Can a dental hygienist in Arizona inject Botox if the supervising dentist asks her to and she has the training?

Plain-English summary

Arizona's dental hygienist statute, A.R.S. § 32-1281, lists thirteen specific procedures hygienists can perform. The interesting part is § 32-1281(C)(3): the legislature gave the Board of Dental Examiners (BODEX) authority to write rules that prescribe the conditions under which a hygienist may "[p]erform other procedures not specifically authorized by this section." BODEX has had a rule on the books since 1999, Ariz. Admin. Code R4-11-601, that lets a hygienist do procedures outside the statutory list when four conditions line up: the supervising dentist prescribes or recommends the procedure, the hygienist has training to do it safely, the work happens under general supervision, and the procedure is not "Irreversible" as defined in R4-11-101.

The legislature spent the last few years debating Botox. In 2022 the dentist scope-of-practice statute was amended to expressly include Botox administration. The corresponding bill for hygienists never passed. Some lawmakers and stakeholders read that as a ban on hygienists doing Botox. The AG's answer is more nuanced: because § 32-1281(C)(3) and R4-11-601 already let hygienists perform procedures beyond the statutory list, no separate sunrise application or scope-of-practice amendment was needed for Botox specifically. As long as the four conditions in R4-11-601 are met, a hygienist can lawfully administer Botox. Whether Botox is "Irreversible" within R4-11-101 is a factual call the AG declines to make and leaves to BODEX, which has the technical expertise.

What this means for you

If you are a dental hygienist or a dentist supervising hygienists

Don't treat the absence of "Botox" from § 32-1281(B) as a ban. The opinion concludes the question turns on R4-11-601 and on whether the procedure is "Irreversible." Before delegating Botox administration to a hygienist, document four things: (1) you, the supervising dentist, have prescribed or recommended the procedure; (2) the hygienist has specific instruction, training, or education adequate to perform it safely; (3) you are providing the supervision the rule requires; and (4) you have a defensible position that the procedure is not "Irreversible" under R4-11-101. Watch for BODEX guidance, the AG explicitly defers to the board on the irreversibility question, so a board policy statement or rule change could move the answer.

If you are a dental patient considering Botox at a dental practice

The legal authority for hygienist-administered Botox is in regulation, not in the dental hygienist statute itself. That doesn't make it improper, but it does mean the conditions matter: did a licensed dentist prescribe or recommend the procedure for you, and is a licensed dentist supervising? You can ask. If something goes wrong, your remedy is through BODEX licensing complaints and through ordinary medical-malpractice channels.

If you are a state legislator or staffer

The opinion is a working example of how administrative rulemaking authority delegated by the legislature can supply scope-of-practice expansion without the sunrise application process. If you don't like that result for a given procedure, the levers are amending § 32-1281 directly, narrowing § 32-1281(C)(3), or changing the definition of "Irreversible Procedure" in R4-11-101. The Governor's veto of S.B. 1248 (which would have eliminated the sunrise process entirely) is, per the AG, irrelevant to interpreting the existing statutes.

If you are a malpractice attorney or risk manager

The opinion is not a license. A hygienist who administers Botox without one of the four conditions met, no recommending dentist, no training, no supervision, or who performs an irreversible step, is acting outside the scope authorized by R4-11-601 and is exposed to discipline, liability, and potentially unauthorized-practice claims. Audit practice protocols against the four-prong test.

Common questions

Why did the legislature need to pass S.B. 1074 to let dentists do Botox if R4-11-601 already covered it?

The dentist scope-of-practice statute, A.R.S. § 32-1202, has no "the board may add procedures by rule" provision. Compare it to the hygienist statute, § 32-1281(C), which expressly delegates that authority. So dentists needed a statutory amendment to add Botox; hygienists already had the regulatory hook to do it under board rule.

Did the unsuccessful 2023 hygienist sunrise application or the H.B. 2373 silence about Botox change anything?

