Overview of the Missouri Dental Board
The Missouri Dental Board is a government agency that has two main functions: regulating the dental profession in Missouri, and educating the public about matters relating to dental professionals. In carrying out these responsibilities, the Dental Board works in conformance with the Dental Practice Act, codified at Mo. Rev. Stat. § 332 et seq.
Although the Missouri Dental Board has the authority to create rules and regulations, it cannot regulate all aspects of the dental profession. More specifically, certain aspects of practice are better suited to oversight and regulation by dentists and dental hygienists themselves, rather than state or federal government agencies . After all, those professionals are generally the most familiar with how the industry works.
This is where dental boards can offer their value, in creating rules that make sense in the context of the profession and that comply with the letter – and spirit – of existing laws. Another important responsibility of the Dental Board is education. Much of the Board’s work involves explaining – to both professionals and consumers – their responsibility and rights. It’s an important role.
Licensing for Missouri Dentists
The licensure of oral healthcare providers in Missouri is governed by Chapter 332 of the Missouri Revised Statutes (RSMo), specifically sections 332.021 – 332.535. To be licensed in Missouri, a dentist must hold a D.D.S., or D.M.D. degree. Persons obtaining a D.D.S. or D.M.D. degree from a dental school outside of the United States must sit for and past a foreign-trained dentist examination pursuant to 20 CSR 2110.092, which includes an examination on Missouri law. The Missouri Board no longer automatically grants licensure by endorsement for dentists with out-of-state credentials, or for dentists who have graduated from non-accredited dental schools. This change in policy does not affect the compliance of current Missouri licensees, nor does it impact other occupations regulated by the Board.
When a dental license is issued, it is valid for three years from the date issued. In order to maintain a current license, dentists must comply with continuing education rules set forth in 20 CSR 2110.090. Eight of the sixteen hours of continuing education required each year must be on clinical topics. Other requirements include verification of CPR certification, disclosure of disciplinary actions taken against the dentist in the past 10 years, and proof of malpractice coverage if treatment is performed outside the scope of employment, if treatment is performed on non-clients or non-employees, or if the dentist pays for the coverage or if it is required by an employer or risk sharing pool.
Practice Scope Regulations
The Missouri Dental Board has established rules and regulations that define the scope of practice for dentists and dental hygienists, including limitations and special considerations that may be unique to a particular type of practice. A dentist is a "person licensed to practice dentistry. . . ." RSMo § 332.031(1). The practice of dentistry includes: (1) Drawing blood for the purpose of diagnosing disease and conditions that are within the authorized scope of the practice of dentistry; (2) Prescribing, ordering, compounding, dispensing and administering drugs, et cetera; (3) Hospital dentistry (which means part of the practice of dentistry rendered by a dentist in the operating room of a hospital or surgical center); (4) Oral and maxillofacial surgery, which means the surgical procedures on hard and soft tissues of the oral cavity, jaws and related structures, excluding the practicing of medicine except as an agent of a physician in conjunction with the practice of oral medicine and anesthesiology, or as a general dentist; (emphasis added) (5) Treatment of patients with a disability including speech impairment, et cetera; (6) General dentistry (meaning the diagnosis, treatment, management and coordination of the treatment of diseases, disorders, etc.; and (7) Administration of nitrous oxide analgesia, et cetera; (8) The extract, removal or transplantation of teeth or grafting or reconstructive surgery of the jaw (i.e. – oral surgery). RSMo § 332.031(1). In addition to these other procedures, in Missouri, a dentist is also authorized to draw blood "for the sole purpose of diagnosing diseases and conditions that are within the authorized scope of the practice of dentistry." RSMo § 332.031(2)(1)(a). The scope of practice for dental hygienists includes: (1) "Direct patient care performed as part of the official duties of a dental hygienist who has been duly and regularly licensed as such in the state of Missouri…" RSMo § 332.081(1)(1); (2) "General supervision of the practice of dental hygiene. The provision of dental hygiene services which occurs when a dentist or a state board licensed dental hygienist is present in the facility where the services are provided. Specific procedures performed under general supervision by a dental hygienist shall be at the direction of a dentist and/or under the indirect supervision of a dentist in accordance with the provisions of 1 CSR 5-3.030[1];" and (3) "Practice of dentistry at a public institution which is owned and operated by a government entity and operated no less than twenty hours per week, with the average daily operation of the facility for no less than eight hours per day. Any dental