Although its primary objective is to safeguard the public, the California Dental Practice Act is an excellent resource for dental professionals to ensure compliance with state law. The California Dental Practice Act is the body of laws in the California Business and Professions Code and the California Code of Regulations governing dental professionals, including dentists, oral and maxillofacial surgeons, orthodontists, dental assistants, and dental hygienists. The Act is intended to serve as a legal guideline for both professionals and the public regarding all aspects of dental practice.
This course is designed for all California dentists, dental hygienists, and dental assistants in all practice settings.
The purpose of this course is to provide California dental professionals with a working knowledge of the contents of the California Dental Practice Act, ensuring that they practice legally and safely.
Upon completion of this course, you should be able to:
- Define the scope of practice of dental professionals in California.
- Describe the standards of licensure of and medication prescription by dental professionals in California.
- Identify possible victims of violence or neglect and outline the appropriate response.
William E. Frey, DDS, MS, FICD, graduated from the University of California School of Dentistry, San Francisco, California, in 1966. In 1975, he completed residency training in Periodontics and received a Master's degree from George Washington University.
Dr. Frey retired from the United States Army Dental Corps in 1989 after 22 years of service. Throughout the course of his professional career, he has continuously practiced dentistry, the first 7 years as a general dentist and the past more than 40 as a periodontist. His military experience included the command of a networked Dental Activity consisting of five dental clinics. In his last assignment, he was in charge of a 38-chair facility. Colonel Frey was selected by the Army to serve on two separate occasions as the Chair of the Periodontal Department in Army General Dentistry Residency Training Programs.
Dr. Frey is the founder and president of Perio Plus, a practice management firm specializing in creating individually-designed hygiene and periodontal care programs for general dentists. He is also the creator of the Inspector Gum patient education series.
Contributing faculty, William E. Frey, DDS, MS, FICD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Mark J. Szarejko, DDS, FAGD
The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Sarah Campbell
The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
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The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.
Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.
#51293: The California Dental Practice Act
The California Dental Practice Act is the body of laws in the California Business and Professions Code (CBPC) and the California Code of Regulations (CCR) governing all dental professionals, including dentists, oral and maxillofacial surgeons, orthodontists, unlicensed dental assistants, registered dental assistants, and dental hygienists. The Act is intended to serve as a legal guideline for both professionals and the public regarding all aspects of dental practice. As defined in Section 1016.(b)1 of the CCR, continuing education on the California Dental Practice Act is required and must include instruction on utilization, scope of practice, prescribing laws, violations, citations, fines, licensure, the identification of abuse, and mandatory abuse reporting [1]. Of course, the Act is a much larger volume, so much so that it is beyond the scope of this course to elucidate every section. The Dental Practice Act is not intended to replace professional oaths and codes of ethics but does define actions and omissions that may lead to legal action and revocation of a license to practice dentistry in the State of California, the laws of which are continually evolving.
The Dental Board of California (a division of the California Department of Consumer Affairs), which consists of eight practicing dentists, one registered dental hygienist, one registered dental assistant (each practicing for at least five years), and five public members, is responsible for licensure of qualified dental health professionals, enforcement of the California Dental Practice Act, and improving the education of consumers and licensees [19]. The Board's highest priority is to protect the health and safety of the public.
In addition, the practice of dental hygiene is regulated by the Dental Hygiene Board of California, the first of its kind in the United States [20].
According to the American Dental Association, dentistry is defined as "the evaluation, diagnosis, prevention, and treatment of diseases, disorders, and conditions of the oral cavity, the craniomaxillofacial area and the adjacent structures and their impact on the human body. This care is provided by dentists within the scope of their education, training and experience in accordance with the ethics of the profession and applicable law" [2]. The CBPC and the CCR provide specific information regarding utilization and scope of practice for dentists, unlicensed dental assistants, registered dental assistants, and registered dental hygienists, as evidenced in the following sections [1].
CBPC Section 1625. Dentistry is the diagnosis or treatment, by surgery or other method, of diseases and lesions and the correction of malpositions of the human teeth, alveolar process, gums, jaws, or associated structures; and such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents, and physical evaluation. Without limiting the foregoing, a person practices dentistry within the meaning of this chapter who does any one or more of the following [24]:
(a) By card, circular, pamphlet, newspaper, Internet website, social media, or in any other way advertises themselves or represents themselves to be a dentist.
(b) Performs, or offers to perform, an operation or diagnosis of any kind, or treats diseases or lesions of the human teeth, alveolar process, gums, jaws, or associated structures, or corrects malposed positions thereof.
(c) In any way indicates that the person will perform by themselves or their agents or servants any operation upon the human teeth, alveolar process, gums, jaws, or associated structures, or in any way indicates that the person will construct, alter, repair, or sell any bridge, crown, denture or other prosthetic appliance or orthodontic appliance.
(d) Makes, or offers to make, an examination of, with the intent to perform or cause to be performed any operation on the human teeth, alveolar process, gums, jaws, or associated structures.
(e) Manages or conducts as manager, proprietor, conductor, lessor, or otherwise, a place where dental operations are performed.
The Board requires that dentists ensure that each patient of record receives a copy of the Dental Materials Fact Sheet (provided by the Board) prior to the placement of his or her first dental restoration [25]. The Dental Materials Fact Sheet details the comparative risks and benefits of available dental restorative materials. The patient must sign an acknowledgment of receipt of the fact sheet, and a copy of the acknowledgment must be placed in the patient's record.
Although unlicensed dental assistants are not Board approved, their duties and actions are governed by the Act and they are required to complete coursework in the Dental Practice Act, infection control, and basic life support. Failure to follow the regulations set forth by California law can result in fines and/or imprisonment. As defined in CBPC Section 1750.(a), "A dental assistant is an individual who, without a license, may perform basic supportive dental procedures, as authorized by Section 1750.1 and by regulations adopted by the board, under the supervision of a licensed dentist" [1]. Basic supportive dental procedures are those procedures that have technically elementary characteristics, are completely reversible, and are unlikely to precipitate potentially hazardous conditions for the patient being treated. A licensed dentist is responsible for assuring unlicensed dental assistants' competence and ensuring that they complete required coursework (e.g., two-hour Dental Practice Act, eight-hour infection control, basic life support) and maintain certification in basic life support (if employed for longer than 120 days). Specific duties pertaining to dental assistant practice can be found in CCR Section 1085 [28]. General information regarding regulations pertaining to dental assistants is located in CBPC Sections 1740–1777; although these sections are not discussed in this course, they should be periodically reviewed to ensure self-compliance with the act. The CBPC may include additional duties for various dental assistant professions.
CCR Section 1085. Dental Assistant Duties and Settings.
(a) Unless specifically so provided by regulation, a dental assistant may not perform the following functions or any other activity which represents the practice of dentistry or requires the knowledge, skill and training of a licensed dentist:
Diagnosis and treatment planning;
Surgical or cutting procedures on hard or soft tissue;
Fitting and adjusting of correctional and prosthodontic appliances;
Prescription of medicines;
Placement, condensation, carving or removal of permanent restorations, including final cementation procedures;
Irrigation and medication of canals, try-in cones, reaming, filing or filling of root canals;
Taking of impressions for prosthodontic appliances, bridges or any other structures which may be worn in the mouth;
Administration of injectable and/or general anesthesia;
Oral prophylaxis procedures.
(b) A dental assistant may perform such basic supportive dental procedures as the following under the general supervision of a licensed dentist:
Extra-oral duties or functions specified by the supervising dentist;
Operation of dental radiographic equipment for the purpose of oral radiography if the dental assistant has complied with the requirements of section 1656 of the Code;
Examine orthodontic appliances.
(c) A dental assistant may perform such basic supportive dental procedures as the following under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.
Take impressions for diagnostic and opposing models, bleaching trays, temporary crowns and bridges, and sports guards;
Apply non-aerosol and non-caustic topical agents;
Remove post-extraction and periodontal dressings;
Placement of elastic orthodontic separators;
Remove orthodontic separators;
Assist in the administration of nitrous oxide analgesia or sedation; however, a dental assistant shall not start the administration of the gases and shall not adjust the flow of the gases unless instructed to do so by the dentist who shall be present at the patient's chairside at the implementation of these instructions. This regulation shall not be construed to prevent any person from taking appropriate action in the event of a medical emergency.
Hold anterior matrices;
Remove sutures;
Take intra-oral measurements for orthodontic procedures;
Seat adjusted retainers or headgears, including appropriate instructions;
Check for loose bands;
Remove arch wires;
Remove ligature ties;
Apply topical fluoride, after scaling and polishing by the supervising dentist or a registered dental hygienist;
Place and remove rubber dams;
Place, wedge and remove matrices;
Cure restorative or orthodontic materials in operative site with light-curing device.
For the purpose of this section, a supervising licensed dentist is defined as a dentist whose patient is receiving the services of a dental assistant in the treatment facility and is under the direct control of said licensed dentist [1]. Direct supervision is defined as supervision of dental procedures based on instructions given by a licensed dentist who must be physically present in the facility when the procedures are performed.
Registered dental assistants (RDAs) are Board-licensed professionals who may perform a greater range of duties than unlicensed dental assistants. Specific information pertaining to RDAs' scope of practice can be found in CCR Section 1086, and general information regarding regulations pertaining to RDAs is located in CBPC Sections 1740–1777, which should be reviewed periodically to ensure self-compliance with the act [28].
(a) Unless specifically so provided by regulation, the prohibitions contained in section 1085 of these regulations apply to registered dental assistants.
(b) A registered dental assistant may perform all functions which may be performed by a dental assistant.
(c) Under general supervision, a registered dental assistant may perform the following duties:
Mouth-mirror inspection of the oral cavity, to include charting of obvious lesions, existing restorations and missing teeth;
Placement and removal of temporary sedative dressings.
(d) A registered dental assistant may perform the following procedures under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.
Obtain endodontic cultures;
Dry canals, previously opened by the supervising dentist, with absorbent points;
Test pulp vitality;
Place bases and liners on sound dentin;
Remove excess cement from supragingival surfaces of teeth with a hand instrument or floss;
Size stainless steel crowns, temporary crowns and bands;
Fabrication of temporary crowns intra-orally;
Temporary cementation and removal of temporary crowns and removal of orthodontic bands;
Placement of orthodontic separators;
Placement and ligation of arch wires;
Placement of post-extraction and periodontal dressings;
Apply bleaching agents;
Activate bleaching agents with non-laser light-curing device;
Take bite registrations for diagnostic models for case study only;
Coronal polishing (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof). The processing times for coronal polishing course approval are set forth in section 1069.
This procedure shall not be intended or interpreted as a complete oral prophylaxis (a procedure which can be performed only by a licensed dentist or registered dental hygienist). A licensed dentist or registered dental hygienist shall determine that the teeth to be polished are free of calculus or other extraneous material prior to coronal polishing.
