This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h0503b.HCA
DATE: 4/11/2023
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 503 Practice of Dentistry
SPONSOR(S): Berfield
TIED BILLS: IDEN./SIM. BILLS: SB 356
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Healthcare Regulation Subcommittee 17 Y, 0 N Osborne McElroy
2) Health Care Appropriations Subcommittee Aderibigbe Clark
3) Health & Human Services Committee
SUMMARY ANALYSIS
The Board of Dentistry regulates dental practice in Florida, including dentists, dental hygienists, and dental
assistants under the Dental Practice Act. A dentist is licensed to examine, diagnose, treat, and care for
conditions within the human oral cavity and its adjacent tissues and structures. A dental hygienist provides
education, preventive and delegated therapeutic dental services. As of December 31, 2022, there were 18,238
licensed dentists, 18,335 licensed dental hygienists, 31,444 licensed dental radiographers, and 35 out-of-state
registered telehealth dentists.
Telehealth is the use of synchronous or asynchronous telecommunications technology by a telehealth provider
to provide health care services. Current law sets the standard of care for telehealth providers at the same level
as the standard of care for health care practitioners or health care providers providing in-person health care
services to patients in this state. This ensures that a patient receives the same standard of care irrespective of
the modality used by the health care professional to deliver the services. Current law does not contain health
care practitioner specific regulations for the use of telehealth. Health care practitioners must adhere to the
applicable standard of care when providing services through telehealth and are subject to disciplinary action if
they fail to do so.
HB 503 revises current regulations for the practice of dentistry and establishes requirements for using
telehealth to provide dental services to patients.
The bill requires every telehealth provider to have a dentist of record who remains primarily responsible for all
dental treatment on the patient regardless of who rendered treatment. The bill requires telehealth providers to
make available to the patient, before services are rendered, the name, the telephone number, practice
address, and state license number for the dentist of record and any other dentist who will be providing dental
services to the patient, and at any time requested by a patient.
The bill requires that an advertisement for dental services provided through telehealth to include a disclaimer.
The bill prohibits anyone other than a licensed dentist, a dental hygienist under general supervision, or a dental
assistant under direct supervision, from taking a dental impression or performing dental digital scan. Under
current law there are no restrictions on who may perform this type of digital scanning.
The bill expands grounds for the denial of a dental license or disciplinary action against a dentist for failure to
conduct an in-person examination in certain circumstances; failure by an individual providing service through
telehealth to provide patients with contact information; or to designate a dentist of record.
The bill has no fiscal impact on state or local government.
The bill provides an effective date of July 1, 2023. STORAGE NAME: h0503b.HCA PAGE: 2
DATE: 4/11/2023
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Regulation of Dental Practice in Florida
The Board of Dentistry regulates dental practice in Florida, including dentists, dental hygienists, and
dental assistants under the Dental Practice Act.
1
A dentist is licensed to examine, diagnose, treat, and
care for conditions within the human oral cavity and its adjacent tissues and structures.
2
A dental
hygienist provides education, preventive and delegated therapeutic dental services.
3
As of December
31, 2022, there were 18,238 licensed dentists, 18,335 licensed dental hygienists, 31,444 licensed
dental radiographers, and 35 out-of-state registered telehealth dentists.
4
Dentists
Any person wishing to practice dentistry in this state must apply to the Department of Health (DOH) and
meet specified requirements. Section 466.006, F.S., requires dentistry licensure applicants to sit for
and pass the following licensure examinations:
The National Board of Dental Examiners dental examination (NBDE);
A written examination on Florida laws and rules regulating the practice of dentistry; and
A practical examination, which is the American Dental Licensing Examination developed by the
American Board of Dental Examiners, Inc., and graded by a Florida-licensed dentist employed
by DOH for such purpose.
5
To qualify to take the Florida dental licensure examination, an applicant must be 18 years of age or
older, be a graduate of a dental school accredited by the American Dental Association or be a student
in the final year of a program at an accredited institution, and have successfully completed the NBDE
dental examination.
