Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board Pursuant to the Requirements of House Bill 15-1309 December 3, 2015

Facilitated by:

December 3, 2015

Dear Colorado Dental Board Members, We are pleased to submit this report pursuant to House Bill 15-1309 (HB15-1309) requiring the Department of Regulatory Agencies to establish an Interim Therapeutic Restorations Advisory Committee to develop uniform standards for consistent training for dental hygienists performing interim therapeutic restorations. This report presents our final recommendations. We appreciate the opportunity to provide our expertise to support the Dental Board. Should you have any questions, please contact our facilitator, Ms. Colleen Lampron of AFL Enterprises, LLC at 720-838-7739.

Sincerely, Deb Astroth, RDH, BSDH William Bailey, DDS, MPH Jo Donlin Elsa Eccles, RDH, M.Ed Michelle Hoffer, RDH, MPHN Jeff Kahl, DDS Dan Wilson, DDS

Interim Therapeutic Restorations Advisory Committee

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Table of Contents Introduction and Legislative History ........................................... 4 Creation of the Interim Therapeutic Restorations Advisory Committee (ITRAC) ..... 4

Background on Interim Therapeutic Restorations ........................... 4 ITRAC Scope ......................................................................... 5 Committee Proceedings .......................................................... 5 Committee Recommendations ................................................... 6 Appendix A – AAPD Policy on Interim Therapeutic Restorations (ITR)...... 7 Appendix B - State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations. ............................ 10 Appendix C – Interim Therapeutic Restoration Advisory Committee Minutes ............................................................................. 24 SEPTEMBER 29, 2015 .......................................................................... 25 OCTOBER 13, 2015 ............................................................................ 27 OCTOBER 30, 2015 ............................................................................ 29

Appendix D – Pacific Center for Special Care University of the Pacific Arthur A. Dugoni School of Dentistry Training Protocols .................... 31

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Introduction and Legislative History On June 5, 2015, Governor Hickenlooper signed House Bill 15-1309 (HB15-1309) Concerning the Placement of Interim Therapeutic Restorations by Dental Hygienists. The new law expands the dental hygienists' Scope of Practice by allowing placement of interim therapeutic restorations under the supervision of a dentist after completing appropriate coursework and applying for and obtaining a permit from the Colorado Dental Board (Board). The new law went into effect on August 5, 2015. Creation of the Interim Therapeutic Restorations Advisory Committee (ITRAC) The law required the Department of Regulatory Agencies (DORA) to establish an Interim Therapeutic Restorations Advisory Committee (ITRAC) to help the Board develop uniform standards for consistent training for dental hygienists performing interim therapeutic restorations. The law also required the ITRAC to complete its work before the Board can create an application process and issue permits. On August 31, 2015, Dickey Lee Hullinghorst, Speaker of the Colorado House of Representatives, and Bill Cadman, President of the Colorado Senate, jointly appointed the following individuals to serve on ITRAC: William Bailey, DDS, MPH as a representative from an accredited dental school in Colorado Dan Wilson, DDS as a dentist with a faculty appointment at an accredited dental school in Colorado Elsa Eccles, RDH, M.Ed as a representative from a dental hygiene school in Colorado Michelle Hoffer, RDH, MPHN as a faculty member from a dental hygiene school in Colorado Jeff Kahl, DDS as a representative from a statewide association of dentists Deb Astroth, RDH, BSDH as a representative from a statewide association of dental hygienists Jo Donlin as a representative from the Division of Professions and Occupations in the Department of Regulatory Agencies The ITRAC held its first meeting on September 29, 2015, and two additional meetings on October 13, 2015 and October 30, 2015. All meetings were noticed according to the Department of Regulatory Agencies’ (DORA) policy and other updated information about the ITRAC was posted on the Colorado Dental Board website and calendar.

Background on Interim Therapeutic Restorations The definition of interim therapeutic restoration (ITR) included in HB 15-1309 states: "Interim therapeutic restoration" or "ITR" means a direct provisional restoration placed to stabilize a tooth until a licensed dentist can assess the need for further definitive treatment. "Interim therapeutic restoration" involves the removal of soft material Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board

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using hand instrumentation, without the use of rotary instrumentation, and the subsequent placement of a glass ionomer restoration.” This type of procedure is generally not painful and does not require dental anesthetic. The softer affected tooth structure is removed using hand instruments. The missing tooth structure is replaced with a glass ionomer adhesive restorative material. The patient is then referred to a dentist for appropriate follow-up care.

ITRAC Scope As specified in HB15-1309, the ITRAC was charged with developing uniform standards for consistent training for dental hygienists performing interim therapeutic restorations by December 3, 2015. While telehealth is mentioned several times in the legislation, the ITRAC made no recommendations related to telehealth because it does not affect the training standards. The institutions that deliver the ITR training based on the uniform standards approved by the Colorado Dental Board may address working in telehealth connected teams as part of the training curriculum. Committee Proceedings The Committee reviewed and discussed state regulatory standards for dental hygienists administering interim therapeutic restorations from California, Idaho, Kansas, Maine, Minnesota, Nebraska, New Mexico, Oregon, and Washington. See Appendix B - State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations. The Committee discussed the provision in HB15-1309 that all faculty responsible for clinical evaluation of students must be dentists with a faculty appointment at an accredited Colorado dental or dental hygiene school. This provision will preclude those dental hygienists trained in other states from applying for a permit until they have completed a course in Colorado. While this concerned the ITRAC, the issue is beyond the Committee’s scope and no recommendation to change this statutory requirement was included in its final recommendations. The Committee also reviewed materials from the American Dental Hygienists’ Association, the American Academy of Pediatric Dentists, and the University of the Pacific. Meeting minutes are included as Appendix C.

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Committee Recommendations After reviewing information from other states and other regulatory documents, the ITRAC recommends the following uniform standards for consistent training for dental hygienists performing interim therapeutic restorations: 1. Courses must meet the following uniform standards: a. Four hours of didactic instruction, including but not limited to: i. Pulpal anatomy ii. Principles of adhesive restorative materials iii. Preparation of the tooth and placement techniques iv. Diagnostic criteria for interim therapeutic restorations v. Evaluation of proper placement and technique vi. Protocols for handling sensitivity, complications, or unsuccessful completion and follow-up. b. Four hours of laboratory instruction that includes placement of interim therapeutic restorations on typodont teeth. c. Criteria for evaluating competency through placement of interim therapeutic restorations on a minimum of four teeth under direct supervision of faculty.

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Appendix A – AAPD Policy on Interim Therapeutic Restorations (ITR)

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Appendix B – State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations.

