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General Supervision: The Simple Truth*

Recently confusion has arisen regarding the appropriate level of dental supervision for the practice of dental hygiene in New York State. In an effort to provide some clarity, this article examines the supervision requirements and discusses what those requirements mean for every day practice. As a general statement, the confusion arises, in part, due to the flexible nature of the supervision standards set by regulation. Ultimately, the appropriate level of supervision is up to the individual dentist and depends on the circumstances of a given situation. Despite the recent controversy, the existing supervision requirements have been in place since at least 1971 and nothing has changed the supervision requirements established under N.Y.S. law and regulations since then.

Supervision Requirements for the Practice of Dental Hygiene:

The Dental Hygiene Practice Act states that "[the] practice of dental hygiene ... must be done under supervision of a licensed dentist." Beyond that statement, the Practice Act is silent on the required level of supervision. Regulations of the State Education Department, however, provide detailed guidance as to the required level of supervision for the dental hygiene practice. The regulations establish two degrees of supervision - general supervision and personal supervision. 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 for different dental hygiene techniques in order to allow for flexible and safe patient care. Personal supervision is clearly the more restrictive of the two. The regulations define personal supervision as supervision by which "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." Clearly, personal supervision requires that the dentist be in the dental office or facility in order for the dental hygienist to perform those services and that the dentist "personally" diagnose, authorize treatment and examine the patient.

For less invasive procedures, the regulations require that the practice of hygiene occur under the "general supervision" of a dentist. The regulations define "general supervision" to mean "that a supervising dentist is available for consultation, diagnosis and evaluation, has authorized a dental hygienist to perform the services, and exercises that degree of supervision appropriate to the circumstances". Unlike the definition of personal supervision, general supervision does not include a requirement that the dentist be in the dental office or facility nor does it include "personally" before the terms "consultation, diagnosis, and evaluation". General supervision, therefore, clearly does not require a dentist to be personally available or in the building. Again, the State Education Department intended, through the absence of the terms, "personally" and the "in the building", to allow dentists and dental hygienists greater practice flexibility for those services performed under general supervision than those under personal supervision. Indeed, the regulations explicitly allow the dentist the authority to "exercise that degree of supervision appropriate to the circumstances".

Why the Recent Controversy?

Recently, some "experts" have offered their own interpretation of the definition of general supervision which would handcuff a dentist by requiring that he or she essentially be "in the building" or at least "readily physically available" in order to respond to any emergency situations. We believe these opinions to be simply inaccurate. If the State Education Department intended availability for purpose of general supervision to mean "personal" and "in the building", it would have said so and used these more restrictive terms, as it did for purposes of personal supervision. It didn't! General supervision simply does not require a level of supervision beyond that deemed appropriate by the dentist. Indeed, SED personnel have indicated in informal meetings with DHASNY that the regulations speak for themselves and refused to place any further restrictions than those imposed by the regulations. As stated previously, the definition of general supervision clearly envisions a level of supervision more flexible than "personal supervision". As such, supervision could occur through other avenues such as telephone or other communications systems, as well as on-site supervision.

Those arguing for an overly narrow interpretation, however, raise the possibility of a life threatening situation in an effort to overcome the clear language of the regulations. Based on that possibility, they argue that the dentist must be close enough to respond to such a situation and, thus, always "readily physically available" or "in the office". This construct seems more concerned with a fear of "opening the door to independent practice by dental hygienists" rather than protecting the public health, welfare and safety. The supervision requirements imposed by NYS statute and regulation allow for dental hygiene practice in a non-life threatening situation and, therefore, permit appropriate practice in an unexpected life threatening situation. The rare instance of a life-threatening event, which would arise from a dental hygienist providing services which require general supervision, strain the rationale for constant on-site supervision. We would suggest that dental hygienists establish clear protocols with their supervising dentists as to appropriate practice and procedures in case of unexpected emergency situations.

So What Does this Mean for Me?

A dental hygienist can perform those services listed under general supervision without on-site supervision, provided that the dentist and the dental hygienist agree that it is appropriate to do so, given the circumstances presented. Circumstances to consider include 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. When considering the appropriate level of supervision, the dentist and dental hygienist should keep in mind their professional obligations as established by New York law which prohibit the performance of professional practice beyond their competence and without the appropriate level of supervision. Ultimately, the appropriate working relationship between the dental hygienist and the supervising dentist is the key to successfully serving and protecting the patient's health and welfare.

*This article was written by Richard Leckerling, Esq., Whiteman Osterman & Hanna. Mr. Leckerling and his associate, Brian Lucey, Esq., are Legislative Counsel for the Dental Hygienists Association of the State of New York, Inc.