Meeting of the Dental Board of California

February 26, 2021

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ANESTHESIA AND SEDATION PERMITS

Legislation (SB 501 Glazer) signed by the Governor in 2018 and scheduled to become effective January 1, 2022, requires significant change to permitting of General Anesthesia, Conscious Sedation, and Oral Conscious Sedation for Minors in the dental setting. These changes include the introduction of a pediatric endorsement and additional patient monitoring requirements when administering general anesthesia or sedation to a minor dental patient and the creation a new Pediatric Minimal Sedation (PMS) permit. The PMS permit will be required to administer or order the administration of minimal sedation to a patient under 13 years of age. The Dental Board now needs to adopt regulation to implement these changes in law.

1. The current General Anesthesia Permit will be replaced by a Deep Sedation/General Anesthesia Permit with changes in initial application and renewal requirements, development of standards for PALS equivalency training in pediatric dental anesthesia related emergencies, and new monitoring standards for patients under the age of seven years.
2. The current Conscious Sedation Permit will be replaced by a Moderate Sedation Permit with similar changes to application, renewal, PALS equivalency training courses, and monitoring of patients below seven years of age.
3. Then current Oral Conscious Sedation Permit for Minors will no longer be issued. It will be replaced by a Pediatric Minimal Sedation Permit with specific monitoring requirements for patients under 13 years of age.
4. The current Oral Conscious Sedation Permit for Adults will remain unchanged and there will be revision to the Medical General Anesthesia Permit required of the physician providing deep sedation or general anesthesia in the dental office.

Comment: The Dental Board expects to receive in May draft language developed by Board staff and legal counsel for regulations sufficient to implement this legislation. It is unlikely the Dental Board will be able to complete the rule-making process in time to meet the January 1, 2022, enactment deadline. In that case, legislation will be sought to extend the enactment date.

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ANESTHESIA AND SEDATION PERMITS
Legislation (SB 501 Glazer) signed by the Governor in 2018 and scheduled to become effective January 1, 2022, requires significant change to permitting of General Anesthesia, Conscious Sedation, and Oral Conscious Sedation for Minors in the dental setting. These changes include the introduction of a pediatric endorsement and additional patient monitoring requirements when administering general anesthesia or sedation to a minor dental patient and the creation a new Pediatric Minimal Sedation (PMS) permit. The PMS permit will be required to administer or order the administration of minimal sedation to a patient under 13 years of age. The Dental Board now needs to adopt regulation to implement these changes in law.

1. The current General Anesthesia Permit will be replaced by a Deep Sedation/General Anesthesia Permit with changes in initial application and renewal requirements, development of standards for PALS equivalency training in pediatric dental anesthesia related emergencies, and new monitoring standards for patients under the age of seven years.
2. The current Conscious Sedation Permit will be replaced by a Moderate Sedation Permit with similar changes to application, renewal, PALS equivalency training courses, and monitoring of patients below seven years of age.
3. Then current Oral Conscious Sedation Permit for Minors will no longer be issued. It will be replaced by a Pediatric Minimal Sedation Permit with specific monitoring requirements for patients under 13 years of age.
4. The current Oral Conscious Sedation Permit for Adults will remain unchanged and there will be revision to the Medical General Anesthesia Permit required of the physician providing deep sedation or general anesthesia in the dental office.

Comment: The Dental Board expects to receive in May draft language developed by Board staff and legal counsel for regulations sufficient to implement this legislation. It is unlikely the Dental Board will be able to complete the rule-making process in time to meet the January 1, 2022, enactment deadline. In that case, legislation will be sought to extend the enactment date.

I have provided a link to a letter of support for SB154 (Pan) Medi-Cal: Restorative Dental Services. This letter was sent today to the Office of Governor Newsom and to Senator Pan. It was reviewed and approved by ex com.
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Natalie Mansour, DMD
Diplomate to the American Board of Pediatric Dentistry
Public Policy Advocate, California Society of Pediatric Dentistry

D0129 Periodic Oral Evaluation – Established Patient

• Allowable once every six months for beneficiaries age three through 20 and once every twelve months for beneficiaries age 21 and over.
• Payable only after procedure D0150 has been billed by the same provider.

D0145 Oral Evaluation for a Patient Under Three Years of Age and Counseling with Primary Caregiver

• Separately payable benefit for beneficiaries under three years of age.
• Payable once in each three month period.
• Maximum fee allowance is $20.00.

D0150 Comprehensive Oral Evaluation – New or Established Patient

• Allowable for beneficiaries age three and older.
• Allowable initially and every 36 months after the last comprehensive oral evaluation or last periodic oral evaluation per beneficiary per provider.
• Allowable more frequently for established patients who present with significant change in health conditions or other unusual circumstances (with documentation).

Paul A. Reggiardo, DDS
CSPD Public Policy Advocate

1. Denti-Cal Beneficiary Utilization (patient access and services provided)
2. Denti-Cal Provider Participation (network adequacy and capacity)
3. Department of Health Care Services Denti-Cal oversight (responsibilities and execution)

The Commission will next likely assemble stakeholder focus groups to identify potential improvements to Deti-Cal operations to recommend to the Department and to the Legislature. The next open meeting is scheduled for November 19.

