First of all, the Hygiene Board has no business making regulation recommendations that encroach on Dentistry as a whole.  Secondly, the need for infection control training for DA's is obviously not an issue in Virginia as it was stated that their have been no significant cases of infection spread in a dental office in Virginia.  Stop looking for things to regulate that do not require regulation.  As professionals with advanced degrees we are all responsible and capable of training our DAs with regards to infection control in our individual practices.  If you have found egregious issues with sterilization procedures in some offices then that is a reflection of the doctor in charge and they should be held accountable.  Whether the DAs are trained or not will not matter if the particular office does not hold a high standard of infection control.  An added regulation will incur costs that will simply be passed on to the public, who in the end, really pay for all of these regulations thereby impacting the affordability of care for those in need.  I respectfully request that you reconsider establishing this needless regulation.

William G. Horbaly, DDS, MS, MDS

Dear Ms. Reen and Members of the Virginia Board of Dentistry:

I write to you on behalf of the American Association of Orthodontists (AAO) in response to the Notice of Intended Regulatory Action (NOIRA) published in the Virginia Register on March 1, 2021 to take regulatory action regarding the training and supervision of digital scan technicians. We appreciate the opportunity to submit public comment at this time.

The AAO is the nation’s largest dental specialty organization and represents more than 19,000 orthodontists in the United States and abroad. We have 396 members who are residents of, or licensed to practice dentistry in, the Commonwealth of Virginia.

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 the training for technicians to practice under the supervision of a dentist licensed in Virginia. The AAO opposed HB 165/SB 122 unless amended, as we believed the bills, as eventually passed, have several provisions that could have unintended consequences and seemingly do not best protect patient health and safety. One proposed amendment, which was not accepted by the legislature, is included below in italicized and bold  font.

[As proposed in section 54.1-2719. Persons engaged in construction and repair of appliances. A.]: Licensed dentists may employ or engage the services of any person, firm, or corporation to construct or repair an appliance, extraorally, in accordance with a written or digital work order. Any appliance constructed or repaired by a person, firm, or corporation pursuant to this section shall be evaluated and reviewed in-person by the licensed dentist who submitted the written or digital work order, or a licensed dentist in the same dental practice. A person, firm, or corporation so employed or engaged shall not be considered to be practicing dentistry. No such person, firm, or corporation shall perform any direct dental service for a patient, but they may assist a dentist in the selection of shades for the matching of prosthetic devices when the dentist sends the patient to them with a written or digital work order.

The AAO suggested amending this section so that the treating dentist, or a licensed dentist in the same dental practice, who orders any appliance, reviews that appliance in person to confirm its accuracy and fit. In the case of another dental appliance, dentures, laws regularly require that a lab creating the appliance send the appliance back to the prescribing dentist prior to receipt by the patient, so the dentist can inspect and confirm that the appliance conforms with the prescription and impressions that were provided. The same reasoning should apply to orthodontic appliances; the dentist should be required to inspect the appliances for conformity to the prescription and impressions (digital or physical) before being sent to the patient to begin treatment. Improperly fitting orthodontic appliances can cause significant harm—certainly physical harm from the appliance (such as cut or bleeding gums), but also significant harm from the unintended or improper movement of teeth caused by an inaccurate appliance. Dental boards regularly direct that treatment administered through teledentistry should maintain the same standard of care as in-person treatment. This principle applies in requiring the inspection and fitting of the appliance in-person by the treating dentist.

As the Board works to fulfill its task to promulgate regulations that specify the responsibility of the dentist for the practice of teledentistry and training and supervision of a digital scan technician, the AAO respectfully asks that you consider language that ensures that an appliance, such as a clear aligner, that is fabricated as a result of a scan taken by a digital scan technician, is verified in-person by the treating dentist to prevent patients from receiving clear aligners that were fabricated based on inaccurate images.

The AAO also emphasizes the importance of establishing a doctor/patient relationship via a faceto-face encounter, specifically before beginning orthodontic treatment, because there are certain diagnoses and evaluations that can only be performed in-person or are best performed in-person (x-rays, etc.). There are a number of categories of problems/conditions that a dentist usually looks for as part of a physical examination at the outset of traditional in-person treatment. These can include conditions or problems that may be quite serious, such as oral cancer, periodontal problems, advanced decay, gum disease, etc. If an in-person examination of the patient by a dentist does not occur, there may be no examination of the patient by a dentist to detect such problems. With that in mind, the AAO believes dental and orthodontic treatment should not occur before a physical, in-person examination/evaluation of the patient and before the treating dentist has inspected and approved any orthodontic appliance created using images taken by a digital scan technician, has occurred by a Virginia licensed dentist. To that end, the AAO proposes inclusion of the following requirement in any dental scan technician regulations:

No person, other than a dentist, shall obtain digital scans for use during the practice of dentistry unless the patient has or will be seen in person by a dentist within six months of the scan.

Thank you in advance for your consideration of these comments. Please do not hesitate to contact the AAO if we can be of any further assistance to the Board in its consideration of these issues.