Removal of excess cement from coronal surfaces of teeth under orthodontic treatment by means of an ultrasonic scaler. (Evidence of satisfactory completion of a board-approved course of instruction or equivalent instruction in an approved RDA program in this function must be submitted to the board prior to any performance thereof.) The processing times for ultrasonic scaler course approval are set forth in section 1069.
(e) Settings. Registered dental assistants may undertake the duties authorized by this section in a treatment facility under the jurisdiction and control of the supervising licensed dentist, or in an equivalent facility approved by the board.
Registered dental assistants in extended functions (RDAEFs) are Board-licensed dental professionals who have a greater breadth of permitted duties than RDAs. Specifics regarding these allowed duties can be found in CCR Section 1087 [28].
CCR Section 1087. RDAEF Duties and Settings.
(a) Unless specifically so provided by regulation, the prohibitions contained in Section 1085 apply to RDAEFs.
(b) An RDAEF may perform all duties assigned to dental assistants and registered dental assistants.
(c) An RDAEF may perform the procedures set forth below under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.
Cord retraction of gingivae for impression procedures;
Take impressions for cast restorations;
Take impressions for space maintainers, orthodontic appliances, and occlusal guards;
Prepare enamel by etching for bonding;
Formulate indirect patterns for endodontic post and core castings;
Fit trial endodontic filling points;
Apply pit and fissure sealants;
Remove excess cement from subgingival tooth surfaces with a hand instrument;
Apply etchant for bonding restorative materials.
(d) Settings. Registered dental assistants in extended functions may undertake the duties authorized by this section in a treatment facility under the jurisdiction and control of the supervising licensed dentist, or in an equivalent facility approved by the board.
In addition to the duties outlined in CCR section 1087, section 1753.5 of the CBPC states that RDAEFs may conduct preliminary evaluation of the patient's oral health, including, but not limited to, charting, intraoral and extra-oral evaluation of soft tissue, classifying occlusion, and myofunctional evaluation, and perform oral health assessments in school-based, community health project settings under the direction of a dentist, registered dental hygienist, or registered dental hygienist in alternative practice [1]. RDAEFs may hold an orthodontic assistant permit, a dental sedation assistant permit, or both.
Registered dental hygienists (RDHs), registered dental hygienists in extended functions (RDHEFs), and registered dental hygienists in alternative practice (RDHAPs) are Board-licensed occupations administered by the Dental Hygiene Committee of California, and the California Dental Practice Act contains the main body of laws and regulations that govern their practice.
The Dental Hygiene Committee of California was created by the Board and consists of nine governor-appointed positions: four public members, four dental hygienists, and one practicing dentist [20]. Responsibilities of the Dental Hygiene Committee include adopting regulations; issuing, reviewing, and revoking licenses; developing and administering examinations; determining fees; and updating continuing education requirements for all dental hygiene licensure categories. The Act contains specific information regarding the permitted duties and settings of RDH practice (CCR Section 1088), RDHEF practice (CCR Section 1089), and RDHAP practice (CCR Section 1090) [28]. Additional laws and regulations pertaining specifically to dental hygiene practice are located in CBPC Sections 1900–1966.6. These sections should be periodically reviewed to ensure self-compliance with the Act.
CCR Section 1088. RDH Duties and Settings.
(a) Unless specifically so provided by regulation, the prohibition contained in Section 1085(a), subsections (1) through (8) of these regulations shall apply to duties performed by a registered dental hygienist.
(b) A registered dental hygienist may perform all duties assigned to dental assistants and registered dental assistants, under the supervision of a licensed dentist as specified in these regulations.
(c) Under general supervision, a registered dental hygienist may perform the following duties in addition to those provided by Section 1760(b) of the Code:
Root planing;
Polish and contour restorations;
Oral exfoliative cytology;
Apply pit and fissure sealants;
Preliminary examination, including but not limited to:
Periodontal charting;
Intra and extra-oral examination of soft tissue;
Charting of lesions, existing restorations and missing teeth;
Classifying occlusion;
Myofunctional evaluation.
Irrigate sub-gingivally with an antimicrobial and/or antibiotic liquid solution(s).
The following direct supervision duties of dental assistants and registered dental assistants:
Dental Assistant.
Taking impressions for diagnostic and opposing models;
Applying non-aerosol and non-caustic topical agents;
Removing post-extraction and periodontal dressings;
Removing sutures;
Taking intra-oral measurements for orthodontic procedures;
Checking for loose bands;
Removing ligature ties;
Applying topical fluoride;
Placing elastic separators.
Registered Dental Assistant
Test pulp vitality;
Removing excess cement from supragingival surfaces of teeth;
Sizing stainless steel crowns, temporary crowns and bands;
Temporary cementation and removal of temporary crowns and removal of orthodontic bands;
Placing post-extraction and periodontal dressings.
(d) A registered dental hygienist may perform the procedures set forth below under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.
Placement of antimicrobial or antibiotic medicaments which do not later have to be removed;
All duties so assigned to a dental assistant or a registered dental assistant, unless otherwise indicated;
Periodontal soft tissue curettage (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof);
Administration of local anesthetic agents, infiltration and conductive, limited to the oral cavity (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof);
Administration of nitrous oxide and oxygen when used as an analgesic, utilizing fail-safe type machines containing no other general anesthetic agents. (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof.)
(e) A registered dental hygienist may undertake the duties authorized by this section in the following settings, provided the appropriate supervision requirements are met:
The treatment facility of a licensed dentist;
Licensed health facilities as defined in Section 1250 of the Health and Safety Code,
Licensed clinics as defined in Section 1203 of the Health and Safety Code,
Licensed community care facilities as defined in Section 1502 of the Health and Safety Code,
Schools of any grade level whether public or private,
Public institutions, including but not limited to federal, state and local penal and correctional facilities.
Mobile units operated by a public or governmental agency or a nonprofit and charitable organization approved by the board; provided, however, that the mobile unit meets the statutory and regulatory requirements for mobile units,
Home of a non-ambulatory patient, provided there is a written note from a physician or registered nurse stating that the patient is unable to visit a dental office.
Health fairs or similar non-profit community activities. Each such fair or activity shall be approved by the board.
Any other facility must be approved by the board.
CCR Section 1089. RDHEF Duties and Settings.
(a) Unless specifically provided by regulation, the prohibitions contained in Section 1085(a) (1) through (8) shall apply to RDHEFs.
(b) An RDHEF may perform all duties assigned to dental assistants, registered dental assistants and registered dental hygienists.
(c) An RDHEF may perform the procedures set forth below under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.
Cord retraction of gingivae for impression procedures;
Take impressions for cast restorations;
Take impressions for space maintainers, orthodontic appliances and guards;
Prepare enamel by etching for bonding;
Formulate indirect patterns for endodontic post and core castings;
Fit trial endodontic filling points;
Apply etchant for bonding restorative materials.
(d) Settings. Registered dental hygienists in extended functions may undertake the duties authorized by this section in a treatment facility under the jurisdiction and control of the supervising licensed dentist, or an equivalent facility approved by the Board.
CCR Section 1090. RDHAP Duties and Settings.
(a) Unless specifically so provided by regulation, an RDHAP may not perform the following functions or any activity which represents the practice of dentistry or requires knowledge, skill and training of a licensed dentist:
Diagnosing and treatment planning;
Surgical or cutting procedures on hard or soft tissue;
Fitting and adjusting of correctional and prosthodontic appliances;
Prescribing medication;
Placing, condensing, carving or removal of permanent restorations, including final cementation procedures;
Irrigating and medicating canals, try-in cones, reaming, filing or filling of root canals;
Taking of impressions for prosthodontic appliances, bridges, or any other devices which may be worn in the mouth;
Administering local or general anesthesia, oral or parental conscious sedation.
(b) Under the supervision of a licensed dentist, an RDHAP may perform the duties assigned to registered dental hygienists by Section 1088, under the same levels of supervision and in the same settings as specified in that section, in addition to those duties permitted by Section 1768(b)(3).
(c) Independently and without the supervision of a licensed dentist, an RDHAP may, upon the prescription of a dentist or a physician and surgeon licensed in California, perform the duties assigned to a registered dental hygienist by Section 1088(c).
All prescriptions shall contain the following information:
The pre-printed name, address, license number, and signature of the prescribing dentist or physician and surgeon.
The name, address and phone number of the patient.
The date the services are prescribed and the expiration date of the prescription. The prescription shall be for dental hygiene services and, if necessary, include special instructions for the care of that patient.
Prior to the establishment of an independent practice, an RDHAP shall provide to the board documentation of an existing relationship with at least one dentist for referral, consultation, and emergency services [1].
All individuals practicing dentistry in California, with the exception of unlicensed dental assistants, must hold a current, valid license issued by the Board; California does not grant reciprocity with other states or nations. The Act requires that dental professionals meet certain education requirements, submit the correct applications and fees, pass the appropriate examinations, and submit a set of fingerprints. Fingerprinting is also required for license renewal if not previously conducted by the California Department of Justice (DOJ) or if records no longer exist [21]. Fingerprinting within California must be conducted using the DOJ Live Scan system; fingerprint records from other institutions (e.g., Department of Motor Vehicles) are not suitable, although ink-on-card fingerprints made at a law enforcement agency are acceptable if unable to travel to California. The required fingerprint cards must be requested from the Dental Board by phone or email [21]. The fingerprints will be used to conduct a criminal history record check and a state and federal level criminal offender record information search.
Issuance, review, and revocation of RDH/RDHEF/RDHAP licenses and the development and administration of license examinations for these auxiliaries are handled by the Dental Hygiene Board of California. All other licensure, including that for RDAs/RDAEFs, is handled by the Dental Board (despite the existence of the Dental Assisting Council, whose purpose is to consider matters related to dental assisting practice and make recommendations to the board). Complaints, investigations, and enforcement are handled by either the Dental Hygiene Board or the Dental Board, according to profession, but the governing regulations and laws set forth in the California Dental Practice Act pertain to all dental professionals. Information about application for licensure to practice as a dentist or dental auxiliary can be found in CCR Section 1028 and CCR Sections 1076–1079.3, respectively. Specific information about the licensure application requirements and process for dentists and dental assistants can be found at https://www.dbc.ca.gov/applicants and for hygienists at https://www.dhbc.ca.gov/applicants.
Effective July 2012, application for licensure may be denied based on delinquent state tax payments [1]. Similarly, current licenses/certifications/registrations may be revoked for failure to pay taxes.
Licenses for all dental professions must be renewed every two years before the last day of the professional's birth month. Practicing without renewing after this date is considered practicing without a license [1]. It is required that dentists have completed 50 hours of continuing education and dental auxiliaries (excluding RDHAPs) have completed 25 hours of continuing education (maximum of 25 hours and 12.5 hours of home study, respectively) upon renewal submission. The continuing education requirement is 35 hours for RDHAPs. Coursework regarding the Dental Practice Act, infection control, and basic life support is mandatory every two years for all licensees. To receive credit, all courses must be from Board-approved providers. In addition, the Board has identified topics that may only constitute a portion of the full continuing education requirement or that are not acceptable at all. A complete listing of allowable and non-allowable courses is available on the Board website.