Cover memo -- Provides an introduction for school districts to the toolkit contents.

Things to consider - This document highlights twelve items for school districts to discuss when considering entering into a contract with a mobile/dental care provider.

Mobile Provider Guidelines - This spreadsheet outlines in more detail items and issues for school districts to discuss when considering contracting with a mobile/dental care provider.

Sample Memorandum of Understanding (MOU) - This sample MOU is an example for school districts to use and tailor to fit their specific needs.

As pediatric dentists, we recognize the importance of regular school attendance and the effect on education of chronic absence. We also recognize the negative financial implications to the school from the state when daily attendance is reduced. For these reasons, we have long urged our members to work with parents and with schools to minimize attendance disruption for oral health services ----- and better oral health through regular preventive care visits is one strategy for accomplishing this goal. It is not realistic, however, to expect that all pediatric and adolescent oral health care services can be delivered outside of school hours. In fact, state law [California Education Code §48205(a)(3)] specifically provides that "a pupil shall be excused from school when the absence is for the purpose of having medical, dental, optometrical, or chiropractic services rendered."

In an effort to provide clarity on this issue to dentists, parents, and school educators, the California Society of Pediatric Dentistry has joined with the California Dental Association to provide a downloadable Message to Parents and School Administrators Regarding School Absence for Dental Appointments. This one-page information sheet, which contains Oral Health Facts for Children, may be downloaded from the CSPD and CDA websites for printing and distribution by dentists and their staffs.

In addition, CSPD has developed a template for a School Attendance Release Form which may be downloaded from the CSPD website and customized by members for individual office printing and distribution (This is a MS Word doc file). The form contains reference to §48205(a)(3) of the Education Code.

Designed for supporting CDA and CSPD efforts in promoting legislation and public policy which improve children’s oral health, the binder contains introductory information on the progressive and largely preventable nature of dental disease, full color illustrations of untreated pediatric dental conditions, and a Children’s Oral Health Fact Sheet.

The binder is available for viewing and for downloading by CSPD members. (PDF Document, 1.2 MB)

Download this Notice of Proposed Rulemaking.

As indicated in the Medi-Cal Dental Program Provider Handbook (March 2008), Denti-Cal uses D0140 not for the broad range of problem-focused cases as specified by the ADA code, but instead, for payment of an initial orthodontic evaluation by a Medi-Cal Dental Program certified orthodontist.

According to a representative of the Department of Health Care Services, because orthodontic services are not generally a benefit of the Denti-Cal program, unless required by the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) medical necessity provisions of the Medicaid act (such as in the delivery of care for cleft lip and palate), the Department needed a CDT-4 diagnostic code for assessing such qualification. They choose D0140.

When asked, therefore, what code was appropriate and payable when a limited oral evaluation of emergency or trauma was provided [and other evaluation codes such as that for comprehensive oral evaluation (D0150) or periodic oral evaluation (D0120) were either inappropriate or unavailable], the DHCS representative suggested that for "problem focused" evaluations, providers should use D9430, which is defined in the Handbook as a catch-all, general "observation" code during regularly scheduled office hours in which no other services are performed (other than necessary radiographs and/or photographs)

Members should be aware, however, that Denti-Cal billing for D9430 requires "written documentation for payment" that "shall include the tooth/area, the chief complaint and the non-clinical treatment taken."

If, under the above DHCS guidelines, members experience claim denials, they are requested to contact CSPD's Public Policy Advocate, Paul Reggiardo, at 714-848-0234 or at Reggiardo@prodigy.net with the detail.

Section 1086 of the California Code of Regulations permits a Registered Dental Assistant to perform coronal polishing subject to certain conditions. One of these conditions is that the procedure must be performed under the direct supervision of a licensed dentist and only pursuant to the order, control and full professional responsibility of that supervising dentist. Under the provisions of direct supervision, the procedure must be checked and approved by the dentist prior to dismissal of the patient from the office. The Act states that "this procedure shall not be intended or interpreted as a complete oral prophylaxis (a procedure which can be performed only by a licensed dentist or registered dental hygienist)" and that the licensed dentist or a registered dental hygienist "shall determine that the teeth to be polished are free of calculus or other extraneous material prior to coronal polishing."

Section 1067 defines coronal polishing as a "procedure limited to the removal of plaque and stain from exposed tooth surfaces, utilizing an appropriate rotary instrument with rubber cup or brush and a polishing agent."

An oral prophylaxis is defined in the same section as "preventive dental procedures including complete removal of explorer-detectable calculus, soft deposits, plaque, stains, and the smoothing of unattached tooth surfaces. The objective of this treatment shall be creation of an environment in which hard and soft tissues can be maintained in good health by the patient."

Only a currently-licensed Registered Dental Assistant (RDA) may perform coronal polishing, which is considered part of an oral prophylaxis. Since January 1, 2006, all Registered Dental Assistants have been required to have completed an approved course in coronal polishing to obtain or renew their licenses.