Exhibit A

Exhibit A

Proposed Changes as requested by DPP#100 project sponsor the Northwest Portland Area Indian Health Board.

The NPAIHB must adhere to the OHA approved extraction criteria. For reference, the extraction

criteria outlined in the agreement are as follows in italics:

a. Only allow a DHAT trainee to perform extractions under the following conditions:

1. All extractions must may be performed under the direct, indirect or general supervision

of the trainee’s dentist. Indirect supervision is defined under ORS 679.010 as supervision

requiring that a dentist authorize the procedures and that a dentist be on the premises while the

procedures are performed. General supervision is defined under ORS.679.010 as supervision

requiring that a dentist authorize the procedures by standing orders, practice agreements or

collaboration agreements, but not requiring that a dentist be present when the authorized

procedures are performed. The authorized procedures may also be performed at a place other

than the usual place of practice of the dentist.

2. For primary and permanent tooth extractions, the DHAT trainee will first receive and

document authorization from the supervising dentist.

OHA Documentation requirements: In reference to approved extraction criteria #1 and #2,

documentation must be in the chart that with the level of supervision under which the procedure

has been performed under indirect or direct supervision as defined ORS 679.010. Documentation

of the order must be entered into the chart record by the ordering supervising dentist, signed and

dated. The order must contain the diagnosis and indication for extraction in addition to the

specific tooth number to be extracted. The supervising dentist that authorizes the extraction must

also be the dentist who supervises the trainee via general, indirect or direct supervision.

3. For primary teeth, the trainee may perform non-surgical extractions on all primary teeth

in accordance with CDT codes D7111 and D7140. teeth that exhibit some degree of mobility.

The trainee will not extract a tooth if it is unerupted, impacted, fractured or decayed to the

gumline, or needs to be sectioned for removal.

4. For permanent teeth, the trainee may perform non-surgical extractions of periodontally

diseased teeth with evidence of bone loss and +2 degree of mobility. The trainee will not extract

a tooth if it is unerupted, impacted, fractured or decayed to the gumline, or needs to be sectioned

for removal.

OHA Documentation requirements: In reference to approved extraction criteria #3 and #4,

documentation must be in the chart that the tooth authorized for extraction meets the criteria

outlined above.

For primary teeth, chart notes and documentation must indicate the diagnosis and degree of

mobility in addition to other supporting diagnostic information relevant to the patient and

procedure. including presence of purulence (suppuration) in addition to other supporting

diagnostic criteria including degree of odontaglia. All diagnostic radiographic and photographic

Exhibit B

documentation must be documented in the chart record. The DHAT trainee will not extract teeth

that are ankylosed. Chart notes, including radiographic images and intra-oral images, must

illustrate that the tooth is erupted, not impacted, not fractured below the gumline, not decayed to

the gumline and does not require sectioning for removal. In addition, chart notes must illustrate

the absence of associated sepsis, facial swelling, trismus or dysphagia. Chart notes must indicate

the absence of dilacerations of the root(s), no proximity to vital structures including maxillary

sinus and inferior alveolar nerve, adequate clinical crown, no tori or other need for alveoplasty.

Documentation must include any hemostasis required or other interventions if applicable.

Documentation of post-operative instructions provided both verbally and in writing. Approved

dental pilot projects are required to be in compliance with Oregon Administrative Rules 333-

010-0400 through 333-010-0470.

For permanent teeth, chart notes must indicate percentage of bone loss, degree of mobility in

addition to other supporting diagnostic information including probing depths, bleeding on

probing, clinical attachment levels, presence and severity of gingival recession, presence of

purulence (suppuration) in addition to other supporting diagnostic criteria including degree of

odontalgia. Chart notes, including radiographic images and intra-oral images, must illustrate that

the tooth is erupted, not impacted, not fractured below the gumline, not decayed to the gumline

and does not require sectioning for removal. In addition, chart notes must illustrate the absence

of associated sepsis, facial swelling, trismus or dysphagia. Chart notes must indicate the absence

of dilacerations of the root(s), no proximity to vital structures including maxillary sinus and

inferior alveolar nerve, adequate clinical crown, no tori or other need for alveoplasty.

