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Virginia Regulatory Town Hall
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Department of Health Professions
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Board of Dentistry
chapter
Regulations Governing the Practice of Dentistry [18 VAC 60 ‑ 21]

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6/27/19  12:12 pm
Commenter: Jeremy Davidson

Strongly Agree
 

I strongly support the designation of intraoral scans taken to provide any dental appliance or treatment as a dental procedure, specifically a "final impression" designated by the Virginia State Board of Dentistry.  Additionally, I also agree that the face-to-face doctor/patient relationship standard should continue to be enforced to ensure that the public is adequately examined and informed before undergoing any dental procedure.  


7/5/19  3:35 pm
Commenter: Wm. Graham Gardner D.D.S.

strongly agree
 

I completely agree with the concerns for patient's well being.  As a minimum, it should be established that "a dental scan to make a dental appliance is a dental procedure" as was established in Georgia.  This already has precedent and is an obvious statement that needs to be established in VA. 

The treatment rendered by the companies with this new aligner modality will put patients at risk more than 50% of the time because the most common patient seeking this treatment has deep bites with more lower crowding than upper.  This will lead to the anterior dentition proclining and premature anterior contact.  The deep bites are very difficult to correct without monitoring.  This will lead to fremitus, anterior wear and potential periodontal concerns. 

Having no patient doctor interaction is asking for problems and may put the board at risk.  Why didn't the board protect these patients when they knew what was going on?  This is a serious ethical consideration for the board to consider.


7/5/19  4:42 pm
Commenter: George Sabol, DDS

support of petition to make digital scans same as final impressions
 

I agree that a digital intraoral scan used to make a dental appliance should be deemed the same as a final impression and require direct doctor supervision.  Additionally a doctor patient relationship should be established, prior to scanning,  with a face to face meeting of the treating doctor and patient and should include a through health history, examination and diagnosis including all necessary diagnostic records required to treat to stand of care.  This is the only way that patients health and safety can be adequately protected and all viable treatment options discussed so proper informed consent can be obtained.  Direct to consumer (DTC) companies are delegating the health history, examination and diagnosis to salespersons who are not adequately trained and not licensed  to obtain informed consent.  This presents a serious risk to the public and it is the Board Dentistry's job to protect the health and welfare of the citizens of Virginia.


7/6/19  10:50 am
Commenter: William Dabney

strongly agree
 

i support this change. i agree with Dr Sabol's points on the need for a doctor patient relationship including a full dental exam before prescribing this procedure


7/7/19  10:36 am
Commenter: Dag Zapatero, DDS

Strongly Agree - "digital impression file," equivalent to the analog "final impression"
 
My petition request to update the definition of a final impression due to technologic advancements and to remain consistent with the statue already in place.  It seeks to define a "digital impression file," equivalent to an analog "final impression" if used to fabricate an appliance to be inserted into a patient's mouth.  It should not matter if the file is produced by scanning a patient's mouth through the use of an intra-oral scanner or scanning a patient's dental cast model by an optical scanner.  Both create a "digital file" containing the patient's personal identifying information which can then be used to fabricate an appliance to be inserted into a patient's mouth just as occurs in the analog equivalent of a "final impression."  
 

Statutory Authority:  § 54.1-2400 and Chapter 27 of Title 54.1 of the Code of Virginia.  § 54.1-2711. Practice of dentistry. 

  • iv) extracts teeth, corrects malpositions of the teeth or jaws, takes impressions for the fabrication of appliances or dental prosthesis, supplies or repairs artificial teeth as substitutes for natural teeth, or places in the mouth and adjusts such substitutes.”
 
The health, safety and welfare of a patient should be paramount whether an impression is taken by analog or digital means. An impression is an impression.  The adopted Guidance document: 60-23 indicates that Teledentistry  "should not be construed to alter the scope of practice of any health care provider or authorize the delivery of health care services in a setting, or in a manner, not authorized by law. In fact, these guidelines support a consistent standard of care and scope of practice notwithstanding the delivery tool or business method used to enable practitioner-to- patient communications. For clarity, a practitioner using teledentistry services in the provision of dental services to a patient (whether existing or new) must take appropriate steps to establish the practitioner-patient relationship as defined in Virginia Code § 54.1-3303 and conduct all appropriate evaluations and history of the patient consistent with traditional standards of care for the particular patient presentation."

