REPRESENTATIVE KOWALKO: Good evening, Ladies and …



Joint Sunset Committee

Wednesday, March 3, 2010

Joint Finance Committee Hearing Room, Legislative Hall

Board of Dental Examiners

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JSC and Staff: Rep. John Kowalko, Chair; Sen. Bethany Hall-Long, Vice-Chair; Rep. Bradford Bennett; Rep. Thomas Kovach; Rep. Clifford Lee; Sen. Colin Bonini; Sen. Joseph Booth; Sen. Brian Bushweller; Sen. Michael Katz; Debbie Puzzo, JSC Executive Director; Kathy Morris, Legislative Council staff.

Absent: Rep. John Atkins

In attendance: Thomas Jenkins, Pres. Del AGD; Louis Raffeto, DIDER; John Lenz, BODE; Sharon Welsh, DSDS Pres.; Thomas Conaty, Leg. Council, DSDS; Thomas W. Mercer, Past Board Member; Jeffrey Cole, DSDS; Brian McAllister, DSDS; Douglas Ditty, DSDS; Connie Grelley, DSDS; Rachel Macher, DSDS; Stephanie Stecker, DSDS; Ray Rafetto, DMD DSDS; Anthony Vattihura, DDS; M.L. Cahoon, DMD; Kimberly Hidemore Bowen, Deidre McCutcheon; Mary Trinkle; Lynda Levine; Angele Mesela; Nancy Brohawn; Merith Taylor; Barbara Nesh, RDH; Joan Morden, RDH; Dott Davidson, RDH; Fay Rust, RH; Bernice Asc, RDH; John Kirby, Public Member, Board of Dental Examiners; Debra Bruhl, RDH; Renee Holt; Vivian Rizzo RDH; Sue Schroeder; Christine Schadel; Laimsa Anthony, DMD; Paul Christian, DMD; Lisa Fagioleth, DMD; Emil Tetzner; G. McClark; Lawrence Coyle; Kay Warren, DPR; Mary Davis, Ned Davis Assoc., Dental Society; Patrick Allen, Ned Davis Assoc., Dental Society; Rita Veale, RDH; M. Julia Ciarrocchi, RDH; Annette Matoni, RDH; Neil McAneny, Board of Dental Examiners; Robert Director, Board of Dental Examiners; James Kramer, DSDS; Hope Thomas-Glavin, Dentist; Allison Reardon, DAG; Blair Jones, Dental Board

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Agenda:

I. Welcome; Introduction of Members

II. Overview of the Sunset Process (JSC Chair)

• Opening Comments by the DE Health Information Network (15 minutes)

• Question and Answer with JSC

III. Public Comments (3 minutes per person)

IV. Concluding remarks (JSC)

V. Adjournment

Rep. Kowalko called the meeting to order at 6:52 p.m.

I. Overview of the Sunset Process

Representative Kowalko welcomed everyone and thanked them for attending. The members of the Committee introduced themselves.

Representative Kowalko explained the Joint Sunset Committee review process. Following tonight's presentation by the Board of Dental Examiners, the Committee will go through its Draft Report, concluding with public comment.

• Opening Comments by Board of Dental Examiners

Dr. McAneny made the following opening comments:

Good evening, Representative Kowalko , Senator Hall-Long, and members of the Joint Sunset Committee. Thank you for the opportunity to appear before you and discuss the review of the Delaware Board of Dental Examiners.

My name is Dr. Neil McAneny. I'm the current Board President, and I'm joined by Dr. Blair Jones, our board secretary; Dr. David Williams, our immediate Past President; Laureen Coyle, Dental Hygenist; Dr. John Lynns, member of our Board; John Kirby, our public member; and Fay Rust and Bonnie Thomas, dental hygiene, and Debbie Berl -- excuse me -- who are with the Dental Hygiene Advisory Committee. Sorry. Rob Director is also here. I didn't get your name in here.

We are also joined by the Board's previous Deputy Attorney General, Allison Reardon. Director James Cullen and Deputy Director Kay Warren are also here representing the Division of Professional Regulation.

The Board and the Division welcome the Sunset Review process because we believe there are opportunities to increase public protection in this area. It is our hope that such opportunities will result from this process. I'm pleased to provide an overview of the Board's activities, address major challenges identified in this committee's draft report, and introduce the Board's suggestions.

The Board currently licenses 456 dentists and 709 dental hygienists. From 2007 to 2009, there were 43 complaints investigated. 21 were closed after the investigation, and 13 were forwarded to the AG's Office for prosecution. Of the 13 complaints forwarded to the AG's office, three were dismissed; three resulted in Board disciplinary action consent agreement, and seven are pending.

The Board was previously reviewed by this Committee in 1995. The Board is in compliance with 25 of the 30 committee's prior recommendations. The remaining five recommendations, including the Board recognizing regional examinations, giving the Board authority to subpoena records from hospitals, regulating dental technicians and dental auxiliary personnel in rule and regulation, removing outdated language referring to the Board's secretary/treasurer, and amended language relating to the issuance of duplicate licenses.

The Board is proposing legislation that would address four of the five recommendations. The regional examination is one of the Board's challenges that will be further discussed this evening.

Under accomplishments, the Board implemented the 1995 Joint Sunset Committee recommendations pursuant to Senate Substitute 1 to SB 240, which was enacted by the 141st General Assembly.

During the 142nd General Assembly, HB 176 was enacted to change the passing score on the national examination for dentists from 80 to 75 to be consistent with the national passing score.

During the 142nd General Assembly, SB 229 was enacted and created a uniform approach throughout Title 24, requiring that the refusal, revocation, or suspension of licenses for professions and occupations regulated under Title 24 be based upon conviction of crimes that are substantially related to the profession or occupation at issue, replacing the former felony language. The Bill required the boards of affected professions and occupations to adopt regulations that specifically identify the crimes that are substantially related to the profession or occupation within 180 days of the enactment of the bill.

The Board adopted Rule and Regulation to identify crimes substantially related to the practice of dentistry and dental hygiene effective July 2005.

In 2004, the Division and the Board relocated the testing facility from Temple University in Philadelphia to Del Tech Wilmington, which decreased costs and was a much more convenient location for applicants.

The Board implemented SB 165 to establish retention and disposition provisions for patient dental records consistent with similar professions in the Medical Practices Act.

The Board implemented HB 67 that established a volunteer license category for qualified dentists and dental hygienists who volunteer their time in non-profit dental clinics or non-profit dental services within the state which are approved by the Delaware Health Care Commission and by the Board of Dental Examiners.

The Board implemented SB 206 to give protection to active-duty military, active reservists, or members of the National Guard from having their professional licenses expire during active military deployments.

The Board updated its web page on the Division of Professional Regulation's website to make it more user friendly for the public to access licensee and disciplinary information, and for applicants and licensees to access licensure requirements, laws, and rules and regulations.

The Board adopted Rules and Regulations on April 1, 2006 to clarify continuing professional education requirements relating to cardiopulmonary resuscitation for dentists and dental hygienists, and to require continuing education on an anesthesia topic for holders of unrestricted permits and restricted one permits.

The Board implemented SB 403 to allow Title 24 boards and commissions to waive convictions substantially related to the professions under certain conditions. These conditions included that, after hearing the Board by an affirmative vote of a majority of quorum, may waive §1122 (c)(4) of Title 24 if certain conditions are met.

The Board implemented HB 36, giving all boards and commissions cease and desist authority, to address unlicensed practice, and to impose fines for those who violate cease and desist orders subject to hearing procedures.

The Board implemented HB 392, creating a volunteer license. This Act will be reviewed for its effectiveness after two years of its passage and, if not reenacted, the Act will expire two years from the date of enactment.

The Board streamlined the renewal process by offering on-line renewal with the use of payment by credit card and the ability of licensees to attest to the continuing education online subject to post-renewal audit.

In 2008, the Board delegated authority to the Division of Professional Regulation to issue licenses to applicants under specific circumstances or in coordination with the Board's credentialing committee. The Board ratifies the issuance of licenses at the next scheduled meeting.

In 2008, the electronic notification of the receipt of dentist and dental hygiene licensure applications and the ability for applicants to track the progress of the application became available online.

The Board implemented HB 135 that created a limited license for a director or chairperson of a dental and maxillofacial surgery residency program.

The Board is evaluating the criteria for residency programs to facilitate licensure of new candidates.

The Board is examining the feasibility of accepting regional examination standards for dental and dental hygiene.

The Board is considering the establishment of requirements for reexamination or other assessment of formal competency when licensees fail to renew and their licenses expire.

Opportunities: To improve public protection, the Board is seeking a licensure requirement that new applicants obtain a State and federal criminal background check; reorganize and modernize statutory provisions similar to other Title 24 boards; ensure that Delaware's minimal standards of practitioner competency and delivery of dental and dental hygiene services are in line with those nationally to ensure the highest level of public protection and access to dental care.

As is evidenced by this summary, the draft report prepared by this committee comprehensively identifies the concerns and needs related to this board. The Board of Dental Examiners and the Division of Professional Regulation welcome the opportunity to work with this committee to address these issues.

• Question and Answer with the JSC

Representative Kowalko stated that the Committee will review the Draft Report. The Committee tries to follow a pattern of going through the Draft Report page by page, and incorporate any of the Points for Consideration listed on page 51.

Representative Kowalko referenced page 4, subheading: Joint Sunset Committee Review History. The Board of Dental Examiners was reviewed by the Joint Sunset Committee in 1985 and again in 1995. Recommendations that were made by the 1995 Joint Sunset Committee and a brief explanation of compliance or noncompliance are listed. The Board is in compliance with Recommendations #1-11.

Recommendation #12 with staff comment in italic:

The Sunset Committee sent a letter to the Board of Dental Examiners asking them to discuss recognition of regional examinations in order to facilitate reciprocity. The Board is not in compliance with the response to the JSC. The initial questionnaire stated that a review of the Board's meeting minutes indicate that the Board has not addressed recognition of regional exams.

Dr. Williams: I'm Dr. Williams. I am a general dentist from New Castle County. And I was past president of the Board of Dental Examiners. And while I can only speak for the past six years that I have been a member of the Board, we have had discussions to evaluate regional exams during our meetings. We have continually compared and reevaluated our examination process with outside examination groups, including regional exams.

Even though our minutes do not reflect these discussions, in 2004 our president and secretary, Dr. Mercer and Merrier, attended a national meeting of the Board of National Dental Examiners. And they did take our dental and dental hygiene exam to that meeting, using it to compare with regional examiners that were there. There was also a discussion of national clinical exam.

President Mercer came back to the Board and did report his findings and stating that the Board -- our Board exam was comparable and a fair exam as related by these other examiners. It was a consensus of the Board after that report that we would continue with our own exam.

The Board continues to be vigilant in its examination of our clinical hygiene and dental exams. And it's our current belief that we are able to best serve the public with a clinical exam developed and implemented by the Board.

Representative Kowlako: Along those lines, you said that they did come back after the 2004 meeting, having gathered information about the efficacy of your exam. Does this, though, speak to the point of facilitating reciprocity? In other words, I don't know that the question being raised by the other Sunset Committee was, in fact, assurances that your exam is appropriate and well done, which I'm sure it is; but I think it was to facilitate reciprocity, which would mean, in my mind, that you would see if there was a like-minded view in other exams so that we could maybe reach some kind of a compromise where we could have reciprocity. Am I correct in that?

Dr. Williams: We do see it in that respect. However, we feel that it is the duty of the Board to maintain its mission to protect the public, and that our exam sets a benchmark for candidates who would like to come and practice in our state, and that the exam is one chance to see those candidates perform. They perform everyday duties. And, once they have passed the exam, they do go on to practice independently.

There is no oversight after that examination process. And if we allow reciprocity and a dentist does come into the State and he does practice substandard care, if he treats one patient, that patient can be injured. And I truly believe that we have a passing rate in the dental exam of 80 to 85 percent, and in the dental hygiene it's a higher -- it's 90 to 95 percent pass rate.