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State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations Prepared October 2015 MINNESOTA Minnesota Board of Dentistry Revised January 27, 2010 Copy write 2013 – State of Minnesota Source: http://mn.gov/health-licensing-boards/dentistry/licensure/resorativefunctions.jsp Restorative Functions Board Approved Course Guidelines. Retrieved 5 Oct. 2015 Instructor 1. Trainers of educators must have taught these procedures in an accredited dental education program Requirements 2. Allied Restorative Functions Educators must have completed a course taught by trainers 3. Supervising dentist is present in the lab and clinic while the procedures are being performed 4. A contract between the school and an outside clinic is utilized a. A contract must be utilized between the school and the school’s outside-instructing-staff for continuity/consistency of instruction, evaluation requirements and communication with the school’s course instructors. b. The contract stresses personal supervision. Both the dentist ad student sign the contract c. The instructors do a final evaluation Admission Qualifications for participants include: Requirements a. Licensed Dental Assistant b. Licensed Dental Hygienist c. Current student in an accredited hygiene program Qualifications for School/course: The course shall be provided by an CODA accredited school Curriculum Components

The restorative procedures include: a. Place, contour, and adjust amalgam restorations b. Place, contour, and adjust glass ionomer c. Adapt and cement stainless steel crowns d. Place, contour, and adjust Class I and V supragingival composite restorations where the margins are entirely within the enamel. The course contains three sections: 1) Didactic; 2) Pre-clinical/Laboratory; 3) Clinical a. There are two testings for demonstration of competency: i. After completion of didactic and laboratory/preclinic

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Minnesota (con’t)

Curriculum Components (con’t)

ii. Final Clinical Test b. The participant can go no longer than a year between sections, and/or must prove competence upon entrance to each section. c. The participant must complete clinical and the final exam within one year. If more time is needed, then an extension request must be submitted to the Board of Dentistry and school. See Extension Request listed below. d. Pre-clinical or Laboratory - these numbers are guidelines; the main criteria is the student must prove competency in primary as well as permanent dentition. Competency is determined by the instructing staff. i. Amalgam Class I, II, V 12 primary 28 permanent ii. Glass Ionomer Class I, II, V 10 primary 16 permanent iii. S S Crowns # needed to obtain competency iv. Composite Class I, V 6 primary 18 permanent e. Clinical – requirements must include a minimum 12 patient experiences which involves primary and permanent dentition: i. Amalgam Class I, II, V 10 surfaces ii. Glass Ionomer Class I, II, V 5 surfaces iii. S S Crowns 4 teeth iv. Composite Class I, V 5 surfaces 3. Must include a component that sufficiently prepares the student to adjust the occlusion on the newly placed restorations. 4. A Dentist does the prepping of the tooth which is to receive the restorative material.

Registering Requirements

Time Involvement

1. The school shall send a course syllabus to the Board of Dentistry. 2. The school shall submit a list of course participants to the Board of Dentistry 3. The school shall request from the Board of Dentistry the required Restorative Function Registration Form for the student to fill out upon completion of the course requirements. 4. The student shall submit to the Board office the required Board of Dentistry Restorative Function Form. 5. The student shall submit to the Board of Dentistry a certificate of completion 6. The Board of Dentistry shall send recognition of completion to the student. Education will dictate time involved. Completion depends on how fast the student completes and passes all the evaluation requirements of the course and patient experiences.

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Extension Requirements

The Course provider will decide on the request validity and monitor. The clinical and competency requirements must be completed within one year and only upon approved demonstrated circumstances to the course provider will one extension of six months be granted. Minnesota includes the placement of glass ionomer as part of the permitted restorative services dental assistants and dental hygienists with a restorative permit are able to administer.

State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations CALIFORNIA Pacific Center for Special Care University of the Pacific Arthur A. Dugoni School of Dentistry May 21, 2014 Source: http://www.dental.pacific.edu/Community_Involvement.html , Retrieved 5 Oct. 2015 Duty Place “Interim Therapeutic Restorations” (ITR) when directed to do so by a collaborating dentist. In HWPP #172, "Interim Therapeutic Restoration" means a direct provisional restoration placed to stabilize the tooth until a licensed dentist diagnoses the need for further definitive treatment. An ITR consists of the removal of soft material from the tooth using only hand instrumentation, without the use of rotary instrumentation, and subsequent placement of an adhesive restorative material. Local anesthesia is not necessary for ITR placement. Length of Training The training protocols are designed to be of sufficient duration for the trainee to develop competency placing Interim Therapeutic Restorations (ITR). The training program for this duty consists of 16 clock hours, including four hours of didactic training, four hours of laboratory training, and eight hours of clinical training Content of Training The training program for this duty includes the following components: 1. Didactic Instruction includes instruction on all of the following areas: a. Pulpal anatomy. b. Theory of adhesive restorative materials used in the placement of adhesive protective restorations including mechanisms of bonding to tooth structure, handling characteristics of the materials, preparation of the tooth prior to material placement, and placement techniques. c. Criteria that dentists use to make decisions about placement of adhesive protective restorations. See Appendix B: “Guidelines for the Placement of Interim Therapeutic Restorations.” d. Criteria for evaluating successful completion of adhesive protective restorations. *See Appendix B: “Guidelines for the Placement of Interim Therapeutic Restorations.” Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board

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Completion Criteria for Training

*Appendix B Guidelines for the Placement of Interim Therapeutic Restorations

e. Protocols for handling sensitivity, complications, or unsuccessful completion of adhesive protective restorations including situations requiring immediate referral to a dentist. See Appendix B: “Guidelines for the Placement of Interim Therapeutic Restorations.” f. Protocols for follow-up of adhesive protective restorations. See Appendix B: “Guidelines for the Placement of Interim Therapeutic Restorations.” 2. Laboratory instruction consists of placement of adhesive protective restorations where trainees demonstrate competency in this technique on typodont teeth. 3. Clinical instruction consists of experiences where trainees demonstrate placement of ITRS under direct supervision of faculty Satisfactory completion of this training is determined using criteria-referenced completion standards, where the instructor determines when the trainee has achieved competency based on these standards, but trainees take varying amounts of time to achieve competency. Any trainee who had not achieved competency in this duty in the specified period of instruction could receive additional training and evaluation. In cases where, in the judgment of the faculty, trainees are not making adequate progress, they would be discontinued from the training program. The Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry (Pacific) has developed the following guidelines for use in training for HWPP #172. These guidelines were developed to train allied dental personnel to place “Interim Therapeutic Restorations” (ITR) when directed to do so by a dentist. The ITR is a provisional restoration designed to stop the progression of dental caries until the patient can receive further evaluation of treatment for that tooth by a dentist. Refer to Appendix B for additional content at www.dental.pacific.edu/Community_Involvement.html, Retrieved 5 Oct. 2015.