 


7/8/19  12:05 pm
Commenter: Sean Murphy, American Association of Orthodontists

Doctor/patient relationship and use of digital scans-strongly agree with Petition
 

 

            The AAO strongly agrees with the Petition in that the AAO believes a digital scan is the practice of dentistry and that TREATMENT should not occur before a physical, in-person examination/evaluation of the patient has occurred by a Virginia licensed dentist.  To begin with, Va. Code Ann. § 54.1-2711(iv) clearly provides that “Any person shall be deemed to be practicing dentistry who . . . (iv) . . . takes impressions for the fabrication of appliances or dental prosthesis, supplies or repairs artificial teeth as substitutes for natural teeth, or places in the mouth and adjusts such substitutes.”  The AAO believes that the term “impressions” under Va. Code Ann. § 54.1-2711(iv) already applies to “digital scans,” since the AAO views a “digital scan” as a “digital impression,” especially when used for the fabrication of appliances.  Nevertheless, an amendment would only further support and clarify this point.  The AAO also sees the importance of establishing a doctor/patient relationship via a face-to-face encounter 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 include conditions or problems that can 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 has occurred by a Virginia licensed dentist in order to establish the doctor/patient relationship.  Moreover, and as stated in the Court’s Memorandum Opinion in Blaine Leeds and SmileDirectClub v. Board of Dental Examiners of Alabama et al., Case No. 2:18-cv-01679-RDP (N.D. Ga.):

 

“Defendants and their amicus [the American Association of Orthodontists] have identified several legitimate goals for requiring the physical presence of a licensed dentist at facilities where [a digital intra-oral scanner] is used. Using [a digital intra-oral scanner] to make digital images of teeth is an intraoral procedure that involves inserting the device into patients’ mouths. Hypothetical legitimate goals for requiring a dentist’s physical presence at facilities where [a digital intra-oral scanner] is used include: (1) ensuring proper sterilization procedures are followed to prevent the spread of illness; (2) ensuring that a skilled, trained dentist is available in the event of a sudden medical emergency caused by the [digital intra-oral scanner] inadvertently dislodging a patient’s crown; (3) ensuring that a licensed dentist has the opportunity to diagnose preexisting conditions that contraindicate the use of clear aligner therapy in the first place, such as gum disease; and (4) ensuring that a dentist can verify in real time that the [digital intra-oral scanner] is accurately capturing a patient’s oral cavity, to avoid having the procedure repeated and to prevent patients from receiving clear aligners that were fabricated based on inaccurate images.  All of these purposes are legitimate state interests that could justify the Board’s regulation. Moreover, a rational basis undoubtedly exists for believing that the regulation would further those hypothesized purposes. Rational arguments exist that requiring a licensed dentist to be physically present at facilities where [a digital intra-oral scanner] is used would advance each of the interests identified above. . . . .”  See https://www1.aaoinfo.org/wp-content/uploads/2019/04/memorandum-order-MTD.pdf (p. 41).

 

Given the foregoing, the AAO is hopeful that the Virginia Board of Dentistry will promulgate rules that only further support and clarify that an “impression” includes “digital scans” and that dental and orthodontic treatment should not occur before a physical, in-person examination/evaluation of the patient has occurred by a Virginia licensed dentist in order to establish the doctor/patient relationship.  We appreciate your consideration of these comments.

     


7/8/19  5:25 pm
Commenter: Scott Frey

Strongly disagree
 

This amendment as worded is a significant step backward for patient education and access to care. It creates artificial barriers which prevent doctors from being able to use digital simulation software to educate patients on the possibilities for their care. 

A clinical exam and clinical radiographs are important to high quality patient care, but it should not be mandated that these pre-empt the collection of digital images in the form of an intra-oral scan. Rather they are important prior to the start of active portion treatment. This amendment establishes a rigid order that makes little sense.

Furthermore, the timing and context of this amendment create a high likelihood of this amendment being ruled as anti-competitive in nature towards DTC aligner companies such as smile direct club down the road and being thrown out on such grounds down the road. 


