish regulations that define the responsibilities of dentists in the practice of teledentistry and for training and supervision of digital scan technicians, the AAO and VAO respectfully request consideration of language that ensures patient safety by requiring that any  appliance-- such as a clear aligner--, fabricated from a scan taken by a digital scan technician be verified in-person by the treating dentist before treatment begins. This safeguard is critical to help prevent the use of appliances based on inaccurate or incomplete scans.

Furthermore, while current Virginia law (§ 54.1-2719. Persons engaged in construction and repair of appliances.) states that any appliance constructed or repaired by a person, firm, or corporation “shall be evaluated and reviewed by the licensed dentist who submitted the written or digital work order...,” the statute does not clarify that the “review” and “evaluation” must be done in-person. 

As written, it permits a dentist to review an appliance remotely—based solely on the digital scan—without verifying, through an in-person examination, the accuracy of the scan itself. This creates an unnecessary risk that a patient may begin treatment based on an appliance that is misaligned with their clinical needs. 

Without an in-person examination by a dentist, there may be no opportunity to identify underlying oral health issues that could affect treatment outcomes. The AAO and VAO, drawing on strong clinical evidence, advocate for patient health and safety by supporting a physical, in-person examination prior to the initiation of orthodontic treatment. Additionally, we emphasize the importance of requiring any orthodontic appliance created using images captured by a digital scan technician be inspected and approved by the treating dentist licensed in the Commonwealth of Virginia. While we acknowledge the challenges faced by the Virginia Board of Dentistry due to the current statutory framework, we believe the Board should take a proactive approach in attempting to protect Virginia’s patients from potential irreversible harm.

The AAO and VAO propose the following changes, at a minimum, in red font below:

18VAC60-21-165 Delegation to digital scan technicians for use in teledentistry

C. The dentist who directs a digital scan technician to take digital scans shall be:

1. Licensed by the board to practice dentistry in the Commonwealth;

2. Accessible and available for communication and consultation with the digital scan technician at all times during the patient interaction; and

3. Ultimately responsible for communicating with the patient or the patient's representative the specific treatment the patient will receive, which aspects of treatment will be delegated to qualified personnel, and the direction required for such treatment, in accordance with this chapter and the Code of Virginia. The dentist must also examine the patient in-person prior to orthodontic treatment, including inspection and review of any appliance made via a digital scan.  

Although digital scans can create an accurate model of the patient’s dentition, there is no ability using them to detect many problems discovered only through an in-person examination and radiographic images that would contraindicate orthodontic treatment. Many of the problems can make a patient an unsuitable candidate for orthodontic treatment until the problems are corrected. The AAO advocates for any patient treated with an appliance created from a digital scan to be examined in-person by a dentist within six months of the scan being taken.

Thank you for your time and dedication to this important matter on behalf of patients in Virginia. The AAO and VAO request that you consider our comments based on clinical evidence for patient safety and incorporate clarity into the current proposed rules for digital scan technicians to protect patients from unnecessary risks. Please find resources based on peer-reviewed, scientific evidence at OrthoFacts.org for more information about issues related to this important subject.

Nathan Mick

Vice President, State and Federal Advocacy

American Association of Orthodontists

 Dr. Jennifer Oakley

President

Virginia Association of Orthodontists