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Iowa Dental Board

Levels of Supervision

Definitions: Supervision Levels
Public Health Supervision
Public Health Supervision Agreements
Annual Reporting Requirements
Silver Diamine Fluoride Protocols & Training Programs

Supervision Required

A licensed dentist must prescribe all services and treatment provided to a patient. General supervision shall not preclude the use of direct supervision when in the professional judgment of the dentist such supervision is necessary to meet the individual needs of the patient. Subsequent examination and monitoring of the patient, including definitive diagnosis and treatment planning, is the responsibility of the dentist and shall be carried out in a reasonable period of time in accordance with the professional judgment of the dentist based upon the individual needs of the patient.

Under the general or public health supervision of a dentist, a dental hygienist may provide assessment, screening, or data collection for the preparation of preliminary written records for evaluation by a licensed dentist. A dentist is not required to examine a patient prior to the provision of these dental hygiene services. Note: Licensed dental hygienists may provide educational services without the supervision of a licensed dentist.

Definitions for Supervision Levels

Effective December 21, 2022, the Board adopted changes to the definitions for supervision in dental offices.  The portions of the definitions, which are underlined below, are new.

“Direct supervision” means that the dentist is present in the treatment facility, but it is not required that the dentist be physically present in the treatment room, or the dentist is not present in the treatment facility but is able to appear using live video upon request with a response time similar to what would be expected if the dentist were present in the treatment facility.

“General supervision of a dental assistant” means that a dentist has examined the patient and has delegated the services to be provided by a registered dental assistant, which are limited to all extraoral duties, dental radiography, intraoral suctioning, and use of a curing light and intraoral camera. The dentist need not be present in the facility while these services are being provided. If a dentist will not be present, the following requirements shall be met:

      1.          Patients or their legal guardians must be informed prior to the appointment that no dentist will be present and therefore no examination will be conducted at that appointment.
      2.          The dental assistant must consent to the arrangement.
      3.          Basic emergency procedures must be established and in place, and the dental assistant must be capable of implementing these procedures.
      4.          The treatment to be provided must be prior-prescribed by a licensed dentist and must be entered in writing in the patient record.

“General supervision of a dental hygienist” means that a dentist has examined the patient and has prescribed authorized services to be provided by a dental hygienist. The dentist need not be present in the facility while these services are being provided. If a dentist will not be present, the following requirements shall be met:

      1.   Patients or their legal guardians must be informed prior to the appointment that no dentist will be present and therefore no examination will be conducted at that appointment.
      2.   The hygienist must consent to the arrangement.
      3.   Basic emergency procedures must be established and in place and the hygienist must be capable of implementing these procedures.
      4.   The treatment to be provided must be prior prescribed by a licensed dentist and must be entered in writing in the patient record.

“Observational supervision” for expanded functions, is for training purposes only and means the dentist is physically present in the treatment room to oversee and direct all services being provided as part of clinical training.

"Personal supervision” means a licensee or registrant is physically present in the room to oversee and instruct all services of the dental assistant trainee as delegated by a licensed dentist.

“Public health supervision” means all of the following:

      1.   The dentist authorizes and delegates the services provided by a registered dental assistant to a patient in a public health setting, with the exception that services may be rendered without the patient’s first being examined by a licensed dentist;
      2.   The dentist is not required to provide future dental treatment to patients served under public health supervision;
      3.   The dentist and the registered dental assistant have entered into a written supervision agreement that details the responsibilities of each licensee/registrant, as specified in IAC 650--Chapters 10 and 20; and
      4.   The registered dental assistant has an active Iowa registration and a minimum of one year of clinical practice experience.

Public Health Supervision

Public Health Settings

For the purposes of this rule, public health settings are limited to schools; Head Start programs; programs affiliated with the early childhood Iowa (ECI) initiative authorized by Iowa Code chapter 256I; child care centers (excluding home-based child care centers); federally qualified health centers; public health dental vans; free clinics; nonprofit community health centers; nursing facilities; and federal, state, or local public health programs. 

In December 2020, the Board issued a statement clarifying public health settings as established in rule.  You may review that statement here.

Eligibility

To be eligible to work under public health supervision, a dental hygienist or a registered dental assistant must have an active Iowa license or registration with a minimum of one year of active clinical practice experience.

Public Health Supervision Agreements

When working together in a public health supervision relationship, a dental hygienist or dental assistant shall enter into a written agreement with a licensed dentist that authorizes and delegates the services that may be provided under the agreement. You may access the public health supervision forms made available by the Bureau of Oral and Health Delivery Systems here.

