9.1 Practicing Within Competence, Staying Current, and Referral

9.1 Practising Within Competence, Staying Current, and Referral

The third content area of the Law and Ethics outline — obligation to the patient — opens with a deceptively simple task: "practice within scope of competence to provide treatment consistent with level of training and experience." California gives that ethical principle a statutory edge, and the exam expects the candidate to recognize that scope of license and field of competence are two different limits and that either one, breached, produces the same result.

Two Limits, Not One (BPC § 1954)

BPC § 1954(a): "It is unprofessional conduct for a person licensed under this article to perform, or hold himself or herself out as able to perform, professional services beyond the scope of his or her license and field of competence, as established by his or her education, experience, and training. This includes, but is not limited to, using an instrument or device in a manner that is not in accordance with the customary standards and practices of the dental hygiene profession."

Read carefully, § 1954 covers three distinct wrongs:

1. Performing beyond the license. Placing a permanent restoration as an RDH. This is also a BPC § 1908(b)(2) exclusion.
2. Performing within the license but beyond personal competence. Operating an ultrasonic unit, an air-polishing device, a diode laser for bacterial reduction, or a novel instrumentation system the hygienist has never been trained on. The duty here is not satisfied by the fact that the procedure is legal for an RDH — it must be legal and something this RDH is trained to do safely.
3. Holding oneself out. Telling a patient, an employer, or the public that one can do something one cannot. The offense is complete at the representation; no patient injury is required.

The statute has one narrow carve-out at § 1954(b): it does not apply to research conducted by accredited dental or dental hygiene schools, or to research conducted under an FDA investigational device exemption.

BPC §§ 1913 and 1914 supply the positive form of the same rule. Section 1913 permits an RDH to perform any procedure within the scope of practice, in any setting, under the appropriate supervision level, "if the registered dental hygienist has completed the appropriate education and training required to perform the procedure." Section 1914 says the same about any material or device. Together with § 1954 they establish that in California, training is a precondition to authority, not a recommendation.

Certain duties make the training requirement explicit and documented. BPC § 1909 conditions soft tissue curettage, local anesthesia, and nitrous oxide-oxygen on the hygienist "submitting to the dental hygiene board evidence of satisfactory completion of a course of instruction, approved by the dental hygiene board, in the procedures." BPC § 1910.5(b) does the same for radiographic decision-making and interim therapeutic restorations, with curriculum requirements at 16 CCR § 1109. BPC § 1917(f) makes curettage, nitrous oxide-oxygen analgesia, and local anesthesia instruction a licensure prerequisite.

Remaining Current

Competence decays. California's answer is mandatory, audited continuing education:

• BPC § 1936.1(a) conditions renewal on assurances that the licensee has "informed themselves of the developments in the practice of dental hygiene occurring since the original issuance of their licenses," and requires the Board to audit at least 5 percent of the licensee population each year.
• 16 CCR § 1017(c) sets the totals: 25 units for an RDH or RDHEF, 35 for an RDHAP, each biennium.
• 16 CCR § 1016(a)(2) defines the qualitative test for coursework: it must be "designed and delivered in a manner that serves to directly enhance the licensee's knowledge, skill and competence in the provision of service to patients or the community."
• 16 CCR § 1016(b)(4) excludes courses of direct personal benefit or outside the scope of California dental practice.

The ethical obligation runs past the unit count. A hygienist who has not treated a medically complex patient in years, or who is returning from a long absence, owes the patient a deliberate refresh — reviewing current periodontal classification, current medication interactions, current emergency protocols — even where the unit requirement is already satisfied on paper.

The Diagnosis Line

Competence questions on this examination frequently resolve into the diagnosis boundary. BPC § 1908(b)(1) excludes "diagnosis and comprehensive treatment planning" from the practice of dental hygiene. An RDH performs a dental hygiene assessment — probing depths, clinical attachment loss, bleeding on probing, furcation involvement, mobility, oral cancer screening, caries risk — and formulates a dental hygiene care plan. A dentist makes the dental diagnosis and the comprehensive treatment plan.

The practical translation for patient conversations: describe findings, not diagnoses. "I am measuring 6 mm pockets with bleeding on the upper right molars, and I've charted a shadow on the distal of tooth 3 for the dentist to evaluate" is a hygiene assessment. "You have three cavities that need fillings, and I'll schedule you" is a diagnosis, a treatment plan, and a § 1908(b)(1) violation in one sentence. An RDHAP carries the same limit with an added advertising overlay under BPC § 1927(a).

Referral as an Affirmative Duty

Referral is not merely permitted; in some settings it is required.

• BPC § 1911(b) — "A registered dental hygienist shall refer any screened patients with possible oral abnormalities to a dentist for a comprehensive examination, diagnosis, and treatment plan." This applies to the unsupervised screening authority in § 1911; a screening that identifies a lesion and stops there is a statutory failure.
• BPC § 1930 — an RDHAP must document to the Board an existing relationship with at least one dentist for referral, consultation, and emergency services. The referral pathway must exist before it is needed.
• BPC § 1931(a)(2) — the 18-month verification rule is a compulsory referral checkpoint built into direct-access practice.
• BPC § 1926(d) — an RDHAP whose dental health professional shortage area designation is removed must annually provide patients with a list of dentists in the former shortage area who may be able to see them for comprehensive services.

Beyond the statutes, referral is the ordinary answer whenever the patient's need exceeds the licensee's competence: suspected oral pathology, refractory periodontitis, a patient whose medical complexity exceeds the hygienist's comfort with local anesthesia, a paediatric patient requiring behavior management the clinician has not been trained in, or a case where an RDHAP identifies restorative need.

A Workable Referral Protocol

1. Document the finding objectively — site, size, duration, character, photographs or radiographs where appropriate.
2. Tell the patient what you found and what you cannot determine, without naming a diagnosis.
3. Make the referral specific: name the type of provider, the urgency, and the reason.
4. Record the referral — date, to whom, why, and what the patient was told.
5. Close the loop. Follow up on whether the patient went, and record the outcome. An undocumented referral is, evidentially, no referral at all.
6. Do not abandon the patient while the referral is pending. BPC § 1950.5(s) requires written notice and an ample opportunity to obtain another licensee's services before hygiene care is discontinued.