Links to information regarding license renewal for dentists and dental assistants can be found at https://www.dbc.ca.gov/licensees, and renewal information for hygienists can be found at https://www.dhbc.ca.gov/licensees/renewals.
Violations of the Act by Board licensees are grounds for suspension of a license/certification and are handled by the Board's Enforcement Program, which is composed of five sections: complaint intake, complaint analysis, inspection, investigation, and probation [22]. Complaints originate from many sources, including dental professionals, healthcare providers, insurance companies, law enforcement agencies, and patients. Complaint intake specialists route these to the appropriate section; for example, an allegation of an unsafe or unsanitary office condition is routed to the inspection section, whereby Board enforcement inspectors may be sent out and are authorized to issue citations and fines. In addition to Board enforcement action, other law enforcement or regulatory agencies are involved when indicated [1]. Dental professionals placed on probation status by the Board for violations of the Act are monitored by the Enforcement Program's probation section. The Board's Enforcement Unit may be contacted at (916) 274-6326. Violations of the Act by hygienists are handled by the Hygiene Board's Complaint Unit, which operates in a similar manner and can be contacted at (866) 810-9899 or by email at DHBCEnforcement@dca.ca.gov.
According to CBPC Section 1670.1, conviction of crimes committed by dental professionals outside of the workplace may also be grounds for Board discipline and can impact licensure status if the crime is "substantially related to the qualifications, functions, or duties of a dentist or dental assistant licensed under this chapter" [1]. These vary considerably on a case-by-case basis. Various lesser convictions, for example, driving under the influence (DUI), illicit drug possession, and prescription drug diversion, may not necessarily lead to license revocation provided the proper steps are taken toward remediation (e.g., entering the Board diversion program, submitting to periodic drug testing) [23]. In general, convictions for assaults, sex crimes, multiple misdemeanors (e.g., second DUI/controlled substance charge), and other egregious violations constitute a basis for denial or revocation of licenses or certifications. In addition to violations outside the workplace, unprofessional conduct, in its many forms, is grounds for Board Enforcement action. Acts and omissions that characterize unprofessional conduct are covered extensively in CBPC Sections 1680, 1681, and 1682 and CCR Section 1018.05.
CBPC Section 1680. Unprofessional conduct by a person licensed under this chapter is defined as, but is not limited to, any one of the following:
(a) The obtaining of any fee by fraud or misrepresentation.
(b) The employment directly or indirectly of any student or suspended or unlicensed dentist to practice dentistry as defined in this chapter.
(c) The aiding or abetting of any unlicensed person to practice dentistry.
(d) The aiding or abetting of a licensed person to practice dentistry unlawfully.
(e) The committing of any act or acts of sexual abuse, misconduct, or relations with a patient that are substantially related to the practice of dentistry.
(f) The use of any false, assumed, or fictitious name, either as an individual, firm, corporation, or otherwise, or any name other than the name under which the person is licensed to practice, in advertising or in any other manner indicating that the person is practicing or will practice dentistry, except that name as is specified in a valid permit issued pursuant to Section 1701.5.
(g) The practice of accepting or receiving any commission or the rebating in any form or manner of fees for professional services, radiograms, prescriptions, or other services or articles supplied to patients.
(h) The making use by the licensee or any agent of the licensee of any advertising statements of a character tending to deceive or mislead the public.
(i) The advertising of either professional superiority or the advertising of performance of professional services in a superior manner. This subdivision shall not prohibit advertising permitted by subdivision (h) of Section 651.
(j) The employing or the making use of solicitors.
(k) The advertising in violation of Section 651.
(l) The advertising to guarantee any dental service, or to perform any dental operation painlessly. This subdivision shall not prohibit advertising permitted by Section 651.
(m) The violation of any of the provisions of law regulating the procurement, dispensing, or administration of dangerous drugs, as defined in Chapter 9 (commencing with Section 4000) or controlled substances, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code.
(n) The violation of any of the provisions of this division.
(o) The permitting of any person to operate dental radiographic equipment who has not met the requirements of Section 1656.
(p) The clearly excessive prescribing or administering of drugs or treatment, or the clearly excessive use of diagnostic procedures, or the clearly excessive use of diagnostic or treatment facilities, as determined by the customary practice and standards of the dental profession. Any person who violates this subdivision is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) or more than six hundred dollars ($600), or by imprisonment for a term of not less than 60 days or more than 180 days, or by both a fine and imprisonment.
(q) The use of threats or harassment against any patient or licensee for providing evidence in any possible or actual disciplinary action, or other legal action; or the discharge of an employee primarily based on the employee's attempt to comply with the provisions of this chapter or to aid in the compliance.
(r) Suspension or revocation of a license issued, or discipline imposed, by another state or territory on grounds that would be the basis of discipline in this state.
(s) The alteration of a patient's record with intent to deceive.
(t) Unsanitary or unsafe office conditions, as determined by the customary practice and standards of the dental profession.
(u) The abandonment of the patient by the licensee, without written notice to the patient that treatment is to be discontinued and before the patient has ample opportunity to secure the services of another dentist, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions and provided the health of the patient is not jeopardized.
(v) The willful misrepresentation of facts relating to a disciplinary action to the patients of a disciplined licensee.
(w) Use of fraud in the procurement of any license issued pursuant to this chapter.
(x) Any action or conduct that would have warranted the denial of the license.
(y) The aiding or abetting of a licensed dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions to practice dentistry in a negligent or incompetent manner.
(z)
The failure to report to the board in writing within seven days any of the following:
the death of the licensee's patient during the performance of any dental or dental hygiene procedure;
the discovery of the death of a patient whose death is related to a dental or dental hygiene procedure performed by the licensee; or
except for a scheduled hospitalization, the removal to a hospital or emergency center for medical treatment of any patient to whom oral conscious sedation, conscious sedation, or general anesthesia was administered, or any patient as a result of dental or dental hygiene treatment. With the exception of patients to whom oral conscious sedation, conscious sedation, or general anesthesia was administered, removal to a hospital or emergency center that is the normal or expected treatment for the underlying dental condition is not required to be reported. Upon receipt of a report pursuant to this subdivision the board may conduct an inspection of the dental office if the board finds that it is necessary. A dentist shall report to the board all deaths occurring in the licensee's practice with a copy sent to the Dental Hygiene Board of California if the death was the result of treatment by a registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions. A registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions shall report to the Dental Hygiene Board of California all deaths occurring as the result of dental hygiene treatment, and a copy of the notification shall be sent to the board.
The report required by this subdivision shall be on a form or forms approved by the board. The form or forms approved by the board shall require the licensee to include, but not be limited to, the following information for cases in which patients received anesthesia: the date of the procedure; the patient's age in years and months, weight, and sex; the patient's American Society of Anesthesiologists (ASA) physical status; the patient's primary diagnosis; the patient's coexisting diagnoses; the procedures performed; the sedation setting; the medications used; the monitoring equipment used; the category of the provider responsible for sedation oversight; the category of the provider delivering sedation; the category of the provider monitoring the patient during sedation; whether the person supervising the sedation performed one or more of the procedures; the planned airway management; the planned depth of sedation; the complications that occurred; a description of what was unexpected about the airway management; whether there was transportation of the patient during sedation; the category of the provider conducting resuscitation measures; and the resuscitation equipment utilized. Disclosure of individually identifiable patient information shall be consistent with applicable law. A report required by this subdivision shall not be admissible in any action brought by a patient of the licensee providing the report.
For the purposes of paragraph (2), categories of provider are: General Dentist, Pediatric Dentist, Oral Surgeon, Dentist Anesthesiologist, Physician Anesthesiologist, Dental Assistant, Registered Dental Assistant, Dental Sedation Assistant, Registered Nurse, Certified Registered Nurse Anesthetist, or Other.
The form shall state that this information shall not be considered an admission of guilt, but is for educational, data, or investigative purposes.
The board may assess a penalty on any licensee who fails to report an instance of an adverse event as required by this subdivision. The licensee may dispute the failure to file within 10 days of receiving notice that the board had assessed a penalty against the licensee.
(aa) Participating in or operating any group advertising and referral services that are in violation of Section 650.2.
(ab) The failure to use a fail-safe machine with an appropriate exhaust system in the administration of nitrous oxide. The board shall, by regulation, define what constitutes a fail-safe machine.
(ac) Engaging in the practice of dentistry with an expired license.
(ad) Except for good cause, the knowing failure to protect patients by failing to follow infection control guidelines of the board, thereby risking transmission of bloodborne infectious diseases from dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions to patient, from patient to patient, and from patient to dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions. In administering this subdivision, the board shall consider referencing the standards, regulations, and guidelines of the State Department of Public Health developed pursuant to Section 1250.11 of the Health and Safety Code and the standards, guidelines, and regulations pursuant to the California Occupational Safety and Health Act of 1973 (Part 1 (commencing with Section 6300) of Division 5 of the Labor Code) for preventing the transmission of HIV, hepatitis B, and other blood-borne pathogens in health care settings. The board shall review infection control guidelines, if necessary, on an annual basis and proposed changes shall be reviewed by the Dental Hygiene Board of California to establish a consensus. The Board shall submit any recommended changes to the infection control guidelines for review to establish a consensus. As necessary, the board shall consult with the Medical Board of California, the California Board of Podiatric Medicine, the Board of Registered Nursing, and the Board of Vocational Nursing and Psychiatric Technicians, to encourage appropriate consistency in the implementation of this subdivision.
The board shall seek to ensure that all appropriate dental personnel are informed of the responsibility to follow infection control guidelines, and of the most recent scientifically recognized safeguards for minimizing the risk of transmission of bloodborne infectious diseases.
(ae) The utilization by a licensed dentist of any person to perform the functions of any registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions who, at the time of initial employment, does not possess a current, valid license or permit to perform those functions.
(af) The prescribing, dispensing, or furnishing of dangerous drugs or devices, as defined in Section 4022, in violation of Section 2242.1.
(ag) Using water, or other methods used for irrigation, that are not sterile or that do not contain recognized disinfecting or antibacterial properties when performing dental procedures on exposed dental pulp.
(ah) The failure by the treating dentist, prior to the initial diagnosis and correction of malpositions of human teeth or initial use of orthodontic appliances, to perform an examination pursuant to subdivision (b) of Section 1684.5, including the review of the patient's most recent diagnostic digital or conventional radiographs or other equivalent bone imaging suitable for orthodontia. New radiographs or other equivalent bone imaging shall be ordered if deemed appropriate by the treating dentist.
