An Ethical Perspective for Emerging Dental Roles: Insights from Dr. Al Rizkalla

Jun 25, 2026 by Dr. Al Rizkalla

In light of the passage of Senate Bill 178/House Bill 970, which permits dental assistants in Virginia to become certified to supragingivally scale teeth, Dr. Rizkalla shares his perspective on the ethics of emerging dental roles and the appropriate lens through which a dental practice should evaluate changes in patient care delivery and team roles.

Q: A lot of the discussion around the country about what duties should be permitted to be assigned to various members of the dental team rightly centers around patient safety. How should a practice evaluate if a change is safe for patients, or if it introduces new patient risks?

Supragingival scaling is, by definition, coronal (above the gum line), which reduces the risk profile compared to subgingival instrumentation. This anatomical boundary lessens the iatrogenic harm to the junctional epithelium, periodontal ligament, and root surface/cementum. The legislation appropriately reflects this by limiting the function to the supragingival area, tying it to direct supervision, and requiring specific training and demonstrated competency. Those limitations are in place for patient safety and protection. That said, the risk is not zero. A dental assistant who cannot reliably distinguish supragingival from subgingival deposits, who lacks tactile sensitivity from inadequate training, or who works in a practice with little or nominal supervision, introduces real risk. The legislation creates a permissive framework, not automatically a safe one. The difference will be entirely in implementation.

Q: Looking at the American Dental Association’s Principles of Ethics and Code of Professional Conduct, dentists are called on to follow high ethical standards, which have the benefit of the patient as their primary goal. How should they determine if a new function or new role will benefit patients?

This is where it gets more interesting and, frankly, more demanding. The principle of nonmaleficence is the floor, not the ceiling. The principle of beneficence calls dentists to act in a positive manner to benefit the patient, not merely to avoid harm, but to actively promote well-being. Supporters of deploying dental assistants to perform supragingival scaling argue that trained dental assistants can bring scaling to patients who would otherwise receive dental care late, or not at all, as dental hygiene appointment backlogs delay preventive care for months. Also, this may allow practices to extend preventive care at a lower cost. These benefits do not override patient safety but are appropriate for ethical discussions.

Q: How does that ethical framework leave space for innovation and evaluating new models? Some dental practices eagerly adopt new technology, new techniques, or newly delegable duties for allied dental personnel in their patient care, while others may be more skeptical of change. What is the appropriate lens through which a dentist should evaluate potential changes in their practice models?

In our profession, this is an ongoing question. Both early adopters and cautious skeptics can act ethically or unethically, depending on why they hold their positions and how they reason through them. To me, it comes down to one word: MOTIVATION. The ethical practitioner needs to distinguish between two very different motivations:

EVIDENCE-BASED ADOPTION: What does the literature say about the outcomes? Where has it been tried, under what conditions, and what were the results? What were the failures, and how were they handled? How does this change the patient experience?
ENTHUSIASM-BASED ADOPTION: Is it new and exciting? Are other practices doing it? Does it improve workflow or revenue? Will it differentiate us in the marketplace?

Both motivations are acceptable. The problem arises when the enthusiasm-based adoption becomes the driving force. A new technology, material, or clinical approach that increases revenue can also benefit patients, but the dentist has an ethical and moral obligation to establish the second point independently of the first.

On the other hand, a dentist who resists a new model or innovation should be able to articulate a patient-centered reason for resistance, not simply because they are uncomfortable with change or to protect existing revenue streams. An example of that is the slow adoption of evidence-based caries management (CAMBRA).

For the supragingival scaling, the legal permission is the beginning, not the end. The ethical question should be:

Is it right for my patients, my team, and my practice?
If this doesn’t work as intended, what happens to patients?

Is this a genuine patient-benefit or a practice-benefit sequencing? This doesn’t mean practice benefit is irrelevant; a financially stable practice serves patients better than one that isn’t. But the directionality of the reasoning matters ethically.

Particularly for changes involving allied personnel taking on new functions, the ethical evaluation must include an honest assessment of the team, not just the concept. A delegation model that works well with a highly trained, experienced, and well-supervised team may not work at all with a different team configuration. The practice model and the team are not separable variables.

This means asking:

Does my team have the training, the temperament, the supervision structure, and the feedback mechanisms to make this work safely?
Has the team itself been part of the conversation?

Dental assistants and hygienists who are asked to take on new functions have their own professional obligations and their own perspective on their readiness. Ethical practice leadership engages that perspective, rather than simply issuing assignments.

