Laws and regulations specifically define the duties that a dentist and each category of Allied Dental Health Professional (ADHP) are allowed to perform. The regulations also define the level of dentist supervision required and the settings in which an ADHP may perform the duties. The two levels of supervision are:
- Direct supervision
- General supervision
Direct supervision means performance of dental procedures based on instructions given by a licensed dentist. A licensed dentist must be physically present in the treatment facility during the performance of those procedures.
General supervision means performance of dental procedures based on instructions given by a licensed dentist, but not requiring the physical presence of a supervising dentist during the performance of those procedures.
Dentistry is defined as:
- The diagnosis or treatment, by surgery or other method, of diseases and lesions.
- The correction of malpositions of the human teeth, alveolar process, gums, jaws, or associated structures. Such diagnosis or treatment may include all necessary related procedures including:
- use of drugs
- use of anesthetic agents
- physical evaluation
Dentistry is NOT the practice of:
- Prescription of weight loss medications.
- Administration of injections such as the Hepatitis B vaccine to staff or others.
- Performance any treatment that falls outside the defined scope of practice.
Scope of Practice for Allied Dental Health Professionals (ADHP)
A clear understanding of scope of practice issues for ADHP is necessary to comply with existing and new regulations. In the past few years there have been many changes to the scope of practice, like:
- New required permits for practice of certain clinical functions.
- New license categories for extension of the existing license.
- New limitations on previous scope of previous categories.
- Training requirements for non-licensed staff.
Before and After the Dental Examination
Scope of practice issues and specific limitations apply to ADHPs, just like certain limitations apply to dentists. A licensed dentist must provide direction to all clinical activities of ADHP. For example:
BEFORE A DENTIST EXAMINES A PATIENT:
A dentist may require or permit an ADHP to perform the following duties, provided that the duties are authorized for the particular classification of ADHP:
- Expose emergency radiographs upon direction of the dentist.
- Perform extra-oral duties or functions specified by the dentist.
- Perform mouth-mirror inspections of the oral cavity, including charting obvious lesions, malocclusions, existing restorations, and missing teeth.
AFTER A DENTIST PRELIMINARILY EXAMINES A PATIENT:
A dentist may require or permit any ADHP to perform procedures necessary for diagnostic purposes, provided that the procedures are permitted under the ADHP’s authorized scope of practice.
This section does not apply to dentists providing examinations on a temporary basis outside a dental office, in settings such as health fairs and school screenings.
Registered Dental Hygienist (RDH)
The practice of dental hygiene includes dental hygiene assessment, development, planning, and implementation of a dental hygiene care plan. It also includes:
- Oral health education
- Nutritional counseling
- Oral health screenings
The specific duties include:
- scaling & root planing
- polish and contour restorations
- oral exfoliative cytology
- apply pit and fissure sealants
- preliminary examination, including but not limited to:
- periodontal charting
- intra and extra-oral examination of soft tissue
- charting of lesions, existing restorations and missing teeth
- classifying occlusion
- myofunctional evaluations
- irrigate sub-gingivally with an antimicrobial and/or antibiotic liquid solutions
Evidence of satisfactory completion of a Board-approved course of instruction in the following three functions must be submitted to the DHCC prior to any performance thereof:
- Periodontal soft tissue curettage.
- Administration of local anesthetic agents, infiltration and conductive, limited to the oral cavity.
- Administration of nitrous oxide and oxygen when used as an analgesic, utilizing fail-safe-type machines containing no other general anesthetic agents.
An individual who becomes licensed as an RDH in California on or after January 1, 2006, may no longer perform the duties in the scopes of practice of an RDA unless they also hold an RDA license.
The practice of dental hygiene does not include any of the following procedures:
- Diagnosis and comprehensive treatment planning.
- Placing, condensing, carving, or removal of permanent restorations.
- Surgery or cutting on hard and soft tissue including, but not limited to, the removal of teeth and the cutting and suturing of soft tissue.
- Prescribing medication.
- Administering general anesthesia or oral or parenteral conscious sedation.
The supervising licensed dentist is responsible for determining the competency of their Allied Dental Health Professionals to perform allowable functions. Each ADHP must know their own scope of practice. It is a criminal offense to perform illegal functions. It is also grounds for license discipline of the person performing the illegal function and any person who aid or abets such illegal activity.
Registered Dental Hygienist in Alternative Practice (RDHAP)
A dental hygienist in alternative practice may provide services to a patient without obtaining written verification that the patient has been examined by a dentist or physician and surgeon licensed to practice in this state. If a dental hygienist in alternative practice provides services to a patient 18 months or more after the first date that they provide services to a patient, the RDHAP shall obtain written verification that the patient has been examined by a dentist or physician and surgeon licensed to practice in this state.