Dentists must maintain professional liability insurance or provide proof of professional responsibility. If
the dentist obtains professional liability insurance, the coverage must be at least $100,000 per claim,
with a minimum annual aggregate of at least $300,000.
6
Alternatively, a dentist may maintain an
unexpired, irrevocable letter of credit in the amount of $100,000 per claim, with a minimum aggregate
availability of credit of at least $300,000.
7
The professional liability insurance must provide coverage for
the actions of any dental hygienist supervised by the dentist.
8
However, a dentist may be exempt from
maintaining professional liability insurance if he or she:
9
Practices exclusively for the federal government or the State of Florida or its agencies or
subdivisions;
Is not practicing in this state;
Practices only in conjunction with his or her teaching duties at an accredited school of dentistry
or in its main teaching hospitals; or
Demonstrates to the Board of Dentistry that he or she has no malpractice exposure in this state.
1
Section 466.004, F.S.
2
Section 466.003(3), F.S.
3
Section 466.003(4)-(5), F.S.
4
Department of Health Agency Bill Analysis of HB 503 (January 25, 2023).
5
A passing score is valid for 365 days after the date the official examination results are published. A passing score on an examination
obtained in another jurisdiction must be completed on or after October 1, 2011.
6
Rule 64B5-17.011(1), F.A.C.
7
Rule 64B5-17.011(2), F.A.C.
8
Rule 64B5-17.011(4), F.A.C.
9
Rule 64B5-17.011(3), F.A.C. STORAGE NAME: h0503b.HCA PAGE: 3
DATE: 4/11/2023
Every dentist licensed in Florida must post and keep conspicuously displayed his or her license in the
office wherein she or he practices, in plain sight of patients.
Dental Hygienists
Any person wishing to be licensed as a dental hygienist must apply to DOH and meet the following
qualifications:
10
Be 18 years of age or older;
Be a graduate of an accredited dental hygiene college or school;
11
and
Obtain a passing score on the:
o Dental Hygiene National Board Examination;
o Dental Hygiene Licensing Examination developed by the American Board of Dental
Examiners, Inc., which is graded by a Florida-licensed dentist or dental hygienist
employed by DOH for such purpose; and
o A written examination on Florida laws and rules regulating the practice of dental
hygiene.
A dental hygienist is not required to maintain professional liability insurance and must be covered by
supervising dentist’s liability insurance.
12
A supervising dentist may delegate certain tasks to a dental hygienist, such as removing calculus
deposits, accretions, and stains from exposed surfaces of the teeth and from the gingival sulcus and
the task of performing root planning and curettage.
13
A dental hygienist may also expose dental X-ray
films, apply topical preventive or prophylactic agents, and delegated remediable tasks.
14
Remediable
tasks are intra-oral tasks which do not create an unalterable change in the oral cavity or contiguous
structures, are reversible, and do not expose a risk to the patient, including but not limited to:
Fabricating temporary crowns or bridges inter-orally;
Selecting and pre-sizing orthodontic bands;
Preparing a tooth service by applying conditioning agents for orthodontic appliances;
Removing and re-cementing properly contoured and fitting loose bands that are not
permanently attached to any appliance;
Applying bleaching solution, activating light source, and monitoring and removing in-office
bleaching solution;
Placing or removing rubber dams;
Making impressions for study casts which are not being made for the purpose of fabricating any
intra-oral appliances, restorations, or orthodontic appliances;
Taking impressions for passive appliances, occlusal guards, space maintainers, and protective
mouth guards; and
Cementing temporary crowns and bridges with temporary cement.
A dental hygienist may perform the following remediable tasks, if the dental hygienist has received
training in a pre-licensure course or through formal training:
Polish restorations or clinical crowns which are not for the purpose of changing the existing
contour of the tooth and may only use burnishers, slow-speed hand pieces, rubber cups, and
bristle brushes;
10
Section 466.007, F.S.