Finally, ethical evaluation of a practice change does not end at adoption. The obligation to assess whether a change is serving patients well continues throughout its implementation. This means structured review—not just responding to complaints, but proactively looking at clinical outcomes, patient experience, and team feedback.

Q: Thinking about considering a change in roles through an additional certification and delegable duty for a dental assistant, what is the dentist’s obligation to their patients as their assistants go through a certification program and begin performing supragingival scaling on that practice’s patients?

Let’s be clear: the first patients on whom a newly certified dental assistant performs supragingival scaling bear a disproportionate share of the risk associated with that assistant's development of competency. This is true of every clinician learning every procedure; it is true of the dentist's own first scaling as a student, of the hygienist’s first patients, and of every surgeon's early cases. The learning curve is real and unavoidable, and it is borne by patients. This is not an argument against allowing assistants to learn. It is a recognition that the dentist has a specific obligation to manage who bears that risk, how much of it they bear, and whether they know they are bearing it.

A dentist who treats certification as the moment the obligation is discharged (“they passed the program, so they're qualified now”) has precisely missed the period during which their patients are most exposed. Certification establishes a minimum competency floor under examination conditions. It does not establish proficiency in the dentist's actual practice, on the dentist's actual patients, or under the dentist's actual time pressures.

Several obligations will fall on the dentist:

First, the dentist must make an honest judgment: Is this the right individual for this expanded role? Certification programs can train technique, but they cannot instill conscientiousness, tactile sensitivity, or the judgment to recognize when something is beyond one's competence and to stop. The dentist who knows this team member’s reliability, their willingness to ask questions, and their honesty about their own limitations is in a position to make that assessment, and is obligated to make it candidly, rather than reflexively endorsing an enthusiastic team member's career development.
Second, Virginia's law does not channel this competency determination through a single, board-administered examination with a uniform passing standard, the way hygiene licensure does. It sets prerequisites of 1,800 hours of prior clinical experience and training and certification from a licensed dentist or licensed hygienist (engaged by a licensed dentist) and then places the decisive judgment in the supervising dentist's hands. The dentist must certify, under oath, that the assistant has completed at least 20 supervised full mouth supragingival scaling procedures. In practical terms, the dentist is the certifying authority. There is no external credentialing body whose standard the dentist can lean on for the question that matters most: Can this person safely scale these patients' teeth?
That structure removes a temptation it might otherwise create. A dentist operating under a regime of external, standardized certification can drift into treating the certificate as proof of readiness and stop there. Virginia leaves no such exit. The dentist cannot outsource the judgment about adequacy because there is no one to outsource it to; the signature on the oath is their own. The 1,800 hours, the certification, and 20 supervised scaling procedures are the floors the state has set. They are not finding that any particular assistant is ready. That finding is the dentist's alone to make and to swear to.
The obligation, then, is to treat those 20 supervised procedures not as a box to be checked, but as the dentist's own evidence-gathering, through enough direct observation, across enough clinical variation, to form an honest judgment that this assistant performs this function safely on real patients. If that judgment cannot be made truthfully at 20 procedures, the ethical response is to keep supervising past 20, not to sign off at 20. This number is the minimum the law will accept. It is not necessarily the standard that the dentist's own patients deserve.
Third is patient selection, where the dentist will have an obligation to decide how much to trust the assistant. A patient with light supragingival calculus, easy access, good cooperation, and uncomplicated anatomy is an appropriate early case. A patient with heavy deposits, restorative complexity, implants, exposed root surfaces, significant anxiety, or a complicated medical history is not. That is when supervision is crucial; it is not a quick glance. It should be a careful attention to technique, deposit removal, and soft tissue handling. When I examine for the ADEX board, every once in a while, we see damaged soft tissue done by a dental student who just completed four years of dental school. The dentist should reach an independent judgment, distinct from the certification, that this assistant performs this function safely on patients. This is a different and more meaningful determination than "completed the program."

The fourth obligation is informed consent. I emphasize this because this is where practices most often fall short, and the ethical principles are imperative to observe. Without the need to alarm the patient or undermine the assistant’s standing, honest transparency requires that the patient be informed that their scaling will be performed by a certified dental assistant under the dentist’s supervision. It is the patient's right to understand who is treating them and to decline if they choose.

Q: In the context of the new credentialing pathway for dental assistants to scale supragingivally, what are some considerations the dentist should have in terms of the patients to which a dental assistant is assigned and what duties the assistant is qualified to perform?