But we have inexperienced or newly licensed dentists take the exam as well as experienced dentists take the exam, and we do have failures. So, as I said, I think it's the best process that we have to protect the public and to look at the dexterity of these dentists that are going to practice in the State.

Representative Kowalko: And I very much appreciate that. I would never expect you to lower standards to meet any, engage in any reciprocity from other states. But is there a chance, though, that we are denying qualified people from out of state coming here with this? Or are we just doing due diligence? You know, I certainly wouldn't want to put my position -- put myself in a position where I'm saying okay, let's lower our standards or let's make it easier or let's just blanket grandfather anyone who comes in that has X, Y, Z qualification. Because I appreciate your point. That does not prove the capabilities and abilities and certainly expertise.

Dr. McAneny: Well, on that issue I think it is very important to realize that our clinical exam is designed to test minimal competency. What we are looking for, the procedures that are done were things that every general dentist does, you know, 80, 85 percent of the time in their office. If someone could not do those very basic procedures, okay, which are very, very critical to the practice of dentistry but very basic, then they shouldn't be licensed, not at that point in time.

They have the opportunity to retake the exam to find out where their failures lie. They can come before the Board, and we will discuss it. They have every opportunity to correct three times. So I think we would greatly diminish the Board's primary objective, which is, you know, defined in Title 24, to protect the welfare of the public from unsafe and unprofessional practices, if we were to have just open reciprocity.

If we don't have the opportunity to look at these candidates and watch them perform, I mean we see how they, you know, how they handle the patients, how they interact, how they conduct themselves, okay, it's a time that we can judge their professional competence and, you know, how they do the procedures and what they think is necessary or not necessary to do. And to eliminate this one step, I think, would be a problem.

You know, some people have said well, physicians, gee, they don't have to take a regional exam. But physicians, you know, they have an internship, and then 80 percent of physicians -- at least it used to be that, or typically specialists, and they go on to further training and residency programs from, you know, any number of years. So our one chance to see these people perform is this clinical exam. After that, we are basically on our own. It's up to each individual's professional integrity to do their very best for every patient who comes in. And I think we have to, for the protection of the public, I think we have to see a demonstration that these people can at least perform competently. And, you know, open reciprocity would really eliminate that opportunity.

I might suggest also that that Point 12 that was asked by the other previous Sunset Committee was that you discuss recognition of regional examinations -- and you have done that. Maybe it should have been part of the formal meeting because that would bring you into -- in my eyes, and I'm certainly not the judge of this committee's opinion, but in my eyes that you did discuss the regional examinations in an attempt to facilitate reciprocity.

But if it's not there because you feel more comfortable and secure in the safety of the citizens of Delaware by having -- administering these tests, that you fulfill this in that sense, in a littler sense, that it be a discussion.

Senator Bonini: If I could jump in. And the only reason I'm going to jump in is I was on this committee in 1995, and I remember this. Bill and I remember this hearing vividly. And I was half the man I am today. Or I guess I'm twice the man now than when I sat, and I'm working on becoming one and a half times the man I was.

But I do remember specifically this -- I don't know how many of you remember that hearing 15 or 16 years ago. I was a freshman, and I got thrown into the hygienist, first dentist, and this ongoing reciprocity issue. I remember specifically the committee specifically did not say go and get the reciprocity done. And it was quite contentious because a lot of people said, "Hey, there is a significantly under-served population. We, quite frankly, didn't have enough dentists. And I remember I was questioning saying, "Hey, wait a minute. Why do we have these restrictive testing?" I called it that at the time.

But the other thing is, and I think -- thank you. It's here in the package -- is sort of the proof is in the pudding. It sounds like the dentist shortage problem is, if not completely solved, well on its way to being solved.

And at the time in 1995 -- and my apologies. I can't remember the statistics off the top of my head, but there were huge numbers of dentists who weren't taking new patients. There were -- I think the much larger, under-served areas. But I do remember specifically, because we debated whether we wanted to specifically say, "Hey, you are going to start accepting the out of state." And so I just wanted to put that perspective in there.

Representative Kowalko : And I appreciate that. That was the point I was trying to make here. I mean I just certainly wanted to elicit a response from you about the discussion. Unless there are other questions from committee members.

Senator Booth: On this point I remember one of the first things I did as the new representative was vote to lower the grade. It went from what to 75?

Dr. McAneny: 80 to 75.

Senator Booth: Eighty to 75, so that may have helped as well. But that kind of leads into my other question. Do you guys -- does the Board of Dental Examiners -- I better sound a little more official than that -- calibrate themselves on the dental or dental hygiene exam? Is there any calibration there?

Dr. McAneny: Well, calibration in the fact, in the aspect of we have executive session before we have the exams. The exams are given in January and usually May for dental hygiene, and June for dentists. And we do have a meeting and go into executive session to talk about those exams and how we are going to perform in the exams.

Senator Booth: So that's done before every test?

Dr. McAneny: Yes.

Senator Booth: You test one time?

Dr. McAneny: Twice. June and January.

Senator Booth: All right. And is it acceptable to go into Executive Session to discuss the exam, the calibration thereof?

Ms. Reardon: I'm sorry. Allison Reardon, Deputy Attorney General. And I was their legal adviser. Another deputy has taken my place. But during this period of time I did give them legal advice that they could go into executive session to discuss the confidential exam. Otherwise, the exam would be compromised.

Senator Hall-Long: We are on the one item, because I know there were the five. And you did a nice job in your testimony of delineating out those that you have complied with now and those that were hanging out there to figure out a mechanism to address or explain.

One point for perhaps other Board members or committee members' information here that I have ascertained through doing a little research on the background here that you did not mention -- because I know this issue with reciprocity is very important, and certain disciplines, I know, we have addressed that. Having lived a few years now down here doing a lot of -- I know James always dreads it when I send him information, James Collins -- you know, doing quite a few title bills, a lot of licensure bills, you know, we look to the profession to do that definition.

And what I had found initially when I was working with some oral health initiatives, I was concerned about the access and not having reciprocity. But, as Senator Bonini had stated, I have seen where there have been changes in the access and number of dentists, et cetera, across the State.

But explain to us, perhaps in somewhat layman's terms, why you chose not to use like the regional exam. Because, as someone who works in a health profession that was licensed as a nurse myself, we chose to because it is a high-performing exam. And it's my understanding that you might be able to share with them some of the concerns with some of the national exams.

Dr. McAneny: Okay. The current Board has not looked into the issue of the -- I would think the NRB exam, the North Regional, would be the one we would be looking at. But we have looked at what we do. Our exam is given by Delaware dentists, all licensed dentists, and I think we have an interest, a priority interest in maintaining high standards of care.

With a regional exam, such as NRB, there are 500 to 600 examiners, and you may get any, you know, any mixture of those 500 to 600 people at any one time. We have, I think, a little bit more consistency on our Board. Even though members come and go, there are always still members there who have been involved in this process for an extended period of time. And I think we have some consistency in our examination.

It certainly is less expensive. The Northeast Regional exam is about $1,875; ours is $250. It could be given at, you know, any site; ours is given at Del Tech in Wilmington, which is convenient to most of the applicants. The NRB examiners are paid. Our Delaware dentists are volunteers who are not paid for that examination. We do get a reimbursement, as you know, from meetings and those kinds of things, but not a direct payment for the examination.

So there are a number of things that I think make our examination, I think, a little preferable to a regional examination.

Senator Bushweller: Thanks. In your remarks about this Item 12 here, you mention that once a dentist or an applicant passes or successfully completes the clinical exam, then he or she is out practicing on their own and they are guided only by their own professional integrity.

Can I assume from that comment that there is no ongoing process or program to assess the continuing competence of dentists who are already licensed?

Dr. McAneny: Yes. With the exception of oral surgeons who do work in hospitals and are on the hospital staff and would be subject to the hospital oversight committees -- Dr. Katz would probably know more about this than I do -- but most general dentists and a number of specialists as well are basically on their own. There is no ongoing oversight committee. You know, we don't have to appear before a Board on any kind of regular basis. No one comes in to, you know, check our work or review slides or anything else.

No. It's up to each and every one of us to maintain our own high standards. And, again, going back to that initial issue, I think it's why it's very important that we know that anyone getting a license in Delaware is at least minimally competent to perform the basic procedures.

Senator Bushweller: In your opinion, should there be, in the interest of patient safety and quality of care, should there be some kind of ongoing process of assessing the continuing competence and quality of care of practitioners?

Dr. McAneny: Well, I think, unless we started to see a tremendous increase in numbers of complaints compared to, you know, other states or something, some evidence that we are not doing a good job on our own, I don't see a need for it. I'm not sure exactly how you would do it. You are going to have to set up some sort of committee to do that. But right now I think in Delaware we are doing a pretty good job.

Dr. Director: Senator Bushweller, there is a continuing education requirement for dentists in Delaware and hygienists. We had a CE requirement, and it is very specific in what qualifies as CE. And it is the second-most stringent CE requirement in the country, so it does provide some oversight. It does not provide, certainly in terms of competency and in terms of technique, it does not provide oversight of actual clinical skills. And, unfortunately, that's one of the reasons I think that we really like to have our own Board examinations. It's one chance to really look at somebody.

I think, from a mechanical standpoint, it would be very difficult to provide ongoing clinical competency. It's not -- Dentists don't typically work in a hospital the way many physicians do, and so they are not being overseen by other members of their colleagues to nearly the degree the physicians are. So it is a problem, but I think we are doing our best. I don't see, off the top of my head, any ongoing mechanism for really reviewing clinical competency. Maybe review of patient records. I'm not sure that other states do that. And I could be wrong, but I don't believe so.

Dr. McAneny: Okay. To answer that question a little bit further, there are a couple things that we do have in place through the Delaware State Dental Society. We do have peer review committees which, if there is a complaint lodged to the Delaware State Dental Society and so forth, that can be brought before the peer review committee, a committee of dentists, and they will take the records and so forth and look over the complaint and see what the problem is and make rulings on that.

And I have been on that before. And, you know, a number of times we have advised, admonished the dentists that, you know, they have done something that was not in line with the professional standards and to correct it.

There are dental legal boards. Okay? There is a Council on Dental Care Program, which is another avenue for patients to bring a complaint before the Delaware State Dental Society. Of course, they always have the right to bring their complaint to the Division of Professional Regulation as well.

Dr. McAneny: So there are some things in place that would handle, you know --

Senator Bushweller: But no comprehensive process assessing --

Dr. McAneny: Not an ongoing, regulated, analyzed program. Not at this point. No.

Senator Hall-Long: Just for public record -- and I know this is being recorded -- if you go to Title 24 and Section 6. You don't have to go there now. I'm not asking you a question. I'm just getting the record where it addresses in the dental title your mandatory CEUs which are due by March 1. The Board of Professional Regulation, as well as they address dental hygienists. So it is there.

Senator Booth: You spoke about the, you know, what was required of dentists. Can you speak about hygienists? Do they also take the regional boards but also have a separate Delaware test as well?

Dr. Williams: Dental hygienists may receive a license in two fashions. One is they take the dental hygiene exam, which is administered twice a year.

Senator Booth: And that's the Delaware Dental Hygiene exam?

Dr. Williams: That's correct.

Senator Booth: Do they also have a NRB?

Dr. Williams: The dental hygienists do have a Northeast Regional NRB exam that they may take. Yes.

Senator Booth: But does Delaware accept -- if somebody takes that examination as a hygienist, do they recognize that?

Dr. Williams: Yes.

Senator Booth: Do they have to -- and they do not have to take the Delaware?

Dr. Williams: Excuse me. New licensed -- New graduates of dental hygiene take the Delaware exam. Dental hygienists that have been practicing out of state for a certain number of years then may come in, apply for licensure by credential, that they have practiced and have been in good standing, and receive a dental hygiene license.