Section 1681. In addition to other acts constituting unprofessional conduct within the meaning of this chapter, it is unprofessional conduct for a person licensed under this chapter to do any of the following:
(a) Obtain or possess in violation of law, or except as directed by a licensed physician and surgeon, dentist, or podiatrist, administer to himself, any controlled substance, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any dangerous drug as defined in Article 8 (commencing with Section 4211) of Chapter 9.
(b) Use any controlled substance, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any dangerous drug as defined in Article 8 (commencing with Section 4211) of Chapter 9, or alcoholic beverages or other intoxicating substances, to an extent or in a manner dangerous or injurious to himself, to any person, or the public to the extent that such use impairs his ability to conduct with safety to the public the practice authorized by his license.
(c) The conviction of a charge of violating any federal statute or rules, or any statute or rule of this state, regulating controlled substances, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any dangerous drug, as defined in Article 8 (commencing with Section 4211) of Chapter 9, or the conviction of more than one misdemeanor, or any felony, involving the use or consumption of alcohol or drugs, if the conviction is substantially related to the practice authorized by his license. The record of conviction or certified copy thereof, certified by the clerk of the court or by the judge in whose court the conviction is had, shall be conclusive evidence of a violation of this section; a plea or verdict of guilty or a conviction following a plea of nolo contendere is deemed to be a conviction within the meaning of this section; the board may order the license suspended or revoked, or may decline to issue a license, when the time for appeal has elapsed or the judgment of conviction has been affirmed on appeal, or when an order granting probation is made suspending imposition of sentence, irrespective of a subsequent order under any provision of the Penal Code, including, but not limited to, Section 1203.4 of the Penal Code, allowing such person to withdraw his plea of guilty and to enter a plea of not guilty, or setting aside the verdict of guilty, or dismissing the accusation, information or indictment.
Section 1682. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for:
(a) Any dentist performing dental procedures to have more than one patient undergoing moderate sedation, deep sedation, or general anesthesia on an outpatient basis at any given time unless each patient is being continuously monitored on a one-to-one ratio while sedated by either the dentist or another licensed health professional authorized by law to administer moderate sedation, deep sedation, or general anesthesia.
(b) Any dentist with patients recovering from moderate sedation, deep sedation, or general anesthesia to fail to have the patients closely monitored by licensed health professionals experienced in the care and resuscitation of patients recovering from moderate sedation, deep sedation, or general anesthesia. If one licensed professional is responsible for the recovery care of more than one patient at a time, all of the patients shall be physically in the same room to allow continuous visual contact with all patients and the patient to recovery staff ratio should not exceed three to one.
(c) Any dentist with patients who are undergoing deep sedation, general anesthesia, or moderate sedation to fail to have these patients continuously monitored during the dental procedure with a pulse oximeter or similar or superior monitoring equipment and ventilation continuously monitored using at least two of the three following methods:
Auscultation of breath sounds using a precordial stethoscope.
Monitoring for the presence of exhaled carbon dioxide with capnography.
Verbal communication with a patient under moderate sedation. This method shall not be used for a patient under deep sedation or general anesthesia.
(d) Any dentist with patients who are undergoing moderate sedation to have dental office personnel directly involved with the care of those patients who are not certified in basic cardiac life support (CPR) and recertified biennially.
(e)
Any dentist to fail to obtain the written informed consent of a patient prior to administering moderate sedation, deep sedation, general anesthesia. In the case of a minor, the consent shall be obtained from the child's parent or guardian.
The written informed consent for general anesthesia, in the case of a minor, shall include, but not be limited to, the following information:
"The administration and monitoring of deep sedation or general anesthesia may vary depending on the type of procedure, the type of practitioner, the age and health of the patient, and the setting in which anesthesia is provided. Risks may vary with each specific situation. You are encouraged to explore all the options available for your child's anesthesia for their dental treatment, and consult with your dentist, family physician, or pediatrician as needed."
Nothing in this subdivision shall be construed to establish the reasonable standard of care for administering or monitoring oral moderate sedation, moderate sedation, deep sedation, or general anesthesia.
Section 1683. (a) Every dentist, dental health professional, or other licensed health professional who performs a service on a patient in a dental office shall identify himself or herself in the patient record by signing his or her name, or an identification number and initials, next to the service performed and shall date those treatment entries in the record. Any person licensed under this chapter who owns, operates, or manages a dental office shall ensure compliance with this requirement.
(b) Repeated violations of this section constitute unprofessional conduct.
Section 1683.1 (a) Any individual, partnership, corporation, or other entity that provides dental services through telehealth shall make available the name, telephone number, practice address, and California state license number of any dentist who will be involved in the provision of services to a patient prior to the rendering of services and when requested by a patient.
(b) A violation of this section shall constitute unprofessional conduct.
Section 1684. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for a person licensed under this chapter to perform, or hold himself or herself out as able to perform, professional services beyond the scope of his or her license and field or fields of competence as established by his or her education, experience, training, or any combination thereof. This includes, but is not limited to, the use of any instrument or device in a manner that is not in accordance with the customary standards and practices of the dental profession. This section shall not apply to research conducted by accredited dental schools or colleges, or to research conducted pursuant to an investigational device exemption issued by the United States Food and Drug Administration.
1684.5. (a) In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for any dentist to perform or allow to be performed any treatment on a patient who is not a patient of record of that dentist. A dentist may, however, after conducting a preliminary oral examination, require or permit any dental auxiliary to perform procedures necessary for diagnostic purposes, provided that the procedures are permitted under the auxiliary's authorized scope of practice. Additionally, a dentist may require or permit a dental auxiliary to perform all of the following duties prior to any examination of the patient by the dentist, provided that the duties are authorized for the particular classification of dental auxiliary pursuant to Article 7 (commencing with Section 1740):
Expose emergency radiographs upon direction of the dentist.
If the dental auxiliary is a registered dental assistant in extended functions, a registered dental hygienist, or a registered dental hygienist in alternative practice, determine and perform radiographs for the specific purpose of aiding a dentist in completing a comprehensive diagnosis and treatment plan for a patient using telehealth, as defined by Section 2290.5, for the purpose of communication with the supervising dentist pursuant to Sections 1753.55, 1910.5, and 1926.05. A dentist is not required to review patient records or make a diagnosis using telehealth.
Perform extra-oral duties or functions specified by the dentist.
Perform mouth-mirror inspections of the oral cavity, to include charting of obvious lesions, malocclusions, existing restorations, and missing teeth.
(b) For purposes of this section, "patient of record" refers to a patient who has been examined, has had a medical and dental history completed and evaluated, and has had oral conditions diagnosed and a written plan developed by the licensed dentist.
(c) For purposes of this section, if dental treatment is provided to a patient by a registered dental assistant in extended functions, a registered dental hygienist, or a registered dental hygienist in alternative practice pursuant to the diagnosis and treatment plan authorized by a supervising dentist, at a location other than the dentist's practice location, it is the responsibility of the authorizing dentist that the patient or the patient's representative receive written notification that the care was provided at the direction of the authorizing dentist and that the notification include the authorizing dentist's name, practice location address, and telephone number. This provision shall not require patient notification for dental hygiene preventive services provided in public health programs as specified and authorized in Section 1911, or for dental hygiene care when provided as specified and authorized in Section 1926.
(d) A dentist shall not concurrently supervise more than a total of five registered dental assistants in extended functions, registered dental hygienists, or registered dental hygienists in alternative practice providing services pursuant to Sections 1753.55, 1910.5, and 1926.05.
(e) This section shall not apply to dentists providing examinations on a temporary basis outside of a dental office in settings including, but not limited to, health fairs and school screenings.
(f) This section shall not apply to fluoride mouth rinse or supplement programs administered in a school or preschool setting.
Section 1685. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for a person licensed under this chapter to require, either directly or through an office policy, or knowingly permit the delivery of dental care that discourages necessary treatment or permits clearly excessive treatment, incompetent treatment, grossly negligent treatment, repeated negligent acts, or unnecessary treatment, as determined by the standard of practice in the community.
CCR Section 1018.05 Unprofessional Conduct Defined. In addition to those acts detailed in Business and Professions Code Sections 1670, 1680, 1681 and 1682, the following shall also constitute unprofessional conduct:
(a) Failure to provide records requested by the Board within 15 days of the date of receipt of the request or within the time specified in the request, whichever is later, unless the licensee is unable to provide the documents within this time period for good cause. For the purposes of this section, "good cause" includes physical inability to access the records in the time allowed due to illness or travel.
(b) Failure to report to the Board, within 30 days, any of the following:
The bringing of an indictment or information charging a felony against the licensee.
The conviction of the licensee, including any verdict of guilty, or pleas of guilty or no contest, of any felony or misdemeanor.
Any disciplinary action taken by another professional licensing entity or authority of this state or of another state or an agency of the federal government or the United States military.
For the purposes of this section, "conviction" means a plea or verdict of guilty or a conviction following a plea of nolo contendere or "no contest" and any conviction that has been set aside or deferred pursuant to Sections 1000 or 1203.4 of the Penal Code, including infractions, misdemeanors, and felonies. "Conviction" does not include traffic infractions with a fine of less than one thousand dollars ($1,000) unless the infraction involved alcohol or controlled substances.
As discussed, various acts or omissions can be cause for revocation or suspension of a license. Violation of any section of the Dental Practice Act can also lead to civil and criminal prosecution, including [1]:
Section 1700. Any person, company, or association is guilty of a misdemeanor, and upon conviction thereof shall be punished by imprisonment in the county jail not less than 10 days nor more than one year, or by a fine of not less than one hundred dollars ($100) nor more than one thousand five hundred dollars ($1,500), or by both fine and imprisonment, who:
(a) Assumes the degree of "doctor of dental surgery," "doctor of dental science," or "doctor of dental medicine" or appends the letters "DDS," or "DDSc" or "DMD" to his or her name without having had the right to assume the title conferred upon him or her by diploma from a recognized dental college or school legally empowered to confer the same.
(b) Assumes any title, or appends any letters to his or her name, with the intent to represent falsely that he or she has received a dental degree or license.
(c) Engages in the practice of dentistry without causing to be displayed in a conspicuous place in his or her office the name of each and every person employed there in the practice of dentistry.
(d) Within 10 days after demand is made by the executive officer of the board, fails to furnish to the board the name and address of all persons practicing or assisting in the practice of dentistry in the office of the person, company, or association, at any time within 60 days prior to the demand, together with a sworn statement showing under and by what license or authority this person, company, or association and any employees are or have been practicing dentistry. This sworn statement shall not be used in any prosecution under this section.
(e) Is under the influence of alcohol or a controlled substance while engaged in the practice of dentistry in actual attendance on patients to an extent that impairs his or her ability to conduct the practice of dentistry with safety to patients and the public.
Section 1700.5. Notwithstanding Section 1700, any person who holds a valid, unrevoked, and unsuspended certificate as a dentist under this chapter may append the letters "DDS" to his or her name, regardless of the degree conferred upon him or her by the dental college from which the licensee graduated.
