Dental Hygiene Practice in NYS: Resources on Supervision and Collaborative Practice

Background to the Issue

New York State Law (statute), notably, Article 133 states that the practice of dental hygiene "must be done under the supervision of a licensed dentist" or in the case of a registered dental hygienist working for a hospital defined in article twenty-eight of the public health law, pursuant to a collaborative arrangement with a licensed and registered dentist who has a formal relationship with the same hospital in accordance with regulations promulgated by the department in consultation with the Department of Health. Such collaborative arrangement shall not obviate or supersede any law or regulation which requires identified services to be performed under the personal supervision of a dentist. When dental hygiene services are provided pursuant to a collaborative arrangement, such dental hygienist shall instruct individuals to visit a licensed dentist for a comprehensive examination or treatment.

The degrees of supervision by the dentist as defined are follows:

1. General supervision shall mean that a supervising dentist available for consultation, diagnosis and evaluation, has authorized the dental hygienist to perform the services, and exercises that degree of supervision appropriate to the circumstances.
2. Personal supervision shall mean that the dentist in the dental office or facility, personally diagnoses the condition to be treated, personally authorizes the procedure and, before dismissal of the patient, personally examines the condition after treatment is completed."

The distinction between these two levels of supervision is an important one. It clearly indicates the State Education Department's ("SED") explicit intent to establish different levels of supervision - back over three decades ago - for different dental hygiene services in order to allow for a more flexible workforce and an assurance of safe patient care.

Dental Hygiene Services and Levels of Supervision Required

The two levels of supervision - personal and general - are defined in regulation, Part 61.9 following………….

The following services may be performed under the general supervision of a licensed dentist OR without supervision pursuant to a collaborative agreement:

1. Removing calcareous deposits, accretions and stains, including scaling and planing of exposed root surfaces indicated for a complete prophylaxis[1];
2. Applying topical agents indicated for a complete dental prophylaxis;
3. Removing excess cement from surfaces of the teeth;
4. Providing patient education;
5. Placing and exposing X-ray films;
6. Performing topical anticariogenic agent applications, including but not limited to topical fluoride applications, and performing topical anesthetic applications;
7. Polishing teeth, including existing restorations;
8. Taking medical history including the measuring and recording of vital signs;
9. Charting caries and periodontal conditions as an aid to diagnosis by the dentist;
10. Applying pit and fissure sealants; and
11. Applying desensitizing agents to the teeth.
12. Taking impressions for study casts. Study casts shall mean only such casts as will be used for purposes of diagnosis and treatment planning by the dentist and for the purposes of patient education;

The following services may be performed only under the personal supervision of a licensed dentist:

1. Placing or removing rubber dam;
2. Removing sutures;
3. Placing or removing matrix bands;
4. Applying a topical medication not related to a complete dental prophylaxis;
5. Placing and removing periodontal dressings;
6. Selecting and prefitting provisional crowns;
7. Selecting and prefitting orthodontic bands;
8. Removing orthodontic arch wires and ligature ties;
9. Taking impressions for space maintainers, orthodontic appliances, and occlusal guards;
10. Placing and removing temporary separating devices; and
11. Placing orthodontic ligatures.

Performance of Services of Certified Dental Assistants by Dental Hygienists

1. The dental supportive services that a licensed dentist authorizes a certified dental assistant to perform under paragraph (18) of subdivision (b) of section 61.13 of this Part, designated in such paragraph as other dental supportive services, may be performed by a licensed dental hygienist under the personal supervision of a licensed dentist who has delegated such function to the licensed dental hygienist, unless general supervision for such service is otherwise expressly prescribed in this section.

Competency Requirements for Practice of Dental Hygiene

1. In accordance with section 29.1(b)(9) and (10) of this Title, a licensed dental hygienist is not permitted to provide dental services or dental supportive services that the licensed dental hygienist knows or has reason to know that he or she is not competent to perform, and a licensed dentist is not permitted to delegate to a licensed dental hygienist dental services or dental supportive services that the licensed dentist knows or has reason to know that the licensed dental hygienist is not qualified by training, experience or by licensure to perform.

Ensuring Competent, Safe and Flexible Care by Dental Hygienists

A dental hygienist can perform those services listed under general supervision without onsite supervision, provided that the dentist and the dental hygienist agree that it is appropriate given the circumstances presented.

Circumstances to consider include such elements as the experience of the dental hygienist and the dentist; the difficulties of the procedures to be performed; the practice setting; the availability of other healthcare or dental personnel; and the overall dental and medical health of the patient.

Ultimately, the appropriate working relationship and professional trust between the dental hygienist and the supervising dentist is the key to successfully serving and protecting the patient's health and welfare.

Recommendations for Office Policy – including such elements as:

• Clearly defined, written job descriptions for the Dental Hygienist

• The job description could be modeled after much of the information already existing in statute and regulation, with practice specific considerations noted.

• The job description is a place to clearly define the agreed upon exemptions for dental hygiene services that might be excluded due to the dentist’s non-presence in the office, competency of the dental hygienist, or overall relationship and decisions made between the supervising dentist and dental hygienist.

• Written office policy negating any opportunity for the Dental Hygienist to be providing services without another staff member on premises at all times.
  • No dental hygienist should be present and performing services of any kind without another staff member present within the office suite.
  • The back up staff member must be practiced and competent in implementing the office emergency protocol should the need arise.

• Written office policy for medical emergencies occurring within the office.
  • Every office should have a written policy and procedure for any emergencies that might arise.The established procedure should be practiced at regular intervals and documentation of staff understanding and competency could be maintained in the Office In-Servicing files.
  • Given the fact that most licensed dentists and dental hygienists are NOT certified in Advanced Cardiac Life Support procedures, a minimal intervention procedure could be adopted that may be as simple as “beginning basic life support and calling 911.”Every staff member licensed or not should be experienced and knowledgeable in basic life support.

• Every Dental Hygienist should carry malpractice with him/herself named as insured.Malpractice insurance is available to Dental Hygienists at a very reasonable cost and ensures coverage should the need arise to defend oneself against any litigation brought forward, for any reason.