Povidone iodine (PVP-I), also known as betadine, is a combination of iodine and polyvinylpyrrolidone, a stabilizer. The World Health Organization (WHO) includes PVP-I formulations on its list of essential medicines, recognizing them as critical components of a functioning healthcare system.¹

A broad-spectrum antiseptic, PVP-I is used as a topical disinfectant; in surgical and nonsurgical site preparation, such as the insertion of catheters; and in antiseptic irrigation including wounds, bladder, and bowel. Oral application of PVP-I includes swabbing, rinsing, and oral irrigation (Figures 1 to 3). PVP-I is easily available over-the-counter (OTC) and can be used as a topical antiseptic for small wounds, burns, and abrasions. Its ability to treat existing infections and stop opportunistic pathogens from spreading makes it an ideal antiseptic.^2-4

The oral and oropharyngeal cavities are an ideal home for potentially pathogenic microorganisms. PVP-I is very effective against numerous viruses, bacterial strains, fungi, and protozoa that are resistant to traditional antibiotics.^3,4 PVP-I encourages the natural proliferation of normal, healthy microbiota to populate the area of application.^4,5 A growing body of data demonstrates that PVP-I is a practical, efficacious, and cost-effective tool in the prevention and treatment of various dental conditions.^2-10

Despite substantial benefits, PVP-I is underused in dental practice. Dental hygienists, as disease prevention specialists, should increase their awareness and knowledge of how PVP-I can be used to deter disease and improve patient outcomes, particularly in public health settings.

Caries Treatment and Prevention

According to the WHO, oral diseases are among the most prevalent noncommunicable diseases, affecting an estimated 3.5 billion people worldwide.¹¹ Approximately 2.3 billion individuals across the globe have undiagnosed caries.¹¹ According to a 2024 United States Centers for Disease Control and Prevention (CDC) report, one in five adults have at least one untreated carious lesion.¹² In addition, children are particularly susceptible to early childhood caries.¹³ The WHO reports more than 530 million occurrences of untreated decay in primary dentitions.¹¹ CDC data indicate that between 11.6% and 24.8% of children ages 6 to 8 have untreated dental decay.¹²

Impact on Streptococcus Mutans

PVP-I is effective in killing and reducing the growth of the bacteria that cause dental caries.^3,4,13-16 A narrative review showed the following results: children remained caries free for up to 1 year with regular preventive treatments of PVP-I, the amount of Streptococcus mutans was reduced after application of PVP-I, and biofilm accumulation was decreased when used in combination with fluoride varnish.³

A systematic review revealed a significantly lower incidence of caries in both primary and permanent teeth when PVP-I was combined with fluoride varnish as compared to fluoride varnish application alone.¹⁴ Data suggest repeated applications of PVP-I enhance plaque control, particularly during dental rehabilitation in children.^13-15 Several studies have demonstrated the ability of PVP-I to suppress S. mutans.^3,4,13-17

Povidone Iodine Used With Fluoride

Modest evidence demonstrates that the synergistic use of PVP-I along with fluoride varnish is superior to fluoride varnish alone.¹⁴ One study concluded that multiple applications of PVP-I and fluoride varnish provided the best protection against pathogenic biofilm.¹³ Another study showed that S. mutans levels were lowest in the fluoride varnish group when compared to chlorhexidine (CHX) varnish and PVP-I groups.¹⁸

PVP-I is particularly appealing in the treatment of children and older adults. Dental hygienists working in mobile and direct-access settings can apply PVP-I alone or in combination with other treatments. When combined with other proven chemical agents, such as silver diamine fluoride and fluoride varnish, PVP-I provides a minimally invasive, simple treatment for high-risk patients.^3,4,14,16 For patients at particularly high caries risk, dental hygienists may choose to educate parents/caregivers and patients on how to apply PVP-I at home.

A widely accepted, standardized, at-home protocol for PVP-I application for the prevention of dental caries has yet to be released. Studies involving PVP-I and oral disease have not been aimed at home use. Additionally, the studies are generally short in length, and often have a low number of participants. Data support PVP-I’s general safety profile and modest benefits; however, more studies are needed with longer trial lengths and higher participant numbers.^3,4,13-16 Studies that incorporate at-home protocols would be beneficial in understanding the relevance of making a recommendation to high-risk patients.

Periodontal Diseases

Best practices for the treatment of periodontal diseases include thorough daily oral hygiene and mechanical removal of the subgingival biofilm with scaling and root planing.^7,9,19 Clinicians may choose to perform subgingival irrigation post-scaling and root planing with various medicaments or water in an effort to further reduce the bacterial burden in the periodontal pocket.^7,9 Popular irrigants for subgingival irrigation include salt water, CHX, and sodium hypochlorite in addition to PVP-I.^7,9,19-24 Subgingival irrigation with boric acid and antibiotic preparations have also been investigated.^9,20-22

PVP-I has been studied extensively as a subgingival irrigant due to its accessibility, low cost, and safety profile.^7,9,19-24 PVP-I is also effective in the presence of organic material such as saliva or wound fluid. Current studies repeatedly demonstrate the efficacy of PVP-I in reducing bacterial levels in deep pockets when used as an adjunct to scaling and root planing.^7,9,20,22-24 Research shows that irrigating with PVP-I after scaling and root planing can reduce plaque (PI) and gingival index (GI) scores, bleeding on probing, and clinical attachment levels.^7,20,21,24 One study showed that a 2% PVP-I irrigation was highly effective against major pathogens and in reducing clinical parameters such as PI, GI, periodontal pocket depths, and clinical attachment levels.²² Compared to baseline, a 2% PVP-I protocol yielded a 40% reduction in Porphyromonas gingivalis and a 50% reduction in Tannerella forsythia at the 3-month evaluation.²²

Is Povidone Iodine More Effective Than Chlorhexidine?

CHX is a widely utilized medicament in the prevention and treatment of oral diseases and is considered the “gold standard” in oral rinse.^7,8,17,25,26 However, CHX has drawbacks, including extrinsic staining, increased calculus formation, and taste alteration.^17,26 In vitro studies have demonstrated that CHX exerts cytotoxic effects on gingival fibroblasts and inhibits collagen production.^26-28 These findings suggest a potential risk for impaired wound healing and delayed periodontal regeneration following surgical procedures, although the clinical significance remains uncertain. Additionally, although generally regarded as a broad-spectrum antiseptic, studies have shown significant limitations in its effects on certain microorganisms.^4,9,25

In contrast, PVP-I has a broader spectrum of antimicrobial activity and does not appear to develop bacterial resistance.^3,4,8-10,25 PVP-I has been found to rapidly kill strains of Gram-positive (methicillin-resistant Staphylococcus aureus) and Gram-negative (Pseudomonas aeruginosa and Klebsiella pneumoniae) bacteria after 30 seconds of exposure and at various dilutions, while CHX failed to kill any of the strains.⁴ Another study showed superior clinical attachment level gains in the PVP-I group compared to the CHX group.⁷ Whether CHX is better than PVP-I at preventing and treating oral disease requires more research.

Although existing studies do not demonstrate a conclusive advantage of PVP-I over CHX, dental hygienists may consider PVP-I a viable alternative. CHX typically requires a prescription and is more costly than PVP-I. However, due to the lack of standardized protocols regarding PVP-I dilution and frequency of use, dental hygienists require further evidence-based guidance on its clinical application.

Fungal Infections and Oral Mucositis

PVP-I has also demonstrated promising therapeutic potential in the management of fungal infections and oral mucositis.^3-6 Unlike alcohol-based antiseptics, which provide broad antimicrobial activity but lack effectiveness against fungal and bacterial spores, PVP-I exhibits activity against both.¹ In vitro research has shown rapid antifungal effects against Candida species, and a clinical study comparing PVP-I with a botanical preparation found that both treatments resolved fungal lesions completely within 2 weeks.⁴ These findings suggest that PVP-I may offer a cost-effective option for managing fungal infections, which are frequently associated with systemic conditions that increase healthcare utilization.

Oral mucositis is a painful and often debilitating side effect of cancer treatment that can significantly diminish a patient’s quality of life. Recent studies have shown that PVP-I rinses reduce the severity and duration of oral mucositis.^29-31 A study comparing 0.1% PVP-I and benzydamine hydrochloride in the prevention of radiation induced oral mucositis demonstrated a statistically significant reduction in oral mucositis among patients who rinsed with PVP-I.³⁰

Additionally, PVP-I exhibits anti-edematous properties by inhibiting inflammatory mediators, such as leukotriene B⁴, thereby suppressing leukocyte extravasation.³

Contraindications

Although PVP-I shows promising efficacy, some downsides exist such as staining of clothes and alteration in taste, which may affect patient compliance. Additionally, caution is advised for individuals with thyroid disorders, as the iodine content could potentially impact thyroid function, though current data on this risk are not conclusive. Individuals who are allergic to iodine and those who are pregnant or breastfeeding should avoid PVP-I.^3,4 According to the American Academy of Allergy, Asthma, and Immunology, PVP-I is safe for use by individuals with shellfish allergy.³²

High-Impact Benefits

With the antimicrobial benefits and low-cost of PVP-I, its use may yield high-impact results. For instance, applying PVP-I intraorally to patients on mechanical ventilators may aid in the prevention of ventilator-associated pneumonia.⁵ Individuals who have difficulty swallowing and are therefore at high risk of aspiration pneumonia may benefit from a preprocedural rinse or swab with PVP-I prior to toothbrushing and interproximal cleaning.⁵

Oral biofilm disruption through brushing and interdental cleaning temporarily elevates bacterial levels in saliva. While this transient increase is not problematic for most, it poses a significant risk among individuals with impaired swallowing reflexes, as aspirated bacteria can contribute to the development of pneumonia.³³

Another high-impact opportunity lies in reducing caries among populations with limited access to care. Daycare centers could implement quarterly fluoride varnish and PVP-I application programs, while pediatric physicians could incorporate PVP-I alongside fluoride varnish during routine visits. Similarly, dental hygienists working in hospitals, nursing homes, and assisted living facilities could integrate PVP-I into their preventive care protocols. Parents/caregivers could also be trained to apply PVP-I on a monthly or bimonthly basis. Given its affordability, broad antimicrobial activity, and ease of use, the potential applications of PVP-I in caries prevention are extensive.