Documentation must include any hemostasis required or other interventions. Documentation of

post-operative instructions provided both verbally and

in writing. Approved dental pilot projects are required to be in compliance with Oregon

Administrative Rules 333-010-0400 through 333-010-0470.

Standard of care for non-surgical uncomplicated dental extractions must be followed by both the

supervising dentist and the DHAT trainee. The DHAT trainee does not have the scope of practice

to cut soft tissue or resolve extractions that become surgical in nature. While the DHAT trainee

is required to complete non-surgical uncomplicated extractions under general, indirect or direct

supervision, the extraction procedure authorized by the dentist must fall within the scope of

approved practice for a DHAT trainee. To this end, DHAT trainees are expected to perform

procedures independently from initiation of the treatment to completion both during

preceptorship and upon receipt of standing orders. Intervention by the supervising dentist should

be a rare occurrence.1 A root cause analysis should always be performed when the supervising

dentist is required to intervene in all treatment cases that have been initiated by the DHAT

trainee. Documentation of analysis results should be included in chart notes.

For purposes of data collection and project evaluation, the DHAT is authorized to perform

procedures D7140 and D7111. While the CDT code description of D7140 contains provisions for

minor smoothing of bone, this is considered a surgical procedure and falls outside the scope of

approved practice for a DHAT trainee in the approved dental pilot project.

Commented [A1]: DHAT trainees are taught to perform

all aspects of D7140 and D7111, including minor smoothing

of bone. Minor smoothing of sharp/rough areas (i.e. with a

curette) is considered to be best practice and encourages

healing of the extraction site. Failure to smooth a sharp

spicule can result in delayed healing. We consider “minor

smoothing” to be distinct from “cutting.”

Exhibit B

NPAIHB must adhere to the project evaluation requirements outlined in Appendix C which

include a recent radiograph of the tooth to be extracted, a pre-operative intra-oral image of the

tooth to be extracted and a post-operative image of the extracted tooth. As stated in Appendix C,

imaging requirements apply at all points during the provision of care during the pilot project

whether under direct, indirect or general supervision.

5. Document all information related to extractions as specified above along with the criteria

required for the project evaluation which include a recent radiograph of the tooth to be

extracted, a pre-operative intra-oral image of the tooth to be extracted and a post- operative

image of the extracted tooth.

Exhibit B

Extracted language from authorizing statute by state(s) with enacted Dental Therapy legislation or under Federal authority under the Federal Community Health Aide Program.

Primary Extractions

Allowed

Permanent Extractions

Allowed Alaskai Community Health Aide Program Certification Board – Standards and Proceduresii “(C) performance of uncomplicated

extractions of primary and permanent teeth;

Arizonaiii 13. perform simple extraction of erupted primary teeth.14. perform nonsurgical extractions of periodontally diseased permanent teeth that exhibit plus three or grade threemobility and that are not impacted, fractured, unerupted or in need of sectioning for removal.

Connecticutiv (M) simple extraction of erupted primary teeth; (N) nonsurgical extraction of periodontally diseased permanentteeth with tooth mobility of three or greater, except a tooth that is unerupted, impacted, fractured or needs tobe sectioned for removal;

Idahov 54-902a.definition--practice of dental therapy. The practice of dental therapy… other dental services as specified by thesupervising dentist and for which the dental therapist is trained unless prohibited by the board in its adopted rules.[Statute did not state specifically the entire scope of practice, Idaho Board of Dentistry defined scope of practice andsupervision requirements, etc.Idaho: Rulemakingvi

Final proposed text. Rules filed with the Idaho Secretary of State December 2019.i. Non-surgical extractions.b. i. Removal of periodontally diseased teeth with class III mobility.ii. Removal of coronal remnants of deciduous teeth.

Mainevii extract primary teeth and perform nonsurgical extractions of periodontally diseased permanent teeth if authorized in advance by the supervising dentist;

Michiganviii Simple extraction of erupted primary teeth.

Nonsurgical extractions of periodontally diseased permanent teeth with tooth mobility +3. However, a dental therapist may not extract a tooth if the tooth is unerupted, impacted, or fractured or needs to be sectioned for removal.