11
If the school is not accredited, the applicant must have completed a minimum of four years of postsecondary dental education and
received a dental school diploma which is comparable to a D.D.S. or D.M.
12
See supra note 8.
13
Section 466.023, F.S.
14
Sections 466.023 and 466.024, F.S. STORAGE NAME: h0503b.HCA PAGE: 4
DATE: 4/11/2023
Apply topical fluorides that are approved by the American Dental Association or the U.S. Food
and Drug Administration;
Remove excess cement from dental restorations and appliances with non-mechanical hand
instruments or ultrasonic scalers;
Remove sutures;
Place periodontal or surgical dressings;
Pre-assess and chart suspected findings of the oral cavity; and
Apply sealants.
A dental hygienist may perform the following remediable tasks if the dental hygienist has training in a
pre-licensure course or on-the-job:
Fabricating temporary crowns and bridges in a laboratory;
Applying topical anesthetics and anti-inflammatory agents which are not applied by aerosol or
jet spray;
Taking or recording patients’ blood pressure rate, pulse rate, respiration rate, case history and
oral temperature;
Retracting lips, cheeks and tongue;
Irrigating and evacuating debris not to include endodontic irrigation;
Placing and removing cotton rolls;
Placing or removing temporary restorations with non-mechanical hand instruments only; and,
Obtaining plaque specimens, which do not involve cutting of the tissue and which do not include
taking endodontic cultures, to be examined under a microscope for educational purposes.
A dental hygienist may apply to be certified to administer local anesthesia under the direct supervision
of a non-sedated, adult patient, if the dental hygienist completes an accredited course of 30 hours of
didactic training and 30 hours of clinical training and is certified in basic or advanced cardiac life
support.
15
Every dental hygienist licensed in Florida must post and keep conspicuously displayed his or her
license in the office wherein she or he practices, in plain sight of patients.
Dentist of Record
Current law requires each patient to have a dentist of record.
16
The dentist of record is primarily
responsible for all dental treatment on such patient regardless of whether the treatment is rendered by
the dentist or by another dentist, dental hygienist, or dental assistant rendering such treatment in
conjunction with, at the direction or request of, or under the supervision of such dentist of record.
17
Rule
64B5-17.002, F.A.C., defines a dentist of record as a dentist who:
Is identified and noted in the patient record as the dentist of record;
Provides a specific treatment or service and is noted in the patient record as the dentist of
record for that treatment or service;
If there has been more than one provider of treatment, is the dentist who places the final
restoration, does the surgical procedure, makes the diagnosis or finishes the service or
procedure in question; or
If the dentist of record is not identifiable, then the owner of the dental practice in which the
patient was treated is the dentist of record.
Rule 64B5-17.004, F.A.C., requires every dentist to provide, either personally, through another licensed
dentist, or through a reciprocal agreement with another agency, reasonable 24-hour emergency
services for all patients under his or her continuing care.
15
Section 466.017(5), F.S.
16
Section 466.018, F.S.
17
Id. STORAGE NAME: h0503b.HCA PAGE: 5
DATE: 4/11/2023
Dental Advertising
Florida regulates dental advertising
18
to ensure that the public has access to information which provides
a sufficient basis to make an informed selection of dentists and protect it from false or misleading
advertisements.
19
A licensed dentist’s advertisements may not contain any false, fraudulent,
misleading, or deceptive statement or claim or any statement or claim which:
20
Contains misrepresentations of fact;
Is likely to mislead or deceive because, in context, it makes only a partial disclosure of relevant
facts;
Contains laudatory statements about the dentist or group of dentists;
Is intended or is likely to create false, unjustified expectations of favorable results;
Relates to the quality of dental services provided as compared to other available dental
services;
Is intended or is likely to appeal primarily to a layperson’s fears;
Contains fee information without a disclaimer that such is a minimum fee only; or
Contains other representations or implications that in reasonable probability will cause an
ordinary, prudent person to misunderstand or to be deceived.