7/9/19  8:26 am
Commenter: Russ Mullen

I support the petition
 

Whether it is taking a physical impression or a digital one, if the goal is to make a physical appliance that will be inserted in the patient's mouth, there should be an in-person exam of the patient by a certified dentist. There should not be a lowering of the standard of care just because digital technology is used.


7/9/19  8:50 am
Commenter: Yugal Behl

Strongly agree
 

I agree that dental impressions and digital scanning should be done under the supervision of a Virginia Licensed dentist. 


7/9/19  8:51 am
Commenter: Monika Madan

Strongly agree
 

Strongly agree.


7/9/19  12:56 pm
Commenter: Steven J Lindauer

Digital Scans are final impressions
 

I am in agreement with the petition that digital scans are the equivalent of final impressions. Virginia Regulations specify that final impressions are only able to be delegated to a Dental Assistant II under the direct supervision of a licensed dentist. If appliances that will be used by a patient are made from the scans that are obtained, then a dentist must be present when they are captured. 


7/9/19  1:03 pm
Commenter: Thomas M. Grisius

Requirements for Doctor/Patient relationship and use of digital scans
 

I strongly agree with the importance of a "hands on" clinical examination by a licensed dental professional for all patients seeking dental treatment.  The information gathered in a thorough examination is paramount to making good treatment decisions and avoiding deleterious ones. 

Dentistry/Orthodontics is a treatment not a commodity and needs to regulated for the safety of the public and patients.


7/9/19  2:04 pm
Commenter: Diana Almy

Strongly in Favor
 

I am strongly in favor of this new law. I have known people that have been hurt by DIY treatment and never saw a dentist. 


7/9/19  3:57 pm
Commenter: Erika Sachno, Short Pump Orthodontics

Agree
 

I strongly agree with and support this amendment..


7/9/19  8:20 pm
Commenter: Frank Iuorno

Digital Impressions are final impressions!
 

There is no question that a digital scan or impression, when used for fabrication of an oral appliance designed to move teeth and change occlusion, represents a "final impression" which by VA law must be taken under direct supervision of a dentist by qualified personnel.  The problem here is that the dental practice act in Virginia has not been updated to include use of new technology in this manner.  Furthermore, the model suggested for tooth movement does not establish the proper doctor-patient relationship to provide safe care to the public.


7/10/19  8:48 am
Commenter: Richard Marcus

Strongly Agree
 

It is widely accepted that digital scans represent the same as a final impression in the practice of dentistry.  Failure to have a licensed dentist as part of this process would in my mind constitute practicing without a license.  I strongly agree that a relationship with a licensed dentist who is part of this treatment process should be required.


7/10/19  9:16 am
Commenter: Michael Hasty, Children's Dentistry & Orthodontics

Strongly Agree with Petition
 

I strongly support the petition requesting that the BOD consider digital files made from intra-oral scans of teeth on a live patient, or an optical scan of patient dental cast used to fabricate an appliance inserted into a patient's mouth to be defined equivalent to the analog definition of a final impression as stated under the guidance of the regulations governing dentistry in our Commonwealth 18VAC60-21-150.


7/10/19  9:52 am
Commenter: Scott R. Miller, D.D.S.

Update to regulation needed!
 

There are many prosthodontic literature articles on the accuracy of digital impressions and the workflow to eliminate taking a final impression to create a master model. The digital scans are accurate enough now to be used to fabricate dentures, fixed implant appliances, crowns, bridges and even orthoodontic aligners. There is no reason a digital impression/file taken on a live patient with an optical scanner should not be consider a final impression! Every modern lab in the state uses a digital scanner to scan a patient's dental cast to fabricate a custom milled crown if they do not get the final digital scan emailed to them. 18VAC60-21-150 should be updated as requested on this petition.


7/10/19  10:15 am
Commenter: Brandon Wong DMD

Strongly agree
 

I strongly agree that a digital scan is the equivalent to an (analog) final impression - when being used to fabricate an intra-oral appliance.  A face to face encounter/evaluation with a dentist licensed in the state of Virginia should be required when using these scans to fabricate appliances. A comprehensive workup, both radiographically and clinically, has always been the standard of care before prescribing any intra-oral appliance to intercept potential complications associated with treatment (periodontal issues, caries, etc).  I believe that failing to have a proper face-to-face evaluation when using digital scans to fabricate intra-oral appliances is performing below the standard of care, is not in the best interest of the patient, and is not providing the patient with the comprehensive care that our profession has pledged to provide them.