Senator Booth: Is it specified how many years they are supposed to have practiced, et cetera, or are there specifications?

Dr. Williams: Yes. We believe it is three years. Yes.

Senator Booth: Okay. Well, I guess my question would be, since I think Senator Hall-Long asked this question of the dentist, I'm going to ask the same thing of the hygienists. Can you give me an example why you wouldn't accept passage of the NRB and why you would need -- Why couldn't Delaware join this Northeast testing group and do away with their State test for dental hygienists? Now, you spoke about the dentists. I'm speaking of the hygienists now. Can you elaborate?

Dr. McAneny: Okay. Can you repeat that question? I'm sorry.

Senator Booth: All right. The question that Senator Hall-Long asked is the dentists were interested in keeping their own State tests for quality, if you will. I'm just going to cut to it. For quality.

I'm asking the same question. Why -- What is the reason, or could you give me an example why you wouldn't accept the regional examination over top and do away with the Delaware State test?

Dr. Williams: For hygienists?

Senator Booth: For hygienists.

Dr. Williams: It's pretty much the same reason as for the dentists, that granted the dental hygienists that do take the hygiene exam, 90 to 95 pass. And so we do see those that do not pass.

And, again, that would be someone who, if they did receive a license after taking an outside exam, that they possibly could be providing substandard care.

Senator Booth: All right. And you testified that you allow somebody that took the regional examination and, say, practiced in Maryland for a certain number of years, two or three years, can come in and practice as a dental hygienist and, I guess, not have to take the Delaware test. However, you don't do the same to dentists, do you?

Dr. McAneny: No.

Senator Booth: If you are a practicing dentist in Maryland, can you just move to Delaware after so many years, three years, and then become a dentist in Delaware or --

Dr. McAneny: You cannot. You need to take the --

Senator Booth: So there is a different standard there?

Dr. Williams: That's correct. There is. And the only explanation I can give you is that, as we said before, the dentists practice individually, independently in their office (this might be Williams) And when they have a dental hygienist come into the practice, the dental hygienist is practicing under the supervision of the dentists. So that if you have, then, a dental hygienist that is providing substandard care, the dentist is there that would be able to recognize that person.

Representative Kowalko: Excuse me, Senator Booth. Before we go any further, I would like to call a dental hygienist, please. I would like the question -- I think the question is more appropriately addressed by a representative of dental hygienists so we can get through this. It's just more appropriate a place.

MS. BOWEN: My name is Kimberly Hickman-Bowen. I'm a licensed dental hygienist in the State of Delaware for 28 years. And I have a bachelor of science degree in dental hygiene with an emphasis in education and health management, and a master's degree in education with an emphasis and specialty in curriculum design and instruction.

I have previously been a dental hygiene educator, a continuing professional education speaker, a dental hygiene consultant, and also a past voting full dental hygiene member of the Delaware State Board of Dental Examiners. And I'm here representing the Delaware Dental Hygienist Association this evening.

Senator Booth, and I did hear your question, so I will address that with my testimony. I have some other points, but I will just bring forward that point of concern to help you.

Representative Kowalko: I guess, if you would, you will have the opportunity for your testimony. I just wanted you to give a more specific response to Senator Booth's questions.

Ms. Bowen: To the NRB.

Representative Kowalko: Yes.

Senator Booth: Typically, what I asked, and I thought it was a good question that Senator Hall asked of the dentists because it goes right to the point of Number 12. And that talked about regional versus statewide tests. The question was, to the dentists, on the issue of quality: Why do you have two separate tests? Why can't we recognize the regional test and have dentists -- They basically said it was an issue of quality.

I asked the same question about hygienists. They also have a regional test. They testified -- Earlier testimony was that you can move to the State of Delaware and be a hygienist, if you have a certain number of years or meet the criteria, and not have to take the Delaware test. So my question is, again, why not just accept the regional test? What would be the issues there?

Ms. Bowen: We really don't see an issue with that. We really feel that they should accept the regional examination for the clinical competency testimony to the licensees for dental hygiene applicants for their credentials.

The only reason to have a separate state clinical examination in the State of Delaware only hurts, as our previous speaker mentioned, the newly licensed graduates. Those individuals that have not practiced for at least three years in another jurisdiction cannot gainfully be employed in the State of Delaware unless they sit for the Delaware clinical exam.

Senator Booth: But those -- and you mentioned that you teach. Those that teach and get out of the programs have already sat for a regional board?

Ms. Bowen: Yes.

Senator Booth: Most of them?

Ms. Bowen: Yes. Almost 95 percent of the dental hygiene students in our State of Delaware sit for the Northeast Regional board, and when we --

Senator Booth: Can I just ask you: Why doesn't the other five percent sit?

Ms. Bowen: Sometimes they know ahead of time if they are moving out of the state.

Senator Booth: Okay.

Ms. Bowen: So their, you know, their life is bringing them to it.

Senator Booth: Personal reasons.

Ms. Bowen: Yes, a personal reason. But the Northeast Regional board would accomplish testifying to the clinical competency. They have a rather calibrated exam. When we look at a dental hygiene education and accreditation that goes into the dental hygiene education, a dental hygienist, a new graduate, comes out with over 2,000 clinical hours dedicated to the education and training and delivery of patient care to the public. So that's certainly a test to their ethical responsibility to be giving prudent and safe care to the public.

Senator Booth: Well, I think you have answered my question. That was what the difference would be in terms -- okay. Thank you.

Senator Bonini: I'm sorry. I just want to know what the pass rate is for the dental hygienist Delaware exam. Whoever wants to answer it.

Dr. McAneny: It's 75, as well.

Ms. Bowen: Your percentage. Your percentage.

Dr. McAneny: Well, it's probably going to be -- It is in the 90, 95 percent range. I don't know if we have any exact specifics, but it's a very high pass rate.

Senator Bonini: Okay. So 95 percent pass.

Dr. McAneny: Yes.

Senator Bonini: Forgive me. What's the problem?

Senator Hall-Long: I don't think there is.

Senator Bonini: Okay. Thank you.

Dr. Williams: If I could answer that, I think still if you have 95 percent pass, you still have one or two that may fail.

Representative Kowalko: The executive director has a point for clarification here.

Ms. Puzzo: Dr. McAneny, you said that the Delaware State Dental Society has a peer review committee. Is that the Delaware State Dental Society or the Board?

Dr. McAneny: No, it's a review committee run through the Delaware State Dental Society. They have set this up to try to address problems and see if they can solve them before they get more involved. Okay? So it's a committee to try to resolve issues at a lower level than going to the Division of Professional Regulation, for instance.

Ms. Puzzo: Okay.

Dr. McAneny: And it's really quite successful.

Ms. Puzzo: Then, with that, so that affects the number -- If I look at the information that was given to me and that number is low, is that because it may have been mediated at a lower, at another venue? Were those complaints maybe filed at the peer review level?

Representative Kowalko: The information that you forwarded to the executive director in the complaints area. The question I believe is being asked, are some of the complaints not registered in your reply because they were handled by the peer review or not included in that reply because they were handled by --

Dr. McAneny: Not included. And these are only complaints that refer the Division of Professional Regulation. You know, I'm sure someone within the Dental Society could, you know, give the statistics on how many times a peer review committee had to meet and so forth. It's normally -- My experience for having been on it for a number of years, it was very, very seldom. In three years, I think we met two, maybe three times, so ...

Ms. Puzzo: Okay. Just to clear up. When I asked the questions about how many complaints were filed with the Board.

Dr. McAneny: Right.

Ms. Puzzo: And those would be patient complaints.

Dr. McAneny: Yes.

Ms. Puzzo: And I was given a number that went to the Board of Dental Examiners. Was there some other number?

Ms. Puzzo: .. Is there some other number that I should have asked for tracking a total number of complaints against dentists?

Dr. McAneny: No. Those are the complaints that went to the Division of Professional Regulation, so those are the true complaints that have been unresolved and that were settled in some way. Okay?

Dr. Director. Imagine yourself as a dissatisfied patient or consumer. You have many options open to you. You have the option of making complaint to the Board, which then, through the Department of Regulation will hire an investigator or has investigators on staff.

You also have the opportunity to go to the Dental Society, which has its own mediation process which is completely separate from the Board. And a patient also has the opportunity to hire an attorney and file a malpractice suit, if they can find an attorney to take the case. So there are a number of options.

I believe you are asking for the Board's data, not any of these other -- We don't know how many patients have filed malpractice suits or, you know.

Ms. Puzzo: No. I guess the question that I was asking was the information that I have from the Board of Dental Practitioners is not the complete amount of complaints that are filed against dentists in the State of Delaware; it's just one of the places that someone can file?

Dr. Director: I think that's reasonable, yes.

Ms. Puzzo: To get a more, a total picture, I would need to -- How many other entities would I have had to have contacted to find that information? The Dental Society?

Dr. McAneny: The Dental Society.

Ms. Puzzo: That would be it?

Dr. McAneny: Basically, the Dental Society.

Senator Hall-Long: And this may be directed toward James Collins, perhaps. Don't jump up because maybe they answered it correctly. I think this would bring clarity. Our request was when there was consumer complaints -- We know now in different titles, Title 24, the practice of medicine, we particularly recently know quite a bit more about that, where complaints can be directed.

And what we have heard here is obviously if they went to the Dental Society. But do we know in State Code does it say just to the Board of Professional Regs? Because I know we discovered recently with the Medical Practice Act that they can certainly filter comments and complaints other directions.

Mr. Collins: On this issue, I mean, there are some members of the Delaware State Dental Society here. If any of them -- Would you like to hear from them on any issue?

Representative Kowalko: Not right now.

Senator Hall-Long: -- to make sure she has gotten the numbers right.

Mr. Collins: If I understand your question correctly, there was a couple things that you said that I wanted to just kind of address for -- if I could just speak for the Board of Medical Practice, the comment that you made for just a second. Wow. No. I'm going to move on from that.

Mr. Collins: We will talk about that a separate day.

Senator Hall-Long: Yeah. Move on.

Mr. Collins: But there are not other entities that -- You know, our understanding is that the Board of Dental Examiners is being reviewed, and the only complaints that we reported were complaints that came to the Board of Dental Examiners. We don't maintain information for any other organizations.

Senator Hall-Long: Okay. That's all we needed. We just needed to know that for us for the report. That's all.

Representative Kowalko: … I want to go to the next item that is noted. The Board is not in compliance. And that is Number 15. The responsibility of the Division of Professional Regulation regarding duplicate certificates referenced in Section 1126, 24 Delaware Code. The Board is not in compliance. The provisions for duplicate licenses are under 1131C as follows: A new license shall replace any license lost, destroyed, mutilated, and may be issued subject to the rules of the Board. A charge shall be made for each such issuance. …

Dr. McAneny: I would like Allison Reardon to address that issue.

Ms. Reardon: During the past year the Board has been undertaking a comprehensive review of its statute. And I believe, in the report, that is one of the items that the Board has indicated that it has proposed legislation to change.

Representative Kowalko: Thank you. That answers my question. Do we have any questions from the committee? Seeing none, we can move on right through Page 6 and to Page 7. Again, just noting Number 26, not in compliance. And that is the outdated wording regarding the duties of the secretary/treasurer to enforce provisions of Chapter 11 of 24 Delaware Code be stricken from Section 1181. That has not been done.

Representative Kowalko: Are you going to be doing that?

Dr. McAneny: Correct. Yes.

Representative Kowalko: Okay. Number 27. Do I get that same answer or?

Dr. McAneny: The words "subpoena records."

Senator Hall-Long: That is medical records.

Dr. McAneny: Yes. Yes. That is in our revisions.

Representative Kowalko: Number 28.

Dr. McAneny: Yes. We will address that. Yes.

Representative Kowalko: We have a point of order here.

Ms. Puzzo: On Number 28 it's also addressed at another point in the report later on under regulations, I believe. For a point of order, that's probably going to require some discussion. Do you want to move on and get to that when you get to it in the report where all the information is, or do you want to do it here as a separate item?