Conclusion

Despite its demonstrated antimicrobial benefits, PVP-I remains underutilized within the dental hygiene process of care. PVP-I is inexpensive, widely available, and exhibits a broad margin of safety. Although numerous studies have examined its efficacy in oral health applications, variations in study design, concentration, and application protocols limit the generalizability of findings. Current evidence indicates that PVP-I may be effective as an adjunctive therapy in periodontal treatment and demonstrates antimicrobial activity against pathogens associated with oral disease. To facilitate evidence-based integration into clinical practice, larger, well-designed, longitudinal trials are needed to establish standardized protocols and best-practice guidelines. Given its accessibility, safety profile, and apparent clinical efficacy, greater consideration of PVP-I in dental practice is warranted.

References

1. World Health Organization. Expert Committee on Selection and Use of Essential Medicines. Available at who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines. Accessed June 2, 2026.
2. Bigliardi PL, Alsagoff SAL, El-Kafrawi HY, Pyon JK, Wa CTC, Villa MA. Povidone iodine in wound healing: a review of current concepts and practices. Int J Surg. 2017;44:260-268.
3. Amtha R, Kanagalingam J. Povidone-iodine in dental and oral health: A narrative review. J Int Oral Health. 2020;12:407-412.
4. Kanagalingam J, Feliciano R, Hah JH, et al. Practical use of povidone‐iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections. Int J Clin Pract (Esher). 2015;69:1247-1256.
5. Tsuda S, Soutome S, Hayashida S, et al. Topical povidone iodine inhibits bacterial growth in the oral cavity of patients on mechanical ventilation: A randomized controlled study. BMC Oral Health. 2020;20:62.
6. Svellenti L, Karacic J, Herzog J, Tanner M, Sahrmann P. Effects of rinsing with povidone-iodine during step II periodontal therapy: A systematic review and meta-analysis. J Clin Med. 2024;13:2111.
7. Kardaras G, Christodorescu R, Boariu M, et al. A low-cost protocol using the adjunctive action of povidone-iodine irrigations and sodium hypochlorite rinsing solution in step 2 of periodontal therapy for patients with stage III-IV periodontitis: A single-blind, randomized controlled trial. Dent J. 2024;12:144.
8. Boyapati R, Peeta J, Dhulipalla R, et al. Comparative evaluation of the efficacy of probiotic, aloe vera, povidine-iodine, and chlorhexidine mouthwashes in the treatment of gingival inflammation: A randomized controlled trial. Dent Med Probl. 2024;61:181–189.
9. Jalaluddin M, Mailankote S, Sam G, Penumatsa NV, Alazmah A, Punde P. Assessment of the efficacy of various subgingival irrigating solutions in chronic periodontitis: A comparative study. World J Dent. 2020;11:221–225.
10. Alves PJ, Gryson L, Hajjar J, et al. Role of antiseptics in the prevention and treatment of infections in nursing homes. J Hosp Infect. 2023;131:58–69.
11. World Health Organization. Global Strategy and Action Plan on Oral Health 2023–2030. Available at who.int/publications/i/item/9789240090533. Accessed June 2, 2026.
12. United States Centers for Disease Control and Prevention. 2024 Oral Health Surveillance Report. Available at cdc.gov/oral-health/php/2024-oral-health-surveillance-report/selected-findings.html. Accessed June 2, 2026.
13. Reilly C, Goettl M, Steinmetz M, Nikrad J, Jones R. Short-term effects of povidone iodine and sodium fluoride therapy on plaque levels and microbiome diversity. Oral Dis. 2016;22:155-161.
14. Gupta A, Nishant, Sharda S, Kumar A, Goyal A, Gauba K. Comparing the effectiveness of topical fluoride and povidone iodine with topical fluoride alone for the prevention of dental caries among children: A systematic review and meta-analysis. Int J Clin Pediatr Dent. 2020;13:559-565.
15. Narayan A, Anandraj S. A comparative study to test the efficacy of two antimicrobial agents (10% povidone-iodine and chlorhexidine varnish) in the prevention of early childhood caries. J Int Oral Health. 2016;8:931.
16. Milgrom P, Tut O, Rothen M, Mancl L, Gallen M, Tanzer JM. Addition of povidone-iodine to fluoride varnish for dental caries: A randomized clinical trial. JDR Clin Transl Res. 2021;6:195-204.
17. Elsawy MS, Abdallah A, Abbas AN. Evaluation of nanohydroxyapatite and povidone-iodine mouthwashes on salivary Streptococcus mutans. Al-Azhar J Dent Sci. 2022;25:531-537.
18. Narayan A, Satyaprasad S, Anandraj S, Ananda SR, Kamath PA, Nandan S. Comparison of efficacy of three chemotherapeutic agents on Streptococcus mutans count in plaque and saliva: A randomized controlled triple blind study. J Indian Soc Pedod Prev Dent. 2017;35:174-180.
19. Smiley CJ, Tracy SL, Abt E, et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. J Am Dent Assoc. 2015;146:525–535.
20. Pham TAV, Phan ND. Comparison of subgingival irrigation effect of boric acid 0.5% and povidone-iodine 0.1% on chronic periodontitis treatment. Oral Health Prev Dent. 2020;18:865-872.
21. Pham TAV, Nguyen MD. Subgingival 0.75% boric acid vs 1% povidone‐iodine adjunctive to subgingival instrumentation in stage II and III periodontitis: A double‐blind randomized clinical trial. Int J Dent Hyg. 2025;23:133-142.
22. Perayil J, Menon K, Biswas R, Fenol A, Vyloppillil R. Comparison of the efficacy of subgingival irrigation with 2% povidone-iodine and tetracycline HCl in subjects with chronic moderate periodontitis: A clinico microbiological study. Dent Res J. 2016;13:98-109.
23. Sindhura H, Harsha RH, Shilpa RH. Efficacy of subgingival irrigation with 10% povidone-iodine as an adjunct to scaling and root planing: a clinical and microbiological study. Indian J Dent Res. 2017;28:514–518.
24. Nguyen ATM, Phan NDD, Pham TAV. Povidone-Iodine as subgingival irrigation in chronic periodontitis treatment. In: Proceedings of the 11th International Dentistry Scientific Meeting. Available at atlantis-press.com/proceedings/idsm-17/25896053. Accessed June 2, 2026.
25. Vasu N, Shetty NJ. Comparative analysis on the effect of chlorhexidine gluconate and povidone iodine mouth rinses on plaque accumulation and gingival inflammation. Int J Adv Res. 2016;4:820-824.
26. Brunello G, Becker K, Scotti L, Drescher D, Becker J, John G. Effect of three Chlorhexidine-based mouthwashes on human gingival fibroblasts: An in vitro study. Applied Sciences (Basel). 2022;12:2417.
27. Coelho AS, Laranjo M, Gonçalves AC, et al. Cytotoxic effects of a chlorhexidine mouthwash and of an enzymatic mouthwash on human gingival fibroblasts. Odontology. 2020;108:260-270.
28. Wyganowska-Swiatkowska M, Kotwicka M, Urbaniak P, Nowak A, Skrzypczak-Jankun E, Jankun J. Clinical implications of the growth-suppressive effects of chlorhexidine at low and high concentrations on human gingival fibroblasts and changes in morphology. Int J Mol Med. 2016;37:1594-1600.
29. Jyothi, Latha S, Pavithra K, et al. Effect of povidone iodine versus chlorhexidine mouthwash on oral mucositis among cancer patients. J Clin Diagn Res. 2021;15:XC09–XC12.
30. Kannarunimit D, Chotirut A, Prayongrat A, et al. A prospective randomized study comparing the efficacy between povidone-iodine gargling and benzydamine hydrochloride for mucositis prevention in head and neck cancer patients receiving concurrent chemoradiotherapy. Heliyon. 2023;9(4):e15437.
31. Handayani P, Budiarti R, Yusmawan W, Antono D, Dewi AMK, Widodo P. The effect of 1% povidone iodine mouthwash on the incidence of oral mucositis and odynophagia in patients with head and neck malignancy. Medica Hospitalia J Clin Med. 2023;10:153–158.
32. American Academy of Allergy, Asthma & Immunology. Iodine Allergy and Fsh. Available at aaaai.org/allergist-resources/ask-the-expert/answers/old-ask-the-experts/iodine-allergy-fish. Accessed June 2, 2026.
33. Funahara M, Imakiire A, Funahara R, et al. A crossover trial of a novel toothbrushing method for prevention of aspiration pneumonia: Toothpaste with povidone-iodine and moisturizing gel mixture. Cureus. 2024;16:e75494.

From Dimensions of Dental Hygiene. July/August 2026; 24(4):12-16

In its third year, the Discovery Expo offers the opportunity to learn from some of the best and most knowledgeable speakers in our profession. With topics from caries management, to infection prevention and control, to periodontal updates, to human trafficking, and more, you are sure to come away from this year’s event with tangible and useful information. Each session has been chosen to broaden your knowledge and understanding of the issues facing dental hygiene professionals today.