Sincerely, 

Trey Lawrence

Vice President, Advocacy and General Counsel

American Association of Orthodontists

Allow someone to scan teeth outside of a dental office is opening the door to facilitate online do it yourself dentistry.  The Board's primary function is to protect the public from unlicensed and/or poor dentistry.  The public does not know the quality of unregulated online/direct to consumer dentistry, they are only focused on convenience and price.  The Board should be protecting patients from online, do it yourself dentistry.  Scanning teeth or selling aligners directly to patients should be illegal.  Pretending that online care is the same as in person care delivered by a licensed, qualified is ridiculous.  Disallowing  scanning by unlicensed, unsupervised personnel is one step in the process of combating do it yourself dentistry.

I support the Virginia Dental Association proposal for the definition of Dental Scan Technician

A B Hammond

Orthodontist

Lexington VA

Good afternoon, 

I strongly support the comments made by the AAO in regards to this NOIRA. I also additionally support the definitions and training protocols that the VDA has proposed to the board. I think it is incredibly important for a dentist or orthodontist who has initiated treatment or fabrication of a dental appliance via teledentistry (where the patient was scanned by specifically a dental scan technician) to be verified for accuracy and appropriate fit prior to delivery. It is disservice to our patients and standards of care to require anything but. 

Thank you for your consideration. 

Good afternoon, 

I strongly support the comments made by the AAO, as well as the definitions and training protocols that the VDA has proposed to the board. It is important for a dentist or orthodontist who has initiated treatment or fabrication of a dental appliance via teledentistry (where the patient was scanned by specifically a dental scan technician) to verify the scan for accuracy and the appropriate fit of the appliance prior to delivery. 

I support the VDA proposal for dental scan technican. 

I have had several grossly negligent orthodontic cases that were misdiagnosed and mistreated by a DIY aligner company.  In one case, it was so bad that the patient had numerous teeth that were decayed to the gum line, moderate periodontial disease, and rampant caries only to be accepted and trays delivered to the patient. Thank heavens the trays didn't fit and the patient came to our office to see what could be done.  There were no in-person exams or x-rays reviewed. The general dentist who recently graduated from dental school lives in Phoenix, Arizona and doesn't even see patients in-person. She generates her income from her home working on a computer to approve as many aligner cases as possible. There is a financial incentive for dentists to approve cases because they get paid for patients that start treatment. At the present time they aren't accountable for their actions. Unless we fix this broken system more innocent people will be taken advantage! It's bad enough to take their money but to cause irreversible harm is totally unacceptable. Let's put the patients first and make laws that protect them not the DIY companies that are focused on how much money they can generated. 

Dear Distinguished Members of the Board,

I am writing regarding the pending NOIRA for Training and Supervision Requirements for Digital Scan Technicians.  I would like to comment from the perspective of a dental specialist in dental public health and orthodontics. I fully support a prior comment made by another clinician, Dr. Julie Staggers, namely that:

“ The Board's primary function is to protect the public from unlicensed and/or poor dentistry.  The public does not know the quality of unregulated online/direct to consumer dentistry, they are only focused on convenience and price.  The Board should be protecting patients from online, do it yourself dentistry. “

I support a dentist being a necessary part of the training and supervision process, but in what exact manner is the question that needs clarification. Quality care also needs to be reasonably accessible and affordable for the public.

In order to help ensure reasonable treatment costs and availability, I hope the Board will also permit dentists to have maximum flexibility in terms of delegating teledentistry related procedures. This would include scanning as well as the final seating of appliances, as long as some form of final check for quality of care, either directly or remotely, is available from a licensed dentist.

As teledentistry continue to expand in fields other than orthodontics, many traditionally under served populations, including Medicaid patients, will benefit from regulations that offer wide freedom to delegate procedures. As has been already dramatically demonstrated in Alaska, remote dentist supervision of dental auxiliaries has been shown to be a safe and clinically successful means of providing often complex dental services.

To summarize, as the Board promulgates regulations for the training and supervision of digital scan technicians, I believe it is quite reasonable that the role of the dentist could be integrated in either a remote or direct manner. In this way the public will benefit from both quality assurance of services rendered, and increased availability and affordability. 

Paul Supan, DDS, MA, MPH

Diplomate, American Board of Orthodontics

An intra-oral scan can not learn the patients's chief complaint, can not get a medical and dental history, can not examine the whole mouth, most of which is soft tissue and can not  assemble a comprehensive problem list and discover any and all oral pathology. While an intra-oral scan can lend to gathering this information, it does not stand alone and can not be verified as accurate without expert analysis. 

Any intra-oral scan must be performed within the context of gathering all the necessary information to provide the patient options for treatment, implications of doing nothing, and the expert professional recommendation on what the dentist believes is in the patient's best interest.  These are the requirements for practicing dentistry.  Accordingly, the gathering of an intra-oral scan must be performed under the direct supervision of a practicing dentist who can assure the accuracy of the scan through direct intra-oral examination and then bring together all the necessary information, as noted above, to form the full context in which the intra-oral scans may be made relevant.  Any intra-oral scan, without this full context, is, at best, meaningless and could provide a basis to bring economic and/or physical harm to the patient.  An intra-oral scan, by itself, does not serve the best interests of the patient.