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State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations MAINE State of Maine Board of Dental Examiners May 21, 2014 Source: State of Maine Board of Dental Examiners http://www.mainedental.org/forms/IPDHTempFillProtocols.pdf Protocols for the Placement of Temporary Fillings by Independent Practice Dental Hygienists. (2001) Retrieved 5 Oct. 2015 Source: The Maine Dental Hygienist Association http://www.mainerdh.org/index.html The Maine Dental Hygienists’ Association. (2015) Retrieved 5 Oct. 2015. The Maine State Board Recognizes the unique position of the Independent Practice Dental Hygienist and the Public Health of Dental Examiners Supervision Hygienists in serving the citizens of Maine. Within the accepted scope of practice of dental hygiene is the ability to place temporary restorations in compliance with the protocol adopted by the Board. It is important to note that not all carious lesions are candidates for temporary restorations. The protocols, available below, include the algorithms used to determine the appropriateness of the placement of a temporary filling. Treatment Algorithm Maine rules provide a protocol for public health dental hygienists and independent practice dental hygienists to determine whether it is appropriate to place a temporary restoration. Because the protocol states that “any temporary filling material must be of a nature that is not harmful to the tooth, and preferably be fluoride releasing” and “reminds its licensees that the standard of care in the placement of any dental restoration would include the use of diagnostic films,” it would appear that an ITR using a material such as glass ionomer is contemplated. Protocols for the Placement of Temporary Fillings by Independent Practice Dental Hygienists Source: http://www.mainedental.org/TemporaryFillingsAlgorithms.htm, Retrieved 5 Oct. 2015.

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State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations IDAHO Dentistry Rules of the Idaho State Board of Dentistry Dental Hygienist Extended Access Dental Hygiene Restorative Endorsement License Endorsements Notwithstanding any other provision of these rules, a qualified dental hygienist holding an extended Rule 29, page 7 access dental hygiene restorative endorsement may perform specified restorative functions under the direct supervision of a dentist in an extended access oral health care program. Permissible restorative functions under this endorsement shall be limited to the placement of a restoration into a tooth prepared by a dentist and the carving, contouring and adjustment of the contacts and occlusion of the restoration. Upon application, the Board may grant an extended access dental hygiene restorative endorsement to a person holding an unrestricted active status dental hygienist’s license issued by the Board who provides satisfactory proof that the following requirements are met: A. The person has successfully completed the *Western Regional Examining Board’s restorative examination or an equivalent restorative examination approved by the Board; or b. The person holds an equivalent restorative permit in another state as of the date of endorsement application which required successful completion of the Western Regional Examining Board’s restorative examination or an equivalent restorative examination approved by the Board for its issuance; and c. The person has not been disciplined by the Board or another licensing authority upon grounds that bear a demonstrable relationship to the ability of the dental hygienist to safely and competently practice under in an extended access oral health care program. Source: http://adminrules.idaho.gov/rules/2012/19/0101.pdf, Retrieved 5 Oct. 2015. Extended Access Effective April of 2007, the Idaho Legislature authorized the Idaho State Board of Dentistry to issue Restorative extended access restorative endorsements to qualified dental hygienists who are licensed in active Endorsement status by the Board of Dentistry. The extended access restorative endorsement allows a licensed dental hygienist to perform specified restorative duties under the direct supervision of a dentist in an “extended access oral health care program.” There are no continuing education requirements in connection with an extended access restorative endorsement. When renewing an active status dental hygiene license, an extended access restorative endorsement will also be renewed at the same time if the licensee indicates a desire to do so on the license renewal application. Source: http://isbd.idaho.gov/pdf/ExtAccessRestorative.pdf, Retrieved 5 Oct. 2015. *Western Regional 2015 Restorative Examination Candidate Guide Examining Board The purpose of the WREB Dental Hygiene Restorative Examination is to evaluate a Candidate’s ability (WREB) to utilize professional judgment and competency in providing restorative procedures as allowed by Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board

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A National Dental and Dental Hygiene Testing Agency States served: Alaska, Arizona, Idaho, Kansas, Missouri, Montana, New Mexico, North Dakota, Oklahoma, Oregon, Texas, Utah, Wyoming

Idaho (con’t)

state statute. The examination consists of the placement, carving and finishing of one (1) Class II amalgam and one (1) Class II composite restoration on an assigned maxillary and mandibular typodont tooth. The Candidate Guide contains all the necessary information to take the WREB Dental Hygiene Restorative Examination. The Policy Guide contains information pertaining to examination policies and protocols.

The Dental Hygiene Restorative Clinical examination covers the condensation and carving of restorative materials in two typodont teeth, using amalgam and composite procedures. To be eligible to attempt the WREB Restorative Exam(s), candidates must meet one of the following requirements and provide the appropriate proof of qualification documentation: • Students: Current enrollment in a degree program at an ADA-accredited dental hygiene school AND certification of successful completion of a local anesthesia and/or restorative course(s). • Graduates: Successful completion of a degree program from an ADA-accredited dental hygiene school AND certification of successful completion of a local anesthesia and/or restorative course(s). Source: www.wreb.org/Candidates/Hygiene/hygienePDFs/2015_WREB_CANGuide_RES.pdf, Retrieved

5 Oct. 2015.

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State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations OREGON Oregon Board of Dentistry Source: http://www.oregon.gov/dentistry/pages/dental_hygienists.aspx, Retrieved 5 Oct. 2015. (1) The Board shall issue a Restorative Functions Endorsement (RFE) to a dental hygienist who holds an unrestricted Oregon license, and has successfully completed: (a) A Board approved curriculum from a program accredited by the Commission on Dental Accreditation of the American Dental Association or other course of instruction approved by the Board, and successfully passed the Western Regional Examining Board’s Restorative Examination or other equivalent examinations approved by the Board within the last five years; or (b) If successful passage of the Western Regional Examining Board’s Restorative Examination or other equivalent examinations approved by the Board occurred over five years from the date of application, the applicant must submit verification from another state or jurisdiction where the applicant is legally authorized to perform restorative functions and certification from the supervising dentist of successful completion of at least 25 restorative procedures within the immediate five years from the date of application. (2) A dental hygienist may perform the placement and finishing of direct alloy and direct anterior composite restorations, under the indirect supervision of a licensed dentist, after the supervising dentist has prepared the tooth (teeth) for restoration(s): (a) These functions can only be performed after the patient has given informed consent for the procedure and informed consent for the placement of the restoration(s) by a Restorative Functions Endorsement dental hygienist; (b) Before the patient is released, the final restoration(s) shall be checked by a dentist and documented in the chart. Source: www.oregon.gov/dentistry/forms/hygiene/rdhrestorativeapp.pdf, Retrieved 5 Oct. 2015.