But the programs aren’t just focused on the present, they are meant to help you confidently face the future. A highly popular program at the Discovery Expo last year was the Legislative Update Forum Presentation. This interactive session is an open discussion about some of the challenges facing our profession today, with frank and honest dialogue. All attendees are invited to share their thoughts and concerns, along with possible solutions to deal with legislative changes.

In addition, you won’t want to miss the presentation from American Dental Hygienists’ Association President Lancette VanGuilder, BS, RDH, PHEDH, CEAS, FADHA, titled “The Evolving Role of Dental Hygienists as Primary Care Providers.” As the session description states: This course empowers dental hygienists to understand the current state of the profession, recognize their role as health care providers, and take actionable steps to elevate patient care. Participants will explore how professional autonomy directly impacts clinical decision-making, patient outcomes, and community health. Coupled with the Legislative Update Forum, this course is a perfect follow-up and will inspire you to broaden your horizons.

As in the past, the registration fee includes all the educational sessions, Lunch and Learn presentations, entrance to the exhibit hall and product demonstrations, tote bags and giveaways, lunches, breaks with snacks, a cocktail reception Friday evening and …. the highlight of the Discovery Expo: The Esther Wilkins Lifetime Achievement Award presentation and reception! This year, we honor Cynthia C. Gadbury-Amyot, RDH, MS, EdD, FADHA, for her outstanding contributions to our profession. During her 30+ years of teaching at the University Missouri-Kansas City, Cindy has helped shape the future for undergraduate, graduate, pre-doctoral, and doctoral students. She is so deserving of this award, and we hope you can join us in celebrating her!

I’ve heard attendees describe the emotions they get from experiencing the Discovery Expo in many ways: inclusive, fun, rewarding, meaningful, and worthwhile. It’s an “I can’t wait until next year” feeling that stays with you months after the event. If it’s your first time attending or you’re a veteran, there is something for everyone, and all are welcome. So, pack your bags and head to sunny California! You’ll be glad you did. Visit dimensionsdiscoveryexpo.com for more information.

From Dimensions of Dental Hygiene. July/August 2026; 24(4):9

Qualitative or Quantitative

Qualitative research seeks to understand participants’ experiences, perceptions, and behavior through observation, open-ended interviewing, and reviewing documents.⁵ An example of qualitative research is starting an oral hygiene education program at a nursing home and surveying residents through questionnaires on the perception of dental care, their current oral hygiene education level, and their attitudes toward learning new oral hygiene skills.⁶

Quantitative research is a methodological approach used to test objective theories by examining the relationships among variables through statistical and numerical analysis. This type of research is primarily concerned with measurement and comparison, allowing researchers to evaluate hypotheses in a systematic manner.^5,7 The primary goals of quantitative research are establishing factual evidence, identifying and predicting future trends, examining relationships between variables, and testing existing theories. Quantitative studies are able to produce objective and generalizable findings when appropriate sampling and experimental controls are used.⁸

Observational Study Design

Observational studies are either descriptive or analytical.^2,9 In most dental public health cases, descriptive observational research attempts to identify and describe the topic being researched to quantify the disease status in a community. Case series reports specifically focus on the prevalence of a disease in a small group and can be useful in building knowledge and generating hypotheses.^{9, 10}

Correlational and historical studies are types of observational descriptive research. Correlational studies are used to examine the degree and direction of relationships between two or more variables without manipulation.^3,9 These studies do not establish causation; rather, they identify whether an association exists between variables. For example, correlational research has been used to investigate potential relationships between periodontal diseases and obesity.

Historical research involves systematic examination of past events, documents, and records to understand their significance. This approach allows researchers to identify patterns and outcomes over time. By analyzing previously collected data and archival materials, historical studies contribute to a deeper understanding of how knowledge and practices have evolved within a given field.

Analytical observational studies attempt to determine the etiology of a disease and quantify the association between exposure and outcome. Examples include case-control studies, cohort studies, ecological studies and cross-sectional studies.⁹ A cross-sectional study is a survey or measurement that represents a snapshot in time.^9,10 In longitudinal analytical studies, results are observed over a period of time.

Case-control studies are retrospective (they look backward) and follow two populations: people with a condition called the cases and individuals without that condition called the controls.^3,9,11 These studies allow researchers to explore associations between potential risk factors and various health conditions. A case-control study demonstrated a link between carcinoma of the lung and smoking tobacco.¹¹

Cohort studies and longitudinal ecological studies are prospective in nature. They measure one group of individuals (the cohort) over time and record information multiple times to determine risks. Cohort studies excel at unraveling the causes of dental ailments. By tracking individuals over time, they can pinpoint factors like socioeconomic status, dietary habits, or early childhood experiences that contribute to the development of caries, periodontal disease, or oral cancer.^11,12

Experimental Studies

Experimental studies, commonly referred to as clinical trials, aim to evaluate cause-and-effect relationships through the deliberate manipulation of variables.⁹ These studies are widely regarded as providing a high level of scientific evidence because they allow researchers to control external factors and minimize potential sources of bias. In experimental research, the independent variable represents the factor that is intentionally manipulated by the investigator, while the dependent variable reflects the outcome or response that is measured to assess the effect of that manipulation.³ The relationship between these variables is central to determining whether a causal link exists.

One of the defining characteristics of experimental studies is the use of controlled environments where conditions can be standardized across participants. This level of control enhances the internal validity of the study and increases confidence that observed changes in the dependent variable are directly attributable to the independent variable, rather than to confounding influences. Internal validity refers to the degree to which a study can confidently demonstrate that the observed effects are caused by the independent variable rather than by the confounding factors, bias, or other alternative explanations.^12,13 Additionally, many experimental designs incorporate randomization and control groups, which further strengthen the reliability and validity of the findings.¹⁴

Key Sampling Techniques

With sampling, the researcher can observe the entire population and add more weight to findings.⁵ Sampling is implemented when limited resources, time, and money make it difficult to obtain answers from a particular population. When a sample accurately reflects the larger population, the data collected can provide reliable results comparable to those obtained from studying the entire population, while reducing bias.^5,6 Reliability and validity are two of the most important indicators of the quality of a measurement instrument.¹⁶

Quantitative research emphasizes systematic measurement of variables in order to answer research questions and test hypotheses.¹⁰ These methods rely on numerical data and statistical analysis to identify patterns, relationships, and trends. Survey research, a quantitative method, is used to describe characteristics such as attitudes, opinions, or behaviors within a population, or to examine associations among variables. Survey designs are particularly useful in dental research for assessing patient experiences, treatment outcomes, and preventive behaviors.¹⁷

The best way to ensure adequate representation is to take a simple random sample. This sample is formulated so that each time or person in the population has the same chance of being included.^{1, 5}

Predictability refers to the extent to which a variable or set of variables can accurately account for study outcomes. High predictability suggests the relationship between variables is consistent and can be used to estimate future outcomes. Bias is systematic error that influences the design, data collection, analysis, interpretation, or reporting of results, leading to conclusions that deviate from the truth.^{10, 18}

Stratified random sampling involves dividing a population into subgroups based on a shared characteristic and then randomly selecting participants from each stratum.¹⁰

Systematic Reviews in Dentistry

Systematic reviews represent the highest level of evidence, as they employ rigorous and transparent methodologies to identify, appraise, and synthesize all relevant studies addressing a specific question. By minimizing bias through predefined protocols, comprehensive literature searches, and standardized assessment of study quality, systematic reviews provide clinicians with reliable summaries of existing evidence to support informed decision making. Systematic reviews play a crucial role in evaluation of the effectiveness of preventive, diagnostic, and therapeutic interventions.¹⁹

Conclusion

Ultimately, applying research in dental hygiene requires cultivating a mindset of curiosity and continuous improvement. It shifts practice from routine care to intentional, informed care. By gradually building these skills, research becomes less intimidating and more of a practical asset; one that enhances both professional growth and patient outcomes.

References

1. Beatty C. Community Oral Health Practice for the Dental Hygienist. 4th ed. New York: Elsevier; 2017.
2. Walker V, Sanderson E, Levin MG, Damraurer SM, Feeney T, Davies NM. Reading and conducting instrumental variable studies: guide, glossary, and checklist. BMJ. 2024;387:e078093.
3. Forrest J, Miller S. EBDM in Action: Developing Competence in EB Practice. 3rd ed. Cave Creek, Arizona: ebdLibrary LLC; 2022.
4. Boyd LD,Mallonee LF, eds. Wilkins’ Clinical Practice of the Dental Hygienist. 14th ed. Burlington, Massachusetts: Jones & Bartlett Learning; 2024
5. Rubinson L, Neutens J. Research Techniques for the Health Sciences. 3rd ed. San Francisco: Benjamin Cummings; 2002.
6. Weening-Verbree LF, Schuller AA, Zuidema SU, Hobbelen JSM. A qualitative evaluation of the implementation of an oral care program in home care nursing. Int J Environ Res Public Health. 2023;20:2124.
7. Tenny S, Brannan JM, Brannan GD. Qualitative Study. Treasure Island, Florida: StatPearls Publishing; 2026.
8. D’Aiuto F, Gkranias N, Bhowruth D, et al. Systemic effects of periodontitis treatment in patients with type 2 diabetes: a 12 month, single-centre, investigator-masked, randomized trial. Lancet Diabetes Endocrinol. 2018;6:954-965.
9. Nathe C. Dental Public Health and Research. 4th ed. London: Pearson; 2017.
10. Creswell JW, Creswell JD. Research Design Qualitative, Quantitative and Mixed Methods Approaches. 6th ed. Thousand Oaks, California: SAGE Publications Inc; 2023.
11. Doll R, Hill AB. Smoking and carcinoma of the lung; preliminary report. Br Med J. 1950;2:739–748.
12. Bhandari P. Internal validity in research: definition, threats and examples. Scribbr. Available at scribbr.com/methodology/internal-validity/. Accessed June 3, 2026.
13. Slack MK, Draugalis JR. Establishing the internal and external validity of experimental studies. Am J Health Syst Pharm. 2001;58:2173-2181.
14. Sundaram V, Selvaganesan P, Deo S, Karnib M. The importance of randomization in clinical research. Indian J Thorac Cardiovasc Surg. 2022;38:562-565.
15. Chowdhary Z, Mohan R. Efficiency of three different polishing methods on enamel and cementum: A scanning electron microscope study. J Indian Soc Periodontol. 2018;22:18-24.
16. Kimberlin CL, Winterstein AG. Validity and reliability of measurement instruments used in research. Am J Health Syst Pharm. 2008;65:2276-2284.
17. Mattos-Vela MA, Evaristo-Chiyong TA, Siquero-Vera K. Quality of survey-based study reports in dentistry. BMC Oral Health. 2023;23:320.
18. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 11th ed. Waltham, Massachusetts: Wolters Kluwer; 2021.
19. Page MJ, McKennzie JE, Bossuyt PM, et al. The PRISMA 2020 Statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:71.