Direct-To-Consumer Teeth Aligner
According to DOH, a direct-to-consumer teeth aligner business model currently exists for consumers.
21
The model consists of dental impressions either being taken by the consumer using a dental
impression kit mailed by the aligner company or by the consumer visiting a location for a digital scan
22
by a technician. The impression or image is then reviewed by a dentist to create custom aligners, which
are shipped back to the consumer for use. This model does not include an in-person examination by a
licensed dentist or include direct supervision by a dentist when digital scanning is performed.
23
Telehealth
Telehealth is not a type of health care service but rather is a mechanism for delivery of health care
services. Health care professionals use telehealth as a platform to provide traditional health care
services in a non-traditional manner. These services include, among others, preventative medicine and
the treatment of chronic conditions.
24
In 2019, the Legislature passed and the Governor signed CS/CS/HB 23, which established a
framework for telehealth services in Florida law.
25
The act broadly defines telehealth as the use of
synchronous or asynchronous telecommunications technology by a telehealth provider to provide
health care services, including, but not limited to:
Assessment, diagnosis, consultation, treatment, and monitoring of a patient;
Transfer of medical data;
Patient and professional health-related education;
Public health services; and
Health administration.
18
Rule 64B5-4.002, F.A.C., defines advertising to mean any statements, oral or written, disseminated to or before the public or any
portion thereof with the intent of furthering the purpose, either directly or indirectly, of selling professional services, or offering to perform
professional services, or inducing members of the public to enter into any obligation relating to such professional services. The
provisions of this rule shall apply to media exposure of any nature regardless of whether it is in the form of paid advertising.
19
Section 468.019, F.S.
20
Id.
21
Department of Health, Agency Bill Analysis of HB 503, (January 25, 2023).
22
A digital scan is an optical impression by an intraoral scanner to optically measure the surface shape of the target teeth or gums
directly in the patient's mouth.
23
Supra note 21.
24
U.S. Department of Health and Human Services, Report to Congress: E-Health and Telemedicine, (August 2016), available at
https://aspe.hhs.gov/system/files/pdf/206751/TelemedicineE-HealthReport.pdf (last viewed April 1, 2023).
25
Ch. 2019-137, L.O.F., codified at s. 456.47, F.S. STORAGE NAME: h0503b.HCA PAGE: 6
DATE: 4/11/2023
Telehealth does not include audio-only telephone calls, e-mail messages, or facsimile transmission
under Florida law.
26
Health care services may be provided via telehealth by a Florida-licensed health care practitioner, a
practitioner licensed under a multistate health care licensure compact of which Florida is a member,
27
or a registered out-of-state-health care provider.
28
Florida-licensed telehealth providers, as well as those licensed under a multistate health care licensure
compact of which Florida is a member, must be one of the following health care practitioners.
29
Behavioral Analyst
Acupuncturist
Allopathic physician
Osteopathic physician
Chiropractor
Podiatrist
Optometrist
Nurse
Pharmacist
Dentist
Dental hygienist
Midwife
Speech therapist
Occupational therapist
Radiology technician
Electrologist
Orthotist
Pedorthist
Prosthetist
Medical physicist
Emergency Medical
Technician
Paramedic
Massage therapist
Optician
Hearing aid specialist
Clinical laboratory
personnel
Respiratory therapist
Physical therapist
Psychologist
Psychotherapist
Dietician/Nutritionist
Athletic trainer
Clinical social worker
Marriage and family
therapist
Mental health counselor
Out-of-state telehealth providers must register biennially with DOH or the applicable board to provide
telehealth services, within the relevant scope of practice established by Florida law and rule, to patients
in this state. To register or renew registration as an out-of-state telehealth provider, the health care
professional must:
Hold an active and unencumbered license, which is substantially similar to a license issued to a
Florida practitioner in the same profession, in a U.S. state or jurisdiction and
Not have been subject to licensure disciplinary action during the five years before submission of
the registration application;
30
Not be subject to a pending licensure disciplinary investigation or action;
Not have had license revoked in any state or jurisdiction;
Designate a registered agent in this state for the service of process;
Maintain professional liability coverage or financial responsibility, which covers services
provided to patients not located in the provider’s home state, in the same amount as required for
Florida-licensed practitioners;
31
and
Prominently display a link to the DOH website, described below, which provides public
information on registered telehealth providers.
