Momentum for New Workforce Models
Where do hygienists stand today?
State by state, stakeholders are reviewing and reimagining the scope of practice for oral healthcare workers. What functions can (should) they perform and under what level of supervision? What are the educational and licensing requirements? Is a new level of practitioner or expanded functions the appropriate response to the access of care dilemma? Or should people be more focused on solutions such as changes in Medicaid coverage? Finally, is there a risk that patients may not receive the same level of care as they would with a doctor?
Currently, each state individually regulates permitted functions and supervision levels for licensed hygienists. A comprehensive list by the American Dental Hygienists' Association (ADHA) details 18 functions1: prophylaxis, x-rays, local anesthesia, topical anesthesia, fluoride, pit/fissure sealants, root planing, soft-tissue curettage, administer N2O, study cast impressions, place periodontal dressings, remove periodontal dressings, place sutures, remove sutures, dental hygiene diagnosis, treatment planning, dental hygiene assessment, and prescriptive authority. Each function is further delineated by level of supervision: direct (dentist needs to be present); personal (dentist needs to authorize, be present, and check prior to patient dismissal); indirect (dentist must authorize procedure and be in the dental office while the procedure is performed); or general (dentist needs to authorize prior to services but need not be present).
Within this maze of regulation, 42 states permit dental hygienists (under certain educational and experiential requirements) to effect care outside a dental practice and without the presence of a dentist, enabling them to treat other patient populations and practice in community settings. Often, these hygiene services are limited in scope and may require public health supervision.2,3
ADHA recently focused on "dental hygiene diagnosis," advocating for its inclusion in the Commission on Dental Accreditation (CODA) Accreditation Standards for Dental Hygiene Education Programs. Dental hygiene diagnosis is defined as "the identification of an individual's health behaviors, attitudes, and oral health care needs for which a dental hygienist is educationally qualified and licensed to provide. The dental hygiene diagnosis requires evidence-based critical analysis and interpretation of assessments to reach conclusions about the patient's dental hygiene treatment needs. The dental hygiene diagnosis provides the basis for the dental hygiene care plan."4
Although "dental hygiene treatment plan" and "dental hygiene diagnosis" had been included in the CODA Accreditation Standards since 1998, the organization removed both functions in 2010. In June 2017, the ADHA submitted proposed revisions to CODA, which were ultimately opposed. Dental hygiene diagnosis was not reincorporated into the Standards. However, as ADHA states, "this does not change the responsibilities of a dental hygienist nor the curriculum taught by dental hygiene educators that teaches students the dental hygiene process of care which includes dental hygiene diagnosis."5
The Next Level
Parallel to the medical model of advanced practice registered nurses, mid-level dental practitioners or dental hygiene therapists offer a bridge to patient care in situations where doctors are less available. At the time of publication, eight states authorized dental therapists, and others were actively considering legislation (see sidebar).
Officially, the ADHA defines a mid-level oral health practitioner, or dental therapist, as "a licensed dental hygienist who has graduated from an accredited dental hygiene program and who provides primary oral healthcare directly to patients to promote and restore oral health through assessment, diagnosis, treatment, evaluation, and referral services. The Dental Therapist has met the educational requirements to provide services within an expanded scope of care and practices under regulations set forth by the appropriate licensing agency."6 ADHA policy supports oral healthcare workforce models that culminate in graduation from an accredited institution, professional licensure, and direct access to patient care.
