The Absent Dentist and the SRP Patient
Dr. Patel owns a two-chair general practice. On Thursday she leaves at 11:30 a.m. for a required continuing education course and will not return until 4:00 p.m. Her hygienist, Lena, RDH, has a full afternoon: three adult prophylaxis appointments, two sealant visits for children, and one patient, Mr. R, age 58, with type 2 diabetes and a 6-mm periodontal pocket on tooth 30 that bleeds on probing. Two weeks earlier Dr. Patel examined Mr. R, diagnosed localized periodontitis, and wrote "SRP lower right quadrant" in the chart. No other dentist is in the office. The front-desk coordinator tells Lena to "handle everything" because Dr. Patel is only a phone call away. Lena is also asked to take a bitewing radiograph on a new patient who has never been examined by Dr. Patel. Lena calls Dr. Patel, who says, "Use your judgment; I trust you."
1. May Lena treat the prophylaxis and sealant patients, and may she perform Mr. R's scaling and root planing, while Dr. Patel is off-site? Explain the supervision standard.
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In Pennsylvania, the Dental Practice Act and Board regulations define supervision levels. In a private dental office, routine hygiene services generally require direct supervision: the dentist must be on the premises, physically available, and must have examined the patient and authorized the service. A phone call does not satisfy direct supervision. General supervision-dentist not on-site but authorizing care-is limited by regulation to specific settings or practitioners, such as public health dental hygiene practitioners in qualifying settings. The prophy and sealant patients may have been examined earlier, but direct supervision still requires Dr. Patel's presence. Mr. R's SRP is nonsurgical periodontal therapy; it requires a dentist's diagnosis and, in private practice, direct supervision. Dr. Patel's chart note does not authorize Lena to proceed while the dentist is away. The same conclusion applies to the sealants: sealant placement is an expanded function that must be properly delegated and supervised. "Use your judgment" cannot override the statutory supervision requirement.
2. May Lena take the bitewing radiograph for the new patient? What authorization is required?
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No. Radiographs are part of the practice of dentistry and must be prescribed by a dentist after a clinical examination or other appropriate indication. A new patient who has not been examined cannot simply be radiographed because the front desk scheduled it. The dentist's prescription and documentation are required. If the patient has an urgent complaint, the office should arrange for a dentist to examine the patient or reschedule. Taking a radiograph without a dentist's order may be practicing beyond the hygienist's scope and can expose both Lena and Dr. Patel to discipline. The proper sequence is dentist examination, determination of need, written order, exposure by a qualified person, and interpretation by the dentist.
3. What should Lena do, and what risks does Dr. Patel face?
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Lena should decline to provide services that require direct supervision while no dentist is on-site, document the schedule conflict, and ask the office to reschedule or have Dr. Patel remain. She should not rely on "use your judgment" because a licensee cannot delegate judgment that the law reserves to the dentist. Dr. Patel risks discipline for aiding unlicensed or unauthorized practice, failing to supervise, and unprofessional conduct; the practice also risks civil penalties. The safest course is to cancel or reschedule the hygiene appointments and arrange dentist coverage. If a patient has an urgent problem, the office should arrange an examination by a dentist rather than have the hygienist proceed alone.