N/a

Front 1

Perform preliminarycharting of the oral cavity and surrounding structures to include casehistories, perform initial and periodic examinations and assessments todetermine periodontal status, and formulate a dental hygiene treatment plan incoordination with a dentist’s treatment plan.

Back 1

G - DH

Front 2

Completepreliminary charting of the oral cavity and surrounding structures with theexception of periodontal probing and assessment of the periodontalstructure.

Back 2

G- LDA

Front 3

Obtain informed consent within scope of practice.

Back 3

G- BOTH

Front 4

Take photographs extraorally or intraorally.

Back 4

G- BOTH

Front 5

Take vital signssuch as pulse rate and blood pressure as directed by a dentist.

Back 5

G-BOTH

Front 6

Make referralsto dentists, physicians, and other practitioners in consultation with adentist.

Back 6

G- DH

Front 7

Completeprophylaxis to include scaling, root planing, polishing of restorations.

Front 8

Dietaryanalysis, salivary analysis and preparation of smears for dental healthpurposes.

Back 8

G-DH

Front 9

Replacement, cementation, and adjustment of intact temporaryrestorations extraorally or intraorally.

Back 9

G- DH

Front 10

Recement intacttemporary restorations.

Back 10

G- BOTH

Front 11

Place temporaryfillings (not including temporization of inlays, onlays, crowns, andbridges).

Back 11

G- BOTH

Front 12

Cut arch wires,remove loose bands, or remove loose brackets on orthodontic appliances.

Back 12

G- BOTH

Front 13

Remove excess bond material from orthodonticappliances.

Back 13

G- DH

D- LDA

Front 14

Remove bondmaterial from teeth with rotary instruments after removal of orthodonticappliances. 5

Back 14

D- DH, LDA

Front 15

Etch appropriate enamel surfaces, applyand adjust pit and fissure sealants. 1

Back 15

G- DH

IN-LDA

Front 16

Administer localanesthesia. 2

Back 16

G-DH

Front 17

Administer nitrous oxide inhalation analgesia pursuant tothe rule provisions. 3

Back 17

G- DH

D-LDA

Front 18

Monitor a patientwho has been induced by a dentist into nitrous oxide-oxygen relativeanalgesia.

Back 18

G-DH

IN-LDA

Front 19

Perform restorative procedures limited to: placing, contouring, and adjusting amalgamrestorations, glass ionomers, and supragingival composite restorations (class I& V) where the margins are entirely within the enamel on permanent/primaryteeth; adapting and cementing stainless steel crowns on permanent/primaryteeth; and placing, contouring, and adjusting supragingival compositerestorations (class II & V) on primary teeth. 6

Back 19

IN- DH, LDA

Front 20

Remove marginaloverhangs.

Back 20

G-DH

Front 21

Place and remove matrix bands.

Back 21

D- DH, LDA

Front 22

Fabricate, cement, and adjust temporaryrestorations extraorally or intraorally.

Back 22

D- DH, LDA

Front 23

Remove temporary restorations with hand instruments only.

Back 23

D- DH, LDA

Front 24

Etch appropriate enamel surfaces beforebonding of orthodontic appliances by a dentist.

Back 24

D- DH, LDA

Front 25

Perform mechanical polishing to clinical crowns notincluding instrumentation. Removal ofcalculus by instrumentation must be done by the dentist or dental hygienistbefore mechanical polishing.

Back 25

G-DH

IN-LDA

Front 26

Takeradiographs.

Back 26

G- DH, LDA

Front 27

Remove excess cement from inlays, crowns, bridges andorthodontic appliances with hand instruments only.

Back 27

G-DH

IN-LDA

Front 28

Apply topical medications such as, but not limited to,topical fluoride, bleaching agents, and cavity varnishes in appropriate dosagesor quantities as prescribed by a dentist.

Back 28

G - DH

IN-LDA

Front 29

Take impressions forcasts and appropriate bite registration. 4

Back 29

G- DH, LDA

Front 30

Place and removerubber dam.

Back 30

G-DH

IN-LDA

Front 31

Preselectorthodontic bands.

Back 31

G-DH

IN-LDA

Front 32

Place and remove elastic orthodontic separators.

Back 32

G-DH, LDA

Front 33

Attach prefit and preadjusted orthodontic appliances

Back 33

D- DH, LDA

Front 34

Remove and replace ligature ties and archwires on orthodontic appliances.

Back 34

G-DH

IN-LDA

Front 35

Remove fixed orthodontic bands andbrackets.

Back 35

D- DH, LDA

Front 36

Delivervacuum-formed orthodontic retainers.

Back 36

G-DH, LDA

Front 37

Remove sutures.

Back 37

G-DH

IN-LDA

Front 38

Place and remove periodontal packs.

Back 38

G-DH

IN-LDA

Front 39

Dry root canals with paper points.

Back 39

G-DH

IN-LDA

Front 40

Place cotton pellets and temporaryrestorative materials into endodontic openings.

Back 40

G-DH

IN-LDA

Front 41

Maintain and remove intravenous lines under supervision ofdentist holding a valid general anesthesia or moderate sedationcertificate. 7

Back 41

IN-DH, LDA

Front 42

Monitor a patient during each phase of general anesthesia ormoderate sedation using noninvasive instrumentation under supervision ofdentist holding a valid general anesthesia or moderate sedationcertificate. 8

Back 42

IN- DH, LDA

Front 43

Initiate and place an intravenous infusion line inpreparation for intravenous medications and sedation under supervision ofdentist holding a valid general anesthesia or moderate sedationcertificate. 9

Back 43

D- DH, LDA

Front 44

Concurrently perform supportive services if the dentistholds a valid general anesthesia or moderate sedation certificate, ispersonally treating a patient, and authorizes the allied dental personnel toaid in treatment including the administration of medications into an existingintravenous line, an enteral agent, or emergency medications in an emergentsituation. 10

Back 44

P- DH, LDA

Front 45

Place nonsurgicalretraction material for gingival displacement. 11

Back 45

D-DH, LDA