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State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations WASHINGTON STATE Washington State Dental Association Source: www.wsda.org, Retrieved 5 Oct. 2015. Washington State Dental The Washington State Dental Association does not have a curriculum for dental hygienist training Association standards for interim therapeutic restorations (communicated with a WSDA representative) Restorative Procedures Washington State is unique in that it is the only state that requires competence in restorative procedures for initial licensure as a dental hygienist. Restorative services are part of the curriculum at all entry-level dental hygiene programs in Washington State. Applicants for licensure in Washington State must pass a clinical restorative test offered by the Western Regional Examining Board (WREB). A licensed dental hygienist in Washington may remove deposits and stains from the surfaces of the teeth, may apply topical preventive or prophylactic agents, may polish and smooth restorations, may perform root planing and soft-tissue curettage and may perform other dental operations and services delegated by a licensed dentist. Under appropriate supervision, the placing of restorations and administration of anesthesia and nitrous oxide are included in the full dental hygiene license even if a dental hygienist will not be doing these procedures. A dental hygienist with an initial limited license may obtain a temporary endorsement to place restorations and administer local anesthesia upon meeting the licensing requirements.

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SB 5606 Dental Professionals Scope of Practice Effective 7/24/2015

Any person licensed as a dental hygienist in this state may remove deposits and stains from the surfaces of the teeth, may apply topical preventive or prophylactic agents, may polish and smooth restorations, may perform root planing and soft-tissue curettage, and may perform other dental operations and services delegated to them by a licensed dentist. Any person licensed as a dental hygienist in this state may apply topical anesthetic agents under the general supervision, as defined in RCW 18.260.010, of a dentist: PROVIDED HOWEVER, That licensed dental hygienists shall in no event perform the following dental operations or services: (1) Any surgical removal of tissue of the oral cavity; (2) Any prescription of drugs or medications requiring the written order or prescription of a licensed dentist or physician, except that a hygienist may place antimicrobials pursuant to the order of a licensed dentist and under the dentist's required supervision; (3) Any diagnosis for treatment or treatment planning; or (4) The taking of any impression of the teeth or jaw, or the relationships of the teeth or jaws, for the purpose of fabricating any intra-oral restoration, appliance, or prosthesis. Such licensed dental hygienists may perform dental operations and services only under the supervision of a licensed dentist, and under such supervision may be employed by hospitals, boards of education of public or private schools, county boards, boards of health, or public or charitable institutions, or in dental offices.

No training curriculum found – but included information on some state scopes of practice State Regulatory Standards for Dental Hygienists Administering Interim Therapeutic Restorations NEW MEXICO Board of Dental Health Care http://www.rld.state.nm.us/uploads/files/Complete%20Rules%20and%20Statutes%201_15_15.pdf, Retrieved 5 Oct. 2015.

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An expanded-function dental auxiliary may perform the following procedures under the direct supervision of a dentist: (1) placing and shaping direct restorations; (2) taking final impressions, excluding those for fixed or removable prosthetics involving multiple teeth; (3) cementing indirect and provisional restorations for temporary use; (4) applying pit and fissure sealants without mechanical alteration of the tooth; (5) placing temporary and sedative restorative material in handexcavated carious lesions and unprepared tooth fractures; (6) removal of orthodontic bracket cement; and (7) fitting and shaping of stainless steel crowns to be cemented by a dentist. I. An expanded-function dental auxiliary may re-cement temporary or permanent crowns with temporary cement under the general supervision of a dentist in a situation that a dentist deems to be an emergency. J. An expanded-function dental auxiliary may perform other related functions for which the expanded function dental auxiliary meets the training and educational standards established by the board and that are not expressly prohibited by the board. K. For the purpose of this section, "collaborative dental hygiene practice" means the application of the science of the prevention and treatment of oral disease through the provision of educational, assessment, preventive, clinical and other therapeutic services as specified in Subsection B of this section in a cooperative working relationship with a consulting dentist, but without general supervision as set forth by the rules established and approved by both the board and the committee NEBRASKA Source: http://dhhs.ne.gov/publichealth/Licensure/Documents/ReportOfRecommendationsAndFindingsJune2015.pdf, Retrieved 5 Oct. 2015. Expanded Function The duties of the Expanded Function Restorative Dental Hygienist would include minor denture Restorative Dental adjustments, placement and finishing of dental restorations, and the extraction of primary teeth Hygienist that are ready to exfoliate, all under general supervision. Report of This proposal would allow these dental hygienists to place and finish the following dental recommendations and restorations: findings on two dental 1) Restorative level 1, including bases, sedative, temporary fillings, restorative class 1, V, and V1; auxiliaries proposals to 2) Restorative level 2, including restorative class 11, 111, and 1V under indirect supervision. Minor license dental assistants denture adjustments would be allowed under public health supervision. and enhance the scope of practice of dental Current duties currently defined in statute and rule and regulation would continue hygienists June 2015 1. Current RDH and EFDH licensure 2. Proof of liability insurance 3. Complete a special course, didactic and clinical, within an accredited dental school, or complete an equivalent examination from another state Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board

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4. Pass a Board approved examination, or the DANB national examination currently under development.

For Public Health Dental Hygienists

Placement and finishing dental restorations and preparation of class 1 and class V restorations would be allowed under general supervision Current duties currently defined in statute and rule and regulation would continue. This proposal would allow these dental hygienists to provide Interim therapeutic technique and prescribe topical mouth rinses and fluoride to decrease risk of tooth decay under public health supervision. Current duties currently defined in statute and rule and regulation would continue. Have a current RDH licensure and have a public health permit, 2) Have proof of liability insurance, 3) Be authorized by the Department of Health and Human Services and report to this department as required.

No information on training standards for interim therapeutic restorations: American Association of Dental Boards Search: Training for Placement of Interim Therapeutic Restorations www.dentalboards.org Arizona State Board of Dental Examiners https://dentalboard.az.gov/ Connecticut State Dental Association Possibly offers some information about training, however the site password protected http://www.csda.com/search-results?indexCatalogue=searchresults&searchQuery=training+standards+interim+therapeutic+restorations&wordsMode=0 Connecticut Dental Hygienist Association http://www.cdha-rdh.com/home.html Kansas Dental hygienists in Kansas who hold an extended care permit III are permitted to identify and remove decay using hand instrumentation and place a temporary filling, including glass ionomer and other palliative materials. Kansas Dental Association http://www.ksdental.org/ Kansas Dental Hygienist Association No information about training standards for ITR. Sent an email to the Kansas Dental Hygienist Association – waiting a response http://www.kdha.org/legislation.html Resources of possible interest: Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board

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Mighty Mouth Fillings http://www.ihs.gov/doh/documents/ecc/NewECCPacket/Fillings.pdf Indian Health Division of Oral Health Carries Stabilization Online Course http://www.ihs.gov/medicalprograms/dentalcde/index.cfm?fuseaction=course.display&year=2010&cat=online&sort=level&c=1451 Council on Clinical Affairs Policy on Interim Therapeutic Restorations (ITR) http://www.aapd.org/media/policies_guidelines/p_itr.pdf ITR Bills 2015 https://www.adha.org/resources-docs/75110_Bills_Signed_Into_Law.pdf

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Appendix C – Interim Therapeutic Restoration Advisory Committee Minutes

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MINUTES INTERIM THERAPEUTIC RESTORATIONS ADVISORY COMMITTEE (ITRAC) SEPTEMBER 29, 2015 NOTE: This meeting was noticed in compliance with Division of Professions and Occupations policy.