Exhibit C

Minnesotaix (a) A licensed dental therapist may perform… (10) extractions of primary teeth;

(b) An advanced dental therapistx may perform nonsurgical extractions of periodontally diseased permanent teeth withtooth mobility of +3 to +4 under general supervision if authorized in advance by the collaborating dentist. The advanceddental therapist shall not extract a tooth for any patient if the tooth is unerupted, impacted, fractured, or needs to besectioned for removal.

Montanaxi Section 2. Community health aide programxii (a)… dental health aide therapist to assist with dental education and primary or preventive dental care as appropriate to the individual's certification, and provided that performing dental extractions or invasive procedures to teeth and gums is prohibited;

Nevadaxiii 8. Simple extraction of erupted primary teeth.17. Nonsurgical extractions of periodontally diseased permanent teeth with tooth mobility. However, a dental therapistshall not extract a tooth for any patient if the tooth is unerupted, impacted, or fractured or needs to be sectioned forremoval.

New Mexicoxiv

“(h) extraction of primary teeth without radiological evidence of roots;”

Vermontxv “(28) Extractions of primary teeth. (29) Nonsurgical extractions of periodontally diseased permanent teeth with tooth mobility of +3. A dental therapist shall not extract a tooth if it is unerupted, impacted, fractured, or needs to be sectioned for removal.”

Washingtonxvi Scope of practice in Washington is determined under Community health aide program.xvii Community Health Aide Program Certification Board – Standards and Proceduresxviii “(C) performance of uncomplicated extractions of primary and permanent teeth;

Exhibit C

i Alaska, Dental Health Aide Therapists authorized under the Indian Healthcare Improvement Act, 25 U.S. Code § 1616l. Indian Healthcare Improvement Act, Community health aide program, Dental Health Aide Therapist https://www.ihs.gov/sites/ihcia/themes/responsive2017/display_objects/documents/home/USCode_Title25_Chapter%2018.pdf Community health aide program details begin on page 454. Community Health Aide Certification Board, Alaska. http://www.akchap.org/html/chapcb.html ii Community Health Aide Program Certification Board Standards and Procedures http://www.akchap.org/resources/chap_library/CHAPCB_Documents/CHAPCB_Standards_Procedures_Amended_2019-09-12.pdf iii Arizona House Bill, Enacted 2018, https://www.azleg.gov/legtext/53leg/2R/bills/HB2235S.pdf iv Connecticut, Enacted 2019, https://cga.ct.gov/2019/ACT/pa/pdf/2019PA-00056-R00SB-00807-PA.pdf v Idaho, Enacted 2019, https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2019/legislation/S1129E1.pdf vi Idaho State Board of Dentistry, Administrative Rulemaking, Dental Therapy https://isbd.idaho.gov/IBODPortal/BoardAdditional.aspx?Board=IBOD&BoardLinkID=126 vii Maine, Enacted 2015, http://legislature.maine.gov/statutes/32/title32sec18377.html viii Michigan, Enacted 2018, http://www.legislature.mi.gov/documents/2017-2018/billanalysis/House/htm/2017-HLA-0541-37427FCC.htm ix Minnesota, Enacted 2009, https://www.revisor.mn.gov/statutes/cite/150A.105 (Dental Therapist) https://www.revisor.mn.gov/statutes/cite/150A.106 (Advanced Dental Therapy) There are two dental therapy models authorized in statute in the State of Minnesota. x Minnesota Department of Health, https://www.health.state.mn.us/facilities/ruralhealth/emerging/dt/index.html Minnesota Dental Therapist and the Advanced Dental Therapist Models in the State of Minnesota, Definitions and Models Compared. xi Montana House Bill 599, Enacted 2019, https://leg.mt.gov/bills/2019/billhtml/HB0599.htm xii 25 U.S. Code § 1616l. Indian Healthcare Improvement Act, Community health aide program, Dental Health Aide Therapist https://www.ihs.gov/sites/ihcia/themes/responsive2017/display_objects/documents/home/USCode_Title25_Chapter%2018.pdf Community health aide program details begin on page 454. States that enact legislation may provide services outlined in the statute and authorized under state law. “(A) In general Subparagraph (B) of paragraph (2) shall not apply in the case of an election made by an Indian tribe or tribal organization located in a State (other than Alaska) in which the use of dental health aide therapist services or midlevel dental health provider services is authorized under State law to supply such services in accordance with State law.” Page 455. xiii Nevada, Enacted 2019. https://www.leg.state.nv.us/App/NELIS/REL/80th2019/Bill/6665/Text xiv New Mexico, Enacted 2019. https://www.nmlegis.gov/Sessions/19%20Regular/final/HB0308.pdf xv Vermont, Enacted 2016. https://legislature.vermont.gov/statutes/fullchapter/26/012 xvi Washington, Enacted 2017. http://lawfilesext.leg.wa.gov/biennium/2017-18/Pdf/Bills/Senate%20Passed%20Legislature/5079-S.PL.pdf xvii Dental Health Aide Therapists authorized under the Indian Healthcare Improvement Act, 25 U.S. Code § 1616l. Indian Healthcare Improvement Act, Community health aide program, Dental Health Aide Therapist https://www.ihs.gov/sites/ihcia/themes/responsive2017/display_objects/documents/home/USCode_Title25_Chapter%2018.pdf Community health aide program details begin on page 454. Community Health Aide Program Expansion. https://www.ihs.gov/chap/ xviii Community Health Aide Program Certification Board Standards and Procedures http://www.akchap.org/resources/chap_library/CHAPCB_Documents/CHAPCB_Standards_Procedures_Amended_2019-09-12.pdf