32
Standards of Practice
26
S. 456.47(1), F.S.
27
Florida is a member of the Nurse Licensure Compact. See s. 464.0095, F.S.
28
Supra note 22.
29
These are professionals licensed under s. 393.17; part III, ch. 401; ch. 457; ch. 458; ch. 459; ch. 460; ch. 461; ch. 463; ch. 464; ch.
465; ch. 466; ch. 467; part I, part III, part IV, part V, part X, part XIII, and part XIV, ch. 468; ch. 478; ch. 480; part II and part III, ch. 483;
ch. 484; ch. 486; ch. 490; or ch. 491.
30
The bill requires DOH to consult the National Practitioner Data Bank to verify whether adverse information is available for the
registrant.
31
Florida law requires physicians, acupuncturists, chiropractic physicians, dentists, anesthesiologist assistants, advanced practice
registered nurses, and licensed midwives to demonstrate $100,000 per claim and an annual aggregate of $300,000 of professional
responsibility (see ss. 458.320 and 459.0085, F.S.; r. 64B1-12.001. F.A.C; r. 64B2-17.009, F.A.C.; 64B5-17.0105, F.A.C.; rr. 64B8-
31.006 and 64B15-7.006, F.A.C.; r. 64B9-4.002, F.A.C.; and r. 64B24-7.013, F.A.C.; respectively). Podiatric physicians must
demonstrate professional responsibility in the amount of $100,000 (see r. 64B18-14.0072, F.A.C.).
32
S. 456.47(4), F.S. STORAGE NAME: h0503b.HCA PAGE: 7
DATE: 4/11/2023
Current law sets the standard of care for telehealth providers at the same level as the standard of care
for health care practitioners or health care providers providing in-person health care services to patients
in this state. This ensures that a patient receives the same standard of care irrespective of the modality
used by the health care professional to deliver the services. A patient receiving telehealth services may
be in any location at the time services are rendered and a telehealth provider may be in any location
when providing telehealth services to a patient.
33
Practitioners may perform a patient evaluation using telehealth. A practitioner using telehealth is not
required to research a patient’s medical history or conduct a physical examination of the patient before
providing telehealth services to the patient if the telehealth provider is capable of conducting a patient
evaluation in a manner consistent with the applicable standard of care sufficient to diagnose and treat
the patient when using telehealth.
Current law does not contain health care practitioner specific regulations for the use of telehealth.
Health care practitioners must adhere to the applicable standard of care when providing services
through telehealth and are subject to disciplinary action if they fail to do so.
Effect of the Bill
HB 503 revises current regulations for the practice of dentistry and establishes requirements for using
telehealth to provide dental services to patients.
The bill requires every dentist, including individuals or entities providing services through telehealth
(telehealth provider), to provide each of his or her patients with the dentist’s name, contact telephone
number, after-hours contact information for emergencies, and, upon the patient’s request, license
information.
The bill requires every telehealth provider to have a dentist of record who remains primarily responsible
for all dental treatment on the patient regardless of whether the treatment is rendered by the dentist of
record, another dentist, a dental hygienist, or dental assistant, in conjunction, or at the direction of, or
under the supervision of, the dentist of record.
The bill requires telehealth providers to make available to the patient, before services are rendered, the
name, the telephone number, practice address, and state license number for the dentist of record and
any other dentist who will be providing dental services to the patient, and at any time requested by a
patient.
