Three Delegation Requests and One Telephone
Dr. M. is the only dentist on site in a two-chair office. At 9:00 a.m. she is midway through a molar endodontic case in operatory 1 when three requests arrive from operatory 2. A hygienist who completed a two-day continuing-education course - no formal program, no certification - asks to give an inferior alveolar block so she can finish a quadrant of scaling. An expanded-function assistant asks to cement and adjust the occlusion on a crown Dr. M. tried in yesterday. A dental assistant with no expanded-function credential asks to take the final impression for an implant crown and to "just numb" the site with topical. Separately, the front desk reports a call from a person 200 miles away in another state requesting a video consult for facial swelling and a prescription.
1. For each of the three chairside requests, state whether the task may be delegated and explain the reasoning method rather than just the answer.
Read the worked answer
The method - apply three filters in order for every task.
- Is the act part of the statutory definition of dentistry? Diagnosis, treatment planning, and irreversible or surgical procedures are reserved to the dentist and cannot be delegated no matter how the office is staffed.
- Has the Board, by rule, expressly assigned this function to this category of auxiliary, with stated training and a stated supervision level? If the function is not on the list, it is not delegable, full stop.
- What supervision level does the rule attach - direct (dentist physically on the premises) or general (dentist available)? The answer is a property of the rule, not of how busy the dentist is.
Request 1 - hygienist giving a block. Local anesthesia by a hygienist is a licensed, credential-dependent act. It requires completion of a Board-recognized education program and authorization, typically under direct supervision. A two-day CE course is not a credential. Decline.
Request 2 - EFDA cementing and adjusting occlusion. A permanently cemented crown with occlusal adjustment is irreversible and is the dentist's own treatment decision; final seating and occlusal adjustment are characteristically reserved even where EFDA lists exist. Decline - the EFDA may perform only the enumerated expanded functions.
Request 3 - uncredentialed assistant taking a final implant impression and "numbing." The assistant holds no credential, so nothing beyond basic supportive duties is available. A final impression at an implant abutment is precision work tied to the restorative plan. Decline. The phrase "just numb" is itself a warning: topical application may be delegable in some circumstances, but casual language about anesthesia in an uncredentialed hands is exactly how scope violations start.
The pressure is not a legal argument. "I'm in the middle of an endo" explains the temptation; it does not create authority. The correct response is to stop, tell the patient in operatory 2 the truth - the dentist will complete this step - and re-sequence the day.
2. How should the practice handle the video consult request from a patient in another state with facial swelling?
Read the worked answer
Two separate questions: licensure and standard of care.
Licensure. The practice of dentistry occurs where the patient is located. Dr. M. holds a New Hampshire license; the caller is 200 miles away in another state. A video encounter that includes history-taking, assessment, and a prescription is practice in that other state, and she is not licensed there. Multi-state telehealth compacts and temporary permits exist in some states for some professions, but she cannot assume coverage - she must verify before the call, not after.
Standard of care. Even if licensed in the caller's state, facial swelling with an airway concern, trismus, or dysphagia is not a video-diagnosable problem. The assessment cannot be completed remotely, and a prescription written without an adequate examination creates both clinical and prescribing-exposure risk.
Practical answer. The front desk should not simply decline and hang up. Give clear, non-diagnostic guidance: facial swelling can be an emergency; the caller should be seen today, in person, by a dentist or at an urgent care or emergency department, especially with fever, swelling of the eye or floor of the mouth, difficulty swallowing, or difficulty breathing. Offer to help identify a provider in the caller's area. Document the call, the advice given, and that no treatment or prescription was rendered.
The judgment point the exam is testing: saying no to the prescription while saying yes to the patient's safety. Refusing to prescribe is not the same as abandoning the caller.
3. Dr. M. resolves the morning by telling the staff, "Just do it, I trust you, I'll sign off later." Analyze what she has actually done.
Read the worked answer
She has converted a scheduling problem into a regulatory one, and the exposure is not hers alone.
The supervision fiction. "I'll sign off later" is retrospective ratification. Supervision rules describe what must be true at the time the service is rendered - who is on the premises, who has examined the patient, who has authorized the step. A later signature cannot retroactively make a delegable act lawful.
The auxiliaries are independently liable. A hygienist or assistant who performs a reserved function is exposed for practicing beyond the scope of their own license or credential. "The dentist told me to" is a mitigation argument, not a defense.
Records and billing contamination. Chart entries will show who did what. If the record implies the dentist performed the crown seat and she did not, the chart is false, and any claim submitted on that entry is a misrepresentation.
What she should have done instead. Build the day so the only dentist is not trapped in one operatory during irreversible steps: schedule hygiene under general supervision where the rule permits it, block endo time when no crown seats are due, and give the team a written delegation matrix posted in the office that lists each function, who may perform it, and the required supervision level. The next best moment to fix this is now - by telling operatory 2 the truth about the wait.