Exhibit C

Dental Pilot Project #100: "Oregon Tribes Dental Health Aide Therapist Pilot Project"

Training/Education/Didatic Phase Employment/Utilization Phase

Education Employment

Dental Health Therapist (DHAT) Educational Program:

DHAT student trainee’s attend the Alaska Native Health Tribal Consortium (ANTHC) Dental Therapy Training Program at Illasgvik College in Alaska to become Dental Health Aide Therapist’s (DHAT).

• 2 full years in length, year-round including summers

• Curriculum accredited by Northwest Commission on Collegesand Universities (NWCCU)

• ANTHC/Illasgvik College has applied for accreditation fromthe Commission on Dental Accreditation (CODA)

Employment: DHAT trainees are employed at the employment/ utilization sites.

DHAT trainees may work under direct, indirect, and general supervision of their supervising dentist, depending upon the procedure and standing orders.

OHA Site

Visit OHA Site

Visit

OHA Site

Visit

OHA Site

Visit OHA Site

Visit

OHA Site

Visit

OHA Site

Visit

Preceptorship:

DHAT trainees

complete a 400 hour

preceptorship under

the direct

supervision of their

supervising dentist

at the employment/

utilization site. Upon

completion,

standing orders are

signed by the

supervising dentist.

Graduate: Student

DHAT trainees

graduate and are

now DHAT

trainees under

DPP#100

Standing

Orders

Exhibit D

1

Memo

DATE: April 9, 2020

TO: Dental Pilot Project #100 – Advisory Committee Members

FROM: Sarah Kowalski, RDH, MS Dental Pilot Project Coordinator Oregon Health Authority

RE: Synopsis of Recommendations & Feedback Received for Primary Extraction Modification Request

On December 12, 2019, the Oregon Health Authority’s (OHA) Dental Pilot Project Program received a modification request from the Northwest Portland Area Indian Health Board (NPAIHB) regarding primary extractions under Dental Pilot Project (DPP) #100. Based on Oregon Administrative Rules (OAR) 333-010-0800, approved dental pilot projects may submit a request to modify their project as part of an approved dental pilot project. All modifications require OHA approval.

OHA sought feedback and recommendations from DPP #100 Advisory Committee members on the proposed modification request. Since the next Advisory Committee meeting is not until June 8, 2020, all communication regarding the request was conducted over email. Advisory Committee members chose not to hold a conference call. The modification request was not open for public comment.

Advisory Committee members were requested to review the modification request and associated materials and complete a feedback form (Exhibit

Advisory Committee

OHA received feedback and recommendations from eleven members of the Advisory Committee for DPP #100.

