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A Closer Look at Competing Compacts

As workforce shortages continue to hinder access to care, the dental hygiene 
profession must choose between two distinct interstate compacts — 
each with far-reaching implications for mobility, safety, and standards.

The United States is grappling with a shortage of dental hygiene practitioners, a challenge that has worsened in the wake of the pandemic. In the 1970s, dental hygiene programs responded to shortages by increasing student enrollment and adding evening clinical sessions. Now, 50 years later, the demand for dental hygiene practitioners has resurged, prompting the dental community to seek innovative solutions. Proposed strategies include expanding the workforce and creating an interstate compact to improve workforce mobility by allowing clinicians to practice across state lines.

Interstate compacts are not new; they provide a framework for licensed professionals to practice in multiple states, although the specific rules vary by occupation. In dentistry, two competing compacts have emerged: one focused on compact “licensure” for member states and the other based on compact “privilege” certificates. Both compacts pertain to dentists and dental hygienists collectively.

Dental hygiene professionals need to be actively involved in the decision-making process as these compacts develop. Unlike physicians and nurses, who each have unique compacts, dental hygiene lacks this autonomy. State dental hygiene leadership must choose between the two available compacts or risk defaulting to another group’s decision. While both aim to address workforce mobility, their approaches differ significantly, impacting patient safety and professional standards.

The Licensure Compact

The Interstate Dental and Dental Hygiene Licensure Compact (IDDLC), supported by the American Association of Dental Boards, advocates for multistate licensure modeled after the Federation of State Medical Board’s compact.1 This system streamlines the licensure process across member states.

The key advantage of this model is that it maintains consistent licensing standards, ensuring all practitioners meet uniform requirements that safeguard public health. The tenants of the IDDLC mandate that dental hygiene practitioners meet the following requirements:

  1. Graduate from a Commission on Dental Accreditation (CODA)-accredited program.
  2. Pass the National Board Examinations of the Joint Commission on National Dental Examinations.
  3. Pass a clinical licensure exam administered by the American Board of Dental Examiners (ADEX) or demonstrate 5 years of clinical practice after passing a regional exam.
  4. Complete a jurisprudence exam on state-specific regulations.
  5. Have no criminal, board-related, Drug Enforcement Administration-related, or other charges or any active investigations.
  6. Hold a full, unrestricted dental hygiene license from a member state.
  7. Fulfill continuing education requirements as mandated by each state.

The IDDLC ensures that member states adhere to essential benchmark requirements, standardizing the clinical examination by recognizing the ADEX as the verifying entity. The ADEX examination, nationally accepted by 48 states, the District of Columbia, US Virgin Islands, Jamaica, and the British Virgin Islands, evaluates a candidate’s psychomotor and didactic performance for entry-level readiness. By establishing a clear legal framework, via multistate licensure, the IDDLC reduces bureaucratic hurdles, facilitating workforce mobility while preserving rigorous standards of practice.

The Privilege Compact

The Dental and Dental Hygiene Compact (DDHC), supported by the American Dental Association and the American Dental Hygienists’ Association, provides a more flexible pathway for licensees to practice in participating states. This compact allows dental hygienists with a “qualifying license” the “privilege” to practice in a “remote state” without obtaining a new license, while retaining their home state license.

The term “privilege” refers to a special right, advantage, or immunity granted to a particular person or group. It often implies that certain individuals have access to opportunities that are not available to others.

The tenets of the DDHC include (italics reflect concerning language):

  1. Graduation from a CODA-accredited program or another recognized accrediting agency recognized by the US Department of Education for the accreditation of dental hygiene programs.
  2. Passing the National Board Examinations or another examination accepted by Commission Rules as a licensure examination.
  3. Successfully completing a “Clinical Assessment.”
  4. Meeting any jurisprudence requirements set by the remote state.
  5. Holding a qualifying license as a dental hygienist in a participating state.
  6. Complete continuing professional development requirements as a condition for license renewal.

