The 90-Minute Lunch: Supervision Levels in a Working Practice
Dr. Alvarez owns a three-chair practice in Duluth. At 11:45 a.m. she leaves for a 90-minute lunch meeting across town. Her afternoon schedule reads: 12:15 - licensed dental assistant (LDA) Kim is to place and carve a composite on tooth #19, already anesthetized; 12:30 - Kim is to expose a bitewing and apply fluoride varnish to a 9-year-old; 1:00 - hygienist Priya, who holds local anesthesia certification, is to administer an inferior alveolar block and complete scaling and root planing on an adult with moderate periodontitis. The practice has a written supervision protocol, signed by Dr. Alvarez, authorizing all three procedures. At 12:40 the receptionist calls Dr. Alvarez: the #19 patient arrived early and Kim has already seated and begun the restoration. Dr. Alvarez is 20 minutes away.
1. Which of the three scheduled procedures could lawfully proceed while Dr. Alvarez was off-site, and which could not? Show your analysis rather than listing answers.
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Start from the rule that delegation in Minnesota is function-by-function: the Board of Dentistry's rules assign each delegable function a supervision level, and a private protocol cannot lower that level.
- Direct supervision generally means the dentist is on the premises, has examined the patient, and is available to intervene.
- General supervision generally means the dentist has authorized the procedure and examined the patient, but need not be present.
Applying that:
- Composite on #19 by an LDA - placement and carving of restorations is a direct-supervision function. Across town is not "on the premises." This appointment should have been rescheduled; the written protocol is irrelevant.
- Bitewing plus fluoride on a 9-year-old - radiographs, fluoride, and sealants are generally delegable to an LDA at the general-supervision level, so this is likely permissible, provided the child was examined and the rule's conditions are met.
- Local anesthesia by the hygienist - conditional on her certification and on whatever supervision level the rules assign to that function. If direct supervision applies, the block cannot be given; hygienist-performed periodontal therapy under general supervision generally can proceed.
The judgment point: verify each function against the current rule, then decide who stays in the building.
2. Kim completes the composite before Dr. Alvarez returns. What are Dr. Alvarez's obligations that afternoon and in the chart?
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The lapse already happened; the question is how to contain it honestly.
- Do not paper over it. Charting that Dr. Alvarez placed or directly supervised the restoration would be falsification - a separate and more serious unprofessional-conduct problem than the supervision violation itself.
- Record the facts: who performed which step, the supervision level actually in effect, and Dr. Alvarez's post-treatment examination of the restoration and occlusion on her return.
- Check the patient's outcome and correct any deficiency at no charge.
- Address the practice failure: review the written protocol, retrain staff on which functions require the dentist on site, and change scheduling so direct-supervision functions are not booked during dentist absences.
- Consider disclosure to the patient that an assistant placed the restoration; patients are entitled to know who rendered their care.
- Self-reporting is not required for every internal lapse, but if the Board later learns of it, documented, timely corrective action is strong mitigation; concealment destroys that.
3. Six months later Dr. Alvarez is considering letting Kim perform nonsurgical periodontal probing and charting on recall patients when no hygienist is scheduled. What must she evaluate before doing so?
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Two separate questions: is the function delegable at all, and at what supervision level?
- Diagnosis is not delegable. Periodontal diagnosis and treatment planning - including interpreting probing depths into a diagnosis and case type - remain the dentist's responsibility. An auxiliary may collect and record data that the rules assign to her scope; she may not diagnose.
- Check the specific function against the Board's delegated-functions rule and against Kim's credential (an LDA credential does not automatically cover every hygiene-type function).
- Confirm the supervision level and whether the dentist must be present.
- Document the authorization in a written protocol and in the individual record, and ensure the dentist reviews the data before a diagnosis is entered.
If any of those conditions cannot be met, the function must be scheduled when a hygienist or the dentist is available.