Utilizing a feedback form, committee members were asked to review each of the question and

make a determination if they agreed or disagreed with proposed modification statement. In the event an individual disagreed with the proposed modification statement they were asked to provide their rationale.

CENTER FOR PREVENTION AND HEALTH PROMOTION Oral Health Program

Kate Brown, Governor

800 NE Oregon St, Ste 825 Portland, Oregon 97232-2186

Office: 971-673-1563 Cell: 509-413-9318 Fax: 971-673-0231

www.healthoregon.org/dpp

Exhibit E

2

Agree = Advisory Committee member indicated agreement with the statement.

Disagree = Advisory Committee member indicated disagreement with the statement.

1. Proposed modification: The DHAT trainee willcontinue to first receive and documentauthorization from the supervising dentist to extractthe primary tooth.

Primary extractions will not require direct or indirect supervision, they may be completed under direct, indirect or general supervision.

Chart notes will document what level of supervision by the dentist occurred for the procedure, direct, indirect or general supervision.

Yes, agree. Primary extractions may be completed under direct, indirect or general supervision. The level of supervision required is stated in the practice plan agreement between the DHAT and the supervising dentist.

No, do not agree. Supervision must remain under indirect or direct supervision.

2. Proposed modification: The tooth requiringextraction will no longer require that it have somedegree of mobility.

DHAT’s will still not be authorized to remove teeth that are ankylosed, impacted or require sectioning for removal.

Yes, agree. Primary extractions may be completed on primary teeth. Teeth are not required to be mobile. Teeth must not be ankylosed, impacted or require sectioning for removal.

No, do not agree. Primary extractions may be only be completed on primary teeth that exhibit some degree of mobility. Teeth must not be ankylosed, impacted or require sectioning for removal.

Exhibit E

3

3. Proposed modification: DHAT’s will beauthorized to extract primary teeth that arefractured below the gumline and/or decayed tothe gumline. DHAT’s are not authorized to cutsoft-tissue. DHAT’s will still not be authorized toremove teeth that are ankylosed, impacted orrequire sectioning for removal. DHAT’s aretrained within their educational program toextract primary teeth that meet theseparameters.

Yes, agree. DHAT’s will be authorized to extract primary teeth that are fractured below the gumline and/or decayed to the gumline. DHAT’s are not authorized to cut soft-tissue. DHAT’s will still not be authorized to remove teeth that are ankylosed, impacted or require sectioning for removal.

No, do not agree. DHAT’s will be not be authorized to extract primary teeth that are fractured below the gumline and/or decayed to the gumline. DHAT’s will still not be authorized to remove teeth that are ankylosed, impacted or require sectioning for removal.

4. Proposed modification: Chart notes willinclude documentation that is relevant to theprocedures(s) and remove charting requirementsthat are not relevant or applicable to theparticular case.

Chart notes will not be required to document the absence of associated sepsis, facial swelling, trismus or dysphagia. Chart notes must indicate the absence of dilacerations of the root(s), no proximity to vital structures including maxillary sinus and inferior alveolar nerve, no tori or other need for alveoplasty. [Alveoplasty is not within the scope of the practice for DHAT’s and it not a procedure a DHAT completes. If there is a need for alveoplasty, this note would be entered by the supervising dentist.] Yes, agree. Charts notes will include documentation that is relevant to the procedure(s) and remove charting requirements that are not relevant or applicable to the particular case.

Chart notes will not be required to document the absence of associated sepsis, facial swelling, trismus or dysphagia. Chart notes must indicate the absence of dilacerations of the root(s), no proximity

Exhibit E

4

to vital structures including maxillary sinus and inferior alveolar nerve, no tori or other need for alveoplasty. [Alveoplasty is not within the scope of the practice for DHAT’s and it not a procedure a DHAT completes. If there is a need for alveoplasty, this note would be entered by the supervising dentist.]

No, do not agree. Chart notes are required to document the absence of associated sepsis, facial swelling, trismus or dysphagia. Chart notes must indicate the absence of dilacerations of the root(s), no proximity to vital structures including maxillary sinus and inferior alveolar nerve, no tori or other need for alveoplasty.