From Dimensions of Dental Hygiene. July/August 2026;24(4):18-22

Dental hygienists often experience repetitive strain injuries.^1-13 The upper extremities, neck, and back regions of the body are often overexerted, sustained in static postures for long periods, and exposed to cumulative trauma which may contribute to persistent pain, fatigue, and functional limitations.

Additionally, the demanding nature of dental hygiene schedules often does not allow for adequate recovery time between loading of the same muscles, ligaments, tendons, and joints.^14,15 Because many of these risk factors are unmodifiable, developing interventions for reducing musculoskeletal (MSD) risk and manging pain is critical. Operatory adjustments, clinician and patient positioning, magnification, and ergonomic instrument designs remain essential for MSD prevention, however these strategies may not fully address the cumulative biomechanical strain that occurs clinically. Therefore, exercise-based mitigation strategies should be part of a comprehensive approach to supporting ergonomic health.

Exercise and Prevention of Repetitive Strain Injuries

While ergonomic equipment and positioning may reduce unnecessary exposure to risk factors, exercise may improve the body’s ability to tolerate unavoidable exposures. A promising area of research is the use of exercise programs to address pain and MSD risk.^16-21

In a recent systematic review, Van Eerd et al¹⁷ summarized the effectiveness of various interventions, including exercise programs, to reduce MSD risk. Findings demonstrated strong, positive effects of resistance training, such as dumbell and kettleball routines, on MSD risk or pain reduction. Overall, results indicated strong evidence for resistance training in preventing work-related MSDs and pain. For dental hygienists, resistance training may be especially relevant because it can improve muscle endurance, postural stability, shoulder and trunk control, grip force capacity, and overall tolerance to repeated muscular loading.

The systematic review also included six studies with moderate to strong evidence supporting stretching exercise programs for reducing MSD risk and pain.¹⁷ In dental hygiene, research has indicated stretching may prevent MSD development and pain.^16-21 With static and awkward postures that often lead to fatigue, overloading of muscles, and overcompensation of antagonist muscles, stretching could allow for recovery or pain reduction with counteractivation of the muscles overutilized in repetitive dental hygiene tasks.²² Based on current evidence, chairside stretching exercises performed between patients may represent a practical strategy for reducing MSD risk.^17-21

Dental hygienists may benefit from incorporating exercise programs into their daily routine as a group at the end of the day.¹⁷ The group accountability may lead to successful implementation and continued use of exercise intervention strategies; however more research is needed.

Researchers explored exercise interventions specifically among oral health professionals in a 2020 systematic review that included 34 studies.¹⁹ Results indicated most physical activity interventions, such as aerobic exercise, yoga, stretching, and general physical activity, were associated with a reduction in MSD pain and frequency. Home exercise routines may support body awareness, breathing regulation, stress management, and recovery from sustained occupational demands.¹⁹

One study found that exercise reduced back pain among dental students, suggesting that interventions for MSDs should begin during professional education.²⁰ Although these findings suggest that physical activity may help reduce MSD pain, a significant limitation is that most studies included participants who already had MSD symptoms, limiting conclusions about its preventive effects.^17-21

Further research should explore exercise as a prevention strategy rather than reduction strategy for MSD pain, as well as the specific types and intensities of exercise that may be best for MSD prevention. Regardless, many dental hygienists experience MSD pain¹–12 and regular exercise can help reduce these symptoms.^16-23

Impact of Stretching

Stretching may also reduce MSD risk.^16-21 Nye et al²¹ examined the effects of chairside stretching exercises by dental hygiene students who were divided into a control group and a stretching intervention group. Researchers found significant differences in self-reported musculoskeletal pain between the control group and treatment group who completed chairside stretching interventions. Interestingly, participants felt neutral about the impacts of chairside stretching on pain. They also reported feeling more aware of their positional ergonomics because of the study, which may have impacted the findings.

Another study demonstrated positive effects on musculoskeletal pain in oral health professionals after stretching interventions.¹⁹ The study of dental hygienists and dentists included 27 participants in the control group and 27 subjects in the stretching intervention group. Stretching interventions were guided by a physical therapist for 30 minutes following a workday. Pain pressure threshold tests were completed on both groups at the end of each day. Oral health professionals who participated in the study demonstrated statistically significant increases in pain pressure thresholds at multiple body sites, along with reductions in overall pain.

These studies indicate a positive association with stretching and a reduction in MSD pain and development.²¹ Dental hygienists should consider incorporating stretching into routines as a preventive and pain-reduction strategy; however, persistent or worsening symptoms may require evaluation and treatment beyond self-directed stretching alone.

When Pain Persists

While exercise may be an appropriate first-line strategy for reducing MSD risk and symptom management, dental hygienists should see a physical or occupational therapist when pain persists, worsens, or begins to interfere with clinical practice or daily function. When persistent numbness, tingling, loss of finger or hand grip strength, pain that interferes with work or home tasks, or symptoms that continue despite self-mitigation strategies are present, medical consult and intervention are necessary.

Physical and occupational therapists can assess individual movement impairments, identify contributing ergonomic and workload factors, prescribe progressive strengthening exercises, and provide adjunctive interventions, such as manual therapy.^24,25 Manual therapy encompasses hands-on techniques, including joint mobilization, soft tissue mobilization, myofascial release, and manual stretching, with the goal of reducing pain, improving mobility, and restoring musculoskeletal function.

Research suggests that manual therapy combined with stretching and strengthening may improve pain, range of motion, and functional capacity more effectively than exercise alone. Therefore, stretching should be viewed as one component of a broader prevention and management approach.^24,25 Given the cumulative nature of occupational MSD risk in dental hygiene, prevention strategies are likely most effective when they are integrated into a daily routine before symptoms become severe or functionally limiting.

Exercise Strategies

Exercise is a meaningful strategy for preventing occupational MSDs and reducing existing pain.^16-25 Dental hygienists should focus on strategies that increase capacity, endurance, and tolerance. While operatory adjustments, positioning, and ergonomic equipment remain essential, exercise may help address some of the cumulative biomechanical strain associated with clinical practice.¹⁷

Stretching programs, resistance training, aerobic exercise, and other methods of physical activity reduce the risk of MSDs and related pain, decrease the need for pain medications, and improve productivity by reducing absences and work schedule modifications.^{16,18,19,21,22} Resistance training may improve physical capacity and muscular endurance while stretching may reduce stiffness and discomfort related to symptoms. Aerobic activity and yoga may provide broader benefits for functional capacity, stress management, fatigue, and overall well-being. Dumbbell strengthening, yoga, chairside or post-appointment stretching, guided post-workday exercise sessions, and aerobic activities have shown promising results in MSD pain reduction.^16-20,23 Although all included studies involved participants with existing MSD pain, exercise programs may also help prevent MSD development.

Prevention should occur as early as possible in the career of a dental hygienist, ideally while enrolled in a dental hygiene education program.^18,19 Preventive exercise routines should be viewed as part of a professional responsibility, investment in career longevity, and a recommended wellness activity for all dental hygienists.^17-20,24 MSDs and pain negatively impact the overall practice as well by increased absenteeism, decreased clinical productivity and performance, reduced job satisfaction, decreased clinical hours, and modified work schedules.^1-13,26 Therefore, strategies that support musculoskeletal health and reduce pain may significantly impact both the clinician and practice.

Conclusion

Future research should focus on developing and validating dental hygiene-specific preventive exercise and recovery protocols for MSDs. In particular, studies are needed to determine the optimal exercise frequency, intensity, duration, progression, and delivery methods best for dental hygienists. Research should also examine long-term adherence, feasibility within clinical schedules, the comparative effectiveness of different exercise approaches, and when prevention programs are best introduced. Prospective studies are especially needed to determine whether exercise can prevent MSDs before symptoms develop. Ultimately, exercise is understood as a practical, low-risk, and evidence-informed strategy that complements adjunctive ergonomic equipment and positioning in reducing MSD pain.