The AG says no. City of Flagstaff v. Mangum warns that "rejection by the house or senate, or both, of a proposed bill is an unsure and unreliable guide to statutory construction." The fact that one bill expanding hygienist scope to Botox died in committee doesn't repeal R4-11-601 or shrink § 32-1281(C)(3).

What does "Irreversible Procedure" mean?

R4-11-101 defines it as "a single treatment, or a step in a series of treatments, that causes change in the affected hard or soft tissues and is permanent or may require reconstructive or corrective procedures to correct the changes." Whether the temporary muscle paralysis caused by Botox fits that definition is a clinical judgment the AG explicitly declines to make.

Can BODEX simply declare Botox to be "Irreversible" and end the practice?

The AG's framing suggests that question rests with BODEX's expertise. BODEX could amend its rules or issue guidance interpreting R4-11-101. Until it does, a hygienist who satisfies the four prongs and reasonably concludes the procedure is reversible can rely on R4-11-601.

What about dermal fillers?

The opinion focuses on Botox but the same analysis applies to any procedure not specifically listed in § 32-1281(B): R4-11-601 controls, and the question is whether the procedure is "Irreversible." Some dermal-filler procedures may be more reversible than others depending on the substance used and the technique.

Does this affect dentists' authority?

Not really. Dentists got express statutory authority for Botox in S.B. 1074 (2022). The opinion is about the parallel question for hygienists, where the source of authority is regulatory rather than statutory.

Background and statutory framework

Two parallel statutes structure dental practice in Arizona. A.R.S. § 32-1202 defines the scope of practice for licensed dentists, and A.R.S. § 32-1281 defines the scope for hygienists. The dentist statute is essentially a single paragraph; it does not delegate procedure-list expansion to BODEX. The hygienist statute, by contrast, contains § 32-1281(C)(3), which directs BODEX to "by rule . . . prescribe the circumstances under which a licensed dental hygienist may . . . perform other procedures not specifically authorized by this section."

That delegation has been on the books since 1990. BODEX exercised it in 1999 by adopting Ariz. Admin. Code R4-11-601, which authorizes hygienists to perform unlisted procedures when (1) the supervising dentist prescribes or recommends, (2) the hygienist has training to perform safely, (3) the work is under general supervision, and (4) the procedure is not "Irreversible" as defined in R4-11-101.

Arizona's sunrise statute, A.R.S. §§ 32-3101 to 32-3106, generally requires health-profession groups to file a sunrise application before the legislature acts to expand a scope of practice. But "increase the scope of practice" is defined as "engag[ing] in conduct beyond the authority granted to a health profession by law." A.R.S. § 32-3101(5). The AG's reasoning is that R4-11-601 grants the authority by law, so performing a procedure consistent with R4-11-601 is not an "increase" requiring a sunrise application, it is simply an exercise of authority the legislature already delegated and the board already used.

The opinion addresses but rejects three counter-arguments: (1) the failed 2023 hygienist sunrise application doesn't matter, because the rule already supplies the authority; (2) the H.B. 2373 silence about Botox doesn't matter, because rejection of legislation is not a reliable guide to statutory construction; and (3) the Governor's veto of S.B. 1248 (which would have eliminated the sunrise process) doesn't matter because the existing sunrise process remains and is satisfied (or unneeded) on the AG's reading.

Citations

• A.R.S. § 32-1281 (dental hygienist scope of practice)
• A.R.S. § 32-1281(C)(3) (BODEX rulemaking authority for additional procedures)
• A.R.S. § 32-1202 (dentist scope of practice; Botox added 2022)
• A.R.S. § 32-1207(A)(1) (BODEX rulemaking generally)
• A.R.S. § 32-3101(5) (definition of "increase the scope of practice")
• Ariz. Admin. Code R4-11-101 (definition of "Irreversible Procedure")
• Ariz. Admin. Code R4-11-601(B)–(C) (conditions for unlisted procedures)
• City of Flagstaff v. Mangum, 164 Ariz. 395, 401 (1990) (legislative rejection unreliable guide)
• S. Arizona Home Builders Ass'n v. Town of Marana, 522 P.3d 671, 676 (Ariz. 2023) (statutory interpretation principles)