hygienist employed at such facility shall have completed at least two years of college-level education in a dental hygiene program accredited by a regional or national agency approved by the American Dental Association Commission on Dental Accreditation or any successor agency before licensure and employment as a dental hygienist." RSMo § 332.081(1)(1). Dental hygienists may also perform "screening and educational services in public places, schools, or private or public institutes of learning or health fairs, or other community events." RSMo § 332.081(1)(3). The limitations on a dental hygienist’s scope of practice include the following: (1) No dental hygienist "shall be permitted to… (A) Practice general or restorative dentistry or surgery; (B) Administer anesthesia; (C) Perform biopsies or exfoliative cytology of hard or soft tissues; (D) Perform periodontal subgingival curettage or exams or interventions in which arteries, veins, nerves and osteitis are involved; endodontic therapy; fixed or removable prosthodontics; or any surgical implant procedures; (E) Diagnose dental disease; (F) Prescribe medications; (G) Diagnose occlusion, establish treatment plans and prognosis, or question judgment of procedures or prescriptions of other persons licensed under this chapter; (H) Prescribe for or order laboratory materials; (I) Diagnose hard or soft tissue disease or conditions; (J) Use general anesthesia, parenteral or enteral conscious sedation, but shall be permitted to use local anesthesia; (K) Prescribe, administer or perform the administration of nitroglycerin or preoperative anxiolytics; (L) Curette subgingivally to a depth greater than one-half of the distance to the mucogingival junction; perform periodontal surgery; care for periodontal packs, dressings or sutures; or incise or drain abscesses; (M) Determine mobility of teeth by means other than percussion or patient mobility tests; (N) Make surgical incisions, excise soft tissue, excise bone, or perform any other surgical procedure; (O) Extract teeth or roots, treat fractures, perform suture of soft or hard tissue, or perform alveolectomy; (P) Perform osseous surgery; or (Q) Treat hard or soft tissue neoplasms." RSMo § 332.081(1)(11). There are furthermore special instructions that limit a dental hygienist’s practice: A dental hygienist who has been registered is authorized to utilize his or her knowledge, skills and ability in the practice of dentistry as defined in this chapter under indirect or general supervision subject to the specific provisions applicable to the procedures performed. Services shall be rendered only after the initial examination and diagnosis is made by a dentist and a comprehensive, systematic and personalized treatment plan is established, as evidenced by the existence of a written record for each current patient showing the nature, frequency, and kind of treatment provided. RSMo § 332.081(2). The foregoing establishes the general rule regarding dentists and dental hygienists. There are exceptions that are established by rule and regulation. If you are a Missouri dentist or dental hygienist, we recommend that you consult with a medical malpractice defense attorney to make sure you are practicing within the limitations of your scope of practice.
Provisions for Compliance and Discipline
All dental professionals within the State of Missouri are required to operate in compliance with the rules and regulations set forth by the Missouri Dental Board. The Missouri Dental Board, a state agency and part of the Division of Professional Registration, is charged with licensing and regulating dental professionals, setting rules and standards of practice, and determing and imposing disciplinary action for violations of licensure law.
Licensure law, also known as the Missouri Dental Practice Act, consists of the statutes and regulations that make up as policies, procedures and guidelines that licensees, applicants, and dental profession applicants must go through to obtain licensure from the Missouri Dental Board. It also includes the policies, procedures and guidelines they must comply with once they have obtained licensure with the Board. The revised act includes licensure requirements, scope of practice, exemptions, exceptions, prohibited practice, licensure application procedures and requirements, exemptions from licensure, and provisions for the imposition of disciplinary action. The Missouri Dental Board currently offers licensure for Dentists, Doctors of Dental Surgery (DDS), Dental Hygienists, Dental Assistants and Dental Laboratories. The Missouri Dental Board currently does not require licensure to practice as a Dental Technician.
Failure to comply with the Missouri Dental Practice Act, or any other applicable rules and regulations in the licensure law, can result in disciplinary action such as revocation, suspension, probation, reprimand, limitation, condition, or other sanction or discipline. Procedurally, disciplinary action must comply with the Missouri Administrative Procedure Act. Disciplinary proceedings must be held in front of the Administrative Hearing Commission or the Missouri Courts, depending on the level of action taken by the Board. The proceedings for disciplinary actions are to be open to the public and begin with the issuance of formal disciplinary charges (a complaint, petition or notice) by the Missouri Dental Board to the licensee or applicant .