The compact agreement further asserts that “state participation in the compact includes providing alternative pathways for individuals to obtain an unrestricted license, which does not disqualify a state from participating in the compact.” Allowing multiple, nontraditional educational pathways can lead to a lack of uniformity in training and experience. Consider on-the-job trained preceptor dental hygienists and internationally trained dentists holding a “qualifying dental hygiene license;” they are not currently eligible to work in most states. However, the DDHC agreement can provide them with a pathway to employment in all compact-participating states.

Furthermore, states have expanded the duties of dental assistants to include coronal scaling; polishing; placing dental sealants; and monitoring and administering nitrous oxide — tasks currently performed by licensed dental hygienists. In Maryland, state-approved training for expanded function dental assistants consists of nonaccredited Department of Education programs, including high school vocational programs, rather than accredited dental hygiene programs.

Equally concerning is the ambiguous language of an undefined assessment of clinical skills for entry-level practice. The compact simply states that candidates must “successfully complete a Clinical Assessment.”

As of January 1, 2021, California allows dental hygienists to demonstrate clinical competencies through alternative methods, such as completing an accredited educational program and passing a written examination. This change aims to streamline the licensing process and address workforce shortages in dental care. However, not all students may be fully prepared to practice upon completing a dental hygiene program. Some students may have limited clinical exposure during their training, while others might excel in theoretical knowledge but struggle with specific clinical skills or procedures. Additionally, dental hygiene faculty may feel pressure from students to pass subjective competencies. Faculty also face pressures to graduate students due to a range of factors, including program accreditation requirements, institutional goals, and workforce demands.

These concerns underscore the need for an unbiased independent clinical examination as a necessary mechanism to assess a candidate’s psychomotor and didactic performance of basic skills for entry-level readiness.

The DDHC model raises additional concerns about accountability and uniformity, as varying state practice acts could allow dental hygienists to practice in states without meeting specific local requirements, thereby compromising patient safety. For example, the educational requirements for administering local anesthesia vary widely among states, leading to potential risks in practice.

Furthermore, variation includes the number of hours required for professional development or continuing education for licensure renewal. The DDHC states, “Complete continuing professional development requirements as a condition for license renewal.”2 However, since there is one license issued by the home state, the licensee would only need to complete continuing education requirements for licensure renewal in their “home” state, not the privilege state. If the licensing state requires 10 continuing education credits, but a privilege state requires 30, a dental hygienist could work in the privilege state with just 10 continuing education credits.

Conclusion

The dental hygiene profession stands at a crossroads, presented with two compact options. Should state leadership support the IDDLC that streamlines licensure pathways while upholding the gold standards for practice, or risk diluting the profession by accepting broadly written DDHC language supporting “alternative pathways” for practice?

A licensure-based compact like IDDLC offers a clear, structured pathway for licensed dental hygienists to practice across state lines without compromising quality of care. It upholds the rigorous standards necessary for ensuring competence and accountability. By maintaining exact standards, the IDDLC preserves the integrity of our profession while streamlining portability via multistate licensure to address workforce shortages.

In contrast, the DDHC model grants a privilege to work across state lines. Currently, most state laws prohibit the practice of on-the-job trained or preceptor dental hygienists as well as the inclusion of internationally trained dentists working as dental hygienists (rather than as dentists). However, the DDHC privilege model supports nontraditional education or experience. This compact undermines the profession by allowing dental hygiene practice under varied and less stringent regulations. Furthermore, it does not guarantee standardization of education and independent assessment of basic clinical skills for job entry readiness.

In short, the IDDLC streamlines the portability of licensed dental hygiene professionals, while the DDHC facilitates the mobility of an alternative workforce to provide dental hygiene services.

As states consider adopting a dental hygiene compact, both public safety and professional accountability must be prioritized while promoting workforce mobility. The dental hygiene profession is on the cusp of momentous change, and state leaders must stay informed and actively engaged in the legislative process. Dental hygienists need to be proactive rather than reactive.

From Dimensions of Dental Hygiene. January/February 2025; 23(1):10-13.

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