Source

• Landing page: https://www.azag.gov/opinions/i23-003-r23-001
• Original PDF: https://www.azag.gov/sites/default/files/2025-06/I23-003.pdf

Original opinion text

To:

The Honorable Jennifer Longdon

Arizona House of Representatives

Questions Presented

Under current law, may dental hygienists administer Botox, or perform other procedures for which they are trained but that are not specifically listed in A.R.S. § 32-1281?

Summary Answer

Current law permits a dental hygienist to perform procedures beyond those listed in A.R.S. § 32-1281, such as administering Botox, so long as four conditions are met: (1) the procedure is recommended or prescribed by the supervising dentist; (2) the dental hygienist has received instruction, training, or education to perform the procedure in a safe manner; (3) the procedure is performed under the general supervision of a licensed dentist; and (4) the procedure is not irreversible, as defined by Arizona Administrative Code R4-11-101. See R4-11-601 (authorized by A.R.S. § 32-1281(C)). The Attorney General does not opine on whether the administration of Botox constitutes an irreversible procedure within the meaning of R4-11-101, however, as this is a factual determination best left to those with specialized expertise.

Background

In November 2019, the Board of Dental Examiners (BODEX) approved a recommendation from its Botox and Dermal Filler Committee that it "change the scope of practice for dentist and hygienist" to include the administration of Botox and dermal fillers. See Minutes from November 15, 2019, Special Board Meeting, Arizona State Board of Dental Examiners, at 3.

In January 2020, H.B. 2134 was introduced to increase the scope of practice for dentists, and would have, among other things, amended A.R.S. § 32-1202 to define the scope of practice for dentistry to include "performance of related adjunctive procedures for any . . . physical condition of the . . . associated tissues of the oral maxillofacial complex, including . . . administering Botulinum Toxin [Botox] and dermal fillers." Notably, although BODEX approved the recommendation to expand the scope of practice for both dentists and dental hygienists, nothing in H.B. 2134 amended the statutes related to the practice of dental hygienists. H.B. 2134 did not move out of committee, and the committee chairperson requested that a "sunrise application" be filed to support the legislation. See A.R.S. §§ 32-3104; 32-3106 (requiring health professional groups seeking an increased scope of practice to submit a report— the sunrise application—to the Legislature explaining a number of factors related to the proposal).

Two years later, the Arizona Dental Association submitted a sunrise application to the Legislature in support of the expansion of the scope of practice for dentists. In January 2022, S.B. 1074 was introduced to increase the scope of practice for dentists. The proposed legislation amended A.R.S. § 32-1202 to define the scope of practice of dentistry to include "performance of related adjunctive procedures for any . . . physical condition of the . . .associated tissues of the oral maxillofacial complex, including . . . administering Botulinum Toxin type A [Botox] and dermal fillers to the oral maxillofacial complex for therapeutic or cosmetic purposes." S.B. 1074 passed through the Legislature and was signed by the Governor on March 18, 2022.

In October 2022, the Arizona Dental Hygienists Association filed its own sunrise application seeking to expand the scope of practice of dental hygienists to include, among other things, the administration of Botox and dermal fillers for therapeutic or cosmetic purposes. In January 2023, H.B. 2373 was introduced to expand the practice of dental hygienists to perform dental hygiene assessments, but made no mention of the administration of Botox or dermal fillers. H.B. 2373 passed through the Legislature without amendment and was signed by the Governor on April 11, 2023.

Another bill introduced this year, S.B 1248, sought to remove the requirement that health professional groups complete a sunrise application when proposing to increase the scope of practice for a health profession. S.B. 1248 passed through the Legislature, but was vetoed by the Governor on March 3, 2023. The Governor explained that while she "agree[d] that we need to make the sunrise application process more effective, efficient, and fair," repealing the process "without replacing it with a better mechanism w[ould] not address the underlying issues, and poses a threat to the health and safety of Arizonans." Governor's Letter to Senate President Explaining Veto of S.B. 1248 (March 3, 2023).