References

1. Lietz J, Kozak A, Nienhaus A. Prevalence and occupational risk factors of musculoskeletal diseases and pain among dental professionals in Western countries: A systematic literature review and meta-analysis. PloS One. 2018;13:e0208628.
2. Saccucci M, Zumbo G, Mercuri P, et al. Musculoskeletal disorders related to dental hygienist profession. Int J Dent Hyg. 2022;20:571-579.
3. Vidal, HF, Soriano EP, Caldas AF, et al. Cumulative trauma disorders among dentists. J Musculoskelet Pain. 2014;22:193-198.
4. Pejcic N, Duric-Jovicic M, Milijkovic N, Popovi, DB, Petrovic V. Posture in dentists: Sitting vs. standing positions during dentistry work – an EMG study. Srpski Arhiv Za Celokupno Lekarstvo. 2016;144:181-187.
5. Howarth SJ, Grondin DE, La Delfa NJ, Cox J, Potvin JR. Working position influences the biomechanical demands on the lower back during dental hygiene. Ergonomics. 2016;59:545-555.
6. Dong H, Loomer P, Barr A, et al. The effect of tool handle shape on hand muscle load and pinch force in a simulated dental scaling task. Appl Ergon. 2007;38:525-531.
7. Dong H, Barr A, Loomer P, et al. The effects of periodontal instrument handle design on hand muscle load and pinch force. J Am Dent Assoc. 2006;137:1123-1130.
8. Dong H, Loomer P, Villanueva A, Rempel D. Pinch forces and instrument tip forces during periodontal scaling. J Periodontol. 2007;78:97-103.
9. Villanueva A, Dong H, Rempel D. A biomechanical analysis of applied pinch force during periodontal scaling. J Biomech. 2007;40:1910-1915.
10. Suedbeck JR, Armitano-Lago C. The effects of the traditional scaling technique versus a modified scaling technique on muscle activity and pinch force generation: a pilot study. J Dent Hyg. 2021;95:6-13.
11. Suedbeck J, Tolle SL, McCombs G, et al. Effects of instrument handle design on dental hygienists’ forearm muscle activity during scaling. J Dent Hyg. 2017;91:47-54.
12. Suedbeck J, Russell D, Armitano-Lago C, Ludwig E. The effects of dental hygiene instrument handles on muscle activity production. Int J Dent Hyg. 2023;21:731-737.
13. Cherniack M, Brammer AJ, Nilsson T, et al. Nerve conduction and sensorineural function in dental hygienists using high frequency ultrasound handpieces. Am J Ind Med. 2006;49:313-326.
14. Karsh BT. Theories of work-related musculoskeletal disorders: Implications for ergonomic interventions. Theor Issues Ergon Sci. 2006;7:71-88.
15. Kumar S. Theories of musculoskeletal injury causation. Ergonomics. 2001;44:17-47.
16. Hayes M. The effect of stainless steel and silicone instruments on hand comfort and strength: a pilot study. J Dent Hyg. 2017;91:40-44.
17. Van Eerd D, Munhall C, Irvin E, et al. Effectiveness of workplace interventions in the prevention of upper extremity musculoskeletal disorders and symptoms: an update of the evidence. Occup Environ Med. 2016;73:62-70.
18. Kim ES, Jo ED, Han GS. Effects of stretching intervention on musculoskeletal pain in dental professionals. J Occup Health. 2023;65:e12413.
19. Roll SC, Tung KD, Chang H, et al. Prevention and rehabilitation of musculoskeletal disorders in oral health care professionals: A systematic review. J Am Dent Assoc. 2019;150:489-502.
20. Shirzaei M, Mirzaei R, Khaje-Alizade A, Mohammadi M. Evaluation of ergonomic factors and postures that cause muscle pains in dentistry students’ bodies. J Clin Exp Dent. 2015;7:e414-418.
21. Nye WH, Partido BB, DeWitt J, Kearney RC. Prevention and reduction of musculoskeletal pain through chair-side stretching among dental hygiene students. J Dent Hyg. 2021;95:84-91.
22. Takeuchi K, Nakamura M, Fukaya T, Nakao G, Mizuno T. Stretching intervention can prevent muscle injuries: a systematic review and meta-analysis. Sport Sciences for Health. 2024;20(4):1119-1129.
23. Ludwig E, Tolle SL. Ensure proper fit. Dimensions of Dental Hygiene. 2017;15(4):24-26.
24. Tauqeer S, Arooj A, Shakeel H. Effects of manual therapy in addition to stretching and strengthening exercises to improve scapular range of motion, functional capacity and pain in patients with shoulder impingement syndrome: a randomized controlled trial. BMC Musculoskelet Disord. 2024;25:192.
25. Speicher TE, Selkow NM, Warren AJ. Manual therapy improves immediate blood flow and tissue fiber alignment of the forearm extensors. Journal of Physical Medicine and Rehabilitation. 2022;4(2):28-36.
26. Occupational Safety and Health Administration. Ergonomics. Available at osha.gov/ergonomics. Accessed June 10, 2026.

From Dimensions of Dental Hygiene. July/August 2026; 24(4):24-26

The incorporation of neuromodulators into dental hygiene practice has gained traction in recent years, reflecting a broader trend toward integrative approaches in dental care.¹ No longer viewed solely through a cosmetic lens, these therapeutic agents have emerged as valuable adjuncts for managing a range of head and neck conditions commonly encountered in dental settings. From chronic orofacial pain and temporomandibular disorders, management of parafunctional habits, cosmetic enhancement and facial balancing, muscle hyperactivity, and selective esthetic enhancement, neuromodulators offer dental hygienists an evidence-based means of addressing both function and form as a minimally invasive procedure. As therapeutic modalities, injectable neuromodulators offer oral health professionals innovative and adjunctive treatments to address various head and neck disorders.

Mechanism of Action

Neuromodulators, or botulinum neurotoxins (BoNTs), are protein neurotoxins derived from Clostridium botulinum that cause muscle paralysis.² Though there are many types of neuromodulators, botulinum toxin type A (BoNT-A) is widely used in cosmetic therapies and pain management.¹ Recognized for its safety and efficacy due to its limited diffusion from the injection site, BoNT-A’s effects on the targeted musculature are also reversible over time.² This article will focus on BoNT-A and will refer to these injectable neurotoxins as neuromodulators.

When injected into muscular tissue, neuromodulators function by binding to the presynaptic nerve terminals, inhibiting the release of acetylcholine.¹ The inhibition of acetylcholine release impacts muscular contraction causing localized, reversible muscle paralysis.² Through inhibition of neuromuscular transmission, neuromodulators decrease both muscle contraction force and contraction frequency, thus reducing repetitive compression of the skin. This effect prevents wrinkle formation and can decrease the severity of existing wrinkles. Beyond esthetic applications and wrinkle reduction, neuromodulators also offer therapeutic uses, including management of chronic pain and parafunctional disorders.³

Pain Management

For patients whose chronic orofacial pain is driven by parafunctional habits, such as bruxism and clenching, injectable neuromodulator therapy offers a promising therapeutic option. Neuromodulator injection therapy can significantly reduce pain associated with excessive muscular contraction. By inhibiting acetylcholine release and both the frequency and force of muscle contractions, oral health professionals can reduce muscular tension and alleviate pain and inflammation induced by repetitive muscle activity.^4,5

BoNT-A has demonstrated effectiveness in the management of orofacial pain, including pain associated with temporomandibular disorders (TMD) and bruxism. For patients with TMD and parafunctional habits, neuromodulator injection therapy reduces excessive masticatory muscle activity, which, in turn, decreases pain and functional impairment. This approach offers a minimally invasive option for patients who do not achieve adequate symptom relief with conventional interventions such as occlusal splints, pharmacologic therapies, or conservative physical modalities.^2-5

Preservation of the Teeth, Joints, and Restorative Work

In addition to symptomatic relief, injectable neuromodulator therapy can prevent tissue damage caused by chronic excessive muscle forces such as dental attrition, force-related restoration damage, and progressive loss of occlusal vertical dimension. Used alongside standard protective measures, such as occlusal guards, neuromodulators address the source of parafunctional activity, while splints redistribute force on the dentition. This complementary approach supports combined therapy for patients at high risk of tooth and joint damage.^3-6

Bruxism affects a substantial portion of adults; a recent meta-analysis estimated the prevalence of sleep bruxism at ~21% and awake bruxism at ~23%, with a combined prevalence of 22%.⁶ Neuromodulators provide a therapy for both sleep and awake bruxism. Many randomized controlled trials and systematic reviews demonstrate reductions in nocturnal masticatory events, bite force, and patient-reported muscle pain.^3-6 Chronic parafunctional activity transmits repetitive, high-magnitude forces to teeth, restorations, and temporomandibular joints, accelerating enamel and dentin wear, increasing fracture risk, and potentially contributing to implant or prosthetic complications and failures of restorations.^7,8

Treatments that reduce parafunctional forces protect restorations, crowns, veneers, and prolong prosthesis survival. When combined with occlusal appliances, careful material selection, and maintenance protocols, neuromodulator injection therapy supports comprehensive preservation of dentition, vertical dimension, and restorative outcomes.^6,7

Esthetic Enhancements

In addition to therapeutic uses, neuromodulator injections play a significant role in esthetics beyond wrinkle correction around the eyes and on the forehead. Targeted neuromodulator injections provide a low-risk method for addressing perioral aging and muscular tension.

These techniques improve the long-term stability of dental work while delivering polished, natural results, making them ideal adjuncts to restorative and cosmetic treatment plans. For example, dental hygienists can utilize neuromodulators in the perioral area to address a gummy smile or a smile that displays more gingiva than desired as opposed to the upper lip covering the maxillary gingiva when smiling.⁹

Because neuromodulators reduce muscle activity by limiting contraction force, if a muscle pulls upward, downward, or backward, neuromodulators help prevent that movement. By selectively administering neuromodulators in the levator labii superioris muscle, this can relax the elevation of the upper lip keeping the maxillary gingiva covered and thus enhance the esthetics of the patient’s smile.⁹

Vertical perioral lines, often referred to as smoker’s lines, can also be addressed with neuromodulator injections. These vertical lines in the skin result from repeated contraction of the orbicularis oris muscle.¹⁰ Administering small doses of neuromodulators along the vermillion border can relax the orbicularis oris muscle fibers, reduce contraction strength, and smooth the upper and lower lip without significantly affecting oral function.¹⁰ This can complement the smile and any anterior restorative treatments creating a softer, more hydrated appearance.