LOCATION:

Colorado Department of Regulatory Agencies 1560 Broadway St, Denver, CO 80202

IN ATTENDANCE:

William Bailey, DDS; Deborah Astroth, RDH; Jeffrey Kahl, DDS; Daniel Wilson, DDS; Michelle Hoffer, RDH, MPHN ; Elsa Eccles, RDH, M.Ed; Jo Donlin;

COMMITTEE STAFF:

Colleen Lampron, Facilitator Lynn Doan, Coordinator

DIVISION STAFF:

Ronne Hines, Deputy Director for Healthcare Maulid Miskell, Program Director, Colorado Dental Board

I.

CALL TO ORDER Colleen Lampron called the meeting to order at 1:45 P.M.

II.

APPROVAL OF MINUTES None at this time.

III.

PRESENTATIONS/APPEARANCES A. Ronne Hines, Division Deputy Director for Healthcare, Colorado Department of Regulatory Agencies – Welcomed the Committee and thanked the members for their service. B. Maulid Miskell, Program Director, Healthcare Branch – Thanked the Committee for their service, and said that he is available for any questions or concerns as the Committee proceeds.

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IV.

DISCUSSION AND DECISIONS A. The Committee decided all decisions would be made by consensus – defined as an agreement, decision, or recommendation that all members of the committee can actively support and that no member actively opposes. B. The Committee decided in-person meeting attendance is preferred, but phone participation will be allowed. Meetings will only be held with a minimum of five The Committee. C. The Committee set their schedule: i. October 13, 2015 ii. October 30, 2015 iii. November 19, 2015 iv. November 24, 2015 D. The Committee asked staff to provide the following information at their next meeting: i. Information that summarizes what other states are doing for their ITR curriculum standards ii. Position/Policy statements from national associations such as American Academy of Pediatric Dentistry & American Dental Hygienist Association

V.

ADJOURNMENT The September 29, 2015, ITRAC Committee Meeting adjourned at 3:57 P.M.

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MINUTES INTERIM THERAPEUTIC RESTORATIONS ADVISORY COMMITTEE (ITRAC) OCTOBER 13, 2015 NOTE: This meeting was noticed in compliance with Division of Professions and Occupations policy. LOCATION:

Colorado Department of Regulatory Agencies 1560 Broadway St, Denver, CO 80202

IN ATTENDANCE:

William Bailey, DDS; Deborah Astroth, RDH; Jeffrey Kahl, DDS; Daniel Wilson, DDS; Michelle Hoffer, RDH, MPHN ; Elsa Eccles, RDH, M.Ed; Jo Donlin;

COMMITTEE STAFF:

Colleen Lampron, Facilitator; Lynn Doan, Coordinator

CALL TO ORDER Colleen Lampron, called the meeting to order at 1:45 P.M. I.

APPROVAL OF MINUTES None at this time.

II.

PRESENTATIONS/APPEARANCES None at this time.

III.

DISCUSSION AND DECISIONS A. The Committee reviewed their charge as specified in HB 15-1309 to develop uniform standards for consistent training for dental hygienists performing interim therapeutic restorations by 12/3/15. B. The Committee reviewed state regulatory standards for dental hygienists administering interim therapeutic restorations.

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C. The Committee drafted uniform standards for consistent training of dental hygienists and will review the draft and receive any public comment at its next meeting. IV.

ADJOURNMENT The October 13, 2015, ITRAC Committee Meeting adjourned at 3:32 P.M.

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MINUTES INTERIM THERAPEUTIC RESTORATIONS ADVISORY COMMITTEE (ITRAC) OCTOBER 30, 2015 NOTE: This meeting was noticed in compliance with Division of Professions and Occupations policy. LOCATION:

Colorado Department of Regulatory Agencies 1560 Broadway St, Denver, CO 80202 via Webinar

IN ATTENDANCE:

William Bailey, DDS; Deborah Astroth, RDH; Jeffrey Kahl, DDS; Daniel Wilson, DDS; Michelle Hoffer, RDH, MPHN ; Elsa Eccles, RDH, M.Ed; Jo Donlin

DIVISION STAFF:

None

PRESIDING:

Colleen Lampron, Facilitator

I.

CALL TO ORDER Colleen Lampron called the meeting to order at 1:30 P.M.

II.

APPROVAL OF MINUTES A motion was made, seconded and carried to approve the September 29, 2015 and October 15, 2015 minutes. Because the October 30, 2015 meeting was the Advisory Committee’s final meeting, these minutes were reviewed and approved via individual e-mail responses.

III.

PRESENTATIONS/APPEARANCES None.

IV.

DISCUSSION AND DECISIONS A. The Committee reviewed the draft uniform standards for consistent training for dental hygienists performing interim therapeutic restorations developed at the 10/15/15 meeting.

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B. A motion was made, seconded and carried to accept the revised uniform standards developed as the final standards to be submitted to the Colorado Dental Board. C. The Committee reviewed and amended a draft report that will accompany the recommended uniform standards to the Colorado Dental Board. D. A motion was made, seconded and carried to delegate authority to the facilitator, Colleen Lampron, to edit and finalize the report. V.

ADJOURNMENT The October 30, 2015, ITRAC Committee Meeting adjourned at 2:22 P.M.

