Here’s a question I was asked by a reader:
“In school we’re taught about morals and ethics. I need to know as a hygienist where I can draw the line. I had a patient tell me that due to her insurance she did not want a comprehensive exam. I explained to her that she could not have a cleaning without a comprehensive exam, and I spoke to the doctor about this, but he was OK with her getting just a prophy and no comp exam. Can we legally do that? I know we’re supposed to do a comprehensive exam, but can I refuse to perform a prophy without a comp? I want to know if there’s anything I can use to back up my argument.”
Here's my answer.
Thank you for your courage to ask about this situation. This is something many of us have experienced, and you’re absolutely not alone in facing this ethical dilemma. Patients will call an office and say they want to “schedule a cleaning.” Frankly, the way patients treat our profession could be a reflection of the experiences they’ve already had—we’ve allowed them to dictate how we approach their care instead of using the evidence-based approaches we’re taught to follow.
We know that morally and ethically new patients should be seen by a dentist before we provide hygiene services. Legally, this may vary between states, but the general standard of care is the same nationwide. While there might not be a universal law that states a new patient must have a comprehensive exam before their hygiene service, we can refer to each state’s dental practice act and our own code of ethics to better support why our patients deserve more than just “a cleaning.”
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Phases of patient care
Let’s rewind to dental hygiene school. In our preclinical course, we learned the phases of the dental hygiene process of care, known as ADPIE(D). Not only do these phases determine appropriate treatment, but they set the standard of care we should aim for. We recognize the following six phases:
First, we assess the patient's medical and dental history, conduct a comprehensive oral exam, and identify any oral health issues. Next, we diagnose specific dental conditions, such as periodontal disease or caries. Once the diagnosis is made, we create a personalized treatment plan tailored to the patient's needs, which may include preventive measures or interventions such as periodontal therapy or fluoride applications. In the implementation phase, we provide the recommended care, followed by evaluation to gauge the effectiveness of the treatment and make any necessary adjustments. Finally, we document the encounter in detail for reference and future care.1
With the phases in place, where does the comprehensive exam come in? For new patients, the assessments should be done with the dentist to establish them as a patient of record. Once a patient is established in the practice and necessary phases are completed, the hygienist can then come in to perform the appropriate hygiene care.
Ethics: Our foundation
In dentistry, our code of ethics serves as guiding principles that shape professional conduct and the responsibilities we should uphold. Approaching our work ethically ensures that patients receive the highest standard of care, and we emphasize their safety and overall well-being. One of our ethical codes is nonmaleficence, or “to do no harm.”2 Providing a hygiene service that is not tailored to the patient due to lack of a comprehensive exam can do more harm than good. We may miss underlying dental issues due to our inadequate treatment planning when we accommodate a “simple cleaning.”
The comprehensive exam the dentist does serves as the crucial first step in a patient’s journey toward adequate, high-quality care. As dental hygienists, we’re called to collaborate with the dentist to collect all the necessary information from a patient to provide a personalized approach to their oral health. Failing to provide a hygiene service without the proper steps showcases that as a profession, dental health-care providers do not exemplify our commitment to excellence in patient care.
The law is there for a reason
Considering the aspects of the law, specific requirements for a comprehensive exam by a dentist can vary among states. Generally, a dentist can make decisions only about patients of record in their practice. A patient of record is someone who has been examined and thoroughly assessed by a licensed dentist. Many state dental practice acts have provisions or guidelines that emphasize that a comprehensive exam is needed before certain dental procedures can be performed, including hygiene services. States that have such an emphasis include:
- California: Section 1684.5 of the California Business and Professions Code specifically states a comprehensive exam must be done prior to any dental procedure, and the patient must be a patient of record for the dentist.3
- Texas: The dental practice act requires dental hygienists to work under the supervision of a dentist, following the dentist’s diagnosis and treatment plan, which includes a comprehensive exam before a hygiene service.4
- New York: The dental practice act requires dental hygienists to practice under the general supervision of a licensed dentist who authorizes and oversees the provision of dental services, including comprehensive exams and hygiene services.5
Note that the language and requirements may differ in each state’s dental practice act, so you should search your state's dental practice act or consult with your state’s dental board or regulatory body.
A shared commitment to patient-centered care
Collaboration between dentists and hygienists is vital and it can be frustrating when disagreements occur, which impact the quality and consistency of patient care. To address this issue, try some resolutions. First, providing educational resources such as the state's dental practice act can help your dentist understand not only the ethical challenges but also the legal risks involved. This can serve as a valuable reference that supports your stance on the importance of a comprehensive exam before providing hygiene services.
Additionally, it can be constructive to promote open communication and allow patients to directly speak with the dentist. By allowing patients to hear firsthand why a comprehensive exam is necessary, the dentist can contribute to a unified approach and foster a shared understanding among the dental team. This patient-centered approach promotes transparency and ensures that everyone is well-informed and aligned regarding the best course of action for optimal patient care.
When it comes to oral health, hygiene services are often viewed as a “cleaning” and routine procedure to maintain a healthy smile. However, the consequences of skipping a comprehensive exam before hygiene services can lead to legal or health ramifications. From a legal standpoint, dental professionals must adhere to state regulations and dental practice acts, which often include the requirement of a comprehensive exam by a dentist.
Consider also that undiagnosed dental issues could slip under the radar, such as decay, periodontal conditions, or serious oral lesions. The one-size-fits-all approach that some practices provide could undermine the effectiveness of our preventive care, compromising long-term oral and systemic health. A shared commitment to patient-centered care is key to approaching any patient-related ethical dilemma. Ultimately, it’s our professional responsibility to ensure legal compliance and provide optimal care, which safeguards patients’ well-being and dental providers’ legal standing.
Editor's note: This article appeared in the August 2023 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
- Gurenlian JR, Sanderson TR, Garland K, Swigart D. Exploring the integration of the dental hygiene diagnosis in entry-level dental hygiene curricula. J Dent Hyg. 2018;92(4):18-26. https://pubmed.ncbi.nlm.nih.gov/30143546/
- California Dental Hygienists’ Association Policy Manual. CDHA. 2022. https://cdha.org/resources
- Required and prohibited conduct. Dental Hygiene Board of California. 2023. https://www.dhbc.ca.gov/licensees/conduct
- Occupations code Title 3. Health professions. https://statutes.capitol.texas.gov/Docs/OC/htm/OC.262.htm
- Article 133, Dentistry and dental hygiene and registered dental assisting. New York State Education Department. https://www.op.nysed.gov/title8/education-law/article-133