If a patient has concerns about frown lines, the contraction force of the depressor anguli oris (DAO) that pulls downward on the corners of the mouth may be addressed. This downward turn contributes to marionette lines and a frowning appearance. Neuromodulators injected into the DAO can subtly lift the corners of the mouth by decreasing the downward pull by the DAO and additionally reduce anterior jawline tension.¹¹

Chronic clenching can create jawline tension that leads to pain and discomfort. Neuromodulators administered to targeted muscles can help relieve this tension. In an esthetic practice, the technique called the Nefertiti lift is used to enhance jawline contour by addressing tension in the DAO and platysmal muscles along the mandibular border.^11,12 When combined with masseter injections, this approach can reduce pain and tension, decrease downward pull, improve jawline definition, and support the longevity of dental prosthetics.¹³ These adjunct therapies not only complement patient treatments but protect restorations by reducing excessive muscle force or overactive muscle movement.

Adverse Reactions and Medical Emergencies

While permanent or severe complications are uncommon, neuromodulators carry potential risks. Once injected, there is no immediate treatment to reverse the effects. The effects must wear off gradually, which may take several months to fully dissipate.¹⁴ Comprehensive knowledge of head and neck anatomy, injection techniques, pharmacology, and emergency protocols is critical for minimizing adverse events and ensuring patient safety. Careful consideration of injection site, needle depth, dosage, product selection, aspiration, and diffusion radius are essential to ensure precise placement and minimize the risk of unintended muscle involvement or adverse effects.

Eyelid ptosis is an adverse reaction associated with unintended muscle involvement.¹⁵ This can happen when a neuromodulator is injected above the brow line, likely with the intention of reducing wrinkles or tension on the forehead, but the neuromodulator diffuses to unintended muscles. If too much neuromodulator is injected or it is injected at too fast of a rate, the neuromodulator can spread to the levator palpebrae superioris via the supraorbital foramen, resulting in temporary drooping of the eyelid. Unfortunately, the effect typically peaks around week 2 and resolves over 8 to 12 weeks.¹⁴ This reinforces the importance of skilled and cautious injectors and emphasizes that providers who inject neuromodulators require both extensive facial anatomy expertise and proper training in technique that focuses on appropriate dosing and deposition rates.

For patients seeking treatment for pain due to bruxism and jawline tension, improper masseter injections can affect the risorius, causing an uneven smile.^14,15 If misplaced, the risorius muscle may be affected, inhibiting its backward pull and limiting smile retraction on one or both sides. When unilateral, it can create an uneven, asymmetrical smile that may resemble a stroke, which is both esthetically undesirable and potentially distressing for the patient. Drooping of the lower lip can be caused by improper DAO injections that spread to the depressor labii inferioris. This does not only lead to a lower-lip droop but can also impact speech.¹⁵

When treating smoker’s lines, injecting too much neurotoxin into the orbicularis oris can also impair speech as well as the ability to eat and drink by excessively inhibiting the muscle movement. Though any adverse reaction is undesirable, a common adverse reaction at the injection site is bruising (ecchymosis).¹⁵ Bruising with any injection is anticipated and can vary in severity. Though not completely avoidable, the likelihood and severity can be minimized with thorough anatomical knowledge, careful injection techniques, vein visualization technology, and proper post-procedure care.^15,16

State Regulations

The legal landscape for neuromodulator administration varies by state and is changing rapidly. Arizona, Oklahoma, and Kansas permit dental hygienists to administer neuromodulators under specific conditions, requiring completion of qualifying training programs and certification.^17-19

Colorado enacted legislation in 2025 authorizing dental hygienists to administer neuromodulators under direct supervision of a dentist. However, this scope addition is still on hold until the new rules have been formally adopted by the Colorado Dental Board.²⁰

In dentistry, neuromodulator injection therapies have expanded significantly with growing evidence supporting their efficacy for managing TMD, bruxism, orofacial pain, and perioral esthetic concerns. Whether directly administering treatment or coordinating care in collaborative models, dental hygienists’ expertise in patient assessment, education, documentation, and follow-up ensures continuity, safety, and high-quality outcomes. As more states recognize the clinical expertise and precision of dental hygienists, the scope of practice continues to expand, opening new opportunities for professional growth. With ongoing education and advocacy, dental hygienists are positioned to play an increasingly integral role in patient esthetic and therapeutic care.

Conclusion

Dental hygienists possess specialized foundational skills to safely incorporate neuromodulator therapy into patient care. In addition to their extensive education, dental hygienists’ daily responsibilities cultivate critical thinking, technique precision, and emergency preparedness, all of which directly support the safe administration of neuromodulators. However, additional education and hands-on training specific to injectable neuromodulators use and technique are essential before incorporating these therapies into practice.

The thoughtful integration of neuromodulators into dental hygiene practice enhances patient care and professional satisfaction, as well as places dental hygienists as integral contributors to modern, evidence-based oral healthcare. As dentistry continues to evolve beyond the teeth alone, the integration of neuromodulators invites oral health professionals to reexamine their role in comprehensive facial care where anatomy, neuromuscular control, and patient quality of life intersect.

References

1. Maci M, Fanelli C, Lorusso M, et al. Botulinum toxin type A and hyaluronic acid dermal fillers in dentistry: a systematic review of clinical application and indications. J Clin Med Res. 2024;16:273-283.
2. Pirazzini M, Rossetto O, Eleopra R, Montecucco C. Botulinum neurotoxins: biology, pharmacology, and toxicology. Pharmacol Rev. 2017;69:200-235.
3. Agren M, Sahin C, Pettersson M. The effect of botulinum toxin injections on bruxism: a systematic review. J Oral Rehabil. 2020;47:395-402.
4. Machado D, Martimbianco ALC, Bussadori SK, Pacheco RL, Riera R, Santos EM. Botulinum toxin type A for painful temporomandibular disorders: systematic review and meta-analysis. J Pain. 2020;21:281-293.
5. Serrera-Figallo MA, Ruiz-de-León-Hernández G, Torres-Lagares D, et al. Use of botulinum toxin in orofacial clinical practice. Toxins (Basel). 2020;12:112.
6. Shim YJ, Lee HJ, Park KJ, et al. Botulinum toxin therapy for managing sleep bruxism: A randomized and placebo-controlled trial. Toxins (Basel). 2020;12:168.
7. Buzatu R, Luca MM, Castiglione L, Sinescu C. Efficacy and safety of botulinum toxin in the management of temporomandibular symptoms associated with sleep bruxism: A systematic review. Dent J (Basel). 2024;12:156.
8. Coelho MS, de Oliveira JMD, Polmann H, et al. Botulinum toxin for the management of bruxism: an overview of reviews protocol. BMJ Open. 2024;14:e082861.
9. Zengiski ACS, Basso IB, Cavalcante-Leão BL, et al. Effect and longevity of botulinum toxin in the treatment of gummy smile: a meta-analysis and meta-regression. Clin Oral Investig. 2022;26:109-117.
10. Hong SO. Cosmetic treatment using botulinum toxin in the oral and maxillofacial area: a narrative review of esthetic techniques. Toxins (Basel). 2023;15:82.
11. Moradi A, Shirazi A. A retrospective and anatomical study describing the injection of botulinum neurotoxins in the depressor anguli oris. Plast Reconstr Surg. 2022;149:850-857.
12. Choi YJ, We YJ, Lee HJ, et al. Three-dimensional evaluation of the depressor anguli oris and depressor labii inferioris for botulinum toxin injections. Aesthet Surg J. 2021;41:NP456-
13. Li K, Tan K, Yacovelli A, Bi WG. Effect of botulinum toxin type A on muscular temporomandibular disorder: a systematic review and meta-analysis of randomized controlled trials. J Oral Rehabil. 2024;51:886-897.
14. Yeh M, Peng JH, Peng HLP. Literature review of adverse events with botulinum toxin in the masseter. J Cosmet Dermatol. 2018;17:675-687.
15. Sethi N, Singh S, DeBoulle K, Rahman E. A review of complications due to the use of botulinum toxin A for cosmetic indications. Aesthetic Plast Surg. 2021;45:1210-1220.
16. Popescu MN, Beiu C, Iliescu CA, et al. Ultrasound-guided botulinum toxin-A injections into the masseter muscle for both medical and aesthetic purposes. Toxins (Basel). 2024;16:413.
17. Mayes K. Dental hygienists’ authority to administer Botox or perform other procedures not specifically listed in A.R.S. § 32-1281(B). Available at azag.gov/opinions/i23-003-r23-001. Accessed June 10, 2026.
18. Oklahoma State Board of Dentistry. Advanced Procedures for Dental Hygienists: Neuromodulator Administration. Available at law.cornell.edu/regulations/oklahoma/OAC-195-15-1-6.1. Accessed June 10, 2026.
19. Kansas Dental Board. Meeting Minutes: Approval of Dental Hygienist Neuromodulator Administration Under Direct Supervision. Available at dental.ks.gov. Accessed June 10, 2026.
20. Colorado Senate Bill 25-194. Neuromodulator Administration by Dental Hygienists Authorized Pending Colorado Dental Board Rulemaking. Available at https://dpo.colorado.gov/DentalSunset. Accessed June 10, 2026.

From Dimensions of Dental Hygiene. July/August 2026; 24(4):28-31

Post-traumatic stress disorder (PTSD) is a lifelong psychiatric condition that may develop after traumatic, life-threatening, or unsettling incidents that elicit emotional or physical harm.^1-3 Common causes include war; physical, emotional, or sexual abuse; severe accidents; natural disasters; domestic abuse; acts of terrorism; and medical ailments.

