4.1 Supervision Levels, Delegation Duties & Non-Delegable Procedures
Key Takeaways
- Direct supervision means the dentist is in the office, authorizes the procedure, stays while it is performed, and evaluates the auxiliary's work before the patient is dismissed (Den 101.13; Den 302.02(a)).
- Indirect supervision differs from direct supervision only in timing: the dentist evaluates the auxiliary's performance at a subsequent appointment (Den 101.17; Den 302.02(b)).
- General supervision means the dentist authorized the procedures under the dentist's diagnosis and treatment plan and personally evaluates and reviews them with the patient at least once in a 12-month period (Den 101.15).
- Public health supervision lets a hygienist work in a school, hospital, other institution, or for a homebound person without the dentist present, provided the dentist reviews the records once in 12 months (Den 101.28).
- RSA 317-A:23, I bars assigning diagnosis, treatment planning, prescriptions, and surgical or other irreversible intraoral procedures to anyone not licensed to practice dentistry.
Supervision Levels and Delegation
Supervision means oversight by a dentist of the duties the Board authorizes for dental hygienists and dental assistants (Den 101.31). Dental hygiene services must be provided under the supervision of a licensed dentist under the Board's rules (RSA 317-A:21-c, III). Nothing in RSA 317-A permits the independent practice of dental hygiene (RSA 317-A:21-d).
The four supervision levels — Den 302.02 and Den 101
| Level | Where is the dentist? | Authorization | When is the work evaluated? |
|---|---|---|---|
| Direct (Den 101.13; 302.02(a)) | In the dental office, and remains there while the procedure is performed | Dentist authorizes the procedure | Before the patient is dismissed |
| Indirect (Den 101.17; 302.02(b)) | In the dental office, and remains there while the procedure is performed | Dentist authorizes the procedures | At a subsequent appointment |
| General (Den 101.15; 302.02(c)) | Need not be present | Dentist authorized the procedures, which are carried out under the dentist's diagnosis and treatment plan | The procedures are personally evaluated and reviewed by the dentist with the patient at least once in a 12-month period |
| Public health (Den 101.28; 302.02(d)) | Need not be present | Dentist authorizes procedures carried out by a hygienist in a school, hospital, or other institution, or for a homebound person | Dentist reviews the records once in a 12-month period |
Public health supervision also covers a dental assistant working in those settings under the supervision of a certified public health dental hygienist (CPHDH) (Den 302.02(d)(2)).
Details that decide exam questions
- "Personally evaluated" (Den 101.25) means a dentist with an active license performs an oral exam on the patient once in a 12-month period. When the dentist evaluates procedures done under general supervision, he or she uses professional judgment about whether a more extensive exam is needed (Den 302.02(e)).
- Direct supervision does not require line-of-sight observation. It requires the dentist to be in the dental office, to authorize, to remain while the procedure is performed, and to evaluate before dismissal. A dentist who leaves the building, even briefly, is no longer providing direct supervision.
- Indirect supervision is defined but currently unused. No duty in the current assistant and hygienist duty lists (Den 404–405) is assigned to indirect supervision. Those lists use general, direct, and public health supervision. Know the definition in case an item asks you to distinguish it.
- Assistants can work under general supervision. Den 404.01(a) lists nine assistant duties performed under general supervision, such as processing and sterilizing instruments, processing radiographs, and taking vital signs. Intraoral chairside duties are generally assigned to direct supervision.
What can never be delegated — RSA 317-A:23, I
None of the following may be assigned to a hygienist, assistant, or anyone else not licensed to practice dentistry:
- Diagnosis, treatment planning, and prescriptions, including prescriptions for drugs and medicaments and authorizations for restorative, prosthodontic, or orthodontic appliances; and
- Surgical procedures on hard or soft tissues in the oral cavity, or any other intraoral procedure that contributes to or results in an irremediable alteration of the oral anatomy.
The one statutory carve-out is RSA 317-A:23, II. Under public health supervision and a written practice agreement, a CPHDH may provide authorized RSA 317-A:21-e services without the patient first seeing a dentist, if the supervising dentist has given written general authorization and standing protocols (section 5.4).
Den 101.12 defines diagnosis as identifying a disease from its signs and symptoms. A hygienist's dental hygiene assessment and care plan under Den 405.01(a) is a different activity. The hygienist identifies dental hygiene treatment needs the hygienist is licensed to treat; that is not a dental diagnosis.
The dentist's delegation duties
| Source | Duty |
|---|---|
| Den 501.01(b) | Protect patients by assigning to hygienists and assistants only those Den 400 duties they are trained to perform correctly |
| Den 501.01(c) | Prescribe and supervise the patient care provided by all hygienists and assistants working under the dentist's direction |
| ADA Code 2.C | Assign to qualified auxiliaries only duties that can legally be delegated, and prescribe and supervise their care |
| Den 304.08(d) | Never delegate tasks outside an auxiliary's scope during sedation, such as placing an IV catheter, drawing up medications, or administering medications. PALS certification does not expand scope |
| RSA 317-A:17, II(i) | Employing or permitting an unlicensed person to practice in the office is professional misconduct |
| RSA 317-A:28 | Dentists who own, manage, or control a place where dental work is done may employ only licensed dentists and hygienists to practice dentistry and dental hygiene |
Worked scenario
Dr. Patel leaves at noon for a conference. After she leaves:
- Jen, RDH, performs a prophylaxis and exposes bitewings on a recall patient whom Dr. Patel examined 5 months ago. This is lawful. Prophylaxis and radiography are general-supervision hygienist duties (Den 405.01(a)(2), (9)), and the dentist reviews the patient at least once in 12 months.
- Sam, a certified dental assistant, places a rubber dam and matrix band for a restoration scheduled with an associate dentist who is in the office. This is lawful, because the associate supplies direct supervision.
- Ana, a qualified dental assistant, places sealants on a patient after every dentist has left. This is unlawful. Sealants by a qualified assistant require direct supervision (Den 302.06(s); Den 404.03(b)). Dr. Patel is also exposed to discipline under Den 501.01(b)–(c) and RSA 317-A:17, II(i).
A dentist remains in the office while a hygienist performs a procedure the dentist authorized. The dentist reviews the result at the patient's next appointment rather than before dismissal. Which supervision level does this describe?
Under Den 101.15, what must be true for a dental hygienist to provide authorized procedures under general supervision while the dentist is away from the office?
Which task may a dentist never assign to a dental hygienist or dental assistant under RSA 317-A:23, I?