Dental Hygiene Practice in NYS: Resources on Supervision and Collaborative Practice

Background to the Issue

New York State Law (statute), notably, Article 133 states that the practice of dental hygiene "must be done under the supervision of a licensed dentist" or in the case of a registered dental hygienist working for a hospital defined in article twenty-eight of the public health law, pursuant to a collaborative arrangement with a licensed and registered dentist who has a formal relationship with the same hospital in accordance with regulations promulgated by the department in consultation with the Department of Health. Such collaborative arrangement shall not obviate or supersede any law or regulation which requires identified services to be performed under the personal supervision of a dentist. When dental hygiene services are provided pursuant to a collaborative arrangement, such dental hygienist shall instruct individuals to visit a licensed dentist for a comprehensive examination or treatment.

The degrees of supervision by the dentist as defined are follows:

  1. General supervision shall mean that a supervising dentist available for consultation, diagnosis and evaluation, has authorized the dental hygienist to perform the services, and exercises that degree of supervision appropriate to the circumstances.
  2. Personal supervision shall mean that 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."

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 - back over three decades ago - for different dental hygiene services in order to allow for a more flexible workforce and an assurance of safe patient care.

Dental Hygiene Services and Levels of Supervision Required

The two levels of supervision - personal and general - are defined in regulation, Part 61.9 following………….

The following services may be performed under the general supervision of a licensed dentist OR without supervision pursuant to a collaborative agreement:

  1. Removing calcareous deposits, accretions and stains, including scaling and planing of exposed root surfaces indicated for a complete prophylaxis[1];
  2. Applying topical a

    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., as Legislative Counsel for the New York Dental Hygienists Association.

    gents indicated for a complete dental prophylaxis;
  3. Removing excess cement from surfaces of the teeth;
  4. Providing patient education;
  5. Placing and exposing X-ray films;
  6. Performing topical anticariogenic agent applications, including but not limited to topical fluoride applications, and performing topical anesthetic applications;
  7. Polishing teeth, including existing restorations;
  8. Taking medical history including the measuring and recording of vital signs;
  9. Charting caries and periodontal conditions as an aid to diagnosis by the dentist;
  10. Applying pit and fissure sealants; and
  11. Applying desensitizing agents to the teeth.
  12. Taking impressions for study casts. Study casts shall mean only such casts as will be used for purposes of diagnosis and treatment planning by the dentist and for the purposes of patient education;

The following services may be performed only under the personal supervision of a licensed dentist:

  1. Placing or removing rubber dam;
  2. Removing sutures;
  3. Placing or removing matrix bands;
  4. Applying a topical medication not related to a complete dental prophylaxis;
  5. Placing and removing periodontal dressings;
  6. Selecting and prefitting provisional crowns;
  7. Selecting and prefitting orthodontic bands;
  8. Removing orthodontic arch wires and ligature ties;
  9. Taking impressions for space maintainers, orthodontic appliances, and occlusal guards;
  10. Placing and removing temporary separating devices; and
  11. Placing orthodontic ligatures.

Performance of Services of Certified Dental Assistants by Dental Hygienists

  1. The dental supportive services that a licensed dentist authorizes a certified dental assistant to perform under paragraph (18) of subdivision (b) of section 61.13 of this Part, designated in such paragraph as other dental supportive services, may be performed by a licensed dental hygienist under the personal supervision of a licensed dentist who has delegated such function to the licensed dental hygienist, unless general supervision for such service is otherwise expressly prescribed in this section.

Competency Requirements for Practice of Dental Hygiene

  1. In accordance with section 29.1(b)(9) and (10) of this Title, a licensed dental hygienist is not permitted to provide dental services or dental supportive services that the licensed dental hygienist knows or has reason to know that he or she is not competent to perform, and a licensed dentist is not permitted to delegate to a licensed dental hygienist dental services or dental supportive services that the licensed dentist knows or has reason to know that the licensed dental hygienist is not qualified by training, experience or by licensure to perform.

Ensuring Competent, Safe and Flexible Care by Dental Hygienists

A dental hygienist can perform those services listed under general supervision without onsite supervision, provided that the dentist and the dental hygienist agree that it is appropriate given the circumstances presented.

Circumstances to consider include such elements as 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.

Ultimately, the appropriate working relationship and professional trust between the dental hygienist and the supervising dentist is the key to successfully serving and protecting the patient's health and welfare.

Recommendations for Office Policy – including such elements as:

  • Clearly defined, written job descriptions for the Dental Hygienist

  • The job description could be modeled after much of the information already existing in statute and regulation, with practice specific considerations noted.

  • The job description is a place to clearly define the agreed upon exemptions for dental hygiene services that might be excluded due to the dentist’s non-presence in the office, competency of the dental hygienist, or overall relationship and decisions made between the supervising dentist and dental hygienist.
  • Written office policy negating any opportunity for the Dental Hygienist to be providing services without another staff member on premises at all times.
    • No dental hygienist should be present and performing services of any kind without another staff member present within the office suite.
    • The back up staff member must be practiced and competent in implementing the office emergency protocol should the need arise.
  • Written office policy for medical emergencies occurring within the office.
    • Every office should have a written policy and procedure for any emergencies that might arise.The established procedure should be practiced at regular intervals and documentation of staff understanding and competency could be maintained in the Office In-Servicing files.
    • Given the fact that most licensed dentists and dental hygienists are NOT certified in Advanced Cardiac Life Support procedures, a minimal intervention procedure could be adopted that may be as simple as “beginning basic life support and calling 911.”Every staff member licensed or not should be experienced and knowledgeable in basic life support.
  • Every Dental Hygienist should carry malpractice with him/herself named as insured.Malpractice insurance is available to Dental Hygienists at a very reasonable cost and ensures coverage should the need arise to defend oneself against any litigation brought forward, for any reason.


[1]The practice of the profession of dental hygiene is defined as the performance of dental services which shall include removing calcareous deposits, accretions and stains from the exposed surfaces of the teeth which begin at the epithelial attachment and ………………………..and any other function in the definition of the practice of dentistry as may be delegated by a licensed dentist in accordance with regulations promulgated by the commissioner. (Article 133, Section 6606 of NYS Law)