The dental setting may be a stressful, triggering environment for those living with PTSD. To provide the best individualized care for those with this psychiatric disorder, oral health professionals need to be knowledgable about PTSD, including clinical symptoms, potential triggers while in the dental office, patient communication strategies, and opportunities for interprofessional collaboration.

With PTSD affecting six out of every 100 people, oral health professionals will likely treat many individuals with PTSD throughout their careers.³ It impacts individuals of all races, ethnicities, gender identities, and ages. Among American adults, the lifelong prevalence of PTSD is 6.8% with women twice as likely to develop the condition than men.^3,4 Oral health professionals should be familiar with PTSD in the dental setting and use culture sensitivity if they suspect a history of mental illness relating to trauma in order to provide appropriate care.

Recognition of Symptoms and Treatment

When individuals experience a traumatic incident, they experience strong feelings of terror, defenselessness, and panic. Common recurring manifestations after the initial event include flashbacks of the traumatic incidents, nightmares, extreme anxiety, and uncontrollable thoughts.^2,5 This chronic heightened emotional state leads to physiological responses. Continual stress increases the release of cortisol and adrenaline, impeding the body’s immune response.⁶

The active treatment of PTSD involves medication that often coincides with therapeutic interventions. Selective serotonin reuptake inhibitors and atypical antidepressants are frequently used to address PTSD. Potential intraoral adverse effects related to these medications include xerostomia, which impacts 15% to 25% of patients,5 along with dysgeusia, glossitis, and stomatitis, which affect about 10% to 40% of patients.¹ Additional oral side effects include gingival hyperplasia, discolored tongue, sialadenitis, and dysphagia.

Exposure and cognitive therapies may be used in conjunction with medication. Exposure therapy includes guiding patients through exercises to confront the traumatic incident, typically with images or asking about the experiences, such as what they saw, heard, smelled, or tasted. Cognitive therapy, which can be used alongside exposure therapy or alone, instructs patients on how to recognize the automatic, irrational, and negative thought patterns that have emerged following the traumatic incident.¹

Unfortunately, less than half of those affected by PTSD seek treatment.^6-8 Traditional referral models for mental health may not be successful among individuals with PTSD.⁴ Oral health professionals should be able to identify what and if patients are undergoing any active therapies, while also recognizing potential oral manifestations relating to the use of specific PTSD medications.

Oral Findings and Preventive Strategies

Existing dental conditions, such as caries, periodontal diseases, and bruxism, may worsen for individuals with PTSD due to the impact of trauma in their daily lives. High decayed, missing, and filled teeth scores and periodontal disease prevalence of more than 62% have been observed in populations with PTSD.⁵ Basic oral self-care habits may be neglected due to a lack of motivation related to the patient’s mental state. Lack of confidence and poor self-image from toothaches or tooth loss may increase seclusion and impair basic functions including talking and chewing food.⁹

Risk factors associated with oral diseases become compounded by the complexity of the mental condition and daily self-care.^1,6 Diet and proper self-care habits are essential for disease prevention and control. Individuals with PTSD are also more likely to engage in substance misuse and smoking. Tobacco use, recreational drugs, and poor diet all increase risk for many oral conditions and impact biofilm accumulation. Additionally, medication-induced xerostomia is common among individuals with PTSD and is a significant, comorbid risk factor for oral diseases.^1,6,10

A study by Tagger-Green et al⁵ compared the oral health of three groups: a control group, a group of individuals with diagnosed PTSD taking medication to manage the mental condition, and a group with diagnosed PTSD not taking medication. The plaque index for each of the PTSD groups was significantly higher than the control group, with the medication group recording the highest result, 80% to 67% to 45%, respectively. The highest percentage of heavy tobacco smoking was found in the PTSD group that was taking medication. While the frequency and severity of the risk factors of smoking, drug use, poor diet, and dry mouth may vary by individual, the amalgamation of any of these multiple risk factors together necessitates preventive care, self-care education on oral diseases, and biofilm control.

The multifactorial nature of PTSD makes the identification and management of oral diseases complex for any oral health professional. Additionally, the pathogenesis of periodontal conditions may be altered by the mental condition. In a review of mental health disorders and oral microbiota, an association between periodontal conditions and PTSD were observed, but there is a lack of diverse studies to explore the correlation.¹⁰ However, constant low-grade inflammation is a risk factor for trauma-related mental conditions.¹¹

Traumatic experiences may trigger chronic stress and the release of specific stress hormones related to oral conditions such as periodontal diseases. Thus, oral health professionals should consider a possible oral systemic link to an altered immune system relating to neuropsychiatric conditions, such as PTSD, and their role in periodontal conditions.¹⁰ The combination of neglect and an altered immune response may speed up the breakdown of dental tissues.¹

The stress related to PTSD can manifest itself as bruxism, leading to facial and temporomandibular joint (TMJ) pain.⁵ Bruxism, or clenching and grinding of the teeth, may damage the teeth in addition to causing orofacial pain. Stress and emotional disturbances, such as those caused by traumatic experiences associated with PTSD, may increase abnormal, habitual bruxism.⁶ Studies have found up to 88% of patients with PTSD exhibited early signs of headaches with increased muscle pain on extraoral structures, increased observed TMJ sounds, and movement limitation with pain upon movement.^5,12 Dental hygienists play a significant role in the early detection of these symptoms via thorough head and neck examinations.

Patient Management and Treatment Modifications

Oral health professionals should treat patients with PTSD similar to other patients with special needs, identifying risks and triggers in the dental office and utilizing communication strategies to open a conversation with patients. Questions related to acoustic and visual prompts or other triggers when individuals reveal PTSD during medical and social history intake may assist the provider in planning and modifying treatments and appointments.¹³ However, some individuals may not be forthcoming in the medical history questionnaire about their PTSD.¹⁴

The dental setting can be a stressful environment for these patients, regardless of formal diagnosis. The very thought of dental treatment may elicit triggers or distressing memories for patients with PTSD.⁴ Common triggering aspects in the dental setting include, but are not limited to, lying in a supine position, “looming over” or “hovering” above the patient, placement of the patient napkin around the neck, the inability to effectively communicate during treatment, local anesthetic administration, the dental light, equipment noise, being touched and the fear of pain during treatment or postoperative pain. Actions that elicit the feeling of gagging or choking may inadvertently remind patients of the traumatic past experiences.¹⁴

Head and neck exams, including oral cancer screenings, require manipulation of the patient’s tongue and palpation of the hard palate, floor of the mouth, or oropharynx. Patients may perceive this as intrusive and forceful. Mouth props, although useful, can cause anxiety because patients cannot close their mouth and make communication challenging. Alginate impressions may elicit a gag reflex and the saliva ejector can cause patients to have difficulty breathing.¹⁵

Offering patients an overview of each step will help to ease their worry. Examples include, advising patients that they may experience a feeling of being out of breath when the saliva ejector is placed in their mouths or demonstrating the use of the air water syringe on their hands before using it intraorally.

An additional strategy to reduce anxiety is to directly ask patients what would make them feel more at ease during their dental visit. At the start of each appointment, clear consent should be obtained as well as a thorough understanding of all planned procedures. A step-by-step explanation of the appointment should also be discussed to ease any potential apprehension and anxiety. Collaborating with the patient to create signals and informing patients that they may use a signal (or a simple raise of the hand) if in need of a break or to pause during their treatment enables patients to feel more in control. Patients may be asked if anything eases their anxiety such as listening to music or visualization.¹⁵

According to a study by Simone et al² that evaluated practicing dental hygienists’ knowledge of PTSD and dental care, the majority acknowledged a link between dental anxiety and PTSD, yet more than 68% did not use any specific strategies during dental hygiene appointments. The study further identified that almost half of participants had no experience during their dental hygiene education treating individuals with a history of trauma and associated conditions. A 2025 study surveying dentists and dental hygienists found that while they believed mental health screening was important, only a small number of providers thought application into practice was feasible.¹⁶

Successful treatment and acceptance of dental care for individuals with PTSD require oral health professionals to potentially screen for these conditions and modify treatment based on the severity of symptoms and triggers. Common recommendations include active listening, careful attention to both verbal and nonverbal cues and actions, asking permission during various times of the appointment when assessing the patient, slow movement of the chair when moving from supine to upright, and adjusted appointment times.^13,14

Short, flexible appointment times and consistency with clinicians and staff provide stability in desensitizing to the dental environment. Building rapport with patients and prioritizing their safety, although time-consuming, may be a pivotal factor in increasing the likelihood of them continuing with treatment and building positive health behaviors.^13,14 Psychological obstacles faced by trauma survivors may result in an underutilization of preventive healthcare services. Depression and anxiety can cause patients to cancel, miss, or reschedule their hygiene appointments. That being said, the use of empathy and sensitivity from providers during treatment has been shown to increase the chances of follow up appointments and engagement from those who have experienced traumatic events. When treated without proper consideration and compassion, this can bring on feelings of revictimization and discourage a patient from seeking help in all aspects of the healthcare system over time.¹⁴

Oral health professionals should include the patient in determining the best methods for individualized care.^6,14 According to a study by Kisely et al⁹ findings included an increased risk of tooth loss and dental caries. Dental hygiene care plans must include therapeutic, evidence-based strategies to match a patient’s risk level. Incorporating salivary stimulating therapies may be necessary depending on the severity of xerostomia and use of medication for management of PTSD. Chewing sugar-free gum to help increase salivary flow, reducing caffeine consumption, and sipping water at regular intervals may help alleviate symptoms.