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Appendix D – Pacific Center for Special Care University of the Pacific Arthur A. Dugoni School of Dentistry Training Protocols

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Office of Statewide Health Planning and Development Health Workforce Pilot Project #172 Training Protocols

Pacific Center for Special Care University of the Pacific Arthur A. Dugoni School of Dentistry May 21, 2014

Interim Therapeutic Restorations Advisory Committee Pacific Center Special Care, University of the Pacific Arthur A. Dugoni School of Dentistry Report to the Colorado DentalforBoard 155 5th St, San Francisco, CA 94103 | 415-929-3384

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http://dental.pacific.edu/Community_Involvement/Pacific_Center_for_Special_Care_(PCSC).html

Office of Statewide Health Planning and Development Health Workforce Pilot Project #172 Training Protocols Contents Sponsoring Organization ..................................................................................................... 1 Institution ........................................................................................................................ 1 Project Director ............................................................................................................... 1 Training Protocols ............................................................................................................ 1 Definitions ........................................................................................................................... 1 Prerequisites ....................................................................................................................... 1 Trainees ........................................................................................................................... 1 Faculty ............................................................................................................................. 2 Training for Radiographic Decision: .................................................................................... 2 Duty: ................................................................................................................................ 2 Length of Training:........................................................................................................... 2 Content of Training:......................................................................................................... 2 Completion Criteria for Training...................................................................................... 3 Training for Placement of Interim Therapeutic Restorations.............................................. 3 Duty: ................................................................................................................................ 3 Length of Training............................................................................................................ 3 Content of Training.......................................................................................................... 3 Completion Criteria for Training...................................................................................... 4 Appendix A: Guidelines for Radiographic Decision Making................................................ 5 Radiographs for new patients ......................................................................................... 5 Frequency of radiographs for patients with previous radiographs................................. 6 Appendix B: Guidelines for Placement of Interim Therapeutic Restorations ..................... 8 Background and Rational ................................................................................................ 8 Criteria for ITR Placement ............................................................................................... 9 Criteria for Completion of an ITR .................................................................................... 9 Protocols for Follow-Up for an ITR ................................................................................ 10 Protocols for Adverse Outcomes After Placement of an ITR ........................................ 10

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Sponsoring Organization Institution The Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry (Pacific) is the sponsor of the California Health Workforce Pilot Project (HWPP) #172. This pilot project was approved by the Office of Statewide Health Planning and Development on December 1, 2010. At the time of the writing of this report, this HWPP has trained 12 registered dental assistants, registered dental hygienists working in public health programs, and registered dental hygienists in alternative practice in the performance of two duties included in HWPP #172.

Project Director Paul Glassman DDS, MA, MBA Professor of Dental Practice Director of Community Oral Health Director, Pacific Center for Special Care University of the Pacific Arthur A Dugoni School of Dentistry 155 5th Street San Francisco, CA 94103 P: 415-929-6490 E: [email protected]

Training Protocols Pacific created training protocols that are used to train the providers who participate in HWPP #172. This document outlines those training protocols.

Definitions 1. "Didactic instruction" means lectures, demonstrations, and other instruction without active participation by students. 2. "Laboratory instruction" means instruction in which students receive supervised experience performing procedures using study models, mannequins, or other simulation methods. 3. "Clinical instruction" means instruction in which students receive supervised experience in performing procedures in a clinical setting on patients. Clinical instruction shall only be performed upon successful demonstration and evaluation of preclinical skills.

Prerequisites Trainees All trainees are licensed and working as either Registered Dental Assistants (RDA), Registered Dental Hygienists working in Public Health Programs (RDH), or Registered Dental Hygienists in Alternative Practice (RDHAP). All trainees have completed training during their educational Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board | P a g e 35 1 Pacific Center for Special Care, University of the Pacific Arthur A. Dugoni School of Dentistry

programs or have a certificate of completion of a course in Radiation Safety and in placement of Pit and Fissure Sealants.

Faculty All clinical instructors are faculty members at a dental education institution. Selection criteria for clinical instructors include: 1. Having a current California dental license, and 2. Having experience and expertise teaching the subjects relevant to this project

Training for Radiographic Decision: Duty: Determine, based on protocols, which radiographs to take, if any, to facilitate an initial oral evaluation by a dentist.

Length of Training: The training protocols are designed to be of sufficient duration for the trainee to develop competency in making decisions about which radiographs to take to facilitate diagnosis and treatment planning by a dentist. The training program for this duty is one-half day in length and includes didactic, laboratory and simulated clinical experiences.

Content of Training: The training program for this duty includes the following components: 1. Review of published guidelines including: a. The American Dental Association's Guidelines on the Selection of Patients For Dental Radiographic Examinations. b. The American Academy of Pediatric Dentistry’s Guidelines on Prescribing Dental Radiographs. 2. Instruction on specific decision making guidelines that incorporate information about the patient's health and radiographic history, the time span since previous radiographs were taken, the availability of previous radiographs, the general condition of the mouth including the extent of dental restorations present, and visible signs of abnormalities, including broken teeth, dark areas, and holes in teeth. See Appendix A “Guidelines for Radiographic Decision Making.” 3. Laboratory instruction consisting of a review of cases with various clinical situations with instructor-led discussion about radiographic decision-making in these situations. 4. Case-based examination with various clinical situations where trainees make decisions about which radiographs to take and demonstrate competency to faculty based on these case studies.

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Completion Criteria for Training Satisfactory completion of this training is determined using criteria-referenced completion standards, where the instructor determines when the trainee has achieved competency based on these standards but trainees take varying amounts of time to achieve competency. Any trainee who had not achieved competency in this duty in the specified period of instruction could receive additional training and evaluation. In cases where, in the judgment of the faculty, trainees are not making adequate progress, they would be discontinued from the training program.

Training for Placement of Interim Therapeutic Restorations Duty: Place “Interim Therapeutic Restorations” (ITR) when directed to do so by a collaborating dentist. In HWPP #172, "Interim Therapeutic Restoration" means a direct provisional restoration placed to stabilize the tooth until a licensed dentist diagnoses the need for further definitive treatment. An ITR consists of the removal of soft material from the tooth using only hand instrumentation, without the use of rotary instrumentation, and subsequent placement of an adhesive restorative material. Local anesthesia is not necessary for ITR placement.

Length of Training The training protocols are designed to be of sufficient duration for the trainee to develop competency placing Interim Therapeutic Restorations (ITR). The training program for this duty consists of 16 clock hours, including four hours of didactic training, four hours of laboratory training, and eight hours of clinical training.

Content of Training The training program for this duty includes the following components: 1. Didactic Instruction includes instruction on all of the following areas: a. Pulpal anatomy. b. Theory of adhesive restorative materials used in the placement of adhesive protective restorations including mechanisms of bonding to tooth structure, handling characteristics of the materials, preparation of the tooth prior to material placement, and placement techniques. c. Criteria that dentists use to make decisions about placement of adhesive protective restorations. See Appendix B: “Guidelines for the Placement of Interim Therapeutic Restorations.” d. Criteria for evaluating successful completion of adhesive protective restorations. See Appendix B: “Guidelines for the Placement of Interim Therapeutic Restorations.” e. Protocols for handling sensitivity, complications, or unsuccessful completion of adhesive protective restorations including situations requiring immediate referral to a dentist. See Appendix B: “Guidelines for the Placement of Interim Therapeutic Restorations.” Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board | P a g e 37 3 Pacific Center for Special Care, University of the Pacific Arthur A. Dugoni School of Dentistry

f.