The bill requires that an advertisement for dental services provided through telehealth include a
disclaimer that reads, in a clearly legible font and size, “An in-person examination with a dentist
licensed under chapter 466, Florida Statutes, is recommended before beginning telehealth treatment in
order to prevent injury or harm” for each of the following dental services:
The taking of an impression or the digital scanning of the human tooth, teeth, or jaws by any
means or method, directly or indirectly;
Furnishing, supplying, constructing, reproducing, or repairing any prosthetic denture, bridge, or
appliance or any other structure designed to be worn in the human mouth;
Placing an appliance or a structure in the human mouth or adjusting or attempting to adjust the
appliance or structure; and
Correcting or attempting to correct malformations of teeth or jaws.
The bill prohibits anyone other than a licensed dentist, a dental hygienist under general supervision, or
a dental assistant under direct supervision, from taking an impression or performing digital scanning of
the human tooth, teeth, or jaws, directly or indirectly, by any means or method, for the purpose of the
33
S. 456.47(2), F.S. STORAGE NAME: h0503b.HCA PAGE: 8
DATE: 4/11/2023
practice of dentistry. Under current law there are no restrictions on who may perform this type of digital
scanning.
The bill expands the grounds for the denial of a dental license or disciplinary action against a dentist to
include:
Failure by the dentist of record, before the initial diagnosis and correction of a malposition of
human teeth or initial use of an orthodontic appliance, to perform an in-person examination of
the patient or obtain records from an in-person examination within the last six months and to
perform a review of the patient’s most recent diagnostic digital or conventional radiographs or
other equivalent bone imaging suitable for orthodontia.
For dental services provided in-person or through telehealth, failing to provide each patient with
the name, contact telephone number, after-hours contact information for emergencies, and,
upon the patient’s request, the license information of each dentist who is providing dental
services to the patient.
For dental services provided through telehealth, failing to designate a dentist of record and
make available, before the rendering of such services and upon the patient’s request, the name,
telephone number, practice address, and state license number for the dentist of record and any
other dentist who will be involved in the provision of dental services to the patient through
telehealth.
The bill provides an effective date of July 1, 2023.
B. SECTION DIRECTORY:
Section 1: Amends s. 466.003, F.S., relating to definitions.
Section 2: Amends s. 466.016, F.S., relating to license to be displayed.
Section 3: Amends s. 466.018, F.S., relating to dentist of record; patient records.
Section 4: Amends s. 466.019, F.S., relating to advertising by dentists
Section 5: Amends s. 466.024, F.S., relating to delegation of duties; expanded functions.
Section 6: Amends s. 466.028, F.S., relating to grounds for disciplinary action; action by the board.
Section 7: Amends s. 409.906, F.S., relating to optional Medicaid services.
Section 8: Provides an effective date of July 1, 2023.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The bill has an indeterminate, negative fiscal impact on DOH which can be absorbed within current
resources.
34
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
34
Supra note 21. STORAGE NAME: h0503b.HCA PAGE: 9
DATE: 4/11/2023
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
According to DOH, requirements of the bill would eliminate certain direct-to-consumer teeth aligner
business models.
35
D. FISCAL COMMENTS:
None.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not applicable. The bill does not appear to affect county or municipal governments.
2. Other:
None.
B. RULE-MAKING AUTHORITY:
DOH and the Board of Dentistry have sufficient rulemaking authority to implement provisions of the bill.
C. DRAFTING ISSUES OR OTHER COMMENTS:
DOH advises that s. 466.018(2), F.S., may need to be updated to reference the new subsection (6) in
the bill. Specifically, to make clear if the dentist of record is not identified in the telehealth patient
record, it shall be presumed as a matter of law that the dentist of record is the dentist-owner of the
telehealth dental practice in which the patient was treated.
36
IV. AMENDMENTS/COMMITTEE SUBSTIT UTE CHANGES
None.
35
Id..
36
Id.