On Friday, the Montana Board of Dentistry voted to allow dental hygienists with advanced training the ability to apply a newer type of fluoride in public health settings.
It’s the final resolution of a matter that’s been before the BOD since November, generating a lot of discussion and some disagreement at two previous meetings.
Friday’s decision, at the full board meeting in Helena, followed a relatively brief discussion, with comments made by board members and officials.
The issue centered on whether dental hygienists with limited access permits (LAP) should be allowed to apply silver diamine fluoride (SDF) to patients’ teeth without a prior screening by a dentist. There are about 80 LAP hygienists in Montana.
LAP hygienists were created to help vulnerable populations access dental care. The Montana Legislature passed a bill regarding the LAP permit in 2003, but the new designation didn’t really become popular until about 2012.
By state statute, these hygienists may provide dental hygiene preventative services to patients in public health settings, including assisted living and skilled nursing facilities, group homes for disabled individuals and Head Start centers. They can care for patients’ teeth without a dentist’s authorization.
Clients, however, must have physician approval that they are healthy enough to receive a LAP hygienist’s services. Hygienists are also required to recommend patients see a licensed Montana dentist once a year.
SDF is a topical fluoride that can be used either preventatively or therapeutically by dentists and dental hygienists. Preventatively, it can arrest tooth decay, turning teeth black to indicate when decay is present and stopping its progress.
The product has been used in other countries for decades. The federal Food and Drug Administration approved its use in the U.S. in 2014 and it went on the market in 2015.
The Montana Dental Hygienists Association, which brought the issue before the board, submitted eight letters from dentists and academics from around the U.S. urging that LAP hygienists be able to use SDF without dental oversight.
The board tackled the issue at its November meeting. A motion that SDF use by dental hygienists be permitted only under the direct supervision of a dentist, and only be applied after a full examination by a dentist, failed for lack of a second.
A separate motion to add SDF to the prescriptive rules of fluoride agents available to LAP hygienists failed on a tie vote, with three dentists and a public member of the board voting no and one dentist, two dental hygienists and a denturist voting yes.
The issue was sent for further consideration to the January meeting of the board’s rules committee. The 90-minute discussion mainly came down to whether LAP hygienists should be able to apply SDF, especially to frail clients in long-term care who can’t visit a dentist, without direct supervision.
Or if patients be required to have a thorough examination and development of a treatment plan by a dentist before an LAP hygienist could apply SDF to the teeth. Another point that came up focused on whether a LAP hygienist should be allowed to use SDF as a preventive measure, as is allowed in statute, but not therapeutically.
A public health nurse suggested the focus be placed on those who lack access to transportation or who live in communities without dentists, yet require regular dental care.
On Friday, Board member and dental hygienist Diedri Durocher made a motion that 38 percent SDF be included in the list of topical agents LAP hygienists be allowed to use. The motion was seconded by Dr. Jane Hayes, board member and Bozeman dentist.
Another board member suggested the motion be amended that the SDF be used preventatively, but not therapeutically. Legal counsel Brad Jones discouraged that amendment, saying to require SDF be only used preventatively could lead to endless complaints that would be difficult to sort out.
“Applying SDF is the exact same in either circumstance,” Jones said. “From a legal perspective, it’s problematic to say if it’s preventative or therapeutic. I think multiple procedures could be argued different ways.”
Jones said his advice would be to allow LAP hygienists to apply SDF to be applied as specified in the motion.
Board President George Johnston, a dentist from Dillon, then called for a vote.
“I think we’ve beat this issue to death,” he said. “We’ve had hours and hours of public comment before the full board and the rules committee.”
A roll call vote was taken after the 15-minute discussion, and the motion overwhelmingly passed. An official vote count wasn't available at press time.