Protocols for follow-up of adhesive protective restorations. See Appendix B: “Guidelines for the Placement of Interim Therapeutic Restorations.” 2. Laboratory instruction consists of placement of adhesive protective restorations where trainees demonstrate competency in this technique on typodont teeth. 3. Clinical instruction consists of experiences where trainees demonstrate placement of ITRS under direct supervision of faculty.

Completion Criteria for Training Satisfactory completion of this training is determined using criteria-referenced completion standards, where the instructor determines when the trainee has achieved competency based on these standards, but trainees take varying amounts of time to achieve competency. Any trainee who had not achieved competency in this duty in the specified period of instruction could receive additional training and evaluation. In cases where, in the judgment of the faculty, trainees are not making adequate progress, they would be discontinued from the training program.

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Appendix A: Guidelines for Radiographic Decision Making. The Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry (Pacific) has developed the following guidelines for use in training for HWPP #172. The guidelines provide greater specificity than guidelines developed and published by national or other dental organizations or associations. These guidelines are intended to result in conservative decision-making based on the fact that a dentist will review the initial set of radiographs which have been chosen and taken by the trainee and can request additional radiographs if needed. It is also recognized that the dentist who will be reviewing the radiographs will be providing additional guidance and calibration for the trainee as this duty is performed over time. In addition, these guidelines are designed to provide general guidance, not precise instructions that are applicable in all circumstances. This approach recognizes that providers delivering care will need to adapt to local circumstances and develop customized procedures for performance and follow-up for this duty.

Radiographs for new patients 1. For adults with no access to previous radiographs: a. If patient has evidence of generalized dental disease or history of extensive treatment or is at moderate to high risk for dental disease based on CAMBRA risk factors and protective factors: i. A full mouth series with a panoramic or periapical and bitewing radiographs. b. If patient appears relatively healthy on clinical exam (for example: has 6 or less individual teeth suspected of having disease in 3 or less sextants of the mouth) and is at low risk for dental disease based on CAMBRA risk factors and protective factors: i. A panoramic radiograph and bitewings, or ii. Bitewings and selected periapical radiographs c. Based upon the patient's disease risk level AND upon visual examination, if there are visible holes in teeth, broken teeth, dark stain within the tooth, there should at least one x-ray that clearly shows that tooth. d. If edentulous i. Based on clinical signs and symptoms 2. For children with primary teeth only: a. If there is evidence of disease: i. Bitewings and selected periapical radiographs b. If the child's teeth appear healthy on visual inspection and the proximal contacts can be examined: Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board | P a g e 39 5 Pacific Center for Special Care, University of the Pacific Arthur A. Dugoni School of Dentistry

i. No radiographic examination is required 3. For children with transitional dentition: a. Bitewings with either a panoramic radiograph or selected periapical radiographs of teeth suspected of having disease

Frequency of radiographs for patients with previous radiographs 1. For adults with previous radiographs: a. Based upon patient's CAMBRA or periodontal disease risk level (as above) i. At increased risk for caries or has caries 1. Bitewing radiographs approximately every 12 months ii. At low risk for caries and no caries present 1. Bitewing radiographs approximately every 24 months iii. At increased risk for periodontal disease or with periodontal disease with clinical signs of acute progression of disease (signs of increasing pocket depth or mobility or inflammation or infection): 1. Bitewing radiographs approximately every 12 months and periapical radiographs of affected teeth) iv. At increased risk for periodontal disease or with periodontal disease without clinical signs of acute progression of disease (signs of increasing pocket depth or mobility or inflammation or infection): 1. Bitewing radiographs approximately every 24 months 2. For children a. Based upon patient's CAMBRA or periodontal disease risk level (as above): i. At increased risk for caries or has caries: 1. Bitewing radiographs approximately every 12 months ii. At low risk for caries or no caries present: 1. Primary and mixed dentition: a. Bitewings approximately every 18 months 2. Adolescent: a. Bitewings approximately every 24 months iii. At increased risk for periodontal disease or with periodontal disease with clinical signs of acute progression of disease (signs of increasing pocket depth or mobility or inflammation or infection): 1. Bitewing radiographs approximately every 12 months and periapical radiographs of affected teeth) iv. At increased risk for periodontal disease or with periodontal disease without clinical signs of acute progression of disease (signs of increasing pocket depth or mobility or inflammation or infection): 1. Bitewing radiographs approximately every 24 months 3. Patients with specific behavioral or physical challenges a. Some patients may not be able to have radiographs taken or may not be able to have all the radiographs taken that are decided based on these criteria. These patients may have behavioral or physical conditions that prevent the provider from being able to perform Interim Therapeutic Restorations Advisory Committee Report to the Colorado Dental Board | P a g e 40 6 Pacific Center for Special Care, University of the Pacific Arthur A. Dugoni School of Dentistry

the necessary procedures. If all the radiographs that are indicated by these criteria are not able to be taken, a note should be placed in the progress notes section of the patient’s chart indicating the circumstances and reasons why the indicated radiographs were not taken.

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Appendix B: Guidelines for Placement of Interim Therapeutic Restorations The Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry (Pacific) has developed the following guidelines for use in training for HWPP #172. These guidelines were developed to train allied dental personnel to place “Interim Therapeutic Restorations” (ITR) when directed to do so by a dentist. The ITR is a provisional restoration designed to stop the progression of dental caries until the patient can receive further evaluation of treatment for that tooth by a dentist. In addition, these guidelines are designed to provide general guidance, not precise instructions that are applicable in all circumstances. This approach recognizes that providers delivering care will need to adapt to local circumstances and develop customized procedures for performance and follow-up for this duty.

Background and Rational An Interim Therapeutic Restoration (ITR) is a preventive technique that places carious teeth in a holding pattern to stop progression of decay until they can be seen by a dentist for follow-up or definitive care. 1 It is part of an approach referred to as “minimally invasive dentistry” where the objective is to preserve natural tooth structure and keep teeth healthy with minimal removal of toot structure.2 Some of the techniques and principles used in this approach include: a. Non-cavitated lesions (white spots) can be remineralized by application of high dose fluoride or fluoride varnish. b. Caries is detected using radiographs and visual examination. Care is taken not to use an explorer to poke at groves and pits in teeth to try to detect a “stick”. If there is demineralized enamel present, poking it with an explorer could break off pieces of the enamel. In addition, if a hole small enough to catch the sharp end of an explorer were present that hole should be covered with a sealant or ITR, something that could be done without poking at the tooth with the explorer. c. Small areas of radiolucency in the dentin of a tooth do not require a conventional filling. If there is a hole in the tooth or enamel groove adjacent to the area of radiolucency, it may be possible to place a sealant or ITR and remove the source of oxygen and food to the lesion and stop the progression of the decay.