Often, state dental boards and other dentist organizations oppose this model, citing concerns about a lower standard of care for patients served by therapists. The American Dental Association (ADA) stated, "There is no available data that demonstrate new models that replicate what dentists already do well have increased access to care at a lower cost…. Rather than add a new category of providers, the ADA believes there is a critical need to connect underserved people seeking care with dentists ready to treat them."7
In 2015, CODA adopted accreditation standards for programs to educate mid-level dental providers-a decision made independently from ADA policy, which states that it is in the best interests of the public that only dentists diagnose dental disease and perform surgical and irreversible procedures.8
Healthcare in a State of Flux
These significant shifts in dental practice are part of a larger movement. With new medical models in healthcare, including the Affordable Care Act, and increasing focus on the oral-systemic link, dental care is being swept along on the tide of systemic change-ready or not. For example, the federal government is now advocating for dental therapists in certain situations. In 2013, the Federal Trade Commission (FTC) filed an advocacy comment with CODA regarding proposed accreditation standards for dental therapy education. While praising CODA for facilitating the development of a nationwide dental therapy profession, the FTC also recommended that CODA omit unnecessary language on supervision and scope of practice, which could constrain the discretion of states and possibly deter innovation in dental care education.9
More recently (December 2017), the White House released a report on health reform that specifically included a recommendation for states to authorize dental therapy and remove restrictive supervision requirements on dental hygiene. The report stated, "For example, advanced practice registered nurses (APRNs), physician assistants (PAs), pharmacists, optometrists, and other highly trained professionals can safely and effectively provide some of the same healthcare services as physicians, in addition to providing complementary services. Similarly, dental therapists and dental hygienists can safely and effectively provide some services offered by dentists, as well as complementary services…. For example, dental hygienists can provide preventive dental care, while dental therapists can provide limited restorative services as well as preventive services.... Extremely rigid collaborative practice agreements and other burdensome forms of physician and dentist supervision are generally not justified by legitimate health and safety concerns. Thus, many states have granted full practice authority to APRNs, but there is significant room for improvement in other states and for other professions. Emerging healthcare occupations, such as dental therapy, can increase access and drive down costs for consumers, while still ensuring safe care. States should be particularly wary of undue statutory and regulatory impediments to the development of such new occupations."10
What the Public Wants
The Health Resources and Services Administration (HRSA) designates dental health professional shortage areas (HPSAs) factoring the number of health professionals relative to the population with consideration of high need. Currently, the United States and its territories have about 5,800 dental HPSAs, with a population near 63 million.11 In the public health and dental space, reports exploring issues with access to care, caries prevention, and other oral health concerns abound. In 2016, the W.K. Kellogg Foundation commissioned a national survey in which more than 80% of respondents said they favored allowing dental therapists to practice in their state.12 Dental therapists (or nurses) have been practicing internationally since the 1920s, so more than enough data are available to ascertain their impact on patient populations and refine their role in the US system to best effect. Following the trends in medical and other professions, these models are likely to increase.
References
1. Dental Hygiene Practice Act overview: permitted functions and supervision levels by state. American Dental Hygienists' Association. https://www.adha.org/resources-docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf. Revised May 2018. Accessed January 8, 2019.
2.Direct access states. American Dental Hygienists' Association. https://www.adha.org/resources-docs/7513_Direct_Access_to_Care_from_DH.pdf. Revised April 2018. Accessed January 9, 2019.
3. Transforming Dental Hygiene Education and the Profession for the 21st Century. Chicago, IL: American Dental Hygienists' Association; 2015.
4. Standards for clinical dental hygiene practice. American Dental Hygienists' Association. https://www.adha.org/resources-docs/2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf. Revised 2016. Accessed January 8, 2019.
5. ADHA remains committed to advancing dental hygiene education standards despite CODA opposition. American Dental Hygienists' Association. https://www.adha.org/resources-docs/ADHA_CODA_Statement_8-15-18.pdf. Published August 15, 2018. Accessed January 4, 2019.
6. Expanding access to care through dental therapy. American Dental Hygienists' Association. https://www.adha.org/resources-docs/Expanding_Access_to_Dental_Therapy.pdf. Accessed January 7, 2019.
7. ADA responds to news coverage of dental therapists. American Dental Association. https://www.ada.org/en/press-room/news-releases/2017-archives/february/ada-responds-to-news-coverage-of-dental-therapists. Published February 21, 2017. Accessed January 9, 2019.
8. ADA American Dental Association statement on accrediting dental therapy education programs. American Dental Association. https://www.ada.org/en/press-room/news-releases/2015-archive/august/american-dental-association-statement-on-accrediting-dental-therapy-education-programs. Published August 7, 2015. Accessed January 9, 2019.
9. Gavil AI, Gaynor MS, Feinstein D [letter]. Federal Trade Commission. https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-comment-commission-dental-accreditation-concerning-proposed-accreditation-standards-dental/131204codacomment.pdf. Published December 2, 2013. Accessed January 8, 2019.
10. Reforming America's healthcare system through choice and competition. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf. Accessed January 8, 2019.
11. Dental care health professional shortage areas (HPSAs). Henry K. Kaiser Family Foundation. https://www.kff.org/other/state-indicator/dental-care-health-professional-shortage-areas-hpsas. Published December 31, 2017. Accessed January 8, 2019.
12. Koppelman J. More than 80 percent of voters favor dental therapy, national survey finds. Pew Trusts. https://www.pewtrusts.org/en/research-and-analysis/articles/2017/01/27/more-than-80-percent-of-voters-favor-dental-therapy-national-survey-finds. Published January 26, 2017. Accessed January 8, 2019.
