Expanding Access to Care with Scope of Practice

There has been longstanding concern about uneven access to oral health services, particularly for children, older adults, racial/ethnic minorities, and the economically disadvantaged.^1,2 Stakeholders with an interest in expanding access to care and improving the oral health status of the underserved are driving efforts to identify and adopt innovative strategies to improve population oral health. Dental hygienists, who are considered experts in prevention education and services, often play important roles in programs that improve access to needed oral health services.³

State-based laws and regulations define legal scopes of practice for health professionals within a state. This contributes to variation in what dental hygienists in different states are legally allowed to do. It is challenging to systematically describe these scope of practice differences, assess their impacts on population oral health, and translate this into policy-relevant information. With support from the United States Health Resources and Services Administration’s National Center for Health Workforce Analysis, researchers at the Oral Health Workforce Research Center, Center for Health Workforce Studies at the State University of New York at Albany developed a professional practice index to describe dental hygienists’ scope of practice across states and studied impacts of this variation on state oral health outcomes. Subsequently, researchers developed an infographic based on this work to depict state-level variation in dental hygienists’ scope of practice to help oral health advocacy groups, policy makers, and other stakeholders better understand these issues. 

DEVELOPMENT OF THE DENTAL HYGIENE PROFESSIONAL PRACTICE INDEX

In 2001,  researchers from the Center for Health Workforce Studies developed the Dental Hygiene Professional Practice Index (DHPPI), which allows scope of practice comparisons across states. The index assigned numerical scores to variables related to dental hygiene practice. The index grouped these variables into four categories: regulatory environment, supervision, allowable tasks, and reimbursement. The total possible composite score ranged from 0 to 100; higher scores reflected broader scopes of practice for dental hygienists.⁴

Researchers used the index to score state-specific dental hygiene scope of practice in 2001 and again in 2014. In 2001, state scores ranged from 10 in West Virginia to 97 in Colorado (Figure 1).⁴ In 2014, DHPPI scores ranged from 18 in Alabama and Mississippi to 98 in Maine in (Figure 1).⁵ In 2016, researchers updated the DHPPI to better reflect new dental hygienist tasks, including supervising dental assistants, administering local anesthesia, and providing basic restorative services under the supervision of a dentist. State DHPPI scores in 2016 ranged from seven in Mississippi to 86 in Maine and New Mexico (Figure 1) .⁶

ASSESSING IMPACT OF DENTAL HYGIENIST SCOPE OF PRACTICE ON ORAL HEALTH OUTCOMES IN A STATE

In 2015, researchers completed an analysis to determine whether broader dental hygienist scope of practice impacted oral health outcomes in a state. Multilevel logistic modeling was conducted using 2014 DHPPI scores and 2012 Behavioral Risk Factor Surveillance System data on oral health status (eg, permanent teeth removed due to decay or disease in the last year), while controlling for a number of state-level (eg, supply of dentists and dental hygienists), and individual-level factors (eg, age, race, gender, income, education, employment status). Researchers found that the DHPPI score had a positive and significant association with adult oral health. Broader dental hygienist scope of practice (ie, a higher DHPPI score) was positively and significantly associated (p < 0.05) with having no teeth removed due to decay or disease among adults in those states. A 10-point increase in the DHPPI score results in a 2.7% relative increase in the percentage of adults with no teeth removed due to decay or disease.⁷

INFOGRAPHIC DEVELOPMENT

Using the DHPPI, researchers systematically measured dental hygienist scope of practice and found wide variation in across states. Further research found that broader dental hygienist scope of practice was associated with better oral health outcomes. Researchers recognized the need to succinctly communicate this information to policy makers and oral health stakeholders. Consequently, they decided to create an infographic that translated dental hygienist scope of practice research to support policy-relevant action.

