Determining what is required to achieve the best possible oral health for a patient is based on many physical, physiological and psychological factors. These include, among other things, the condition of the patient’s dentition and periodontium, salivary flow, mucosal integrity, masticatory function and systemic health, as well as the patient’s desires and expectations. Thus, optimal oral health cannot be defined only by the absence of pathology. The challenge facing every practitioner is how to determine what care is appropriate and needed for each patient.

To achieve this goal, most clinicians—deliberately or unwittingly—follow predetermined algorithms. These algorithms may have been learned during a practitioner’s professional training, gained from textbooks or articles, based on the particular practitioner’s experience or drawn from a combination of many different resources. A common algorithm is the "SOAP" note: Ascertain the patient’s Subjective complaint, perform an Objective examination, make an Assessment and initiate a Plan of action—or, in other words, "determine what care is appropriate and needed." To achieve the proper outcome, the clinician needs to ensure that the preceding variable—the assessment or diagnosis—is correct.

Scope of practice can be described as the lawful sphere of activities of a health care provider. Such activities commonly are defined by the tasks the provider is allowed to perform. But acquiring the clinical skills necessary to perform particular tasks is not enough to become a competent professional health care provider. To optimize the benefit of learned and acquired clinical proficiencies, these skills need to be accompanied by a comprehensive theoretical background.

Acceptance into dental school is based on analytical and scholastic achievements, not necessarily dexterity and hand-eye coordination. We are taught basic clinical skills, and we hone these skills during our years in dental school and beyond. Yet, clinical performance still is a process based on theoretical principles. Not all cavity preparations can adhere to the classical doctrine put forth by Dr. G.V. Black. The clinician must be able to adapt and adjust on the basis of the unique circumstances presented by a particular patient. To do so, the clinician relies on theoretical principles of topics such as tooth anatomy, dental materials, pharmacology, pathology and maybe even medicine. Risk and benefit of treatment is not a linear relationship. Each patient inherently possesses unique vulnerabilities and, consequently, distinctive responses. Although provision of standard treatment almost always will result in typical responses, our concerns are the unusual and infrequent responses.

The decision to scale a patient’s teeth should not be based solely on the recognition of erythematous and edematous gingival tissue accompanied by attachment loss. Nor should it be based solely on a practitioner’s ability to débride the teeth mechanically. Rather, a thorough knowledge and understanding of the etiology of the pathological process is necessary. Does this patient have clinical manifestations of periodontal breakdown caused by accumulation of plaque and calculus, or is there an underlying systemic condition, such as immune suppression, causing exacerbation and changes in the periodontium? Or does the patient have a yet-to-be diagnosed systemic illness, such as diabetes mellitus? The patient has the right to demand that the practitioner be able to make a proper diagnosis and modify his or her care accordingly.

Diagnostic processes may differ, but the reasons for providing care remains. The sine qua non of health care is rendering appropriate care predicated on an accurate diagnosis. This is an axiom embraced by every health care discipline. Provision of health care doesn’t equal health. It is only a means to achieve health. Consequently, scope of practice is not only the issues of who provides what type of care and how it is done, but also—and maybe even more importantly—why the care is needed. The ability to apply appropriate modifications to standard procedures under extraordinary circumstances to achieve expected outcomes unquestionably is every patient’s expectation. It surely is every patient’s right to be treated by practitioners who possess such skills, knowledge and erudition.