The question presented is whether, under current law, dental hygienists may legally administer Botox, or perform other procedures for which they are trained that are not specifically listed in A.R.S. § 32-1281 and not specifically prohibited.

Analysis

When interpreting statutes, courts must "determine the meaning of the words the legislature chose to use." S. Arizona Home Builders Ass'n v. Town of Marana, 522 P.3d 671, 676, ¶ 31 (Ariz. 2023). In doing so, courts "give the words their ordinary meaning, unless the context suggests a different one." State ex rel. Brnovich v. City of Phoenix, 249 Ariz. 239, 244, ¶ 21 (2020). Courts "apply the same rules in construing both statutes and rules." Smith v. Arizona Citizens Clean Elections Comm'n, 212 Ariz. 407, 412, ¶ 18 (2006).

I. If BODEX regulations allow a dental hygienist to perform a procedure not listed in A.R.S. § 32-1281, then no sunrise application is needed to increase the scope of practice for dental hygienists.

When a health professional group seeks to increase the scope of practice for a health profession, it must file a sunrise application with the Legislature. See A.R.S. §§ 32-3104; 32-3106. A "health professional group" means "any health professional group or organization, any individual or any other interested party that . . . proposes to increase the scope of practice of a health profession." A.R.S. § 32-3101(3). To "increase the scope of practice" means "to engage in conduct beyond the authority granted to a health profession by law." A.R.S. § 32-3101(5). Thus, if a health professional is already permitted by law to engage in particular conduct, then no sunrise application is necessary.

The scope of practice for dental hygienists is defined in A.R.S. § 32-1281. Section 32-1281(B) provides a list of thirteen procedures and tasks that may be performed by dental hygienists. Additionally, § 32-1281(C)(3) provides that BODEX "by rule shall prescribe the circumstances under which a licensed dental hygienist may . . . '[p]erform other procedures not specifically authorized by this section.'"[1]

The scope of practice for dentists is defined in A.R.S. § 32-1202. Unlike § 32-1281, this section governing dentists contains no provision allowing BODEX to prescribe by rule additional procedures that a licensed dentist may perform. Compare A.R.S. § 32-1202, with § 32-1281. Section 32-1202 consists of a single paragraph describing the procedures a dentist may perform. See A.R.S. § 32-1202. Conversely, § 32-1281(C) anticipates that hygienists may be asked to perform procedures other than those listed in the statute and grants authority to BODEX to prescribe by rule the conditions under which a dental hygienist may perform those procedures.

Thus, although the Arizona Dental Association was required to file a sunrise application to increase the scope of practice for dentists, the same does not necessarily hold true for dental hygienists. If BODEX's rules prescribe circumstances under which a licensed dental hygienist may "perform other procedures not specifically authorized" by § 32-1281, then those procedures do not constitute "conduct beyond the authority granted to a health profession by law" and performing those procedures would not meet the definition of "increase the scope of practice" in A.R.S. § 32-3101(5). As discussed below, R4-11-601, as currently written, authorizes dental hygienists to administer Botox, as well as perform other procedures not specifically authorized by § 32-1281, provided that several conditions are met and the procedure is not "irreversible."

Finally, neither the fact that the Arizona Dental Hygienists Association filed an unsuccessful sunrise application to increase the scope of practice for dental hygienists to include the administration of Botox and dermal fillers, nor the Governor's veto of S.B. 1248, affects the meaning of the statute's plain language. See City of Flagstaff v. Mangum, 164 Ariz. 395, 401 (1990) ("Rejection by the house or senate, or both, of a proposed bill is an unsure and unreliable guide to statutory construction."). Nothing in A.R.S. §§ 32-1281, -3101(5), or -3106, prevents the Arizona Dental Hygienists Association from filing a sunrise application. But the plain language of A.R.S. § 32-1281(C)(3) provides another way (through administrative rulemaking) for dental hygienists to receive authorization to perform procedures not specifically listed in the statute.