It is prudent for the dentist to be extra conservative when assigning which patients will see the dental assistant: patients with no prior diagnosis of periodontal disease, clinical attachment loss, or history of SRP. Other considerations include, but are not limited to, medical history and complexity, age, behavior, number of deposits, BOP that may suggest early periodontitis, furcation involvement, and presence of complex restorations or implants.

Clear internal protocols should specify what instruments and procedures the assistant may use, require the dentist/hygienist to screen and triage patients before assignment, and mandate that the assistant stop and call the dentist for any abnormal findings or suspected subgingival needs. Finally, the practice should treat this as a privileged duty supported by formal training, competency sign‑offs, periodic quality audits, and documentation that identifies the assistant as the provider working under dentist supervision.

Q: Are there any special considerations that a dental practice should take in terms of documenting how they are incorporating this dental team member’s duties into their patient care flow and billing practices?

I will answer this question by asking three questions:

From a clinical point of view, what was done to this patient, and what still needs to be done? This question addresses continuity of care.
Was the dental assistant properly certified and under proper supervision? This question obviously relates to the Board of Dentistry.

Does the claim accurately reflect the services provided? This ensures billing integrity.

As far as documentation is concerned, it must clearly note that the dentist explained the treatment plan and explicitly informed the patient that a certified dental assistant will perform the procedure under proper supervision.

As far as the notes, they should explicitly state that the treatment was limited to supragingival deposits, and if subgingival deposits are present, tenacious calculus or more complex than anticipated, the record should reflect the handoff to the hygienist or the dentist. If any deposits are left in the sulcus, and the patient is under the impression that “they got their teeth cleaned,” are we helping or hurting the patient? This is where clinical judgment, ethical practice, and legal liability intersect.

When it comes to billing, ultimately, it is the individual practitioner’s responsibility, after reading the full CDT Code entry, to determine the procedure code that accurately describes the service provided. Information should be captured in the patient’s dental records and should be sufficiently robust enough to support selection of the CDT code reported on the claim.

Please note that: The ADA’s position is that a patient’s record should accurately document all procedures delivered on a given date of services. “Code for what you do” is the fundamental rule to apply when documenting services delivered both in the patient record and on a claim submission. This guidance is derived from the ADA’s Principles of Ethics and Code of Professional Conduct, specifically the principle of Veracity (“truthfulness”), which is professional, not state statutory or regulatory guidance. The “Principles…” are posted online at Code of Ethics | American Dental Association (ada.org).

The dental benefit plan coverage determines the guidelines, policies, and exclusions, not the ADA. Third-party payer reimbursement for services is determined by provisions of the dental benefit plan or applicable participating provider contract. Any questions concerning third-party payers’ claim adjudication criteria or patient responsibility are addressed by contacting the particular insurance companies involved.

Q: When a dentist assigns an allied dental team member a duty related to patient care, whether that team member is a licensed hygienist or a dental assistant, the dentist has an obligation to protect the health of their patients by only assigning duties to qualified personnel and only assigning those duties to which they can be legally delegated. The dentist also has an obligation to prescribe and supervise all patient care provided by allied team members working under their direction. Can you share more about this responsibility in the context of this role for dental assistants?

What you're describing is the foundational principle of vicarious liability and supervisory responsibility in dental practice, but framed correctly, as an ethical obligation rather than merely a legal one. That distinction matters enormously.

The legal framework says that a dentist can be held liable for the acts of those working under their direction. The ethical framework says something deeper: The dentist is the author of the care plan, and everything that flows from that plan is their professional responsibility, regardless of whose hands execute it.

When a dentist assigns a duty to a hygienist or dental assistant, the dentist’s professional and ethical accountability for the outcome of that duty does not diminish. It is not transferred to the team member, even when the team member acts negligently or outside their instructions. The dentist who created the conditions for that outcome, who hired, trained, assigned, and supervised, remains the responsible party.

This is not a burden that should be resented or minimized. It is the structural reason why dentists hold the authority they do over treatment planning, over team configuration, and over the clinical environment. Authority and accountability are not separable. A professional culture that seeks to claim “authority without fully accepting the accountability” has lost something important about what it means to be a licensed professional responsible for patient care.

Note: Dr. Al Rizkalla is a past president of the Northern Virginia Dental Society (NVDS), executive board member of the VDA, and past president of the Virginia Board of Dentistry. Dr. Rizkalla has held several positions in the VDA and the NVDS, including Continuing Education Chair, Peer Review Committee Chair, Executive Committee Chair, Ethics Committee Chair, and Dental Health and Public Information Committee member. He is an examiner for the CWC testing agency and previously served on ADEX's examination committee.