Prior to the establishment of an independent practice, an RDHAP shall provide to the committee documentation of an existing relationship with at least one dentist for referral, consultation, and emergency services. The individual must also have:
- Been engaged in clinical practice as a dental hygienist for a minimum of 2,000 hours during the immediately preceding 36 months in either California or another state.
- A bachelors degree or its equivalent
- Completion of 150 hours of an approved educational program.
- Pass a written examination in California law and ethics required by the committee.
- Has received a letter of acceptance into the employment utilization phase of the Health Manpower Pilot Project No. 155 established by the Office of Statewide Health Planning and Development pursuant to Article 1 (commencing with Section 128125) of Chapter 3 of Part 3 of Division 107 of the Health and Safety Code.
For the comprehensive Dental Board List of Permitted Duties, please visit: www.dbc.ca.gov/formspubs/pub_permitted_duties.pdf for the California Dental Board list of permitted duties.
The Dental Assistant’s Scope of Practice
The dental assisting profession in California is comprised of several different licensing tiers. Statutory language defines what type of care each level of assistant may perform and the level of supervision required. “Allowable Duties” in California for each dental assistant category are required to be posted conspicuously in all dental offices and the full list of duties can be found at the California Dental Board website www.dbc.ca.gov.
Legislation implemented January 1, 2010, had a profession-wide impact on all unlicensed dental assistants and their employers, and also applicants for Registered Dental Assistant (RDA) or Registered Dental Assistant in Extended Functions (RDAEF) licenses. The law added new allowable duties in all of these categories, and created two new permit categories:
- Dental Sedation Assistant.
- Orthodontic Assistant.
Current license holders may be required to take additional coursework to perform the new duties. Unlicensed dental assistants hired on or after January 1, 2010 are required to complete two hour California Dental Practice Act course and an 8-hour Infection Control course which includes in-person clinical instruction.
Additionally, all dental assistants will be required to keep current certification in basic life support in accordance with American Heart Association courses for healthcare providers.
Dentist employers are responsible for ensuring any unlicensed dental assistant hired on or after January 1, 2010, and employed beyond 120 days, provide evidence of course completion for the two required courses within 12 months of the date of hire, including completion of at least 12 months of work experience as a dental assistant. The employer is also required to ensure any unlicensed dental assistant maintains basic life support certification.
A dental assistant, without a license, may perform basic supportive dental procedures, as authorized by law, under the general supervision of a licensed dentist. Basic supportive dental procedures are defined in law as: those procedures that have technically elementary characteristics, are completely reversible, and are unlikely to precipitate potentially hazardous conditions for the patient being treated.
These basic supportive dental procedures do not include those procedures authorized only for registered dental assistants (B&P 1750.1). The supervising licensed dentist is responsible for determining the competency of the dental assistant to perform the basic supportive dental procedures.
An unlicensed dental assistant’s allowable clinical duties includes extra-oral (not in the mouth) tasks which may include:
- Charting/clinical recordkeeping procedures
- Sterilization tasks
- Infection control duties
Several new duties are currently permissible for the dental assistants, and include duties such as:
- Facebow transfers
- Intra-oral and extra-oral photography
- Bite registrations
- Taking intraoral impression for all non-prosthodontic appliances
Registered Dental Assistant (RDA)
A Registered Dental Assistant may perform all the same duties of an unlicensed dental assistant as well as additional duties such as the following:
- Coronal polishing, after providing evidence to the Dental Board of having completed a board-approved certification course in the procedure
- Application of topical fluoride
- Application of sealants, after providing evidence to the Dental Board of having completed a board-approved Certification course in the procedure, certification is due by second license renewal
- Other duties as defined on the Dental Board website at www.dbc.ca.gov.
RDAs licensed after January 1, 2010, may chemically prepare teeth for bonding, place bonding agents, and place, adjust and finish direct provisional restorations after completing a board-approved course on these duties. A registered dental assistant licensed on and after January 1, 2010, shall provide evidence of successful completion of a board-approved course in the application of pit and fissure sealants prior to their second renewal. The license of a registered dental assistant who does not provide evidence of successful completion of that course shall not be renewed until evidence of course completion is provided.
Currently licensed RDAs must complete Board-approved education and training before they may chemically prepare teeth for bonding, place bonding agents, and place, adjust and finish direct provisional restorations.
As of January 1, 2010, the supervising licensed dentist is responsible for determining whether an authorized procedure performed by an RDA should be performed under general or direct supervision, except for procedures performed in specified public health clinics pursuant to Section 1204 of the Health and Safety Code or a clinic owned and operated by a hospital that maintains the primary contract under Section 17000 of the Welfare and Institutions Code. Within these specified clinics, coronal polishing, application of topical fluoride and application of sealants are allowed by either RDAs or RDAEFs under the direct supervision of a RDH or RDHAP.
