Scope Of Practice: “The Most Misunderstood Concept In Dentistry”

Ken-Berley

Scope Of Practice: “The Most Misunderstood Concept In Dentistry”

  It is unusual for a week to go by where I do not read an article or position paper from some organization or association that purports to outline the “Scope of Practice” for some discipline or field of dentistry.  As I review these position papers, it is not difficult to identify the agenda of the organization that is proffering the alleged scope of practice proclamation.  We ALL have certain agendas!  I am not saying that it is illegal or even wrong to have an agenda.   I do however, feel that it is wrong for any organization to imply that it is illegal for a dentist to provide treatment contrary to their self-serving “Scope of Practice – Position Paper”.

            A dentist’s scope of practice is divided into three separate and identifiable parts:

A.  Dental Practice Act/Board of Dental Examiners

—  “The Black Letter LAW”

—  Any rulings of the Board of Dental Examiners

  1. B.    Education and training

C.  Employer/Insurance

—  Limitations placed by the Dentist’s place of employment or insurance coverage.

We will take a look at each of these areas as they relate to your “Scope of Practice”.

1.          Dental Practice Act/Board of Dental Examiners:   

Within the definition of the “practice of dentistry” in your state’s dental practice act, is the description of your scope of practice.  This is the terminology used by your State Board of Dental Examiners to define the procedures, actions, and processes that are permitted by licensed dentists in your state.  Most states have adopted the ADA model definition or some variation thereof.  It reads as follows:

ADA’s Definition of Dentistry:  

      The evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.
Adopted: ADA Resolution 1997

Obviously, this model definition is only a model for state boards to reference. However, it has received favorable review and acceptance by many state boards.  As you can see, the definition of the practice of dentistry is very broad in scope.  Each state’s dental practice act and the included definition of the practice of dentistry, is much like our U.S. Constitution in that it is an evolving document which changes and grows as the practice of dentistry progresses. The definition of the practice of dentistry (Scope of Practice) is written so that it purposefully overlaps other professions.  If one reviews the “scope of practice” for Dentists and ENTs, one will find that there is a great amount of overlap.  Additionally, all dental practice acts are searchable online making access easy for all practitioners.

I personally practice in Northwest Arkansas and the Arkansas Legislature has adopted the ADA Model with some modifications.  This is my Scope of Practice:

—   17-82-102. DEFINITIONS.

—  (1)(A) “Practicing dentistry” means:

—  (i) The evaluation, diagnosis, prevention and treatment by nonsurgical, surgical or related procedures of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body, but not for the purpose of treating diseases, disorders and conditions unrelated to the oral cavity, maxillofacial area and the adjacent and associated structures……..

 

Notice that my scope of practice is for any type of treatment, of any type of condition, of the “oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body…”.

So, any condition that has any oral-facial component is well within the definition of the practice of Dentistry for the State of Arkansas.  The State Board of Dental Examiners can then limit these broad privileges if the occasion arises.  For example, in my 30 plus years of practicing dentistry, the Arkansas regulations and requirements for providing sedation have changed several times.  While sedation broadly falls within the scope of practice for a dentist in Arkansas, the Arkansas Board of Dental Examiners have promulgated regulations defining the educational requirements and office/emergency equipment necessary to provide this service.

2.         Education and training

As a general statement, one’s education and training is far more important in determining a dentist’s “SCOPE OF PRACTICE” than your state’s dental practice act.  All dental practice acts are so broad they encompass all the areas of dentistry as well as many areas of medicine.  In most states, oral surgeons and general dentist both operate under the same definition of the practice of dentistry even though, the scope of their practices are vastly different.

So what is the difference?  Levels of education!!!  One’s training is the primary determinate in establishing one’s SCOPE OF PRACTICE!!!!!!  Using that premise it is easy to see that two general dentists practicing next door to each other can have different scopes.  Personally, I love implant dentistry.  In our office we routinely perform sinus lifts, ridge augmentations, PRP for grafting and wound healing, and placement of implants.  I placed my first blade implant in 1984.  So the question remains, what is my scope of practice compared to the dentist next door?  The difference is the 5000 hours of continuing education which qualifies me to practice at the level that I have chosen.

Therefore, general dentists in the same state can have different Scopes of Practice. Additionally, each dentist can choose to change his or her scope of practice by becoming competent in a new area of study.  From a medical/legal stand-point the issue is whether adequate levels of training have been achieved to insure competence.  Each practitioner should be prepared to document his training and experience to the Board of Dental Examiners or a jury if the need arises.   In each new area of study, practitioners should document courses taken and the conventions attended keeping a list of the dates of each course and the names of lecturers.  Additionally, one should become a member of the prominent professional associations in that area and routinely read the appropriate journals.