Section 1701. Any person is for the first offense guilty of a misdemeanor and shall be punishable by a fine of not less than two hundred dollars ($200) or more than three thousand dollars ($3,000), or by imprisonment in a county jail for not to exceed six months, or both, and for the second or a subsequent offense is guilty of a felony and upon conviction thereof shall be punished by a fine of not less than two thousand dollars ($2,000) nor more than six thousand dollars ($6,000), or by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, or by both such fine and imprisonment, who:
(a) Sells or barters or offers to sell or barter any dental degree or any license or transcript made or purporting to be made pursuant to the laws regulating the license and registration of dentists.
(b) Purchases or procures by barter any such diploma, license or transcript with intent that the same shall be used in evidence of the holder's qualification to practice dentistry, or in fraud of the laws regulating such practice.
(c) With fraudulent intent, makes or attempts to make, counterfeits or alters in a material regard any such diploma, certificate or transcript.
(d) Uses, attempts or causes to be used, any such diploma, certificate or transcript which has been purchased, fraudulently issued, counterfeited or materially altered, either as a license to practice dentistry, or in order to procure registration as a dentist.
(e) In an affidavit, required of an applicant for examination, license or registration under this chapter, willfully makes a false statement in a material regard.
(f) Practices dentistry or offers to practice dentistry as it is defined in this chapter, either without a license, or when his license has been revoked or suspended.
(g) Under any false, assumed or fictitious name, either as an individual, firm, corporation or otherwise, or any name other than the name under which he is licensed, practices, advertises or in any other manner indicates that he is practicing or will practice dentistry, except such name as is specified in a valid permit issued pursuant to Section 1701.5.
Section 1701.1. (a) Notwithstanding Sections 1700 and 1701, a person who willfully, under circumstances or conditions that cause or create risk of bodily harm, serious physical or mental illness, or death, practices or attempts to practice, or advertises or holds himself or herself out as practicing dentistry without having at the time of so doing a valid, unrevoked, and unsuspended certificate, license, registration, or permit as provided in this chapter, or without being authorized to perform that act pursuant to a certificate, license, registration, or permit obtained in accordance with some other provision of law, is guilty of a public offense, punishable by a fine not exceeding ten thousand dollars ($10,000), by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, by imprisonment in a county jail not exceeding one year, or by both the fine and either imprisonment.
(b) A person who conspires with or aids and abets another to commit any act described in subdivision (a) is guilty of a public offense and subject to the punishment described in subdivision (a).
(c) The remedy provided in this section shall not preclude any other remedy provided by law.
The California Dental Practice Act states that only doctors of dentistry are permitted to prescribe drugs, including analgesics, sedatives, and antibiotics, although prescription of oral conscious sedation to children younger than 13 years of age requires a permit. Dental assistants and dental hygienists are not permitted to write prescriptions [1]. There are many federal and state laws and regulations pertaining to prescribing. It is the responsibility of each Drug Enforcement Administration (DEA)-registered prescriber (or those exempted) to be familiar with and maintain knowledge of all applicable laws and regulations. Pertinent citations of federal laws governing the prescription of controlled substances are included in the DEA Practitioner's Manual, available at https://www.deadiversion.usdoj.gov/pubs/manuals. The California Uniform Controlled Substances Act (part of the California Health and Safety Code) can be found at https://leginfo.legislature.ca.gov/faces/codesTOCSelected.xhtml?tocCode=HSC. The Substances Act begins at Section 11000, and information regarding prescriptions begins in Section 11150.
There must be careful consideration when prescribing to addicts or suspected addicts, particularly when patients are requesting specific drugs. As of 2016, California legislation requires that all prescribers of controlled substances register to access CURES, the state prescription drug monitoring program database intended to aid prescribers and dispensers in identifying fraudulent activity, thereby reducing prescription drug abuse and diversion without affecting legitimate medical practice or patient care. As of October 2018, all licensees authorized to prescribe, order, administer, furnish or dispense controlled substances in California must, with some exceptions, check a patient's prescription history in CURES 2.0 before prescribing a Schedule II, III, or IV substance [27].
The following section of the California Business and Professional Code addresses unprofessional conduct related to furnishing prescription drugs and excessive prescribing.
Section 725. (a) Repeated acts of clearly excessive prescribing, furnishing, dispensing, or administering of drugs or treatment, repeated acts of clearly excessive use of diagnostic procedures, or repeated acts of clearly excessive use of diagnostic or treatment facilities as determined by the standard of the community of licensees is unprofessional conduct for a physician and surgeon, dentist, podiatrist, psychologist, physical therapist, chiropractor, optometrist, speech-language pathologist, or audiologist.
(b) Any person who engages in repeated acts of clearly excessive prescribing or administering of drugs or treatment is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) nor more than six hundred dollars ($600), or by imprisonment for a term of not less than 60 days nor more than 180 days, or by both that fine and imprisonment.
(c) A practitioner who has a medical basis for prescribing, furnishing, dispensing, or administering dangerous drugs or prescription controlled substances shall not be subject to disciplinary action or prosecution under this section.
(d) No physician and surgeon shall be subject to disciplinary action pursuant to this section for treating intractable pain in compliance with Section 2241.5.
The following sections of the Uniform Controlled Substances Act addresses the facilitation of abuse by prescribing practices, including the new CURES reporting requirements.
Section 11150.2. (a) Notwithstanding any other law, if cannabinoids are excluded from Schedule I of the federal Controlled Substances Act and placed on a schedule of the act other than Schedule I, or if a product composed of cannabinoids is approved by the federal Food and Drug Administration and either placed on a schedule of the act other than Schedule I, or exempted from one or more provisions of the act, so as to permit a physician, pharmacist, or other authorized healing arts licensee acting within their scope of practice, to prescribe, furnish, or dispense that product, the physician, pharmacist, or other authorized healing arts licensee who prescribes, furnishes, or dispenses that product in accordance with federal law shall be deemed to be in compliance with state law governing those acts.
(b) For purposes of this chapter, upon the effective date of one of the changes in federal law described in subdivision (a), notwithstanding any other state law, a product composed of cannabinoids may be prescribed, furnished, dispensed, transferred, transported, possessed, or used in accordance with federal law and is authorized pursuant to state law.
(c) This section does not apply to any product containing cannabinoids that is made or derived from industrial hemp, as defined in Section 11018.5 and regulated pursuant to that section.
Section 11153. (a) A prescription for a controlled substance shall only be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his or her professional practice. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. Except as authorized by this division, the following are not legal prescriptions: (1) an order purporting to be a prescription which is issued not in the usual course of professional treatment or in legitimate and authorized research; or (2) an order for an addict or habitual user of controlled substances, which is issued not in the course of professional treatment or as part of an authorized narcotic treatment program, for the purpose of providing the user with controlled substances, sufficient to keep him or her comfortable by maintaining customary use.
(b) Any person who knowingly violates this section shall be punished by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, or in a county jail not exceeding one year, or by a fine not exceeding twenty thousand dollars ($20,000), or by both that fine and imprisonment.
(c) No provision of the amendments to this section enacted during the second year of the 1981–82 Regular Session shall be construed as expanding the scope of practice of a pharmacist.
Section 11164.1. (a)
Notwithstanding any other law, a prescription for a controlled substance issued by a prescriber in another state for delivery to a patient in another state may be dispensed by a California pharmacy, if the prescription conforms with the requirements for controlled substance prescriptions in the state in which the controlled substance was prescribed.
A prescription for Schedule II, Schedule III, Schedule IV, or Schedule V controlled substances dispensed pursuant to this subdivision shall be reported by the dispensing pharmacy to the Department of Justice in the manner prescribed by subdivision (d) of Section 11165.
(b) A pharmacy may dispense a prescription for a Schedule III, Schedule IV, or Schedule V controlled substance from an out-of-state prescriber pursuant to Section 4005 of the Business and Professions Code and Section 1717 of Title 16 of the California Code of Regulations.
(c) This section shall become operative on January 1, 2021.
Section 11165. (a) To assist health care practitioners in their efforts to ensure appropriate prescribing, ordering, administering, furnishing, and dispensing of controlled substances, law enforcement and regulatory agencies in their efforts to control the diversion and resultant abuse of Schedule II, Schedule III, Schedule IV, and Schedule V controlled substances, and for statistical analysis, education, and research, the Department of Justice shall, contingent upon the availability of adequate funds in the CURES Fund, maintain the Controlled Substance Utilization Review and Evaluation System (CURES) for the electronic monitoring of, and Internet access to information regarding, the prescribing and dispensing of Schedule II, Schedule III, Schedule IV, and Schedule V controlled substances by all practitioners authorized to prescribe, order, administer, furnish, or dispense these controlled substances.
(b) The Department of Justice may seek and use grant funds to pay the costs incurred by the operation and maintenance of CURES. The department shall annually report to the Legislature and make available to the public the amount and source of funds it receives for support of CURES.
(c)
The operation of CURES shall comply with all applicable federal and state privacy and security laws and regulations.
CURES shall operate under existing provisions of law to safeguard the privacy and confidentiality of patients. Data obtained from CURES shall only be provided to appropriate state, local, and federal public agencies for disciplinary, civil, or criminal purposes and to other agencies or entities, as determined by the department, for the purpose of educating practitioners and others in lieu of disciplinary, civil, or criminal actions. Data may be provided to public or private entities, as approved by the department, for educational, peer review, statistical, or research purposes, if patient information, including information that may identify the patient, is not compromised. The University of California shall be provided access to identifiable data for research purposes if the requirements of subdivision (t) of Section 1798.24 of the Civil Code are satisfied. Further, data disclosed to an individual or agency as described in this subdivision shall not be disclosed, sold, or transferred to a third party, unless authorized by, or pursuant to, state and federal privacy and security laws and regulations. The department shall establish policies, procedures, and regulations regarding the use, access, evaluation, management, implementation, operation, storage, disclosure, and security of the information within CURES, consistent with this subdivision.
Notwithstanding subparagraph (A), a regulatory board whose licensees do not prescribe, order, administer, furnish, or dispense controlled substances shall not be provided data obtained from CURES.
The department shall, no later than January 1, 2021, adopt regulations regarding the access and use of the information within CURES. The department shall consult with all stakeholders identified by the department during the rulemaking process. The regulations shall, at a minimum, address all of the following in a manner consistent with this chapter:
The process for approving, denying, and disapproving individuals or entities seeking access to information in CURES.
The purposes for which a health care practitioner may access information in CURES.
The conditions under which a warrant, subpoena, or court order is required for a law enforcement agency to obtain information from CURES as part of a criminal investigation.
The process by which information in CURES may be provided for educational, peer review, statistical, or research purposes.