Researchers in collaboration with the American Dental Hygienists’ Association, conducted a series of five focus groups with dental hygiene leaders from across the country in October of 2016.⁶ Participants received a brief description of the project and a copy of the components of the updated DHPPI. Participants were asked to identify the most important functions and tasks to include in the infographic.

Across the five focus groups, the following functions and tasks were among the most frequently recommended for inclusion in the infographic:

• Dental hygiene diagnosis
• Dental hygiene treatment planning
• Prescriptive authority
• Level of supervision for administering local anesthesia
• Supervision of dental assistants
• Direct Medicaid reimbursement
• Provision of sealants without prior examination
• Direct access to prophylaxis from a dental hygienist

Once these eight tasks and functions recommended for inclusion in the infographic were finalized, researchers reviewed the 2016 DHPPI scores for each of the 50 states to determine where these tasks and functions were and were not allowed.  This information served as the basis for building the infographic (Figure 2).

POLICY IMPLICATIONS

Efforts to systematically quantify profession-specific scope of practice variation across states and measure impacts of this variation on population health are critical to helping stakeholders understand why scope of practice matters. Policymakers and other stakeholders need information that can help them understand the striking variability in state-to-state scope of practice for dental hygienists. Research has demonstrated that broader scopes of practice for dental hygienists are correlated with better oral health outcomes. This infographic depicts that variability. The impact of scope of practice is an important consideration for policymakers when identifying strategies to increase the availability of preventive oral health services, particularly for underserved populations. Oral Health Workforce Research Center researchers plan to update the infographic annually, reflecting recent changes in state-level dental hygienist scope of practice.

BOTTOM LINE

• The Dental Hygiene Professional Practice Index (DHPPI) allows scope of practice comparisons across states.
• State DHPPI scores in 2016 ranged from seven in Mississippi to 86 in Maine and New Mexico.⁶
• Broader dental hygienist scope of practice (ie, a higher DHPPI score) was positively and significantly associated with having no teeth removed due to decay or disease among adults in those states.
• Broader dental hygienist scope of practice was associated with better oral health outcomes.
• Efforts to systematically quantify profession-specific scope of practice variation across states and measure impacts of this variation on population health are critical to helping stakeholders understand why scope of practice matters.

REFERENCES

1. Institute of Medicine, National Research Council. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Available at: hrsa.gov/ sites/ default/ files/ publichealth/ clinical/ oralhealth/ improvingaccess.pdf. Accessed February 25, 2019.
2. Legislating the Midlevel Practitioner. Perspectives on the Midlevel Practitioner, a Supplement to Dimensions of Dental Hygiene. 2015;12(10):14–20.
3. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Available at: adha.org/ resources-docs/ 2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf. Accessed February 25, 2019.
4. Rensselaer NY. The Professional Practice Environment of Dental Hygienists  in the Fifty States and the District of Columbia, 2001. Available at: http:/ / docplayer.net/ 13728482-The-professional-practice-environment-of-dental-hygienists-in-the-fifty-states-and-the-district-of-columbia-2001-april-2004.html. Accessed February 25, 2019.
5. Oral Health Workforce Research Center. A Dental Hygiene Professional Practice Index by State, 2014. Available at: chwsny.org/ wp-content/ uploads/ 2016/ 03/ DH_ Professional_ Practice_ Index_ By_ State_ 2014.pdf. Accessed February 25, 2019.
6. Oral Health Workforce Research Center Development of a New Dental Hygiene Professional Practice Index by State, 2016. Available t: chwsny.org/ wp-content/ uploads/ 2016/ 12/ OHWRC_ Dental_ Hygiene_ Scope_ of_ Practice_ 2016.pdf.  Accessed February 25, 2019.
7. Langelier M, Continelli T, Moore J, Baker B, Surdu S. Expanded scopes of practice for dental hygienists associated with improved oral health outcomes for adults. Health Affairs. 2016;35:2207–2215.

From Dimensions of Dental Hygiene. March 2019;17(3):12–14.