1.

American Academy of Pediatric Dentistry (AAPD). Policy o Interim Therapeutic Restorations. 2001, revised

2008. Interim Therapeutic Restorations Advisory Committee 2. Murdoch-Kinch, McLeanBoard ME. Minimally Invasive Dentistry. JADA 2003:134:87-95. Report to the ColoradoCA, Dental

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d. A systematic review of the literature had demonstrated that children who have ITRs placed have less pain and are less afraid of subsequent dental work than children who have similar lesions treated with conventional fillings. Therefore an ITR can be considered a preferable treatment compared to a conventional restoration in an area where it is indicated. 3 e. A full review of the literature supporting the use of Interim Therapeutic Restorations in HWPP #172 has been published. 4

Criteria for ITR Placement 1. Patient factors: a. The patient's American Society of Anesthesiologists Physical Status Classification is Class III or less. b. The patient is cooperative enough to have the restoration placed without the need for special protocols, including sedation or physical support. c. The patient, or responsible party, has provided consent for the procedure. d. The patient reports that the tooth is asymptomatic, or if there is mild sensitivity to sweet, hot, or cold that the sensation stops within a few seconds of the stimulus being removed. 2. Tooth factors: a. The cavity is accessible without the need for creating access using a dental handpiece. b. The margins of the cavity are accessible so that clean non-carious margins can be obtained around the entire periphery of the cavity with the use of hand instrumentation. c. The depth of the lesion is more than two millimeters from the pulp on radiographic examination or is judged by the dentist to be a shallow lesion such that the treatment does not endanger the pulp or require the use of local anesthetic. d. The tooth is restorable and does not have other significant pathology. 3. In some circumstances the available records may not be ideal for making the decision to place an ITR. The collaborating dentist has the option to request further records or information. However, there will be circumstances where the existing records are the best that can be obtained for that patient. It is then up to the collaborating dentist to use his or her clinical judgment to determine the risks and benefits of placing the ITR and to make a decision about whether to treatment plan the ITR.

Criteria for Completion of an ITR Criteria for evaluating successful completion of adhesive protective restorations includes all of the following: 1. The restorative material is not in hyper-occlusion. 2. There are no marginal voids. 3.

Carvalho, T, et. al. The Atraumatic Restorative Treatment Approach: An “atraumatic” alternative. Med Oral Patol Oral Cir Bucal. 2009 Dec 1;14 (12):e668-73. Glassman P, Subar P, Budenz A. Managing Caries in Virtual Dental Homes Using Interim Therapeutic Restorations. Interim4.Therapeutic Restorations Advisory Committee CDA Journal 2013:41(10):745-752.

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3. There is minimal excess material.

Protocols for Follow-Up for an ITR The following are protocols which are suggested for follow-up after the placement of an ITR. 1. One week follow-up a. All patients or caregivers of patients who have ITRs placed are provided with contact information for the trainee who placed the ITR and told how they may be contacted for questions or if they have any problems. b. The trainees who placed the ITR calls patients or caregivers of patients who have ITRs placed within 1 week after ITR placement. The patient or caregiver is asked whether the ITR is still in place and whether there is any pain or other problems connected with the restoration. The trainee records the results of these conversations. 2. Three month follow-up a. Trainees arrange for a three month follow-up visit with patients who have ITRs placed. b. At the initial three month follow-up visit, a visual inspection of the tooth is performed to determine if the ITR is intact. If the ITR is not intact at any visit subsequent to placement, and the cavitation is still present in the tooth, the supervising dentist will decide if the ITR should be replaced or decide on another treatment plan. 3. Six-month and 1 year follow-up a. Trainees arrange for continued three month follow-up visits with patients who have ITRs placed. b. At six months intervals, if the ITR is intact, the trainees complete the following procedures: i. Take an X-ray that includes the tooth/teeth with the ITR. The x-ray(s) can be a part of the normal recall x-ray series to be taken at that time. 1. Bitewings for posterior teeth 2. Periapical radiograph for anterior teeth 3. Intra-oral photographs to include the tooth with the ITR ii. Additional record collection for the patient that is appropriate for a periodic recall visit. 4. These follow-up protocols may be modified by the oral health providers involved based on local circumstances.

Protocols for Adverse Outcomes After Placement of an ITR Below are several theoretical adverse outcomes from ITR placement although none of these outcomes has occurred in HWPP #172 at the time of this writing. The list contains suggested responses to each theoretical outcome. 1. During the placement of an ITR there is an exposure of the pulp a. Small area (pinpoint) i. Cover the exposure with a small amount of Glass Ionomer material, cure that increment of material and then completes the restoration. ii. The patient should receive a consultation by, or a referral to, a dentist for an appointment to take place Committee within a week or two. Interim Therapeutic Restorations Advisory Report to the Colorado Dental Board | P a g e 44 10 Pacific Center for Special Care, University of the Pacific Arthur A. Dugoni School of Dentistry

b.

Large area Holds a dry cotton pellet over the exposed area until bleeding stops. Place a new cotton pellet over exposed area Place a glass ionomer restoration on top of cotton pellet. The patient should receive a consultation by, or a referral to, a dentist for an appointment to take place within a few days. 2. During or after the placement of an ITR part of the tooth breaks a. Repair the area with glass ionomer if it is a small area. b. If it cannot be repaired, then the patient should receive a consultation by, or a referral to, a dentist. 3. During the placement of an ITR the gingival tissue is injured i. For a small area of injury, the gingival tissue usually heals quickly. There may be no specific treatment or follow-up required. ii. For a larger area of injury the patient should receive a consultation by, or a referral to, a dentist. 4. During the placement of an ITR or at a subsequent visit the ITR is determined to be too high a. The patient may or may not experience pain. b. If possible, reduce the height of the ITR so it is no longer too high. If the tooth is not sensitive it should continue to be monitored using the follow-up protocols listed above. If the tooth is sensitive see “The Tooth is Sensitive” below. c. 5. The margins are not sealed a. Add additional material to seal the margin if possible. b. If the margin cannot be sealed, the patient should be referred to a dentist for an appointment within a few weeks. 6. The tooth is sensitive a. If the tooth becomes sensitive post-ITR placement, the ITR should be checked to see if it is too high. See “The ITR is too high” above. b. For mild initial sensitivity the patient should wait to see if it gets better. Mild sensitivity may resolve over several weeks or months. c. If the tooth becomes sensitive post-ITR placement and continues for some time or the patient is experiencing more than mild sensitivity, then the patient should receive consultation by, or a referral to, a dentist. i. ii. iii. iv.

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