7/10/19  10:34 am
Commenter: Mike Catoggio, D.D.S. Virginia Family Dentistry

Strongly Agree!!
 

There is no question that the use of a digital scanner, rather than impression material, to translate information to a dental laboratory for the purpose of fabricating an oral appliance constitutes a "final impression." Any tool, whether it be impression material or digital images, when used to fabricate materials that can permanently alter or potentially harm another human being should require the oversight of a qualified dental professional.


7/10/19  12:23 pm
Commenter: Eric Wilson, Wilson Dental PC

Digital Scans are equal to analogue impressions
 

Digital scans are exactly the same as analogue impressions. Dentists and dentists only should be taking final impressions whether digital or analogue. 


7/10/19  12:46 pm
Commenter: MICHAEL DOTY

I strongly agree,
 


7/10/19  1:01 pm
Commenter: John Sinclair, Coastal Cosmetic and Implant dentistry

Agree
 

Agree that final impression should include digital scans


7/10/19  1:14 pm
Commenter: Dwight Buelow DDS MS, Virginia Family Dentistry

Strongly Agree
 

I support this petition as a means to protect the pubic from harmful, unsupervised treatment.


7/10/19  1:25 pm
Commenter: David Jones

Strongly Agree!
 

This new law should help prevent DIY medical/dental companies from harming our citizens with unsupervised treatments.


7/10/19  1:50 pm
Commenter: Dr. Marc Gamache, Virginia Family Dentistry

Digital impressions are final impressions.
 

I Strongly agree


7/10/19  2:12 pm
Commenter: Deidre Smith, DDS, Wilson Dental PC

Digital Impressions are equivalent to final impressions
 

A digital impression made with an intra-oral scanner of teeth on a live patient is equivalent to a final analog impression previously defined by the BOD. Therefore, the definition of "final impression" should be updated in order to regulate that only dentists with a valid license are making these final impression, in both analog form and intra-oral scanner digital file form.


7/10/19  3:00 pm
Commenter: Neil Landy, Landy Periodontics

Digital Impressions should be considered the same as final impressions
 


7/10/19  8:21 pm
Commenter: Danielle McCormack, Virginia Family Dentistry

Strongly Agree
 

I strongly support the amendment that a digital scan is the equivalent of a final impression and to specify that a patient/doctor relationship should be established in a face-to-face encounter. Many times patients are referred to periodontists for treatment prior to or during orthodontic care, or may be monitored closely throughout treatment by the orthodontist and general dentist if a future referral may be suspected. Unsupervised treatment can lead to potential harm and irreversible damage which would result in early tooth loss for the patient.


7/10/19  9:13 pm
Commenter: Deborah Bassham

Petition
 

 I am in agreement with the AAO whom strongly agrees with the Petition that a digital scan is the practice of dentistry. Prior to treatment, as in any medical field, a thorough examination is needed in order to evaluate the oral health of the patient to see if the proposed treatment should even be a consideration.  Informed consent should occur after the patient is aware of their dental health through examination prior to any treatment realizing the limitations or risks possible from their individualized treatment plan by a licensed Virginia dentist.

To begin with, Va. Code Ann. § 54.1-2711(iv) clearly provides that “Any person shall be deemed to be practicing dentistry who  takes impressions for the fabrication of appliances or dental prosthesis, supplies or repairs artificial teeth as substitutes for natural teeth, or places in the mouth and adjusts such substitutes.”  I believe that the term “impressions” under Va. Code Ann. § 54.1-2711(iv) already applies to “digital scans,” since the a “digital scan” and/or “digital impression,” especially when used for the fabrication of appliances.  Nevertheless, an amendment would only further support and clarify this point.  I also see the importance of establishing a doctor/patient relationship via a face-to-face encounter 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 include conditions or problems that can 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 has occurred by a Virginia licensed dentist in order to establish the doctor/patient relationship.  Moreover, and as stated in the Court’s Memorandum Opinion in Blaine Leeds and SmileDirectClub v. Board of Dental Examiners of Alabama. 