Actions that may result in disciplinary proceedings include but are are not limited to:
The bright line tests as imposed by the Missouri dental board are as follows:
*Income derived from other dentists not employed by them; or commissions
*Failure to refer patients as required by practice; or referring to his/her own practice
*Inconsistencies between patient’s chief complaint and findings
*Referring for consultation when there is no complaint – or to his/her own practice
*Unusual number of x-rays, or unusual order of x-rays
*Normal limit of adjunctive procedure used consistently in one practice – such as prophy appointments, or fluoride
*More surgical extractions, or extractions of abraded teeth than normal
*Inconsistencies in restorations or restorative material
*Unusual radio-opaque fillings or unusual restorations of abraded teeth
*Unusual amount of restorative work for a given age group
*Unusual amount of tooth trauma
*Unusual amount of restorations of teeth with evidence of dental disease
*Unusual amount of endondontic work for a given age group
*Unusual amount of occlusal adjustments
*Unusual number of diagnostic casts, or occlusive splints
*Excessive number of vital and non-vital pulpotomies, or need for nerve treas
*Unusual amount of pulp amputations, or harvesting of blood vessels
*Unusual need for partial dentures
*Unusual amount of relationship of partial dentures such as clasps, rest or indirect retention
*Unusual number of regional blocks
*Unusual number of teeth restored based on appoinment length, or appointment records
*Unusual number of post-operative visits
*Unusual number of broken teeth necessitating restorative treatment
*Unusual treatment of teeth due to medical history
*Unusual lack of diagnostic records or use of diagnostic materials
*Unusual patient history and lack of previous treatment
*Unusual treatment overload, and client dissatisfaction
*Inability to intubate or extubate
*A radiograph requirement of diagnostic quality – as required by ADA
*Improper and inconsistent foram elevation, or hyper extension of the mandible
*Disclosure of history of drug or alcohol abuse, felon conviction or prior disciplinary issues
*Inconsistent referral practices
*Erratic application of behavior management techniques
*Unjustifiable use of Chapter 186- Dentists- Commercial Review Organization
*Unusual treatment patterns detrimental to health, safety or welfare of the public
*Providing information contrary to treatments, fees, anesthesia
*Inadequate, inaccurate treatment plans
*Swapping of treatment plans or treatment objectives
*Record keeping of unsatisfactory nature; inconsistent
*Billing patterns inconsistent
*Non-verbal communication techniques
*Continuing education inconsistent
*Inconsistent scheduling
*Inconsistent coverage
*Referring to dentists inconsistent with treatment need – undue advancement of doctors own network – bill padding
*Inconsistent patient base – consistent out of state clients – increased referrals of same clients to different specialists
*Unprofessional advertisement
*Frequent changes in providers, especially after referrals
*Extension of medication without examining the patient – extending muequosol, anxiolytics, analgesics, muscle relaxants, anti-inflammatories, antibiotics, narcotics and combination therapy
*Prescription for cocaine, heroin, lysergic acid, hallucinogens, and Hashish, chloral hydrate, quaalude
*Issuing prescription for drugs and abuse and dependence
*Improper claim of financial responsibility for services
*Misrepresentation of impression materials, caps, crowns, veneers
*Failure to cooperate with an investigation
*Reporting false information
*Negligence of the care to continue the treatment of an ongoing treatment plan
*Failure to provide records in a timely manner
*Failure to release records to client
*The sales of vital signs, heart monitors, psychometric test
*Radiographs do not meet ADA standards
*Failure to maintain and sterilize equipment
*Improper disposal methods
*Failure to maintain adequate record keeping
*Significant under treatment of dental issues
*Oral or written false advertising
*Failure to notify client of continuing education
*Failure to submit to dental boards subpoena, or failure to submit to random sample
*Failure to annually report drug abuse
*Failure to report any change in employment status
*Failure to report any fraud, misrepresentation, misleading or deceptive act
*Failure to report any assault, drug, and alcohol abuse, and felony conviction
*Negligent active treatment plans
*Fraudulent activity in the nature of billing procedures
*Failure to disclose the risk of procedures
*Failure to disclose client’s medical history
*Referring to non-board approved practitioners
*Instigation of a drug ring
*Instigating a financial gain outside of the approved practice
*Referral to non-compliant colleagues
*Inconsistent billing cycles
*Refusing to accept new clients
*Refusing to admit you have a manual for the practice
*Licensed the practice to others
*Failure to verify insurance plans validity
*Refusal of walk-ins, "pull-ins" or emergency patients
*Lack of use of PPE
*Minor City ordinance violations