Representative Kowalko: Let's put this in its appropriate place. We will be discussing this more later in the report. The way we have the report crafted, certainly I don't want to miss anything previous, but we will reference that.

Senator Bushweller: With regard to the 1995 recommendations of the Joint Sunset Committee, and specifically with regard to the five we just discussed where the Board is not in compliance, I understand that on some of those you are dealing with them in the proposed revisions right now. Why has it taken 15 years to start the process of complying?

Dr. Williams: Again, we can only speak to the -- I can only speak to the six years I have been on the Board, and so that we were not aware of these noncompliant issues until the Sunset Review came up. And so that that is really -- We did not look at the '95 JSC report until we were notified that we were coming up with the Board review.

Senator Hall-Long: And, if I could clarify because I know he raises a point. But, as I had read it, that there were actually 30 noncompliant areas to address back in '95, so you have addressed all but five is how I had read that. But perhaps I read something -- It doesn't matter. But I hear what he is, you know, saying, I mean, moving along.

Dr. McAneny: I suppose, Madam Chair, that I could -- and I won't do it right now -- but I suppose I could tell the Joint Sunset Committee as to our own procedures for following up on the recommendations that we make.

Representative Kowalko: We do now, and we will continue to do so under this chair. I promise you that. So that doesn't do any good for looking backward. I understand that, and I appreciate that. And I'm not in a position to chastise, but I do raise eyebrows when I realize what your point is. And, certainly, I am going to ask this point, why has it taken so long. And, quite frankly, and it's not a reflection on anyone that is new to the Board, not being there for 15 years. But the fact is, if you walk into a board -- I don't care who you are -- and there is something laying there that's been in the waste can for 15 years, you either empty it or find out if there is a use for it. And that's not a critical statement. I'm just saying that, you know, we have to move forward with these things.

Dr. Director: I think this is something that should be done administratively to keep us on our toes and keep you on your toes. With the exception of Senator Bonini, I guess the rest of us rotate off these things every 10 or 15 years.

…

Representative Kowalko: Accomplishments on Page 14. It runs through the first part of 15.

Senator Hall-Long: I will make a very quick comment as someone who, when I entered the General Assembly, had a lot of concern for dental hygiene, dental services, and access. I think, as you will see in more recent years, I know there has been a concerted effort. And I think all of us here are very pleased with the initiatives of dental hygienists and our dentists looking at creative ways to provide and expand services and give the kids a Smile Day or access programs or residency programs. So a number of us recognize your accomplishments.

So, again, as he stated at the beginning of our meeting, tonight isn't always about everything people will do incorrectly, but also what things are working well. So that's all.

Representative Kowalko: Challenges - bottom of Page 15. There is a question there in our Points for Consideration. We have talked about the feasibility of accepting regional examination standards. In case there are any questions, certainly this committee is considering, you know, what our role is in this. We have heard what you said, why you feel comfortable without having accepted those. You know, we certainly will be considering, you know, our feelings on that. It will never be to undermine, certainly undermine the efficacy of your standards, but also as it relates to the hygienists and things like that. So that will be certainly something we will be talking about as committee members. Any questions from the committee members?

Senator Bonini: On that same subject, and again to echo Senator Hall-Long, tremendous congratulations. Access to dental care is a lot better than as recently as 15 years ago. There is no question about it. ..But you clearly deserve, the dentists and the dental hygienists, especially. Clearly, there is greater access to dental care now than there was as recently as 10 or 15 years ago in Delaware. And I think you deserve a lot of congratulations on that.

I did notice, in the demographic data in the back of this lengthy report, that one in five dentists is thinking of retiring within one to five years. Did you see this point? And I didn't know where to ask this. Because we were talking about licensure, this seems like an appropriate time.

I mean are you, with the current licensure process, going to be able to absorb that? Are we going to get back to a position that we had scarcity, or I mean that's a -- When you have one to five-year work, licensed guys, people getting ready to perhaps step out, you are going to have to fill positions.

Dr. McAneny: If I could address just a few points on that. The Board of Dental Examiners does it more specifically on care and access to issues. But there are some members here from the Dental Society who have worked in that. And if you would like to have one of them come forward.

Senator Bonini: I guess the more specific question is with the -- this is not supposed to be -- but restrictive testing that we have, and I can understand the justification for that restrictive testing. Do you think that's going to be -- I mean if we end up, let's say in five years, with a shortage, is that test going to be a problem getting the fill-in -- this isn't the right terminology, the fill-ins -- fillings, hey -- for gaps in service that they have?

Dr. McAneny: Well, as I said before, our pass rate is as high as or possibly higher than the Northeast Regional exam pass rate. So the testing procedure is not not meant to be a barrier; it's meant to fulfill our mandate. Which our primary objective is to protect the public. If somebody cannot perform competently, they shouldn't be licensed. And that's all we are trying to look for there. And, as you can see from the pass rates, most do; but some don't.

Representative Bennett: Yes. I just had a question about the process. What if somebody's license expires? What's the process then? Do they have to -- I mean, is there a period of time where they pay a late fee to get their license back, or is there -- What's the period of time, once their license is expired? They have to go through the whole process?

Dr. McAneny: Up to one year they can apply to have their license renewed. They have to pay all the fees and so forth. If it's over a year, then they have to apply as a new applicant and they have to go through the process, go through the criminal background check, which will now be required, and -- excuse me -- the same procedures as a new applicant. Now, if it's only over one year, I mean if they continue to practice, we are not going to make them retake the clinical examination at that point in time.

Representative Bennett: Is the criminal background check only required for new licensures or current people that are licensed?

Dr. McAneny: New applicants.

Representative Bennett: How would you know if someone gets arrested once they are currently practicing? Like in my business -- I have a security business. You get licensed. You have a criminal background check in the beginning, and then you have your license renewed every five years. And you have to get another check done at that time just in case. You know, it's the obligation of the employer to report it if you know about it, obviously. But, for some reason if something were to happen, someone gets arrested, you just don't know about it. How would you know?

Dr. McAneny: Well, it possibly could be brought to the attention of Professional Regulations…

Mr. Collins: There are a couple of points there. And, Representative Bennett and I, I think we had this conversation before as well.

Representative Bennett: In a previous board, but it's the same thing. And I know I understand part of the concern was flooding the State Police with applicants. But with different people expiring at different times, I mean, I just think it would be a valid thing to have just to --

Mr. Collins: I agree. I agree.

Representative Bennett: Not that I am worried something is going to happen in that particular industry, but it's good to know. You know, you just never know anymore.

Mr. Collins: And it does happen. Currently, the process is self disclosure on their renewal whether or not they have had any convictions during the renewal period. What I would like to see -- and I'm aware of this model in other jurisdictions, and it's something that certainly is on our list of projects -- is to, just as we do continuing education, we do a post-renewal audit. So the way people attest during their renewal that they have completed their continuing education after their renewal, we actually send out to a -- whatever percentage the Board elects -- a post-renewal audit saying send us proof that you did your continuing education.

What I would like to do is add an electronic post-renewal check for criminal background checks. So during the renewal people would identify whether or not they have been convicted during the renewal period. And then electronically I would like to check after the renewal whether that response was accurate.

Mr. Collins: You mentioned about one of five dentists in that survey as being retired. Number one, if you will notice in the statistics in the back, the number of patients per dentist in Delaware is decreasing in spite of a great influx of people into Delaware. So it must mean a lot of dentists are coming to Delaware also compared to surrounding states. And the other thing is, with the economy, I guarantee you one in five dentists will not be retiring in the next five years.

Dr. Director: And if I could follow-up, we do have programs that are continuing to go to dental schools to attract dentists to Delaware. So, if we continue with those programs, I don't see a drop.

Senator Bonini: …Do we track how many people who are receiving the DIDER assistance come back and practice in Delaware?

Dr. McAneny: Yes, I'm sure we do. And some others on the DIDER Board are here.

Senator Bonini: You have answered now. If I could get that information --

Dr. McAneny: Okay.

Senator Bonini: -- later is fine. And I guess the second, the follow-up question is, is there a requirement that people who receive the DIDER assistance come back to practice in Delaware?

Dr. Rafetto: My name is Dr. Louis Rafetto. I'm privileged to serve as the chair of DIDER. DIDER, as you may know, is similar to the medical side of DIMER. We were reconstituted in 2001. Several things have been accomplished. First of all was the loan repayment program. We have 15 people who are actively involved in that, signed up now, serving in under-served areas and accepting designated amounts of Medicaid patients.

With respect to do we follow. You know, those people are already here. We track and monitor their activities. Probably the biggest thing has been the purchase, if you will, of seats at Temple Dental School. We originally had six seats per year. We are down to five now, just because of funding cutbacks. When we started the program in 2006, there were four -- I'm sorry -- there were six Delaware residents at Temple Dental School. There are now 23. We do follow them. We meet with them once a year at a dinner event. We talk with each and every one. The first group is just now finishing school, so; but we have a very good feel of where they are going.

Dr. Rafetto: … We also are in the process of developing a program with the University of Delaware where we get Delaware residents admission into Temple after three years rather than four. And both sides have agreed to the terms, but the ink hasn't been put to paper yet.

Senator Bonini: Okay. Is it a requirement that they come back to practice in Delaware?

Dr. Rafetto: No. It is not a requirement based on the DIMER model where it was found to not be enforceable. So that is something that we actually have brought up about twice a year.

Senator Bonini: Yeah, because it's my --preference is I think you get more bang for the buck when you reimburse for the loans on the back side. I mean, and I understand we don't have a dental school. I understand we don't have a medical school. And we want to make sure our students have access. But, to me, the bang for the buck is on the flip side. And I'm glad to hear you are doing a loan reimbursement. I think that's where we really get the people to come back in Delaware, which is what we want them to do.

Dr. Rafetto: And then they are tracked and monitored. I can tell how many there are and all that sort of thing.

Senator Bushweller: Question on Page 20, at the end. And I'm going to apologize if I don't know the history of the Board and its make up and so forth, but this is my first time looking at the makeup of the Board. And I notice that while this Board governs and regulates both dentists and dental hygienists, there is only one dental hygienist on the Board.

And there is a thing. I would like you to explain it. It says "exam committee" by her name. And I'm just wondering if that's enough representation on the Board for dental hygienists. Do they get a fair shot here? And is the person who is on the Board only there when it's something related to the exam? Or what does that mean?

Dr. Williams: The dental hygiene member, there is one. Then there is an Advisory Committee of three dental hygienists. The committee of three dental hygienists participate in the make up of the dental hygiene exam. They are equal members when it comes to examining candidates in the dental hygiene exam, in addition to the professional member who is a dental hygienist. So that makes up four dental hygienists at the time of conceptualizing the exam, changing the exam, and then administering the exam.

Senator Bushweller: I take it that's the only time the members of the Advisory Committee get to vote on Board actions?

Dr. Williams: The Advisory. Yes. That's correct.

Senator Bushweller: That's what it says in there.

Dr. Williams: That's correct.

Senator Bushweller: So, on all other matters, RDH -- Is that a registered dental hygienist? Is that what that is?

Dr. Williams: Correct.

Senator Bushweller: Does the RDH on the Board get to participate on all Board activities?

Dr. Williams: The professional member does. Yes.

Senator Bushweller: And what does the phrase "exam committee" mean after her name? I notice that -- Is that like she is the chair of the committee? What is it?

Dr. Williams: Yes. We have a dental hygienist who is part or chair of the dental, the exam committee, as well as a dentist.

Senator Bushweller: And, I mean, at first glance, given that the Board regulates both of these professions, one could argue that it's weighted heavily in favor of one of the professions and not in favor of the other one.

Dr. Williams: The exam committee is really an open committee. Anyone can attend a meeting. So that when the Board asks for the exam committee to meet, anyone from the Board, Dental Advisory Committee, professional members, may attend the exam committee meeting.

Senator Bushweller: But in regular Board business, it's only the RDH who can vote on anything?