Registered Dental Assistants in Extended Functions (RDAEF)
An RDAEF may perform all duties assigned to dental assistants and registered dental assistants. An RDAEF may perform the procedures listed below under the direct supervision of a licensed dentist when done so under the direct order, control and full professional responsibility of the supervising/employer dentist. The allowable duties of an RDAEF must be checked and approved by the supervising dentist prior to dismissal of the patient from the office.
- Cord retraction of gingivae for impression procedures
- Take impressions for cast restorations
- Take impressions for space maintainers, orthodontic appliances and occlusal guards
- Prepare enamel by etching for bonding
- Formulate indirect patterns for endodontic post and core castings
- Fit trial endodontic filling points
- Apply pit and fissure sealants
- Remove excess cement from subgingival tooth surfaces with a hand instrument;
- Apply etchant for bonding restorative materials.
Registered dental assistants in extended functions may undertake the duties authorized by this section in a treatment facility under the jurisdiction and control of the supervising licensed dentist, or in an equivalent facility approved by the board.
Several new duties have been added to this license that may be performed by RDAEFs licensed after January 1, 2010. Currently licensed RDAEFs may perform these new duties after completing education and training and successfully passing a state administered examination. RDAEFs licensed after January 1, 2010 may perform all duties and procedures that an RDA is authorized to perform and under the direct supervision of the dentist may:
- Conduct a preliminary evaluation of the patient’s oral health, including, but not limited to, charting, intraoral and extra-oral evaluation of soft tissue, classifying occlusion, and myo-functional evaluation.
- Perform oral health assessments in school-based community health project settings under the direction of a dentist, RDH, or RDHAP.
- Cord retraction of gingiva for impression procedures.
- Size and fit endodontic master points and accessory points.
- Cement endodontic master points and accessory points.
- Take final impressions for permanent indirect restorations.
- Take final impressions for tooth-borne removable prosthesis.
- Polish and contour existing amalgam restorations.
- Place, contour, finish and adjust all direct restorations.
- Adjust and cement permanent indirect restorations.
Currently, licensed RDAEFs must successfully complete an examination consisting of the procedures above before they may perform procedures 1, 2, 5, 7, 8, 9, and 10.
An RDA or RDAEF may perform the following procedures while employed by or practicing in a primary care clinic or specialty clinic, or a clinic owned and operated by a hospital that maintains the primary contract with a county government to fill the county’s role under the Welfare and Institutions Code, under the direct supervision of a registered dental hygienist or a registered dental hygienist in alternative practice:
- Coronal polishing (with certification)
- Application of topical fluoride
- Application of sealants (with certification)
A law passed in a 2014 legislative session, permitting RDAEFs with additional training to perform additional expanded functions:
- Determine which radiographs to perform on a patient who has not received an initial examination by the supervising dentist for the specific purpose of the dentist making a diagnosis and treatment plan for the patient, following protocols established by the supervising dentist, in the following settings:
(A) In a dental office setting
(B) In public health settings, using telehealth for the purpose of
communication with the supervising dentist, including, but not
limited to,schools, head start and preschool programs, and community clinics, under the general supervision of a dentist.
- Place protective restorations, identified as interim therapeutic restorations, and defined as a direct provisional restoration placed to stabilize the tooth until a licensed dentist diagnoses the need for further definitive treatment. An interim therapeutic restoration consists of the removal of soft material from the tooth using only hand instrumentation, without the use of rotary instrumentation, and subsequent placement of an adhesive restorative material. Local anesthesia shall not be necessary for interim therapeutic restoration placement. Interim therapeutic restorations shall be placed only in accordance with both of the following:
(A) In either of the following settings:
(i) In a dental office setting, under the direct or general supervision of a dentist as determined by the dentist.
(ii) In public health settings, using telehealth for the purpose of communication with the supervising dentist, including, but not limited to, schools, head start and preschool programs, and community clinics, under the general supervision of a dentist.
(B) After the diagnosis, treatment plan, and instruction to perform the procedure provided by a dentist.
Orthodontic Assistant and Dental Sedation Assistant Permits
Effective January 1, 2010, dental assistants, registered dental assistants, and registered dental assistants in extended functions, who meet specified work experience and course requirements, and who pass a written examination may obtain an orthodontic assistant permit or dental sedation assistant permit.
Requirements for orthodontic and sedation permits:
- Work Experience Requirement: Completed at least 12 months of experience as a dental assistant (training may not begin prior to 6 months work experience)
- Board-Approved Course Requirements:
- Dental Practice Act
- 8 Hour infection control
- Basic life support
- Dental sedation assistant course
- Orthodontic assistant course
- Examination Requirements
Completed at least 12 months of experience as a dental assistant (training may not begin prior to 6 months work experience.)
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