*Refusal to provide care to the disabled or handicapped
*Negligence to re-examine a patient
*Extensive failures to examine
*Unprofessional conduct
*Unsafe or inadequate treatment plans
*Unprofessional conduct
*Using another provider’s name
*Attempting to practice outside the protocols of the practice
*Attempting to practice outside your area of expertise
*Performing unnecessary procedures for the purpose of obtaining remuneration
*Lack of patient authorization
*Exceeding the scope of practice
*Failure to give documentation to the court
*Failure to report seeing or hearing of a coworker engaging in unsafe practices
*Failure to report pulmonary breaches, dangerous communicable diseases, or failure to obtain clearance before returning to work
*Violent, aggressive or hostile demeanor
Recent Regulatory Developments
Of late, the Missouri Dental Board has made a number of revisions and additions to its rules and regulations that are important to know if you operate a dental practice in the state. Rather than amending existing rules provisions, the board’s changes have either added new requirements entirely or modified previously existing requirements.
In 2010, for example, the Missouri Dental Board added a new rule requiring that dentists and dental hygienists who obtain continuing education credits online or via home study submit certificates of completion to the board by July 15 of each licensing period. Previously, this requirement only applied to courses offered in-person (although no deadline was specified for certificates of completion). The new rule also increased the total number of hours that can be completed online in any given licensing period from 18 to 34.
Another recently added rule effective Jan. 1, 2011, now requires dentists who offer nitrous oxide analgesia or minimal sedation to implement specific policies and maintain detailed records. Although some board members expressed concerns about the new rule at a meeting in November 2010, the board approved it in December.
The board recently made additional rule changes, but these amendments predominantly relaxed existing requirements. For example, dentists will no longer need board approval to administer minimal sedation directly, provided that they follow certain protocols. The board originally imposed strict requirements with regard to signage. Now, the board has amended the requirement so signage only needs to use "plain language." Further, the ceiling for anesthesia services is now $75 which previously was $100, and dentists no longer need to submit patient medical histories prior to administering moderate sedation.
In anticipating new rule changes by the Missouri Dental Board at some point this year, it will be important for dentists and administrative personnel to be aware of these regulations. Because many of the new rules will require administrative changes related to policy and record keeping, failing to comply with the new requirements could result in administrative penalties and fines.
Updates and Changes to the Rules and Regulations
A plethora of resources is available for currently licensed and aspiring Missouri dental professionals. The resources include professional associations, legal and regulatory assistance, leadership and education opportunities, publications, and continuing education.
Professional Associations
The Missouri Dental Association (MDA) and its components – the St. Louis Dental Society, Greater St. Louis Dental Society, Dental Society of Western Missouri and Kanawha Valleys, and Central Counties Dental Society – organize events, publications, continuing education seminars and a wealth of other resources and services.
In addition to the MDA family, the American Dental Association provides resources and services for dentists, dental team members and the public, including many useful publications and articles.
Legal Resources
The Missouri Division of Professional Registration oversees the State Board of Dentistry, but the Missouri Dental Board and the Missouri Dental Association are good resources when dentists have questions about rules, regulations and compliance . For legal assistance and representation, the Missouri Dental Board and MDA recommend the services of a dental attorney, such as our dental law practice, which has worked with numerous Missouri dentists on board applications, disciplinary actions and continuing education issues.
Professional development opportunities, including training, education and leadership roles, are also provided by the MDA.
Publications and Books
Dentistry Unplugged: 30 Years of Ideas to Keep Your Practice Thriving is a book published by Walt and Carole Rothfeld in 1990. The book was updated in 2007 with new information on dental marketing strategies, employees, compensation planning, service fees, retirement plans and preventing fraud.
See MDA for Everything Else
The MDA provides additional services that help dentists with public relations, dental benefits management, a fee management program, advertising advice, surveys, forms and computers. The MDA also provides many valuable links and information to further assist dentists.