Dr. Williams: Correct. Professional member. Yes.

Senator Bushweller: Has that proven to be a problem in the past?

Dr. Williams: I have not noticed that it's a problem.

Senator Bushweller: I might ask the same question of some hygienists if they come up. But thank you.

Senator Booth: On this, somewhat on this point with the make up of the Board. Has there ever been an instance where the hygienists and the dentists come from the same practice, or maybe two dentists that are on the Board from the same practice?

Dr. Williams: Not that I am aware of.

Senator Booth: So you never have had, even with the Advisory Committee, somebody that's on the Advisory Committee may not be out of the same practice as somebody on the Board?

Dr. Williams: I would not be able to answer that 100 percent, but not while I have been on the Board that I can remember.

Senator Booth: Well, let me just ask. There is nothing in the statute that prohibits two members from the same practice being on either the Board or the Advisory Committee. Nothing prohibits it.

Dr. Williams: That's right. Nothing.

Senator Hall-Long: We would like to be able to ascertain and particularly get into some of the issues with the hygienists prior to going to public testimony. So we are trying to move things along a little here. We certainly don't want to be disrespectful to committee members not to have all the questions answered. But we recognize many of you have practices to be open and be present first thing in the morning, so that's one of the reasons we are going to try to move quickly. And, again, if you need a quick break, feel free to do so.

Representative Kovach: I have a quick question about the vacancy appears to have been vacant since December 2008, the Dental Hygiene Advisory Committee. Is the committee still active in meeting, and has a replacement member been sought?

Dr. McAneny: A replacement member has just been brought on Board..

Ms. Puzzo: On pg. 29, the first bullet, submit proof satisfactory… And there is a difference in the passing grade. I think the regulations have one score and the statute has a different score. Did I read in your responses that you are going to propose to just have pass/fail so that would not matter?

Dr. Williams: That's correct.

Representative Kovach: We briefly touched on this before about the reporting of criminal violations. And the qualification section at the bottom of Page 27 talks about the "shall not have a criminal record or conviction." Is there some requirement that requires folks to alert the Board of a criminal conviction related -- or pending charge related to an offense, circumstances of which are substantially related to the practice of dentistry?

Mr. Reardon: I think the question is there a duty to report in the statute by some other entity should someone be convicted, perhaps the court or law enforcement or something like that. Is that what you are thinking?... There is no specific duty to report by any entity that might have a record of some kind of criminal conviction or arrest.

Representative Kovach: Representative Kovach: A duty to self report?

Ms. Reardon: There is a duty to self -- Well, not an immediate duty to self report. Self report on renewal is the only time that you would find that a person has to self report a conviction.

Representative Kovach: Or pending criminal charge too.

Ms. Reardon: Correct.

Representative Kovach: So that means just an arrest but --

Ms. Reardon: Yeah. But it's only going to come up at the time of renewal.

Representative Kovach: Just that renewal?

Ms. Reardon: Correct.

Representative Kovach: And renewal is five years?

Ms. Reardon: Two years.

Senator Katz: Thank you. My question deals with the organizational chart on Page 24. And I'm not sure who the appropriate individual is to ask this. I'm wondering why the Board of Dental Examiners or how the structure in the Department of State has been determined. It seems that they are segmented into three different sections of supervision for the different boards. And why are the different sections not organized by specialty or area of interest?

Mr. Collins: James Collins, Director of the Division of Professional Regulation. Good question, Senator Katz. And I would have liked to have organized it that way, but the reality of it is that the lion's share of our licensees are in the health care professions, and so we would have had to -- We would have had one huge team instead of three smaller teams.

Senator Katz: Are there any areas of crossover of issues that are covered in the different health entities that could be leveraged? Because, essentially, you are setting up three different areas where they have got to learn multiple different topics when you could have some specialization that may help with efficiencies.

Mr. Collins: And that was really the basis for us organizing this way. We have only been in this structure for about two years. Prior to that, it was a what I call a silo structure, so like one administrative specialist would provide administrative support for anywhere from three to five professions, depending on the size and complexity of those professions.

The problem came when that person wasn't there, no one could receive service. So we moved to a team structure. And the only way that we could equitably assign the work among the teams was to use what we called a workload rating as opposed to doing it based on like professions.

Senator Katz: Thank you.

Representative Kovach: (pg. 30) Yes. Under volunteer license, any particular reason or rationale that you know of or think might be the case of why there have been no applications for a volunteer license? Is there anything we could do or you could do to encourage volunteer licenses?

Dr. Williams: I don't know that I have an answer to that, other than advertising.

Representative Kovach: The reason I ask is because provision sunsets on July 3, 2010. And if we haven't got anybody to volunteer, it would seem that whatever we established isn't necessarily working, so -

Senator Hall-Long: If I could adhere, perhaps when we are in committee we can have a little discussion of how we got to that point.

Representative Kowalko: Okay. I will tell you what. I'm about ready, very shortly, to go to public comment. But let's see how far we go. And then we will have a dialogue and bring the people, the members of the public for their questions. Page 40, any questions on complaints?

Representative Kovach: (pg. 40) Yes. Thank you, Mr. Chair. We talked briefly about complaints earlier, and it was mentioned that the number of complaints reported was, I guess, not the number of complaints against dentists, necessarily, but the complaints reported to the Board, to the Division. I guess that leads to the question that was referenced earlier about where the complaints actually get directed to and how complaints against dentists or dental hygienists get handled.

Dr. McAneny: I think probably someone, James Collins from the Division, would probably be better to tell you the administrative structure on that better.

Mr. Collins: James Collins, Director of the Division of Professional Regulation. The statute in Title 2987 gives the Division of Professional Regulation investigative authority for all of the boards and commissions under the Division.

So, generally, the way a complaint is handled, anyone can file a complaint against, you know, any of the professions, which we regulate. We have statutory timeframes in which we need to log the complaint in. We actually provide the person that's being complained about -- which would be the respondent -- information about the complaint so that they can actually provide us the other side of the story.

We involve, in accordance with the statute, we involve a member of the Board, which we call a contact person in the investigation. And they, in many cases, provide us some technical expertise and guidance on our investigations.

Representative Kovach: And, more directly, instead of -- And I appreciate your explanation of the complaint process. I appreciate that. More to the question of, I guess, how complaints get to your office. You mentioned that the number of complaints received were only complaints received by your office. And that kind of seemed to indicate to me that maybe complaints were also going somewhere else or ending up somewhere else, at the AG's office or, you know.

Mr. Collins: Complaints have to come in writing to our office, so our complaints come in writing. There are situations where we may get a complaint and we may refer it on to another appropriate agency. For example, if it's a more of a billing issue, it's not within the jurisdiction of the Division or the Board to get into billing issues. It may be a consumer affairs issue, so we will refer that matter to the Attorney General's Office.

Representative Kovach: Let me be a little more specific.

Mr. Collins: I'm sorry if I am not answering your question.

Representative Kovach: It's quite all right. What I am trying to get to, if somebody has a complaint about a dentist, how do you make sure it gets to you, where it's supposed to go? I mean what's the funneling mechanism to make sure that someone making a complaint somewhere in our state bureaucracy ends up in your office?

Mr. Collins: I'm not sure how to answer that. How I make sure complaints get to the Division?

Representative Kovach: I mean, you know, communications to other divisions, other law enforcement agencies, the Better Business Bureau? I mean, how do you make sure that, if somebody has a complaint and isn't familiar with the statute, how do they know, you know, how can you ensure that all complaints about dentists are getting to you for review?

Mr. Collins: I'm not sure I have an answer for your question. I mean, are you thinking --

Representative Kovach: Yeah, I mean it's similar to a point raised about a related and horrific subject. People didn't necessarily know who to complain to or, if they got complaints somewhere, they just stopped instead of being funneled. So, in light of that sort of process not being there to funnel those complaints, it's, you know, it's a realization that maybe we should think about having some sort of similar mechanism for funneling complaints to the right place.

Mr. Collins: Such as a duty to report or? I'm just trying to distinguish. I mean, one of the things in our strategic plan and related to the other situation that you are referring to is just generally a public awareness. I mean the big question for us in the other situation was, you know, why didn't we get a complaint. And so we think public awareness is part of that.

But I also think there are some other elements that we can certainly talk about off line because I think generally there is a chilling effect in our complaint process, especially when it comes to peers and colleagues complaining on each other. And so I do think that there is some change necessary there, and we are working on those things already.

Representative Kovach: Great. Great. And, conceivably, we would not eliminate a chilling process of having dental hygienists complain about dentists.

Mr. Collins: You are referring to exactly what I am talking about.

Dr. McAneny: Another item on that. The Dental Society president has just mentioned that there is a form on the Delaware State Dental Society website which can be downloaded if there is a problem.

Senator Bushweller: A very quick question. The statistics about complaints on Pages 40 and 41 -- or 41 and 42. I'm sorry. There are 31 complaints referenced over three years. Of the 31, three times it says dental hygienists. Can I assume that the other 28 complaints were with regard to dentists?

Dr. McAneny: yes.

Ms. Puzzo: I just have a question, and I guess it might go to James. I think there has been some discussion about some changes being made between the Medical Society and the Board of Medical Practices. Would that then carry over to the same type of connection that's going to be made between the Dental Society and the Board of Dental Practitioners with regard to that issue that was just being discussed by Representative Kovach?

Mr. Collins: It's late. I think some of the changes that we are discussing will affect the professions, in general, under the Division of Professional Regulation. But a point that was being raised a few minutes ago probably is relevant to this review and this particular Board as far as a duty to report and, you know, similar to what the Board of Medical Practice has. Because if we have got complaints that are, by law, supposed to be vetted by the Dental Board and being vetted by other entities, then that is a potential issue. And they are not being reported to the Board.

Ms. Puzzo: So the same safeguards that you are putting in place for medical doctors, you are going to also place those safeguards, public safeguards, to the dentists?

Mr. Collins: You know, a lot of that is still in the formative stages. But from what I can see at this point, the ones that will impact multiple provisions will most likely be the public awareness, changes to the complaint process, some changes to the hearing process. Those are the ones that I think will cross most of the professions, and some aspects of treating minors or treatment of minors and the supervision during that time.

Ms. Puzzo: Would that, then, preclude any -- two years down the line or five years down the line someone saying that, "I had an incident in a dentist's office." However, it was reported not to the Board but to the Dental Society. Would the precautions that you are taking, would that help that issue or resolve that, "Oh, my gosh, there was no communication"?

Mr. Collins: I don't think so. I mean, and the reason I just want to be clear on that is because if this committee sees a need to do that and this Board, I think this committee should do what they think needs to happen in that regard. That provision already exists in the Board of Medical Practice statute, so that's nothing that we are going to change. The duty to report that requires the Medical Society, hospitals, law enforcement, that provision currently exists. It's not something that we are working on.

Representative Kowalko: Mr. Collins. Ms. Puzzo. Right now we have arrived at a critical moment that we are going to -- If we keep following this report, we are going to run into too much time. So I'm going to rule from the Chair that we will reconvene. For tonight, we will move now into the public comment section.

And I say that, Mr. Collins, so that you can compose an answer, and we will go back and revisit that. Right now we are going to move into the public comment section, and we will start with the primary speaker for the dental hygienists.

Senator Hall-Long: Excuse me. For the Board, again, you are welcome to stay for the public comment. But we need to perhaps look at our calendar. If you have to depart, we can certainly throw out options or perhaps

III. Public Comments

Ms. Bowen: Good evening. Actually, you have a hard copy. I'm going to start on Page 3, for your reference, Chairman, because we already addressed the first portion of my prepared statement in the questions that we answered with Senator Booth and some other members of the committee.

So in addressing our second point on behalf of the Delaware Dental Hygienist Association and in response to a previously stated question by Senator Bushweller, we would like to address the inconsistency which appears in the language of Title 24, Section 1105, as -- There seems to be confusion. It's the spiral-bound testimony that you have.