In accordance with federal and state privacy laws and regulations, a health care practitioner may provide a patient with a copy of the patient's CURES patient activity report as long as no additional CURES data are provided and the health care practitioner keeps a copy of the report in the patient's medical record in compliance with subdivision (d) of Section 11165.1.
(d) For each prescription for a Schedule II, Schedule III, Schedule IV, or Schedule V controlled substance, as defined in the controlled substances schedules in federal law and regulations, specifically Sections 1308.12, 1308.13, 1308.14, and 1308.15, respectively, of Title 21 of the Code of Federal Regulations, the dispensing pharmacy, clinic, or other dispenser shall report the following information to the department or contracted prescription data processing vendor as soon as reasonably possible, but not more than one working day after the date a controlled substance is released to the patient or patient's representative, in a format specified by the department:
Full name, address, and, if available, telephone number of the ultimate user or research subject, or contact information as determined by the Secretary of the United States Department of Health and Human Services, and the gender, and date of birth of the ultimate user.
The prescriber's category of licensure, license number, national provider identifier (NPI) number, if applicable, the federal controlled substance registration number, and the state medical license number of a prescriber using the federal controlled substance registration number of a government-exempt facility.
Pharmacy prescription number, license number, NPI number, and federal controlled substance registration number.
National Drug Code (NDC) number of the controlled substance dispensed.
Quantity of the controlled substance dispensed.
The International Statistical Classification of Diseases (ICD) Code contained in the most current ICD revision, or any revision deemed sufficient by the State Board of Pharmacy, if available.
Number of refills ordered.
Whether the drug was dispensed as a refill of a prescription or as a first-time request.
Prescribing date of the prescription.
Date of dispensing of the prescription.
The serial number for the corresponding prescription form, if applicable.
(e) The department may invite stakeholders to assist, advise, and make recommendations on the establishment of rules and regulations necessary to ensure the proper administration and enforcement of the CURES database. A prescriber or dispenser invitee shall be licensed by one of the boards or committees identified in subdivision (d) of Section 208 of the Business and Professions Code, in active practice in California, and a regular user of CURES.
(f) The department shall, prior to upgrading CURES, consult with prescribers licensed by one of the boards or committees identified in subdivision (d) of Section 208 of the Business and Professions Code, one or more of the boards or committees identified in subdivision (d) of Section 208 of the Business and Professions Code, and any other stakeholder identified by the department, for the purpose of identifying desirable capabilities and upgrades to the CURES Prescription Drug Monitoring Program (PDMP).
(g) The department may establish a process to educate authorized subscribers of the CURES PDMP on how to access and use the CURES PDMP.
(h)
The department may enter into an agreement with an entity operating an interstate data sharing hub, or an agency operating a prescription drug monitoring program in another state, for purposes of interstate data sharing of prescription drug monitoring program information.
Data obtained from CURES may be provided to authorized users of another state's prescription drug monitoring program, as determined by the department pursuant to subdivision (c), if the entity operating the interstate data sharing hub, and the prescription drug monitoring program of that state, as applicable, have entered into an agreement with the department for interstate data sharing of prescription drug monitoring program information.
An agreement entered into by the department for purposes of interstate data sharing of prescription drug monitoring program information shall ensure that all access to data obtained from CURES and the handling of data contained within CURES comply with California law, including regulations, and meet the same patient privacy, audit, and data security standards employed and required for direct access to CURES.
For purposes of interstate data sharing of CURES information pursuant to this subdivision, an authorized user of another state's prescription drug monitoring program shall not be required to register with CURES, if the authorized user is registered and in good standing with that state's prescription drug monitoring program.
The department shall not enter into an agreement pursuant to this subdivision until the department has issued final regulations regarding the access and use of the information within CURES as required by paragraph (3) of subdivision (c).
(j) If the dispensing pharmacy, clinic, or other dispenser experiences a temporary technological or electrical failure, it shall, without undue delay, seek to correct any cause of the temporary technological or electrical failure that is reasonably within its control. The deadline for transmitting prescription information to the department or contracted prescription data processing vendor pursuant to subdivision (d) shall be extended until the failure is corrected. If the dispensing pharmacy, clinic, or other dispenser experiences technological limitations that are not reasonably within its control, or is impacted by a natural or manmade disaster, the deadline for transmitting prescription information to the department or contracted prescription data processing vendor shall be extended until normal operations have resumed.
Section 11165.1. (a)
A health care practitioner authorized to prescribe, order, administer, furnish, or dispense Schedule II, Schedule III, Schedule IV, or Schedule V controlled substances pursuant to Section 11150 shall, upon receipt of a federal Drug Enforcement Administration (DEA) registration, submit an application developed by the department to obtain approval to electronically access information regarding the controlled substance history of a patient that is maintained by the department. Upon approval, the department shall release to that practitioner or their delegate the electronic history of controlled substances dispensed to an individual under the practitioner's care based on data contained in the CURES Prescription Drug Monitoring Program (PDMP).
A pharmacist shall, upon licensure, submit an application developed by the department to obtain approval to electronically access information regarding the controlled substance history of a patient that is maintained by the department. Upon approval, the department shall release to the pharmacist or their delegate the electronic history of controlled substances dispensed to an individual under the pharmacist's care based on data contained in the CURES PDMP.
A licensed physician and surgeon who does not hold a DEA registration may submit an application developed by the department to obtain approval to electronically access information regarding the controlled substance history of the patient that is maintained by the department. Upon approval, the department shall release to the physician and surgeon or their delegate the electronic history of controlled substances dispensed to a patient under their care based on data contained in the CURES PDMP.
The department shall implement its duties described in clauses (i), (ii), and (iii) upon completion of any technological changes to the CURES database necessary to support clauses (i), (ii), and (iii), or by October 1, 2022, whichever is sooner.
The department may deny an application or suspend a subscriber, for reasons that include, but are not limited to, the following:
Materially falsifying an application to access information contained in the CURES database.
Failing to maintain effective controls for access to the patient activity report.
Having their federal DEA registration suspended or revoked.
Violating a law governing controlled substances or another law for which the possession or use of a controlled substance is an element of the crime.
Accessing information for a reason other than to diagnose or treat a patient, or to document compliance with the law.
An authorized subscriber shall notify the department within 30 days of a change to the subscriber account.
An approved health care practitioner, pharmacist, or a person acting on behalf of a health care practitioner or pharmacist pursuant to subdivision (b) of Section 209 of the Business and Professions Code may use the department's online portal or a health information technology system that meets the criteria required in subparagraph (E) to access information in the CURES database pursuant to this section. A subscriber who uses a health information technology system that meets the criteria required in subparagraph (E) to access the CURES database may submit automated queries to the CURES database that are triggered by predetermined criteria.
An approved health care practitioner or pharmacist may submit queries to the CURES database through a health information technology system if the entity that operates the health information technology system certifies all of the following:
The entity will not use or disclose data received from the CURES database for any purpose other than delivering the data to an approved health care practitioner or pharmacist or performing data processing activities that may be necessary to enable the delivery unless authorized by, and pursuant to, state and federal privacy and security laws and regulations.
The health information technology system will authenticate the identity of an authorized health care practitioner or pharmacist initiating queries to the CURES database and, at the time of the query to the CURES database, the health information technology system submits the following data regarding the query to CURES:
The date of the query.
The time of the query.
The first and last name of the patient queried.
The date of birth of the patient queried.
The identification of the CURES user for whom the system is making the query.
The health information technology system meets applicable patient privacy and information security requirements of state and federal law.
The entity has entered into a memorandum of understanding with the department that solely addresses the technical specifications of the health information technology system to ensure the security of the data in the CURES database and the secure transfer of data from the CURES database. The technical specifications shall be universal for all health information technology systems that establish a method of system integration to retrieve information from the CURES database. The memorandum of understanding shall not govern, or in any way impact or restrict, the use of data received from the CURES database or impose any additional burdens on covered entities in compliance with the regulations promulgated pursuant to the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations.
No later than October 1, 2018, the department shall develop a programming interface or other method of system integration to allow health information technology systems that meet the requirements in subparagraph (E) to retrieve information in the CURES database on behalf of an authorized health care practitioner or pharmacist.
The department shall not access patient-identifiable information in an entity's health information technology system.
An entity that operates a health information technology system that is requesting to establish an integration with the CURES database shall pay a reasonable fee to cover the cost of establishing and maintaining integration with the CURES database.
The department may prohibit integration or terminate a health information technology system's ability to retrieve information in the CURES database if the health information technology system fails to meet the requirements of subparagraph (E), or the entity operating the health information technology system does not fulfill its obligation under subparagraph (H).
A health care practitioner authorized to prescribe, order, administer, furnish, or dispense Schedule II, Schedule III, Schedule IV, or Schedule V controlled substances pursuant to Section 11150 or a pharmacist shall be deemed to have complied with paragraph (1) if the licensed health care practitioner or pharmacist has been approved to access the CURES database through the process developed pursuant to subdivision (a) of Section 209 of the Business and Professions Code.
(b) A request for, or release of, a controlled substance history pursuant to this section shall be made in accordance with guidelines developed by the department.
(c) In order to prevent the inappropriate, improper, or illegal use of Schedule II, Schedule III, Schedule IV, or Schedule V controlled substances, the department may initiate the referral of the history of controlled substances dispensed to an individual based on data contained in CURES to licensed health care practitioners, pharmacists, or both, providing care or services to the individual.
(d) The history of controlled substances dispensed to an individual based on data contained in CURES that is received by a practitioner or pharmacist from the department pursuant to this section is medical information subject to the provisions of the Confidentiality of Medical Information Act contained in Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code.
(e) Information concerning a patient's controlled substance history provided to a practitioner or pharmacist pursuant to this section shall include prescriptions for controlled substances listed in Sections 1308.12, 1308.13, 1308.14, and 1308.15 of Title 21 of the Code of Federal Regulations.
(f) A health care practitioner, pharmacist, or a person acting on behalf of a health care practitioner or pharmacist, when acting with reasonable care and in good faith, is not subject to civil or administrative liability arising from false, incomplete, inaccurate, or misattributed information submitted to, reported by, or relied upon in the CURES database or for a resulting failure of the CURES database to accurately or timely report that information.
(g) For purposes of this section, the following terms have the following meanings:
"Automated basis" means using predefined criteria to trigger an automated query to the CURES database, which can be attributed to a specific health care practitioner or pharmacist.
"Department" means the Department of Justice.
"Entity" means an organization that operates, or provides or makes available, a health information technology system to a health care practitioner or pharmacist.
"Health information technology system" means an information processing application using hardware and software for the storage, retrieval, sharing of or use of patient data for communication, decisionmaking, coordination of care, or the quality, safety, or efficiency of the practice of medicine or delivery of health care services, including, but not limited to, electronic medical record applications, health information exchange systems, or other interoperable clinical or health care information system.
(h) This section shall become operative on July 1, 2021, or upon the date the department promulgates regulations to implement this section and posts those regulations on its Internet website, whichever date is earlier.