II. Current BODEX regulations allow dental hygienists to perform procedures not listed in A.R.S. § 32-1281 provided they meet certain conditions and the procedure is reversible.

As currently written, R4-11-601 allows dental hygienists to perform procedures not listed in A.R.S. § 32-1281 under certain conditions. R4-11-601 provides in relevant part:

B. A dental hygienist may perform a procedure not specifically authorized by A.R.S. § 32-1281 when all of the following conditions are satisfied:

The procedure is recommended or prescribed by the supervising dentist;

The dental hygienist has received instruction, training, or education to perform the procedure in a safe manner; and

The procedure is performed under the general supervision of a licensed dentist.

C. A dental hygienist shall not perform an Irreversible Procedure.

This rule has been in place since 1999, see 5 Ariz. Admin. Reg. 580, 593, and it expands the procedures a dental hygienist may perform, subject to certain conditions. First, the supervising dentist must have prescribed or recommended the procedure. R4-11-601(B)(1). Thus, the rule does not permit a dental hygienist to exceed a dentist's scope of practice. Second, a dental hygienist must receive "sufficient instruction, training, or education to perform the procedure in a safe manner." R4-11-601(B)(2). BODEX is responsible for determining whether a dental hygienist has received sufficient instruction or training to perform a procedure not specifically authorized by A.R.S. § 32-1281. See A.R.S. § 32-1207(A)(1) ("The board shall . . . [a]dopt rules that are not inconsistent with this chapter for . . . regulating the practice of dentists and supervised personnel[.]"); see also R4-11-605, -607(B)(4) (establishing a Dental Hygiene Committee, which has the duty to, among other things, "make recommendations to the Board concerning statute and rule development which affect dental hygienists' education, licensure, regulation, or practice"). Third, the procedure must be performed under the supervision of a licensed dentist. R4-11-601(B)(3). And finally, the procedure must not be an "Irreversible Procedure," R4-11-601(C), which is defined as "a single treatment, or a step in a series of treatments, that causes change in the affected hard or soft tissues and is permanent or may require reconstructive or corrective procedures to correct the changes," R4-11-101. This restriction on performing irreversible procedures prevents a dentist from delegating some tasks to a dental hygienist.

Assuming that the administration of Botox is not an "Irreversible Procedure," current law would permit an adequately trained or educated dental hygienist to administer Botox under the supervision of a licensed dentist when prescribed or recommended by the supervising dentist.

Whether a particular procedure is "irreversible" however, is a factual determination best left to those with specialized expertise, such as BODEX. See A.R.S. § 32-1207(A)(1); R4-11-607 (B)(5)(authorizing the Dental Hygiene Committee to provide "advice to the Board on standards and scope of practice which affect dental hygiene practice"). Thus, the Attorney General does not opine on whether Botox constitutes an irreversible procedure within the meaning of BODEX's regulations.

Conclusion

The statute regulating dental hygienists, A.R.S. § 32-1281, grants BODEX the authority to prescribe conditions under which dental hygienists may perform procedures not specifically authorized by the statute. BODEX has prescribed these conditions in R4-11-601(B)–(C). So long as the administration of Botox is not an "Irreversible Procedure" under R-4-11-601(C) and is performed in accordance with the requirements of R4-11-601(B), current law allows dental hygienists to perform the procedure.

Kris Mayes

Attorney General

[1] This provision was added to the statute in 1990. See H.B. 2299, 39th 2d Reg. Sess. (Ariz. 1990) (adding the provision granting authority to BODEX to prescribe conditions under which a dental hygienist might perform other procedures); A.R.S. § 32-1281(D)(2) (1990) ("The board shall, by rule, prescribe the circumstances under which a licensed dental hygienist may . . . [p]erform other procedures not specifically authorized by this section.").