Responsibilities of the Dentist

  1. Be available to provide communication and consultation with the dental hygienist or dental assistant;
  2. Have age- and procedure-specific standing orders for the performance of dental services. Those standing orders must include consideration for medically-compromised patients and medical conditions for which a dental evaluation must occur prior to the provision of dental services;
  3. Specify a period of time in which an examination by a dentist must occur prior to providing further services. However, this examination requirement does not apply to educational services, assessments, screenings, and fluoride if specified in the supervision agreement; and
  4. Specify the location or locations where the services will be provided under public health supervision.

Responsibilities of the Dental Hygienist

A dental hygienist providing services under public health supervision may provide assessments; screenings; data collection; and educational, therapeutic, preventive, and diagnostic services as defined in rule 10.3(153), except for the administration of local anesthesia or nitrous oxide inhalation analgesia. The hygienist can only provide services as specified in the written supervision agreement and under the protocols specified in the agreement.

  1. Maintain contact and communication with the dentist providing public health supervision;
  2. Practice according to age- and procedure-specific standing orders as directed by the supervising dentist, unless otherwise directed by the dentist for a specific patient;
  3. Provide to the patient, parent, or guardian a written plan for referral to a dentist and assessment of further dental treatment needs;
  4. Have each patient sign a consent form that notifies the patient that the services that will be received do not take the place of regular dental checkups at a dental office and are meant for people who otherwise would not have access to services; and
  5. Specify a procedure for creating and maintaining dental records for the patients that are treated by the dental hygienist or dental assistant, including where these records are to be located.

Information about the application of silver diamine fluoride is copied below.

Responsibilities of the Dental Assistant

A registered dental assistant providing services under public health supervision may only provide services which are limited to all extraoral duties, dental radiography, intraoral suctioning, and use of a curing light and intraoral camera and must:

  1. Maintain contact and communication with the dentist providing public health supervision;
  2. Practice according to age- and procedure-specific standing orders as directed by the supervising dentist, unless otherwise directed by the dentist for a specific patient;
  3. Provide to the patient, parent, or guardian a written plan for referral to a dentist and assessment of further dental treatment needs;
  4. Have each patient sign a consent form that notifies the patient that the services that will be received do not take the place of regular dental checkups at a dental office and are meant for people who otherwise would not have access to services; and
  5. Specify a procedure for creating and maintaining dental records for the patients that are treated by the dental hygienist or dental assistant, including where these records are to be located.

Annual Reporting Requirements

Each dental hygienist or dental assistant who has rendered services under public health supervision must complete a summary report at the completion of a program or, in the case of an ongoing program, at least annually. The report shall be filed with the Bureau of Oral and Health Delivery Systems of the Iowa Department of Health & Human Services on forms provided by the department and shall include information related to the number of patients seen and services provided so that the department may assess the impact of the program. The department will provide summary reports to the board on an annual basis.

Silver Diamine Fluoride Protocols (SDF) and Training Programs

Effective October 3, 2018, the Board adopted rules that allow dental hygienists to use silver diamine fluoride under public health supervision.  The written agreements for public health supervision must be filed with the Bureau of Oral Health and Delivery Systems, and must also be maintained by the dentist and the dental hygienist and made available to the Board upon request.  The agreement must be reviewed, at a minimum, every two years.  The agreement establishes the locations and services that may be provided under public health supervision. 

Iowa Administrative Code 650-10.5(3) establishes the requirements for the use of silver diamine fluoride in public health settings.

  • The supervising dentist and the dental hygienist must complete Board-approved training on the use of silver diamine fluoride if the services are included in the supervision agreement; and
  • The agreement must include specific guidelines for the use of silver diamine fluoride and must comply with Board-approved protocols.

Board-Approved SDF Protocols

At its September 28, 2018 meeting, the Board approved protocols for the use of silver diamine fluoride in public health settings.  The protocols were developed by the Iowa Department of Public Health, now the Department of Health & Human Services, in conjunction with the University of Iowa College of Dentistry.  The approved protocols are available here.

Board-Approved SDF Training Courses

The Iowa Dental Board has approved the following courses for the purposes of training in the use of silver diamine fluoride under public health supervision:

University of Iowa College of Dentistry
Contact: Amanda Shoemaker
Email: Amanda-Shoemaker@uiowa.edu
Website: www.dentistry.uiowa/ce
Phone: (319) 335-7166; Fax: (319) 335-7155

Mary Kelly, L.L.C.
Contact: Mary Kelly, R.D.H., B.S., M.S.
Email: MaryKellyRDH@msn.com
Phone: (515) 321-5125

Iowa Dental Association
May 2019 Meeting
"Medical Model of Caries for the Modern Dental Practice: Silver Diamine Fluoride (SDF) and More"
Presented by: Dr. Jeremy Horst
Approved by the Iowa Dental Board: 4/5/2019