Section 11165.2. (a) The Department of Justice may conduct audits of the CURES Prescription Drug Monitoring Program system and its users.
(b) The Department of Justice may establish, by regulation, a system for the issuance to a CURES Prescription Drug Monitoring Program subscriber of a citation which may contain an order of abatement, or an order to pay an administrative fine assessed by the Department of Justice if the subscriber is in violation of any provision of this chapter or any regulation adopted by the Department of Justice pursuant to this chapter.
(c) The system shall contain the following provisions:
Citations shall be in writing and shall describe with particularity the nature of the violation, including specific reference to the provision of law or regulation of the department determined to have been violated.
Whenever appropriate, the citation shall contain an order of abatement establishing a reasonable time for abatement of the violation.
In no event shall the administrative fine assessed by the department exceed two thousand five hundred dollars ($2,500) for each violation. In assessing a fine, due consideration shall be given to the appropriateness of the amount of the fine with respect to such factors as the gravity of the violation, the good faith of the subscribers, and the history of previous violations.
An order of abatement or a fine assessment issued pursuant to a citation shall inform the subscriber that if the subscriber desires a hearing to contest the finding of a violation, a hearing shall be requested by written notice to the CURES Prescription Drug Monitoring Program within 30 days of the date of issuance of the citation or assessment. Hearings shall be held pursuant to Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.
In addition to requesting a hearing, the subscriber may, within 10 days after service of the citation, request in writing an opportunity for an informal conference with the department regarding the citation. At the conclusion of the informal conference, the department may affirm, modify, or dismiss the citation, including any fine levied or order of abatement issued. The decision shall be deemed to be a final order with regard to the citation issued, including the fine levied or the order of abatement which could include permanent suspension to the system, a monetary fine, or both, depending on the gravity of the violation. However, the subscriber does not waive its right to request a hearing to contest a citation by requesting an informal conference. If the citation is affirmed, a formal hearing may be requested within 30 days of the date the citation was affirmed. If the citation is dismissed after the informal conference, the request for a hearing on the matter of the citation shall be deemed to be withdrawn. If the citation, including any fine levied or order of abatement, is modified, the citation originally issued shall be considered withdrawn and a new citation issued. If a hearing is requested for a subsequent citation, it shall be requested within 30 days of service of that subsequent citation.
Failure of a subscriber to pay a fine within 30 days of the date of assessment or comply with an order of abatement within the fixed time, unless the citation is being appealed, may result in disciplinary action taken by the department. If a citation is not contested and a fine is not paid, the subscriber account will be terminated:
A citation may be issued without the assessment of an administrative fine.
Assessment of administrative fines may be limited to only particular violations of law or department regulations.
(d) Notwithstanding any other provision of law, if a fine is paid to satisfy an assessment based on the finding of a violation, payment of the fine shall be represented as a satisfactory resolution of the matter for purposes of public disclosure.
(e) Administrative fines collected pursuant to this section shall be deposited in the CURES Program Special Fund, available upon appropriation by the Legislature. These special funds shall provide support for costs associated with informal and formal hearings, maintenance, and updates to the CURES Prescription Drug Monitoring Program.
(f) The sanctions authorized under this section shall be separate from, and in addition to, any other administrative, civil, or criminal remedies; however, a criminal action may not be initiated for a specific offense if a citation has been issued pursuant to this section for that offense, and a citation may not be issued pursuant to this section for a specific offense if a criminal action for that offense has been filed.
(g) Nothing in this section shall be deemed to prevent the department from serving and prosecuting an accusation to suspend or revoke a subscriber if grounds for that suspension or revocation exist.
Section 11165.4. (a)
A health care practitioner authorized to prescribe, order, administer, or furnish a controlled substance shall consult the patient activity report or information from the patient activity report obtained from the CURES database to review a patient's controlled substance history for the past 12 months before prescribing a Schedule II, Schedule III, or Schedule IV controlled substance to the patient for the first time and at least once every six months thereafter if the prescriber renews the prescription and the substance remains part of the treatment of the patient.
If a health care practitioner authorized to prescribe, order, administer, or furnish a controlled substance is not required, pursuant to an exemption described in subdivision (c), to consult the patient activity report from the CURES database the first time the health care practitioner prescribes, orders, administers, or furnishes a controlled substance to a patient, the health care practitioner shall consult the patient activity report from the CURES database to review the patient's controlled substance history before subsequently prescribing a Schedule II, Schedule III, or Schedule IV controlled substance to the patient and at least once every six months thereafter if the prescriber renews the prescription and the substance remains part of the treatment of the patient.
A health care practitioner who did not directly access the CURES database to perform the required review of the controlled substance use report shall document in the patient's medical record that they reviewed the CURES database generated report within 24 hours of the controlled substance prescription that was provided to them by another authorized user of the CURES database.
For purposes of this paragraph, "first time" means the initial occurrence in which a health care practitioner, in their role as a health care practitioner, intends to prescribe, order, administer, or furnish a Schedule II, Schedule III, or Schedule IV controlled substance to a patient and has not previously prescribed a controlled substance to the patient.
A health care practitioner shall review a patient's controlled substance history that has been obtained from the CURES database no earlier than 24 hours, or the previous business day, before the health care practitioner prescribes, orders, administers, or furnishes a Schedule II, Schedule III, or Schedule IV controlled substance to the patient.
(b) The duty to consult the CURES database, as described in subdivision (a), does not apply to veterinarians or pharmacists.
(c) The duty to consult the CURES database, as described in subdivision (a), does not apply to a health care practitioner in any of the following circumstances:
If a health care practitioner prescribes, orders, or furnishes a controlled substance to be administered to a patient while the patient in any of the following facilities or during an emergency transfer between any of the following facilities, or for use while on facility premises:
A licensed clinic, as described in Chapter 1 (commencing with Section 1200) of Division 2.
An outpatient setting, as described in Chapter 1.3 (commencing with Section 1248) of Division 2.
A health facility, as described in Chapter 2 (commencing with Section 1250) of Division 2.
A county medical facility, as described in Chapter 2.5 (commencing with Section 1440) of Division 2.
Another medical facility, including, but not limited to, an office of a health care practitioner and an imaging center.
A correctional clinic, as described in Section 4187 of the Business and Professions Code, or a correctional pharmacy, as described in Section 4021.5 of the Business and Professions Code.
If a health care practitioner prescribes, orders, administers, or furnishes a controlled substance in the emergency department of a general acute care hospital and the quantity of the controlled substance does not exceed a nonrefillable seven-day supply of the controlled substance to be used in accordance with the directions for use.
If a health care practitioner prescribes, orders, administers, or furnishes a controlled substance to a patient as part of the patient's treatment for a surgical, radiotheraputic, or diagnostic procedure and the quantity of the controlled substance does not exceed a nonrefillable seven-day supply of the controlled substance to be used in accordance with the directions for use, in any of the following facilities:
A licensed clinic, as described in Chapter 1 (commencing with Section 1200) of Division 2.
An outpatient setting, as described in Chapter 1.3 (commencing with Section 1248) of Division 2.
A health facility, as described in Chapter 2 (commencing with Section 1250) of Division 2.
A county medical facility, as described in Chapter 2.5 (commencing with Section 1440) of Division 2.
A place of practice, as defined in Section 1658 of the Business and Professions Code.
Another medical facility where surgical procedures are permitted to take place, including, but not limited to, the office of a health care practitioner.
If a health care practitioner prescribes, orders, administers, or furnishes a controlled substance to a patient who is terminally ill, as defined in subdivision (c) of Section 11159.2.
If all of the following circumstances are satisfied:
It is not reasonably possible for a health care practitioner to access the information in the CURES database in a timely manner.
Another health care practitioner or designee authorized to access the CURES database is not reasonably available.
The quantity of controlled substance prescribed, ordered, administered, or furnished does not exceed a nonrefillable seven-day supply of the controlled substance to be used in accordance with the directions for use and no refill of the controlled substance is allowed.
A health care practitioner who does not consult the CURES database under subparagraph (A) shall document the reason they did not consult the database in the patient's medical record.
If the CURES database is not operational, as determined by the department, or cannot be accessed by a health care practitioner because of a temporary technological or electrical failure. A health care practitioner shall, without undue delay, seek to correct the cause of the temporary technological or electrical failure that is reasonably within the health care practitioner's control.
If the CURES database cannot be accessed because of technological limitations that are not reasonably within the control of a health care practitioner.
If consultation of the CURES database would, as determined by the health care practitioner, result in a patient's inability to obtain a prescription in a timely manner and thereby adversely impact the patient's medical condition, provided that the quantity of the controlled substance does not exceed a nonrefillable seven-day supply if the controlled substance were used in accordance with the directions for use.
(d)
A health care practitioner who fails to consult the CURES database, as described in subdivision (a), shall be referred to the appropriate state professional licensing board solely for administrative sanctions, as deemed appropriate by that board.
This section does not create a private cause of action against a health care practitioner. This section does not limit a health care practitioner's liability for the negligent failure to diagnose or treat a patient.
(e) All applicable state and federal privacy laws govern the duties required by this section.
(f) The provisions of this section are severable. If any provision of this section or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.
(g) This section shall become operative on July 1, 2021, or upon the date the department promulgates regulations to implement this section and posts those regulations on its internet website, whichever date is earlier.
In accordance with California Penal Code Section 11165.7, dentists, dental assistants, and dental hygienists are mandated reporters of child abuse and neglect [3]. Reporting suspected abuse is not only an ethical duty but is also a legal obligation.
Section 11164. (a) This article shall be known and may be cited as the Child Abuse and Neglect Reporting Act.
(b) The intent and purpose of this article is to protect children from abuse and neglect. In any investigation of suspected child abuse or neglect, all persons participating in the investigation of the case shall consider the needs of the child victim and shall do whatever is necessary to prevent psychological harm to the child victim.
Section 11166. (a) Except as provided in subdivision (d), and in Section 11166.05, a mandated reporter shall make a report to an agency specified in Section 11165.9 whenever the mandated reporter, in the mandated reporter's professional capacity or within the scope of the mandated reporter's employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter shall make an initial report by telephone to the agency immediately or as soon as is practicably possible, and shall prepare and send, fax, or electronically transmit a written follow-up report within 36 hours of receiving the information concerning the incident. The mandated reporter may include with the report any nonprivileged documentary evidence the mandated reporter possesses relating to the incident.