7/11/19  8:32 am
Commenter: Pete Appleby

I strongly agree.
 

I strongly agree that a digital scan is the equivalent to an (analog) final impression and should be done under the direct supervision of a dentist after an in-person, face-to-face encounter with the patient. 


7/11/19  10:55 am
Commenter: Eser Tufekci

Strongly agree!
 

I support the petition as in today's dental technology digital scans are equivalent of final impressions as appliances can be made using these scans. Impressions used in fabrication of final appliances need to be taken by the Auxilary dental staff under the direct supervision of a dentist. 


7/13/19  1:37 pm
Commenter: Dr Walt Wexel, Wexel Orthodontics

Strongly agrree with expanding definition final impression to include digital scanning
 


7/13/19  3:26 pm
Commenter: Narinder Singh

Agree
 

Agree i am agree with you. mesothelioma attorneys us navy veteran


7/14/19  7:07 pm
Commenter: Scott Parr, DDS

Strongly support
 

Strongly support. Needed to protect patients from unregulated procedures


7/14/19  8:56 pm
Commenter: Albert Konikoff

Digital Impressions should be equilavent to current final impressions
 

 In the interest of providing the best care for our patients, it is necessary that digital impressions be considered equivalent to the current Final impression definition in the Virginia state dental practice act. Bypassing this will allow procedures to be completed but at what cost? The cost will be a lack of diagnostic information resulting in less then adequate results and missed diagnoses while the patients believe that because it is legal the care they are getting is equivalent to what they are now receiving. This will open the door to procedure based essentially unsupervised dentistry,  setting  our profession back many years. As of the regulatory body in charge of dentistry for the State of Virginia hi feel it is on incumbent upon you to protect the citizens of the Commonwealth.


7/15/19  10:03 am
Commenter: Mike McCormick

Strongly support his suggestion!
 


7/15/19  11:20 am
Commenter: Fallon Berger DMD

Strongly agree
 


7/15/19  12:36 pm
Commenter: Charles PooleDMD

strongly agree that digital impressions should be considered equivalent to final impressions!!
 


7/15/19  4:38 pm
Commenter: Shannon Brinker

Agree to this amendment
 


7/15/19  4:52 pm
Commenter: John C. Cranham DDS

STRONGLY AGREE
 


7/15/19  5:46 pm
Commenter: Allison Purcell DDS

Strongly AGREE
 

I strongly agree that digital scans are the equivalent of final impressions. For the protection and safety of the public, digital scans used for the fabrication of appliances should only be taken under the direct supervision of a licensed dentist and after the patient/doctor relationship has been established.


7/15/19  10:05 pm
Commenter: Erik Roper, DDS,MAGD

STRONGLY AGREE!!
 

I strongly agree that a digital image is the equivalent of a final working traditional impression. 


7/16/19  12:02 pm
Commenter: Patrice Wunsch, DDS MS

Strongly agree!
 

7/16/19  12:04 pm
Commenter: Richard L Taliaferro, DDS

Support to better define Teledentistry
 

I agree with the petition.  This will prevent uniformed "patients" from injuring themselves doing do it yourself dentistry at home with poor or no supervision.                                                                                                                                                                                                                                                                                                                                                                                                                                                          


7/16/19  1:25 pm
Commenter: Justin Norbo

I agree
 

I agree that digital impressions are equivalent to traditional analog impressions and can be used as such only after a direct face to face doctor to patient relationship has been established.  Furthermore, these impressions should be verified by a licenses on site dentist after the impression is taken.  


7/16/19  1:59 pm
Commenter: Albert Lin, DMD Lighthouse Dental Group / Mahanes Dental Group

Strongly Agree
 

If no radiographs taken there is too much risk


7/16/19  2:00 pm
Commenter: Alan Mahanes, DDS Lighthouse Dental Group / Mahanes Dental Group

Strongly Agree
 

7/16/19  2:04 pm
Commenter: Stephen Goldstein, DDS Lighthouse Dental Group / Mahanes Dental Group

Strongly Agree