Employer/Insurance

As we all know, not all dentists work for themselves.  Many of us are employed in various capacities where our employer determines the services and procedures that we perform.  In that situation, our employer may limit our scope of practice and establish guidelines for that organization.  For example, it is likely within the scope of practice for all dentists to remove impacted wisdom teeth. However, not every office is prepared to offer this service.  Limitations placed by the dentist’s place of employment or available insurance coverage, are a real restriction to one’s scope.  I would not recommend that any dentist add a new procedure to his practice without consulting his liability/malpractice carrier to insure coverage.

How do you determine whether a new procedure or service is within your scope of practice?

  1. Review your states definition of DENTISTRY.
    1. Within that definition is your “Scope of Practice”
    2. Review any rulings from your Board of Dental Examiners for restrictions relative to the therapy/procedure in question.
      1. If any adverse rulings have been handed down, was the limitation based on education levels or was there a prohibition of that procedure?
      2. If the procedure falls broadly within the definition of dentistry and no determination or ruling has been made to the contrary by your Board of Examiners, there is a legal presumption that the technique/treatment/procedure is within your scope of practice.
  1. Education:
    1. Join the major professional organizations in your new area of study.  “Look Like You Are One of the Group”
    2. Read the professional journals regularly and keep notes and abstracts which you can reference for review.
    3. Attend as many continuing education courses as possible to get up to speed as fast as you can.
      1. Document all courses taken.
        1. Name of course
        2. Presenter
        3. Date
        4. Sponsoring organization
  1. Employer/Insurance
    1. Are there any restrictions that have been placed on you by your employer that will limit your ability to provide this treatment?
    2. Will your insurance company provide adequate coverage for this procedure?  If the answer is no, can you pay an additional premium to get the coverage?

Do State Medical Practice Acts limit my “Scope of Practice”?

This is a common misconception among dentists.  It is amazing to me that dentists think they are prohibited from treating any condition that may also be treated by an MD. This could not be farther from the truth.  There is broad overlap in the definitions of the practice of medicine and the practice of dentistry. However, the practice of dentistry and the practice of medicine are governed by separate boards and are regulated separately.  It is the intention of state legislatures that the disciplines work together to provide care for our patients.  Additionally, the medical practice act of each state specifically exempts the practice of dentistry from any prohibitions expounded within the Medical Practice Acts.  For example the Arkansas Medical Practice Act defines the practice of medicine as:

—   (2) “Practice of medicine” means:

—  (A) Holding out one’s self to the public within this state as being able to diagnose, treat, prescribe for, palliate, or prevent any human disease, ailment, injury, deformity, or physical or mental condition, whether by the use of drugs, surgery, manipulation, electricity, or any physical, mechanical, or other means whatsoever;

—  (B) Suggesting, recommending, prescribing, or administering any form of treatment, operation, or healing for the intended palliation, relief, or cure of any physical or mental disease, ailment, injury, condition, or defect of any person with the intention of receiving, either directly or indirectly, any fee, gift, or compensation whatsoever;

—  (C) The maintenance of an office or other place to meet persons for the purpose of examining or treating persons afflicted with disease, injury, or defect of body or mind;

—  (D) Using the title “M.D.,” “M.B.,” “D.O.,” “Physician,” “Surgeon,” or any word or abbreviation to indicate or induce others to believe that one is engaged in the diagnosis or treatment of persons afflicted with disease, injury, or defect of body or mind, except as otherwise expressly permitted by the laws of this state relating to the practice of any limited field of the healing arts; or

—  (E) Performing any kind of surgical operation upon a human being.

—  17-95-203. Exemptions.

—  Nothing herein shall be construed to prohibit or to require a license with respect to any of the following acts:

—   (3) The practice of the following professions as defined by the laws of this state, which Sub-Chapters 2-4 of this chapter are not intended to limit, restrict, enlarge, or alter the privileges and practice of, as provided by the laws of this state:

—  (A) Dentistry;

—  (B) Podiatry;

—  (C) Optometry;

—  (D) Chiropractic;

—  (E) Cosmetology.

Therefore, as long as the new treatment or procedure falls broadly within your state’s definition of the practice of dentistry, you are exempted from any regulations, restrictions or requirements enacted by your state’s Medical Practice Act.  However, it is critically important for each dentist to know when to refer!  Know your limitations and levels of competence.  If in doubt, send it out!!!!

In Conclusion:  Every dentist is ultimately in control of his or her Scope of Practice.  Very few limitations have been placed in our way.  In my opinion this has been purposefully done to encourage each practitioner to expand his or her knowledge and abilities to the fullest.  We should not become stagnant!  With that in mind, never allow any individual or organization other than your state’s Board of Dental Examiners, to dictate your “Scope of Practice”.  In my career, I have repeatedly been told that I cannot perform certain procedures because I am just a “Dentist”.  These many encounters have provided an incentive to expand my level of knowledge!

So where do we go in the future?  The sky is the LIMIT!!!

 

Respectfully Submitted:

Ken Berley DDS, JD

Disclaimer:

—  NOT GIVING LEGAL ADVICE

—  Contact attorney in your state

—  Seek an opinion from an attorney with experience practicing before your state dental board

—  THIS IS JUST MY OPINION