Section 11165.9. Reports of suspected child abuse or neglect shall be made by mandated reporters, or in the case of reports pursuant to Section 11166.05, may be made, to any police department or sheriff's department, not including a school district police or security department, county probation department, if designated by the county to receive mandated reports, or the county welfare department. Any of those agencies shall accept a report of suspected child abuse or neglect whether offered by a mandated reporter or another person, or referred by another agency, even if the agency to whom the report is being made lacks subject matter or geographical jurisdiction to investigate the reported case, unless the agency can immediately electronically transfer the call to an agency with proper jurisdiction. When an agency takes a report about a case of suspected child abuse or neglect in which that agency lacks jurisdiction, the agency shall immediately refer the case by telephone, fax, or electronic transmission to an agency with proper jurisdiction. Agencies that are required to receive reports of suspected child abuse or neglect may not refuse to accept a report of suspected child abuse or neglect from a mandated reporter or another person unless otherwise authorized pursuant to this section, and shall maintain a record of all reports received.
Preventing serious morbidity and mortality involves intervening at the first suspicion or indication of abuse and/or neglect. Dentists and dental hygienists are often the healthcare professionals who have the most frequent interactions with children and should be attentive to any signs of neglect and physical abuse—as abusive injuries commonly involve the face, jaw, mouth, teeth, and tongue [4]. One study found that orofacial trauma was concurrent with 49% of documented cases of child physical abuse [5]. Other studies show that craniofacial and neck injuries occur in 50% to 65% of child abuse victims and that the lips are a site for abusive injury in 54% of cases [6,7].
The American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect and the California Dental Association have published useful articles regarding the identification of the orofacial signs of abuse and particular injuries of concern. According to these sources, possible signs of abuse include [6,7,12]:
Forced feeding injuries caused by eating utensils, bottles, hands, fingers, and other objects; scalding liquids; or caustic substances. These may be responsible for burns, contusions, or lacerations of the lips, tongue, buccal mucosa, gingival alveolar mucosa, frenum, or palate (soft and hard). Objects forced into the face/mouth may also cause facial bone and jaw fractures and avulsed, displaced, or fractured teeth.
Mouth gagging injuries resulting in bruises, lichenification, or scarring at the corners of the mouth
Strangulation injuries resulting in bruising, a hoarse or raspy voice, and difficulty breathing
Discolored teeth from previous trauma
Serious trauma (e.g., retropharyngeal abscesses, posterior pharyngeal injuries) resulting from caregivers with factitious disorder (i.e., Münchausen syndrome) by proxy
Injury to the petechiae of the palate (particularly at the junction of soft and hard palate) resulting from forced oral sex
Sexually transmitted oral/perioral infections (e.g., gonorrhea, human papillomavirus warts), although these can be transmitted by other means as well
Bite marks or bruises on the head or face, strangulation marks, or black eyes
Missing hair from hair pulling
Welts in the shape of objects (e.g., belt buckle, clothes iron)
Other suspicious trauma/bruises indicative of abuse (e.g., rope marks)
During examination, excessive caries, gingivitis, and oral infections/diseases should be noted as possible signs of neglect. (Parents or caretakers with an ignorance of proper oral care, who have no perceived value of oral health, with limited access to health care or insurance, and/or geographic isolation should be differentiated from those with a willful disregard for the child's health [6].) Perioral and intraoral injuries and infections in various stages of healing, especially those that seem inappropriate for the child's developmental age, should be documented. Additionally, abuse and neglect are more prevalent (up to four times more common) in individuals with developmental or physical disability [12].
Although accidental injuries are common in pediatric patients, the history of trauma, including mechanism and timing, must be weighed against the injury features. Characteristics of the injury that do not seem to match the reported history should spur suspicion of abuse. The acronym RADAR is commonly used to assist in the routine abuse screening of patients [29]:
Routinely screen for signs and symptoms of abuse/neglect
Ask direct, non-judgmental questions with compassion
Document your findings
Assess patient safety before the patient leaves the medical setting
Review, refer, report
A parent or primary caretaker may be genuinely unaware of the abuse or injuries and may not be able to offer information relevant to the history. It is important not to make judgments of family members (either innocent or guilty), apportion blame, or attempt to personally undertake a criminal investigation. The scope of dental practice does not include these actions, and they may interfere with a law enforcement investigation. The AAP notes that the dental professional's role in a criminal investigation is to interpret medical information for nonmedical professionals in an understandable manner that accurately reflects the medical evidence [8]. Identify the medical problem, document the suspected abuse (e.g., names, photos, body map, preserve evidence), treat the injuries, and offer honest, factual medical information to parents, families, law enforcement, and justice officials.
As noted in the California Dental Practice Act, dental healthcare professionals have a legal and ethical responsibility to report suspected child abuse to the proper authorities, not to punish perpetrators of abuse but to protect the abuse victims. One author writes, "The dentist must view himself as a child advocate. Simply treating dental and facial injuries of abused children while ignoring the social needs of the child and family is unacceptable" [9].
Nonetheless, the decision of whether or not to report suspected abuse is ethically challenging. Although healthcare professionals are obligated to report suspected abuse, suspicion of abuse is somewhat of a judgment call and certain biases may influence the decision to report. It has been noted that well-intentioned professionals in all fields are swayed by both negative and positive social biases (e.g., sex, race, socioeconomic status, physical appearance, job status), and it is advisable to challenge personal biases and weigh only the facts of the case. A 2008 prospective, observational AAP study found that, "clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse" because of various biases and experiences [10]. However, patients who had an injury that was not a laceration, who had more than one family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who had a parental history of substance abuse, or who were unfamiliar to the clinician were more likely to be reported.
Professionally mandated reporters are protected from civil or criminal prosecution in consequence of a good-faith report of abuse, and no clinician in the aforementioned AAP study was sued for malpractice as a result of reporting abuse [7,10]. However, it is possible for dental professionals to be sued, and a state petition for up to $50,000 in recompensatory legal fees is available for dentists having to defend themselves in court [7]. On the other hand, civil or criminal penalties for willfully not reporting abuse or impeding a report when abuse has been found to have occurred include 6 months in jail and/or a fine of $1,000 or, in cases of serious injury/death following a failure to report, 12 months in jail, and/or a fine of $5,000.
Abusive injuries to the mouth and oral cavity of elder or dependent (e.g., developmentally or physically disabled) adults are similar in type and causation to those sustained by pediatric patients, including trauma from forced feeding, object insertion, mouth gagging, and being slapped, hit, or strangled, but also include damage to and from prostheses. The number of new elder and dependent adult abuse cases is usually about 18,000 per month in California alone, with family members constituting two-thirds of perpetrators [11,26]. However, researchers estimate that for each incident of reported abuse there are at least five (and perhaps up to 14) unreported incidents [11]. Studies have shown that dental professionals are reluctant to report elder or dependent abuse/neglect and that they have a low index of suspicion of this category of abuse [13].
The national frequency of elder abuse is estimated at up to 10%, with a steady increase in reporting over the last few decades [14]. Contrary to popular belief, the overwhelming majority of abuse and neglect occurs in domestic, rather than institutional (e.g., residential care) settings, largely due to the shift in care in the last 50 years from state institutions to the home (particularly for younger disabled individuals) [12,14]. Women are the victims of elder abuse two-thirds of the time.
Elder and dependent adults are also at risk for poor oral health due to caretaker neglect. In fact, neglect is one of the most common causes of elder injury reporting (roughly 500,000 cases per year in the United States) [14]. These populations are also at a high risk for self-neglect, accounting for more than 500,000 additional reported cases in the United States per year. A 2010 study revealed that 40% of individuals 65 years of age or older suffer from some form of neglect [15].
Laws pertaining to mandatory elder and dependent adult abuse reporting are found in the California Welfare and Institutions Code Sections 15600 to 15632 [16].
Section 15600. (a) The Legislature recognizes that elders and dependent adults may be subjected to abuse, neglect, or abandonment and that this state has a responsibility to protect these persons.
(i) Therefore, it is the intent of the Legislature in enacting this chapter to provide that adult protective services agencies, local long-term care ombudsman programs, and local law enforcement agencies shall receive referrals or complaints from public or private agencies, from any mandated reporter submitting reports pursuant to Section 15630, or from any other source having reasonable cause to know that the welfare of an elder or dependent adult is endangered, and shall take any actions considered necessary to protect the elder or dependent adult and correct the situation and ensure the individual's safety.
Section 15630. (a) Any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter.
(b) (1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section 15658, within two working days.
Intimate partner violence is defined as violence directed at a "spouse, former spouse, cohabitant, former cohabitant, or person with whom the suspect has had a child or is having or has had a dating or engagement relationship" [7]. In the United States in 2011, severe physical violence by an intimate partner (including acts such as being hit with something hard, being kicked or beaten, or being burned on purpose) had been experienced by an estimated 22.3% of women and 14.0% of men during their lifetimes [17].
Dental professionals should be vigilant in recognizing signs of abuse among adolescent and adult patients. One-half to two-thirds of abusive injuries occur to the head (particularly areas covered with hair) and neck, and facial injuries occur in 94% of intimate partner violence cases and are similar to those already discussed [7,18]. Again, dental visits may be a patient's only contact with healthcare professionals, making identification of abuse an important part of dental visits [7]. A history of intimidation, fear, isolation, and dependency is often present in victims of abuse, so it is especially important to determine the origin of orofacial or craniofacial injuries through the use of nonjudgmental questions. The Stanford School of Medicine recommends the following lines of indirect questioning for most age groups [31]:
How is everything going at home?
Is there anything going on at work/school or at home that's difficult for you to talk about or is stressful for you?
Are you having any problems with your parents/caretakers/partner/husband?
Alternately, lines of direct questioning may be used [31]:
Did someone kick, hit, hurt, or threaten to hurt you? Was it your parent/caretaker or partner/husband?
Are you in a relationship with (or do you live with) someone who hits, kicks, or threatens to hurt you?
Have you ever been slapped, pushed, or shoved by your parent/partner?
Have there been times when you felt afraid at home being around another person?
Have you been hit or scared since the last time I saw you?
Is it safe for you to go home today?
It is up to the practitioner's judgment which line of questioning to employ. Remember that the objectives are to advocate for and protect the patient. The questions can be framed in a way that does not cause a patient to feel singled out [31]:
I don't know if this is (or has ever been) a problem for you, but many of the patients I see are dealing with abuse/abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I have started asking everyone about it.
From past experience with other patients, I'm concerned that some of your medical problems or injuries may be the result of someone hurting you. Is that happening?
When working cross-culturally, it is helpful to learn the colloquialisms used to describe abuse. For example, in some Latino cultures "disrespected me" refers to intimate partner violence or sexual assault [30]. If abuse is suspected and there is a cultural disconnect, consider the assistance of a knowledgeable co-worker, who may be able to act as a cultural broker.
Although its primary objective is to safeguard the public, the California Dental Practice Act is an excellent resource for dental professionals to ensure compliance with state law. Dental professionals with a good knowledge of the Dental Practice Act and its effects on dental care will practice legally and safely.
| California Dental Practice Act |
| https://www.dbc.ca.gov/about_us/lawsregs/laws.shtml |
| California Dental Association |
| https://www.cda.org |
| Dental Hygiene Board of California |
| https://dhbc.ca.gov |
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