Health Professions Council
POST-HEARING UPDATE OF PRELIMINARY REPORT:
DENTISTS

The Council issued its Dentists Scope of Practice (Preliminary Report) in July 1998. The public hearing was held on 14 September 1999. The following are changes to the Preliminary Report which arose from the submissions made either at the public hearing or in subsequent written submissions.

I.     SCOPE OF PRACTICE

The Council’s Preliminary Report recommended the following scope of practice for dentists:

The practice of dentistry is the maintenance of health through the assessment, diagnosis, management, treatment and prevention of any disease, disorder or condition of the orofacial complex and associated structures.

The Council has determined that, as a general matter, scope of practice statements should not contain or attempt to list the reserved acts granted to a profession. Accordingly, the Council has removed the term "diagnosis" from the scope of practice statement for dentists.

There is no doubt, however, that dentists may perform diagnosis as that reserved act has been granted to them.

II.     RESERVED ACTS

In its Preliminary Report, the Council recommended the following reserved acts for dentists:

1. Making a diagnosis identifying a disease, disorder or condition of the orofacial complex as the cause of signs or symptoms of the individual.

2. Performing the following physically invasive acts:
   1. procedures on tissues of the orofacial complex that would penetrate the epidermis or the surface of a mucous membrane, and procedures in or below the surface of the teeth, including the scaling of teeth;

   2. harvesting of tissue for the purpose of surgery on the orofacial complex;

   3. setting a fracture of a bone of the orofacial complex or reducing a dislocation of a joint of the orofacial complex;

   4. administering a substance by injection or inhalation.

3. Applying or ordering the application of a hazardous form of energy.

4. Prescribing, compounding or dispensing by any means a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act.

5. Prescribing appliances, or dispensing or fitting such prescribed appliances, for dental conditions.

A.     Fabricating Dental Appliances

In its Preliminary Report, the Council made the following recommendation:

The Council … proposes the following … reserved (act) for dentists:

Prescribing appliances, or dispensing or fitting such prescribed appliances, for dental conditions. (Emphasis added.)

In the Dental Technicians Scope of Practice (Preliminary Report), issued in June 1999, the Council defined "dispensing" to include fabricating appliances. Therefore, the effect of the Council’s recommendation on dentistry was that fabricating appliances for dental conditions would be granted to dentists.

The College of Dental Technicians of British Columbia strongly opposed this recommendation.

In support of its position, the College of Dental Technicians of British Columbia stated that dentists are not trained and educated to perform the act of fabricating or manufacturing dental appliances. Further, it pointed out that under the Council’s delegation protocol with respect to supervised acts, a dentist would be able to hire an untrained person who is not a registered dental technician to fabricate and manufacture dental appliances as long as the dentist supervises the process. In a subsequent submission, the College of Dental Technicians of British Columbia stated that giving dentists the authority to fabricate dental appliances expands dentists’ scope of practice beyond its current limits. At the public hearing, the College of Dental Technicians of British Columbia submitted that fabricating dental appliances is dangerous and should not be granted to dentists.

Dr. Perry Trester spoke at the hearing on behalf of the College of Dental Surgeons of British Columbia and the Association of Dental Surgeons of British Columbia He indicated that dentists perform fabrication routinely, including making mouthguards, repairing dentures, relining dentures, making surgical splints and many other services. Dr. Trester stated that fabrication is a fundamental part of dentists' scope of practice, particularly orthodontists. With regard to the allegation that dentists hire untrained people, he stated that it would make no sense to hire untrained people who could not perform proper services. He stated that dentists are fundamentally responsible for the patient's well-being and, as such, ensure that patients are not unduly exposed to risk. Dr. Trester did, however, concede that very few dentists perform the type of fabrication services carried out by dental technicians.

The Council has carefully reviewed the submissions and presentations on the issue of fabricating dental appliances. The Council is satisfied that fabricating dental appliances is an integral part of the practice of dentistry. While there is some risk of harm in the practice of fabricating, dentists are more than qualified to address these risks should they arise.

That said, as Dr. Trester suggested, most dentists do not perform the more sophisticated fabrication procedures performed by dental technicians. As a result, most dentists either send fabrication requests out to dental technology laboratories or hire individuals in their offices to perform these services. Pursuant to the current Dental Technicians Regulation under the Health Professions Act, non-registrants are prohibited from performing services provided by dental technicians for anyone. This restriction is subject to an exemption which applies to a person who performs the services of a dental technician under direct supervision and in the office of a dentist and exclusively for the practice of the dentist (Reg. 509/95, Sec. 5).

The College of Dental Technicians of British Columbia requests the retention of the prohibition and the elimination of the exemption. It is concerned that under the new regulatory model, dentists will be entitled to delegate this reserved act to anyone they consider to be adequately trained. This issue was considered in more detail in the review of dental technology. In the Council’s post-hearing changes for that profession, the Council recommended the following:

No person other than a registrant of a regulated health profession acting within their scope of practice may, for another, dispense prescribed appliances or devices for dental conditions unless such person performs such services under direct supervision in the office of a dentist or medical practitioner and exclusively for the practice of the dentist or medical practitioner.

B.     Polishing

Prior to the public hearing, the College of Dental Surgeons of British Columbia (College) submitted that the act of polishing should be a reserved act and granted to dentists, dental hygienists and certified dental assistants. The College of Dental Hygienists of British Columbia stated that with the reserved acts model as currently worded, this service will be in the public domain and would create an unnecessary risk of harm. Dr. Trester, speaking on behalf of the dental profession, stated that polishing can involve soft tissue, and that there is a risk of tissue damage and infection if the service is not performed properly. The Council has reviewed this issue, including the documentation submitted by the College, and finds that polishing does not raise a significant risk of harm and should not be a reserved act.

C.     Should "Attachments" be Added to Dispensing Dental Appliances

In its Preliminary Report, the Council recommended the following reserved act for dentists:

The Council … proposes the following … reserved (act) for dentists:

Prescribing appliances, or dispensing or fitting such prescribed appliances, for dental conditions.

Prior to the public hearing, the College proposed that the placing of orthodontic appliances which are attached to the teeth, on the surface of the teeth, be reserved and therefore proposed the following change to this reserved act:

Prescribing appliances, or dispensing or fitting such prescribed appliances for dental conditions of the orofacial complex, including all attachments to the teeth.

During the public hearing, Dr. Trester stated "attachments" should be added to this reserved act for the purpose of clarity. He was concerned that the present wording of the act may exclude attachments. In the Council’s view, "attachments to the teeth" is included in the reserved act of "prescribing appliances, or dispensing or fitting such prescribed appliances, for dental conditions," and need not be listed separately.

D.     Invasive Acts (Reserved Act 2)

The Council did not address the issue of invasive acts in its Preliminary Report because the BC Federation of Dental Societies and the College did not request any of the invasive acts on the Council’s list of reserved acts. However, prior to the hearing, the College revised its original request and proposed that the following reserved act be granted to dentists:

Putting an instrument, hand or finger(s)

1. beyond the external ear canal,
2. beyond the point in the nasal passages where they normally narrow,
3. beyond the pharynx,
4. beyond the opening of the urethra, or
5. into an artificial opening into the body.

The submission also listed various procedures which required dentists to perform these reserved acts. None of the participants at the public hearing objected to this proposal.

In the Council’s view, the inclusion of these reserved acts reflects the current scope of practice of dentistry.