January 4, 2024

Hygienist Procedures – What’s Legal and How to Know

By Blain Lagergren, Attorney

The dental hygienist profession has grown far beyond teeth cleaning and polishing. Today, dental hygienists are at the forefront of patient care. Given their expanding role, it’s important for dental practice owners to know what procedures hygienists are legally allowed to perform without having a dentist present.

States Make the Rules

The practice of dentistry is overseen and regulated by each individual state. As a dental practice owner, that requires you to follow the rules set by the state where you are licensed to work. While there may be similarities, each state has its own set of requirements for what treatments a hygienist can perform, and how much supervision a dentist must provide. Regulations refer to three levels of supervision. The following are based on the Missouri code of state regulations.

1. General Supervision

General supervision does not require dentist’s physical presence in the facility. Patients must be notified of this. Patient authorization, either verbal or written, must be recorded in the patient’s file and is valid for 12 months. The type of procedures allowed under general supervision include common procedures such as:

  • Scaling and polishing teeth
  • Applying dental sealants
  • Periodontal root planing, debridement, and curettage
  • Nonsurgical periodontal procedures
  • Procedures that could otherwise be delegated to a dental assistant

2. Indirect supervision

For this level of supervision, the dentist has authorized the procedure for a patient and remains in the treatment facility while the procedure is performed. Depending on the state, a hygienist may be permitted to administer nitrous oxide analgesia or local anesthesia with indirect supervision.

3. Direct supervision

At this level, the dentist has authorized the procedure for a patient, remains in the treatment facility, but does not need to be in the treatment room while the procedure is performed. The dentist is responsible for evaluating the procedure prior to patient dismissal.

Depending on state regulations, a hygienist with the necessary permits may perform the following expanded functions under direct supervision:

  • Etch enamel surfaces before bonding of orthodontic appliances by a dentist
  • Remove bond material from teeth with rotary instruments after removal of orthodontic appliances
  • Attach prefit and preadjusted orthodontic appliances
  • Remove fixed orthodontic bands and brackets

Consult Your State’s Dental Practice Act

As a dental practice owner, you should become familiar with your state’s dental practice act, which can be found on your state’s Board of Dentistry or Board of Dental Examiners website. Each state lists its rules, including what procedures hygienist are allowed to perform, CE requirements for various procedures, supervision levels, etc. Each state determines its own unique set of limitations for what hygienists can do. Checking your state’s dental practice act should become an annual routine since rules, regulations, and CE requirements can change.

State Regulations for Hygienists Vary

State requirements can vary significantly. For example, dental hygiene treatment planning without the supervision of a dentist is allowed in Oregon, Colorado, and in the states of Nevada, Kansas, and California with prior authorization. Treatment planning is allowed under general supervision or with a collaborative practice permit in New York, Minnesota, Iowa, and North Dakota.

Western Regions Tend to Adopt Broader Scopes Sooner

Looking at regulations suggests that states on the West Coast are more willing to advance scopes of practice as compared to other regions. In the state of Washington, dental hygienists have been able to administer local anesthesia under indirect supervision since 1971. By comparison, Alabama hygienists have only been allowed to administer infiltrations since 2018 under direct supervision if they hold an infiltration anesthesia permit.

Only a few states allow dental hygienists to do a limited amount of minor restorative services, of which some may require additional education, regional board exams, or certifications. For example, a Massachusetts dental hygienist can cement and remove temporary crowns and bridges under general supervision. In Washington state, hygienists who have completed expanded function education through their CODA-accredited hygiene program can perform restorative functions.

Regardless of where you work, be sure to read and understand your state’s rules and laws on your scope of practice. Many states have specific rules and details that are required for certain dental treatments.

Not Knowing the Rules Can Cost You

Not knowing your state requirements and rules and abiding by them may lead to fines, license probation, or lawsuits, all of which become public information and can be highly damaging to your practice, not to mention your reputation.

Remember, the dentist is ultimately responsible for patient care. Even when, as the practice owner, you delegate authority to a hygienist, you still hold ultimate responsibility for your patients’ well-being.

If you have questions about how regulations may impact your practice, contact the team at Engage Advisors who can work with an attorney to help.