It appears in the language of Title 24. Title 24, Section 1105, as it relates to the Dental Hygiene Advisory Committee. Section 1105A of the Title 24 Code: Those created as State Dental Hygiene Advisory Committee which shall serve the Board on matters pertaining to the policy and practice of dental hygiene.

We understand from the section of the code that the original intent was to create the Advisory Committee's role to serve on matters pertaining to the policy and practice of dental hygiene.

If we look at the Delaware Dental Board of Examiners' current membership, as Senator Bushweller pointed out, one licensed dental hygienist serves on the Board as a professional member with full voting participation on all matters before the Board. If you refer to the Section 1105A which talks about the Dental Hygiene Advisory Committee, that was created to look at all matters pertaining to the policy and practice of dental hygiene.

However, in the Code under 1105C, it states that the Dental Hygiene Committee, a committee of three licensed dental hygienists, are restricted in their participation to the Board by only voting on dental hygiene matters specifically listed in three areas; licensure qualification, composition of clinical practical exams, and renewal of licensure. Not all matters that are related to the policy and practice of dental hygiene.

I would like to direct your attention and ask that you consider the original intent of the Code in formulating the Dental Hygiene Advisory Committee. And what is their role? And to name just a few that their role affects: It prevents, when we restrict their voting to only those three areas, it prevents their full participation of the committee and limits their role in only the three areas of policy and practice. And it does not support the Code's effort to participate as a full Advisory Committee to all matters on the policy and practice of dental hygiene. It reduces the utilization of the professional expertise already available to the Board on Dental Hygiene matters. It prevents the collaboration and partnership of each professional contributing to the main objectives of the Board -- public safety, quality standards of care for the public.

Why do we think the Advisory Committee should uphold the manner of the Code with voting capacity on all dental hygiene matters of policy and practice? Here are a few of the many reasons: As the only other licensed required professional member of the dental team, dental hygienists provide educational, clinical, research, administrative, and therapeutic care supporting the role of health of the public as part of the patient's total health.

They are consultants on all dental hygiene matters and are responsible and accountable for their practice, conduct, and decision making.

They implement and evaluate the dental hygiene component of the care plan, providing an integral part of the comprehensive dental diagnosis as prepared by the dentist.

They access and utilize current and reliable evidence-based research in clinical decision making. They take action to prevent situations where patients' safety and wellbeing could potentially be compromised.

I think it is fair to say that the profession of dental hygiene is truly a quality profession where dental hygienists are willing to assume responsibility for the quality of care they provide and especially earnest in their ethical responsibility to protect the general public from unsafe and unprofessional practices.

Therefore, we support reconciling conflicting languages in Title 24 by striking Section 1105C and creating, so that we may eliminate the inconsistencies in the interpretations of the Code and request that the Joint Sunset Committee uphold the practice act in the original intent when establishing the State Dental Hygiene Committee to vote on all policy matters.

Thirdly, the DDHA would like to offer an editorial change relating to the definition of the practice of dental hygiene. In Section 1105, Item A, where it talks about the definition of dental hygiene where it states including application of chemicals to the teeth and periodontal tissues designed for the prevention of dental carries. We would like to strike caries and insert disease.

Utilization of the updated language encompasses all the care procedures that a licensed professional dental hygienist provides for his or her patients daily in the prevention of dental disease not only affecting the teeth as dental caries or cavities, but the gingiva and the gum and the supporting tissues of the teeth in the periodontal disease.

Additionally, DDHA would like to ask that the Joint Sunset Committee consider the above-listed definition to include the delivery of local anesthesia as a care procedure that a licensed dental hygienist who is fully educated and certified be allowed to provide for the patient's comfort during care delivery. While we do not advocate a laundry list of procedures in the definition of a practice of dental hygiene, it is imperative that this definition truly reflect the current national standard of the dental hygiene care and recognize the professional education and expertise of a licensed dental hygienist.

Thank you for the time to speak with you this evening and your consideration of our points. Are there any questions?

Senator Bonini: Do you know what other states that allow a dental hygienist to administer local anesthesia?

Ms. Bowen: Yes. There are currently 43 states across the nation, and the District of Columbia, that allow dental hygienists to deliver local anesthesia. Local anesthesia has been delivered by dental hygienists as far back as 1972 in the State of Washington.

Ms. McCutcheon made the following statement:

My name is Deidre McCutcheon. I am a licensed dental hygienist with a bachelor's degree in dental hygiene, with a specialty in education, and have been licensed in Delaware for 26 years. I am a dental hygiene educator and I practice full time in a private clinical setting.

I would like to thank the Committee for the opportunity to speak about the education, licensure, and practice of dental hygiene in Delaware. I want to speak specifically to the point of consideration brought by the committee regarding the recognition of a regional examination in order to facilitate reciprocity.

Currently, Delaware is one of only four jurisdictions in the U.S. that administers its own clinical examination, and those other jurisdictions include Florida, the U.S. Virgin Islands, and California. All other boards contract that responsibility to one of five regional testing agencies.

The American Dental Association has adopted policy regarding dental licensure which states that "While the ADA recognizes and supports the State's right to regulate dental licensure, it has adopted policies on licensure issues, including the freedom of movement for dentists, increased standardization of clinical licensing examinations, specialty licensure, and the use of human subjects in clinical examinations."

It is the issue of standardization of clinical examinations that is of concern to me. We need to ask if the clinical dental hygiene examination given in Delaware is standardized. The answer is no. Standardization can be defined as a consistent set of procedures for designing, administering, and scoring an assessment. The purpose of standardization is to ensure that all individuals are assessed under the same conditions and are not influenced by different conditions.

This is accomplished by assuring for inter and intra rater reliabilities. Inter rater reliability refers to assuring that two different examiners evaluate a candidate in the same way. Intra rater reliability assures that each examiner evaluates a candidate the same way every time. This consistency can only be attained by routine clinical calibration exercises performed by the examiners. These examiners are a vital part of the education process and also in examiner prosecution of an exam.

An example of a calibration exercise would be to check that not only is each examiner using the same instrument to check a candidate's work, but also that each examiner is using that instrument the same way. Research of the Board of Dental Examiners minutes, which are a public record, reveals this lack of clinical calibration has resulted in dental hygiene test scores that are inconsistent. The construction and administration of a standardized dental hygiene licensure examination demonstrates integrity and fairness. The results of such an exam protects the health, safety, and welfare of the public by assuring that only competent and qualified individuals are allowed to practice dental hygiene. Thank you.

Representative Kovach: Is the passage rate somewhere around 90 to 95 percent?

Ms. McCutcheon: I am not the best person to provide that information. An administrative person from Del-Tech could provide that info.

Representative Kovach: You raised some good points. My question, without bias, would be “what's the harm?” If this exam is being offered and it's only to a small segment of the population, you have reciprocity if people have been practicing over three years, what's the harm in allowing Delaware to regulate its new admittees into the practice of dental hygiene?

Ms. McCutcheon: It is very restrictive. If a dental hygienist within that first three years of practice, for whatever reason, doesn't take the Delaware exam, that hygienist cannot work here. The regional examinations are set up in such a way that it allows movement.

There are men and women moving across state lines all the time, and it ends up being very restrictive. Because there is a regional exam in place, which is already offered in Delaware, most of our students take that examination, the Northeast Regional Board. That certainly fulfills the requirement necessary to then go ahead and get that licensure and be able to not only work in Delaware but work in many other states immediately.

Senator Booth: Is there a fee for the exam?

Ms. McCutcheon: The fee is $250. The Northeast Regional Board is a much more expensive exam, but when you divide it out by the number of states, it actually ends up being less expensive per state.

Ms. Trinkle made the following statement:

Hi. My name is Mary Trinkle. I'm a licensed dental hygienist in the State of Delaware here, and I work in private practice as well as in the clinical setting as a dental hygiene educator.

I too would like to offer an alternative to the State clinical exam. And one that we could utilize is the one we have just been talking about, the Northeast Regional Board. That is the closest one to us and the one surrounding us. And, as previously had been mentioned, there are five regional boards across the United States, and almost all the states use them except for what we have just heard, California, Delaware, Florida, and plus the Virgin Islands.

As we just stated too, there is 16 regional boards -- I mean 16 members of the Northeast Regional boards. The ones who are closest to us who are members of that would be Maryland, New Jersey, Pennsylvania, and District of Columbia. Now, the Northeast Regional Board examiners are required to pass multiple tests before they can grade any candidate. First, the individual examiner must pass a yearly on-line calibration test.

Second, at each testing site prior to administering the clinical exam, the team of examiners must complete a calibration or an exercise to make sure that they are synchronized.

And, lastly, all Northeast Regional Board members must participate and attend an annual four-day training session to improve their examination standards for public safety and their candidate grading.

The exam for a dental hygienist is offered in 71 testing sites throughout the regional boards, Northeast Regional boards. And they are offered three times in our surrounding area. They have a winter session, a spring session, and a summer session as availability for hygienists.

The other nice thing about the Regional Board is portability. It gives portability to his or her license. Whether you are from -- want to move to West Virginia or to Maine, you have that availability to have your license to be accepted. I, as a hygienist, feel as if it is, um, it makes sense as a hygienist and for the State of Delaware to have the Regional Boards. Thank you for your time.

Ms. Brohawn made the following statement:

Hello. Good evening, Joint Sunset Committee members, Delaware State Board of Dental Examiners, representatives, senators. And thank you very much for this opportunity to present this information.

My name is Nancy Brohawn. I'm a licensed dental hygienist with a bachelor of science degree in dental hygiene. I have worked as a clinician in the same general dental practice for over 37 years. I have also been an adjunct faculty member at Delaware Technical Community College. And I'm a native Delawarean.

I was honored to be on the first Dental Hygiene Advisory Committee to the Delaware Board of Dental Examiners, and I was reappointed for successive terms and later served two terms as a voting member on the Delaware State Board of Dental Examiners.

In 43 states and the District of Columbia, as was mentioned previously, dental hygienists are administering local anesthesia for the comfort of the patients they treat. This began with the State of Washington in 1971, followed by Oregon, Utah, Missouri, Nevada, Arkansas, Arizona, and other states.

Delaware is one of seven states remaining in which dental hygienists are not permitted to provide local anesthesia for the patients they care for each day. A dental hygienist holding a local anesthesia permit in the State of Delaware would be able to execute dental procedures in a more comfortable and timely manner as well as provide another level of pain management for the public.

This could enable the practice to operate more efficiently and effectively, or even possibly assist the dentist in administering local anesthesia to his or her patients, as hygienists in the neighboring states of Maryland, Pennsylvania, New Jersey, and Virginia are licensed to do.

Now, if a licensed dental hygienist chooses to be certified with a local anesthesia permit, possible criteria could be, but not limited to, 30 hours of education as a graduate of CODA, Council on Dental Accreditation; a dental hygiene program which includes the successful completion of a course in the local administration of general anesthesia and would provide a certificate of education completed by the State Board of Dental Examiners; or any currently licensed dental hygienist who has graduated from a CODA accredited dental hygiene program and has acquired 30 hours of education, based on the completion of a course sponsored by a dental or dental hygiene program or outside educational agency and provides a certificate of education completed by the dental or dental hygiene program -- and my last page -- or educational agency on a form again provided by the State Board of Dental Examiners.

A cost would be incurred, meaning the State would be paid for the certificate and additional cost over the licensure for this permit when the relicensure occurs. To be recertified for a local anesthesia permit, a dental hygienist under this certification process would have included at least three credits of the mandated 24 education hours relating to the administration of local anesthesia or pharmacology. This permit would allow dental hygienists in Delaware to join those in neighboring states and across the country to treat patients in a more comfortable, relaxed and efficient manner. Thank you.