Comments and Feedback received by Question:

Advisory Committee feedback was required if an individual disagreed with the proposed modification statement.

Question 1: The DHAT trainee will continue to first receive and document authorization from the supervising dentist to extract the primary tooth. Primary extractions will not require direct or indirect supervision, they may be completed under direct, indirect or general supervision. Chart notes will document what level of supervision by the dentist occurred for the procedure, direct, indirect or general supervision

• “The need for indirect supervision. I don’t need to remind you that this is a trainingprogram. And while the procedure code and tooth designation (letter or number) may bethe same, each patient presents with a unique clinical problem set. In my opinion, it isvery important that the dentist be on the premises (indirect supervision) during thistraining phase. Once the training period is completed and the dental therapists buildsclinical experience and a professional relationship with the supervising dentist it may bepossible to move towards general supervision. But that is beyond the scope and intentof this pilot project for dental therapy trainees.”

• “If a trainee operates under general supervision and is unable to complete the extractionthen the procedure will be incomplete; a patient could be discharged in harm and pain.”

Question 2: The primary tooth requiring extraction will no longer require that it have some degree of mobility. DHAT’s will still not be authorized to remove teeth that are ankylosed, impacted or require sectioning for removal.

• “Deciduous teeth should be retained until normal exfoliation when possible. This isimportant to lessen the chance of needing orthodontic treatment later. There does not

Exhibit E

5

appear to be training to diagnosis anklylosed teeth in the curriculum.”

• “The limitation of extracting mobile teeth is a prudent one. Whenever possible in thevast majority of time, the deciduous teeth should be restored and maintained to lessenthe need for subsequent orthodontic treatment. Extracting teeth that are fractured ordecayed to or below the gum line if not mobile will become a surgical extraction,particularly for deciduous molars with the extreme flaring of the roots. If we want to seethis pilot project be most successful, then we should not create opportunities forcomplications that lead to a poor result for the patient, the dental therapists andsubsequent poor assessment of the pilot program.”

Question 3: DHAT’s will be authorized to extract primary teeth that are fractured below the gumline and/or decayed to the gumline. DHAT’s are not authorized to cut soft-tissue. DHAT’s will still not be authorized to remove teeth that are ankylosed or impacted. DHAT’s are trained within their educational program to extract primary teeth that meet these parameters.

• “I am worried that the teeth that are fractured below the gumline and/or decayed to thegumline will be more likely to become a surgical extraction.”

• “Attempting to extract primary teeth that are fractured or decayed at/below the “gumline”greatly increases the likelihood of fractured/retained roots. Removal offractured/retained primary roots is a technique-sensitive procedure that has high risk fordamage to the developing permanent tooth.”

• “Another reason to retain mobility of deciduous teeth as a parameter is to preventinadvertent extraction of an ankylosed tooth, which is prohibited. Ankylosed teeth arenot mobile because the root is fused to the bone. Diagnosis of ankylosed teeth does notseem to appear in the curriculum. Assessing proximity to vital structures and dilaceratedroots are important in assuming that all extractions by dental therapist trainees are“simple or less complicated”. The smoothing of bone is a surgical procedure, andanother reason that extractions by dental therapist trainees should be done underindirect supervision so that the dentist can do the osteoplasty(minor smoothing). Thisshould not be necessary very often, as mobile teeth normally exhibit a succedaneoustooth or bone loss. Alveoloplasty does not appear in the curriculum and so it would beassumed that they are not trained to perform this procedure.”

Question 4: Charts notes will include documentation that is relevant to the procedure(s) and remove charting requirements that are not relevant or applicable to the particular case.

• “Chart notes must be complete. To leave out the signs and symptoms, diagnosis andtreatment plan, would not meet the standard of care for chart documentation as requiredby the board of dentistry.”

• “There needs to be documented authorization for all extractions and authorization toproceed from the supervising dentist which is signed and dated. This includes adiagnosis and indication for extraction based on the signs, symptoms and diagnosticaids. This is good practice and the standard of care. To not have this minimum level ofdocumentation would not meet record keeping standards in accordance with the Boardof Dentistry.”

Exhibit E