Ms. Rust made the following statement:

Good evening. My name is Fay Rust. I'm a registered dental hygienist in the State of Delaware. I have been in dentistry for 33 years, starting out as a certified dental assistant, and I have been licensed as a hygienist for the past 20, closing up on 20. I served on the first appeals panel that the Sunset Committee had recommended, and I have been on the Dental Hygiene Advisory Committee. I'm in my fourth term.

To start, I would like to answer Senator Booth's question. Earlier you had asked a question about statute regarding whether or not two people of the same practice could serve on the Advisory Committee and the Board of Examiners at the same time. There is not a statute that says that. It has happened twice. The first time was prior to 1999 before I came on Board, and this happened one other time since I was on there. That was to answer your question.

The other thing that I just would like to address is being on the Appeals Panel. I think it is very important that as a professional in the practice of dental hygiene, that all of us serving on the Advisory Committee -- excuse me -- on the Advisory Committee should be able to vote on all matters pertaining to dental hygiene. We have three public members that serve with the Board. They also get to vote on everything that comes before the Board of Dental Examiners.

So I think it's very important that we should be able to put forth our recommendations regarding our profession to vote on anything. I'm not asking for dental. We are not looking for anything pertaining to dentistry. Dental hygiene. I would really like you to consider that. And I think that was the main intent that was spoken to earlier. It's just other things got added to that. Thank you for your consideration.

Dr. Rafetto made the following statement:

Good evening. Thank you. My name is Dr. Ray Rafetto. I'm a member of the Delaware State Dental Society, past president of the Delaware State Dental Society, Past Vice Chair of the Delaware Health Coalition, and currently a member of the DIDER Commission.

Just some quick points to not make the evening long, but I do want to make sure we distinguish the Board's charge of testing competence and not getting it confused with access or restriction issues. I would like to think that the focus is to protect the public and emphasize competence.

As far as dollars, looking at the landscape, I was under the impression there was ten different Board examinations. It was previously reported nine here. I'm not sure. One or the other. Some landscape on that is, unfortunately, it has been sort of a lobbying process that every different board exam has the best exam. So I want to make sure we don't get lost in the pitch of each individual board exam selling their board exam as the exam that everyone should have, and look at the product of the exam that really focuses on competence rather than a popularity contest.

And as far as fees, it's an interesting thing that Northeast Regional is $1,870, and apparently some sites charge a site fee. Southeast Regional Boards charges $1,800, and they charge a $250 site fee. That's $2,000 for an applicant. And Delaware is only $250. And the challenge there is you hate to see someone -- You only practice in one state, so you can say, "Well, you get eight states with this board or 15 with this board," or what have you. You practice in one state. It costs you 2,000 bucks to set up your shop, and that is a consideration, I think, especially when you look at restrictive issues.

And then lastly on restriction. It's, you know, important to note the beauty of having a small state is to tap into the dignity of shareholders and be able to meet at meetings like this. And good news to report is simply out of 3,141 counties in the United States, almost half are federally qualified underserved areas. Delaware had two out of 310 years ago. We now have zero. We are on the up and up. We actually have 10 new dental schools opening up. We have a nice pipeline of people coming in. We have great marketing and target to loan recruitment programs. Thank you for you guys to make this successful.

Dr. Louis Rafetto made the following statement:

Well, I want to just, since there is always a discussion, some sort of a segue between licensure and access, I just wanted to finish up what I started speaking about earlier with DIDER, and that is to look at it in terms of outcome measures. And here's the bottom line in terms of outcome measures: Last year 10 general practice residents finished the program at Christiana Care. In the past they were all able to find full-time employment. Last year was the exception. Several people had to take part-time jobs. I think that is an outcome assessment that, while bad news to the GPR residents, is good news to the people who had been affected by access issues 15 years ago when this Board previously met.

I want to comment, if I may, then, on a slightly different thing using a different hat. I'm also the director of didactic education for the section of oral maxillofacial surgery in Christiana Care. And I'm also a site visit for accredited of American Dental Association program, such as oral maxillofacial surgery programs. But also I'm aware of the standards for other programs, including dental hygiene.

We heard earlier that 43 states allow the administration of local anesthesia. But what we did not hear was under what level of supervision. Because in Delaware there is a general level of supervision. The dentist may not be there when the hygienist is administering that local anesthesia. Consider that many dental hygienists, certainly not all, but many, more than half, have two years post high school education.

Given the medical complexity of people that are currently able to now get into offices that maybe couldn't even get there before on multiple medications and the like, I leave you with the question of who do you want to manage an emergency should it occur in an office? What level of training is necessary to meet that standard that you would feel comfortable? Thank you.

Dr. Welsh made the following statement:

Good evening. I'm Dr. Sharon Welsh. I am the current president of the Delaware State Dental Society, and I wanted to thank you for some of the discussions this evening.

The purpose of the Dental Society is to represent the dentists, its members, to listen to their concerns. And I wanted to summarize briefly some of the accomplishments that have occurred. In 1995 I wasn't even here. I am actively licensed in another state. I moved here in 1996, took the Delaware boards, and set up a practice from scratch in Newark, Delaware. Why? Because I wanted to live here. I love living here. I plan on staying here until someday I retire.

I have seen some changes, though, between 1998 and 2008. And primarily the dentist population ratio, as Dr. Rafetto alluded to. We have no federal shortage areas in Delaware anymore. There used to be two out of three counties that qualified for such. So we have made great strides with that.

In 1998, only 4 percent of our dentists were Medicaid providers. We now have 68 percent of our members that are Medicaid providers. When I was at the ADA President-Elects convention last January in Chicago, we were rated Delaware had an excellent Medicaid program. So I'm very proud of our members for stepping up to the plate.

We also have one of the highest CE credits in the United States. In Maryland, as I said, I have an active license. I'm required to take 24 credit hours every two years. Here it's 50.

The Delaware dentists have also provided support to the School SEEN(?) Program. Since 1998, the sizable residency program at Christiana has increased. There has been loan repayment programs. We just finished speaking to dental students through the ADA block credit programs where we go into the dental schools and talk to the dental students. We just went to the University of Maryland at Baltimore. The five seniors that I spoke to that were from Delaware all plan on coming back here to practice. So we are targeting Temple and University of Pennsylvania Dental School next.

There is presently a program that was instituted with the help of our past president, Dr. Jeff Cole. We have the Delaware Amalgam Program where we have voluntarily stepped up to the plate to look at amalgam waste control. 35 percent of our dentists volunteer at half a day and night at Christiana Care, not to mention thousand of hours given to the special olympics, cleft palate clinics, et cetera.

And, last but not least, we have had, as many of you know, Give Kids a Smile event, and I want to thank all of you, particularly (inaudible) Senator Bonini. We have donated over $328,000 of dental care collectively as a group, and 1,155 children have been seen since Give Kids a Smile started in 2004.

So I'm proud to practice here and, you know, I just wanted to point out some of the things that the Dental Society has accomplished since the last sunset review. Thank you..

Senator Bonini said the Give Kids a Smile event was amazing. The Senator asked if dentists are taking loss on Medicaid reimbursement.

Dr. Welsh replied, “Yes, technically speaking, especially our younger dentists. I was a Medicaid provider in the State of Maryland before I moved here to Delaware. The requirements became so restrictive. For example, they paid us $10 to remove a tooth. Okay. You couldn't even get the anesthesia and pay for the materials for that cost. Here in Delaware, what Senator Bonini is talking about is that our Medicaid providers basically take a 20 percent adjustment, a courtesy adjustment on the bill for a Medicaid patient.”

“A younger dentist who is just starting out, if their overhead is typically 90 to 95 percent and they are working at 80 percent of their fee, it becomes a problem. So, yes, we are happy to help, but it does make it really tough, especially for our younger dentists.”

Senator Hall-Long stated that for the record, we are talking Medicaid children.

Dr. Connaty made the following statement:

Chairman Kowalko, Co-Chair Hall-Long, Honorable Members of the General Assembly, and fellow Delawareans, my name is Dr. Tom Connaty. I'm on the Delaware State Dental Society Legislative Committee. I have practiced in Delaware now for 42 years.

How the times have changed. When I took that Board exam 44 years ago, it seemed to be a test of what you didn't know. Today, it's simply a test of minimal competence. Also, in those days we dentists were not expected to deal with access to care. That was left to State health care agencies. How the times have changed.

While the Board's primary function is to protect the people of Delaware, it was suggested -- no, I want to say directed by Senator Patty Blevins a decade ago, that more should be done to solve the access problem at the Sunset hearing. Therefore, I think it's appropriate, when I talk about what the Delaware dentists have done and how they all have been vanguard of trying to solve this slightly important health care problem of access to care.

In 1998, the State and the federal government partnered and they created a children's Medicaid program. There were two negatives about this program. It was a reduced fee program. 20 percent of our -- we didn't get 20 percent of our fee. And, secondly, Medicaid patients historically have a high failure rate. In spite of these problems, Delaware dentists have stepped up to the plate, and the State has one of the highest participation ratios in the United States of America.

The American Dental Association Survey Center says the average participation in states throughout the United States is 26 percent. In Maryland, it's 16 percent. In Pennsylvania, it's 12 percent. In New Jersey, it's 6 percent. Six. In Delaware, as you heard from Dr. Welsh, it is 68 percent of our Delaware State Dental Society members that participate.

These children deserve and receive the best care available in the most efficient setting for delivering dental care to private offices of dentists. Speaking of children, as Chairman Kowalko talked about, he has been six of our seven Give Kids a Smile -- and Bethany has been to quite a few, and Senator Bonini has been to some. Weren't you, Senator Booth, the one -- you have been invited, I know that. Everybody is invited.

The dentistry, for the seventh year in a row, has sponsored and organized Give Kids a Smile program. It's a program where we keep children who sort of fall between the cracks, children who aren't eligible for Medicaid or into the wear of Medicaid. Many of the children that come in there don't even know they have Medicaid. Since the start of our program, as you just heard, since 2004, 1,155 children have been treated, and over $400,000 have been donated in services and in treatment.

I'm going briefly mention some of the other examples of Delaware dentists helping to solve the access problem. DIDER, with the help of former Lieutenant Governor John Carney, and our chairman, Lou Rafetto, Dr. Lou Rafetto, DIDER increased the positions at Temple University of Dental School for Delaware residents from six to 23. I can't get through it in one minute. I'm so a talker.

DIDER also initiated legislation for loan repayment program for recent dental graduates so that we commit to practice in underserved areas of the state.

The Hope Charity Clinic, it is located in Dover and it serves the people, the poor of Dover. Dr. Tom Mercer, a former board member, he started this program in August of 2007. They have donated $200,000 in care to the people of Dover needing dentistry.

The Ministry of Caring. Delaware State Dental Society dentists have a long history of volunteering at the Ministry of Care Dental Clinic in Wilmington. This treats the poor people, adults in Wilmington.

The residency. The residency program is staffed by professional dental educators and over 100 unpaid dental volunteers. The primary mission of the general practice residency is to train neophyte dentists, but this year it also provided dental care to 10,774 indigent patients at five separate locations in our state. And also, even though 50 percent of the residents are from out of state, fully 90 percent of them stay in Delaware.

To sum up the contributions made by Delaware's dentists: The access to care; the Give Kids a Smile program; increasing the number of dentists at Temple Dental School; loan repayment plans that attract dentists to underserved areas; the Hope Dental Clinic in Delaware; the volunteer dentists of the Ministry of Caring Clinic in Wilmington; the residency program that not only trains dentists but delivers care of the indigent; and, of course, the Children's Medicaid Program.

Now, the question is what's the next step in access to care in Delaware? I know we are going through tough economic times. However, there is no care available from our State for disadvantaged adults. Delaware is one of seven states that does not fund dental care for this group.

Delawareans have great pride in our state. It's small enough for people to know and understand one another and large enough to blend successful agricultural and sophisticated business interests. Yet, we do not provide for citizens who cannot afford dental care. The best solution to access for the dental means of these citizens is for the Federal and State governments to adequately fund Medicaid. The prototype plan to treat these patients has existed for over 10 years in Delaware. It's our children's Medicaid program.

All right, Mr. Chairman. This is finishing it up. Delaware leads the nation in dentist participation. It is certainly logical to conclude that Delaware's dentists also would volunteer to help adults.

When this program is initiated, Delaware's access program for disadvantaged adults will take a giant step forward. I will entertain any questions.

Dr. Thomas Mercer made the following statement:

Good evening. Representative Kowalko , Chair, and other senators and representatives, thank you for this evening. Thank you for allowing me to address. I am Dr. Thomas Mercer. I come before you tonight in five different capacities, and I would like a little bit of additional time because I want to answer some questions I think that you asked earlier that I can shed some light on.

First of all, I come to you as a lifelong resident of the State of Delaware. Second, I come to you as a dentist who has enjoyed 39 years of private practice in the City of Dover and blessed still to be going strong. Third, I come to you as a former member of the State Board of Dental Examiners for six years and who served two terms as its president. Fourth, I come before you as a former member of DIDER. And, fifth, I am especially proud of being vice president of the board of directors of Hope Medical Dental Clinic Incorporated and director of its dental services for the past three years.

I have seen firsthand as a dental examiner roughly 140 dental and 180 hygiene applicants for licensure go through the process of our state's clinical examination. Over a period of six years, as gubernatorial appointees, four other dental examiners and I became the front line of defense for protecting the citizens of Delaware from clinicians who lack the minimum skills of performing even the most basic dental procedures.

And I shall talk a little bit more about those in a minute or two. Dr. Brian McAllister of Middletown, Dr. Stephen Allaban of Milford, Dr. Dawn Grant of Dover, and I see adult patients between the ages of 26 and 65 who financially qualify for pro bono dental care.

With only private and corporate donations and funding, the Hope Medical Dental Clinic provides a much-needed service to Delaware residents. In spite of the fact that all of its volunteer health care providers give of their time, skills, and expertise without compensation, this charitable clinic requires a great deal of money to operate. This compelling fact alone gives credence to the theory that licensing more dentists in Delaware will not solve the affordability of dentistry dilemma for indigent adults.

Let us not confuse need with want. There is no doubt that there are many Delaware residents, both indigent and non-indigent, who need varying degrees of dental care. Because many of these Delawareans do not place any value on dental care but, instead, want other seemingly more important, yet optional things of everyday life, they do not want dental care until they end up as a dental emergency. Neglect leads to more serious problems, sometimes even death.

For those of us involved with charitable clinics, we see this all the time. We experience patients who, once they are free of pain, do not return for future free dental treatments. It never fails, when I was on the Board of Examiners, and we would end up two days of examining dental clinicians who wanted to be licensed in the State of Delaware, that we would -- examiners would comment to each other that we were glad we were there to be the front-line defense for the residents of the State of Delaware. Because, being in the trenches and up front where we were, we saw mostly good, thank goodness, but we saw a lot of bad.

There was never any applicant that failed the exam by a near miss. I mean, the failures were decisive in nature. If the argument is that prospective dentists for license do not apply in Delaware because of its clinical exam, then why do 400 and some odd dentists and I who presently practice in Delaware do so? What about all the dentists that preceded us who are now retired or deceased?

There is an argument that by having reciprocity, this, in turn, will encourage more dentists to practice in Delaware; that, by having more dentists, fees will be more competitive. That's the argument. Are dentists who are graduating dental school as much as 175,000 to a quarter of a million dollars in debt going to give away their services? I don't think so. Should we accept the results of non-Delaware clinical examinations? I strongly oppose the idea.

A copy of our Delaware clinical examination was shown to a Dr. Robert Pavloki of Casper, Wyoming, a professional examination validator. He was very impressed with our examination and thought it to be very comprehensive and fair while allowing for remediation. Dr. Merriam and I traveled to Chicago for the aforementioned trip when we met with all these regional exams and looked into it and investigated it, and we found nothing but confusion and struggle for territorial rights as to who was going to examine who, and they were all quibbling over about $7 million in examination fees.

We used to use the NRB DAR exam. That's the diagnosis of oral medicine and radiology exam, and we bought that from them.

I just want to say very quickly, before Dr. Cole comes up, I'm familiar with the Hope Clinic, and it does wonderful work both in dental services as well as medical services. And I commend you for that as well as all the other people who are involved in it.

Dr. Cole made the following statement:

I'm Dr. Jeffrey Cole. I'm the immediate past president of the Delaware State Dental Society, and I also serve as the delegate from Delaware to the American Dental Association. I also sit on the Curriculum Advisory Committee of the Delaware Technical and Community College hygiene program.

The one thing that I wanted to touch on, which I think Dr. Mercer did a bit, was on Page 5, that Item 12 where I saw that the Board was not in compliance. That struck me as strange. Because I had been on the executive committee of the Delaware State Dental Society for eight years, and I remember when we had members of the Northeast Regional Board, particularly Dr. Guy Champane from Maryland, come and do a presentation to the Dental Society on behalf or at the request of Dr. Merrier and Dr. Mercer. And so I know that they were in conversation with him.

One of the things that's happened at the American Dental Association and the conference to which Dr. Mercer referred was that there was a movement within the American Dental Association to try to get some of these various testing agencies together, and that's what that conference was for. And what I will tell you is it was more of a mud slinging than it was anything else. And what we found out was all the problems that were with these other exams.

But I did want to tell you that I even have documentations, letters, coming to me as an ADA delegate from the American Dental association saying this group met and that Delaware was there. And so, you know, if there is any question whether or not the Board lived up to that, I would say that they did.

The one thing I would say, I am not in favor of us moving to the NRB. And just last night at the Curriculum Advisory Committee for the hygiene school, I heard that the dental hygienist students have to borrow money to pay the $1,200 to take the Northeast Regional Board. And that's a lot more than the $100 that Delaware charges.

And so when you look at their failure rate and you look at what you have to pay after you fail the $1,200, it's significant. I want to say it was $675. I do not have those. I wasn't prepared to speak on that. But I just want to say that, in addition to that, while you pass an exam that's accepted in those states, if you want to -- if you want to go to three or four or more states, you have to pay other licensing fees in order to get your license. And so before we strap some of the Delaware residents who only want to pay $100 and practice in Delaware, don't force them to take a $1,200 exam. Thank you.

Dr. McAllister made the following statement:

Good evening. I'm Dr. Brian McAllister. I practice in Middletown, Delaware, Past President of Delaware State Dental Society, and I'm currently legislative chair for Delaware State Dental Society.

I find it pretty hard to go last, mainly because everyone is asleep and because everyone has said everything that I want to say. But, with that said, I would like to take a few minutes to clean up a few points.

One, I would like to reiterate that the dental community heard JSC in 1995 loud and clear. We heard that there was an access problem, and we rolled up our sleeves and we addressed it. And you have heard all the ways we addressed it over the last 15 years, and we are continuing to address it.

And, to once again go back to Senator Bonini's comment that we are looking at dentists retiring, some of the programs we have put into effect are attracting young dentists. The Student Loan Repayment Program, having spots at Temple, going to dental schools and recruiting young dentists to practice here. So I think we will be able to meet that challenge, by the way. And, if not, challenge us again, and we will come up with some more creative solutions.

One of the last things I want to address is in reading through the draft, there was some comments that we picked up on. I think it's on Page 47 in regards to supervision. And I think they were rightly brought up. There is really no stipulation in the current code for supervision of assistants. And we feel that that probably is an oversight, and we would -- and I'm going to speak on behalf of the legislative chair of Delaware State Dental Society -- recommend that we incorporate some language in the Code to have direct supervision of dental assistants.

With that said, we also believe there is a problematic area in supervision of dental hygienists. For years, we have allowed dental hygienists to operate under general supervision, and that can be a little bit of a loose category.

Myself, as a dentist, I'm responsible for everything that's done in my office. And I'm not comfortable with this category. We have discussed this, and we feel as though we should reconsider the category of general supervision to direct or, at minimal, indirect supervision of dental hygienists.

So I will close there. And, hopefully, if you would like any points or discussion on that, we can exchange e-mails.

Representative Kowalko: I just want to sum up some things here before I entertain any summation from any committee members.

I just want to remark that, you know, and it's certainly not conclusions I am drawing or predispositions of my own point of view. It's food for thought for the committee members and for the attendees at this meeting. And that is that there seems to be points of contention certainly about reciprocity as far as dentists and the NRB and reciprocity as far as hygienists and the NRB.

And I think it's fair to say that the hygienists consider one thing. And, that is, if their membership does not have an unwillingness to pay a $1,600 or $1,700, whatever that test, NRB test costs, I don't know how I would distinguish between the rights of the hygienists to determine, since they are a supervised group in the dental office, whether they should be or not be. And I'm not predisposing. Just I want to make this a public discussion.

I don't know that it would be beyond the stretch or beyond the pale to allow a separate reciprocity. That's certainly not engaging it to a reciprocity agreement for dentists. And the committee should consider that, what we have heard today. And I say that so that everyone in this room has an opportunity to comment that, if they so choose, to this committee. And there are pros and cons of their thoughts on that. And, with that being said, we will arrive at a date for another meeting.

Senator Hall-Long: I know we have some new members of the legislature who perhaps do not know our State Director of Dentistry who is hiding in the back, in the back. Dr. McClure, perhaps you will waive. He has done a phenomenal job. Many of us walk out of Legislative Hall, and we see the van parked outside this past winter with oral access and the federal grant that we have working with dentists. So, for some of the members who perhaps haven't put a face with your name, we wanted to acknowledge your presence. Thank you for being here.

Senator Bonini: Real quickly to both of you, the dentists and the dental hygienists. And Tom said it better than I could. Fifteen years ago the issue was -- I know what some of the issues are, and we are going to revisit those, trust me, but the issue was clearly access.

And I think there is really a lot of congratulations in both professions and the whole community. There is no question that you guys have made an absolute good-faith effort, and the results have been there.

And I have got to tell you, when I went to the event last week and when I started reading through the Draft Report, I was really pleased to see the extraordinary difference in the numbers in terms of access to dental care that Delawareans have. And I just wanted to say thank you on behalf of, I think, all of the constituents who needed that access 10 or 15 years ago and now have it. So, well done, very well done on that.

The Committee returned back to its review of the Draft Report.

Sen. Katz: Previous testimony was mentioned about the 3 levels of supervision direct and indirect in general. I'm not sure if it is in this report, I haven't seen it, but could you provide definitions of each one of those levels for our review, not necessarily here, but in writing.

Dr. McAneny: Yes, we'd be glad to do that in writing for you.

Ms. Puzzo: Could you also bring a definition of dental technician and dental auxiliary personnel?

Response: Yes, I believe Patricia Murphy did respond to that. Maybe you didn't get that response, but we will definitely provide you an answer to both of those.

Rep. Kovach: Just a note that the previous recommendation about the effectuating a Code change to refer to the specific parts of the statute – its' the first recommendation of the Rules and Regulations of the Board – rewriting the rules and regulations to refer to specific Code sections for ease of implementation.

Ms. Puzzo: I also think that during the writing of the report or drafting of it, there was an issue about whether, in 1995 it said that the board did not have the statutory authority to create the positions, and I think maybe there was some – that probably needs more discussion at a later time.

Dr. McAneny: We will address that as well.

Rep. Kowalko: Seeing no further questions, this will conclude the committee gathering, the public gathering of evidence, so to speak. We are done with this part of the review and we will be moving on to Committee meetings.

IV. Concluding remarks

Rep. Kowalko: I want to explain to my committee members that on the 10th at 3:30, we will be reconvening the public hearing for DHIN that we aborted so that we didn't have to keep going late into the evening. It will be a continuation of the on-going information gathering, question asking session.

There was discussion among the JSC members regarding public testimony at the up coming DHIN JSC meeting. Rep. Kowalko stated that he would allow the public to testify at the DHIN meeting.

V. Adjournment

The meeting was adjourned at approximately 9:45

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