The use of remineralization treatments, such as topical fluoride application, should coordinate with nutritional education relating to diet and dental caries. Because patients with PTSD may experience challenges with focus, memory and long-term recall, all self-care instructions should be provided in writing for easy reference.¹³ Lastly, discussions on oral disease risks associated with alcohol, tobacco, and recreational drug use are necessary for comprehensive dental hygiene care. When discussing these topics, oral health professionals should recognize that these coping mechanisms are typically related to the patient’s prior traumatic experiences. The conversations should be positive and nonjudgmental. This will help patients become more comfortable talking about their habits and behavior changes, as well as remaining involved in their treatment.¹⁵

Future Considerations

Because of the high incidence of traumatic events, oral health professionals are likely to treat many patients with PTSD. Any experience that violated individuals’ autonomy may play a role in their outlook on dental and medical treatment. Frequently, oral health professionals see their patients more often than medical providers. In addition, patients often remain in the same dental practice from childhood throughout adulthood, therefore oral health professionals may be more attuned to changes in their patients’ behavior or obvious trauma.¹⁵

Medical history intakes should include tailored questions regarding all mental health conditions, but specifically inquire about PTSD. Some evidence suggests that interprofessional collaboration with providers, such as social workers, mental health providers, and other primary care providers, promotes more collaborative care.^6,13 This collective approach may include education for other members of the healthcare team on the oral manifestations associated with medication use. Collaboration may improve access to care and reduce obstacles for those with histories of trauma.⁹ However, this may not be feasible for individual practice settings or all providers. Continuing education on mental health, trauma, and conditions such as PTSD may promote awareness of the individual needs of this patient population.

Oral health professionals should maintain a list of local resources and referrals for patients with PTSD as well as those who may experience potential ongoing trauma. A general knowledge of these resources can help to encourage patient involvement in their dental care and help to support a trusting and lasting relationship with their dental professional. If ongoing trauma is a concern, oral health professionals should be knowledgeable about their legal obligations and each state’s mandated reporting requirements.

References

1. Friedlander AH, Friedlander IK, Marder SR. Post-traumatic stress disorder: psychopathology, medical management, and dental implications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97:5-11.
2. Simone CB, Smallidge DL, Libby L, Vineyard J. Experiences, knowledge and perceptions of dental hygienists, in the treatment of patients with post-traumatic stress disorder. J Dent Hyg. 2022;96:35-42.
3. United States Department of Veteran Affairs. How Common Is PTSD in Adults? Available at ptsd.va.gov/understand/common/common_adults.asp. Accessed June 8, 2026.
4. Hoeft TJ, Stephens KA, Vannoy SD, Unützer J, Kaysen D. Interventions to treat post-traumatic stress disorder in partnership with primary care: A review of feasibility and large randomized controlled studies. Gen Hosp Psychiatry. 2019;60:65-75.
5. Tagger-Green N, Nemcovsky C, Fridenberg N, Green O, Chaushu L, Kolerman R. Oral and dental considerations of combat-induced post traumatic stress disorder (ptsd)-a cross-sectional study. J Clin Med. 2022;6:3249.
6. Xu Q, York JA, Yuan S. Trauma’s impact on oral healthcare: a biopsychosocial and trauma-informed approach. J Calif Dent Assoc. 2024;52:1.
7. Hoge CW, Auchterlonie JL, Milliken CS. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 2007;298:2141-2148.
8. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629–640.
9. Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders – a systematic review and meta-analysis. J Affect Disord. 2016;200:119-132.
10. 10 Martínez M, Postolache TT, García-Bueno B, et al. The role of the oral microbiota related to periodontal diseases in anxiety, mood and trauma- and stress-related disorders. Front Psychiatry. 2022;12:814177.
11. Loupy KM, Luczynski CA. Post-traumatic stress disorder and the gut microbiome. In: Oxford Handbooks Online in Neuroscience. Oxford, United Kingdom: Oxford University Press; 2019.
12. de Oliveira Solis AC, Araújo ÁC, Corchs F, et al. Impact of post-traumatic stress disorder on oral health. J Affect Disord. 2017;219:126-132.
13. Kelsch, N. Treatment considerations for post-traumatic stress disorder dental patient. Journal of the California Dental Hygienists’ Association. 2017;35(1):16-24.
14. Heaton L, Cheung H. Trauma-informed care in oral health care: the role of dental hygienists. J Dent Hyg. 2024;98:50-55.
15. Raja S, Hoersch M, Rajagopalan CF, Chang P. Treating patients with traumatic life experiences: Providing trauma-informed care. J Am Dent Assoc. 2014;145:238-245.
16. Mishler O, Trembley C, Oates TW, et al. Dental providers’ perceptions toward mental health screening at routine practices: a mixed-methods approach. BMC Oral Health. 2025;25:1208.

From Dimensions of Dental Hygiene. July/August 2026; 24(4):32-35

Ongoing disparities in oral health remain a significant public health concern.¹ Community health workers (CHWs) play a key role in bridging the gap between healthcare systems and communities by using cultural insight and community collaboration.²

As healthcare systems recognize the value of community-based interventions, CHWs are significantly impacting oral health promotion. Through education, outreach, and care coordination, they address the underlying causes of health disparities and encourage lasting behavioral changes. However, their role is often limited by inconsistent training standards, ambiguous roles, and unstable funding.

Today, an estimated 58,550 CHWs practice in the United States , primarily in schools, community centers, and patient homes.³ A CHW is a frontline public health worker who connects people to health and social services; helps improve service delivery; and builds community capacity by providing outreach, education, support, and advocacy.⁴ CHWs serve as trusted liaisons between health systems and residents. CHWs do not need to come from healthcare backgrounds, but rather close ties with their communities make them especially effective. They provide culturally appropriate health education, support, care coordination, and advocacy.

While CHWs receive training through state-approved or community-based programs, collaboration with dental hygienists is essential in oral health settings. Dental hygienists contribute clinical expertise and evidence-based guidance, while CHWs help ensure that health messages are delivered in ways that align with the values, beliefs, and needs of the communities they serve.

CHWs receive training tailored to the populations they serve. They can pursue various pathways, including certificate programs offered by the Michigan Department of Health and Human Services (MDHHS) and Michigan Community Health Worker Alliance.⁵ Training opportunities are also available through the National Association of Community Health Workers (NACHW).⁶ Some CHWs receive training through instructor-led programs or job shadowing.

The American Dental Association also introduced a type of CHW, the community dental health coordinator (CDHC). CDHCs are specially trained CHWs with an oral health focus who serve as a bridge between underserved populations and dental care providers. Working in schools, community centers, long-term care facilities, and other community settings, CDHCs help individuals navigate the healthcare system, connect with dental homes, overcome barriers, such as transportation and financial challenges, and receive oral health education tailored to their needs. The program emphasizes prevention, care coordination, and community outreach, making CDHCs uniquely positioned to address oral health disparities and improve access to care among vulnerable populations. By combining community engagement skills with oral health knowledge, CDHCs represent a valuable extension of the dental team.⁷

CHWs extend the reach of traditional healthcare providers by addressing barriers to care, supporting patients through education and advocacy, and linking clinical and community resources.¹ Their efforts improve population health, reduce health disparities, and contribute to more efficient and effective healthcare delivery.

The Role of Community Health Workers in Oral Health

An increasingly popular strategy for preventing dental disease and improving community health is integrating oral health promotion into primary care. This approach not only supports the prevention of dental diseases but also encourages healthier lifestyles through consistent, community-based interventions.⁸

In US-based models, the role of the CHW centers on education, navigation, and connecting individuals to appropriate care.¹ CHWs use behavior change models, such as the health belief model (HBM), to encourage healthy lifestyle changes. The HBM explains why people may not engage in preventive healthcare behaviors by assessing perceived susceptibility to dental disease, potential severity of untreated dental conditions, and benefits of preventive care.⁹ CHWs also use motivational interviewing to support behavior change (see Table 1).^10,11

CHWs increase access to dental care by navigating, referring, educating, and coordinating care.¹ Many CHWs work with dental offices to refer individuals for treatment and help them establish ongoing care. They also support individuals in understanding insurance coverage, completing enrollment processes, and addressing financial or logistical barriers that may delay care. Through these efforts, CHWs enable individuals to better utilize available services. They also educate communities by sharing information and distributing oral hygiene products through printed materials and presentations.

CHWs support their communities by raising awareness of social determinants of health (SDOH), the conditions in which people live, such as income, education, and environment, and by connecting individuals to local resources (Table 2).^12-14 Enhancing organizational awareness of SDOH is vital for effectively supporting community health. Additionally, expanding care coordination is crucial to delivering seamless, integrated healthcare, as it enables communication among care teams.⁴

Equally important, CHWs play a significant role in increasing consumer satisfaction and building trust in healthcare organizations. When patients feel satisfied with their care and trust their providers, they are more likely to engage with health services and follow recommended treatments, ultimately, improving health outcomes. Furthermore, CHWs provide culturally competent care, which addresses the unique needs of diverse populations and helps reduce health disparities.¹⁵

CHWs aid in improving health outcomes for individuals with limited English proficiency by facilitating tailored communication, providing language assistance, and delivering culturally appropriate health education. They can also serve as knowledgeable guides, bridging gaps with interpreter services and enhancing patient engagement within healthcare organizations.¹² When serving rural populations, CHWs are instrumental in addressing barriers such as limited access to healthcare providers, transportation challenges, and a lack of specialized services.

Individuals with chronic health conditions are well served by CHWs as they provide ongoing support, education, and resources. Monitoring individuals’ oral health progress, coordinating care between dental and medical clinicians, and promoting adherence to treatment plans are key ways CHWs help improve quality of life and long-term outcomes.

In addition, CHWs support the delivery of behavioral health care by integrating mental health and substance use education into oral health promotion, offering screenings, referrals, and educational resources.⁸ By facilitating comprehensive care coordination and communication, CHWs help ensure that individuals receive support for their oral health and overall health needs.

Promoting preventive oral health care, reducing unnecessary emergency visits, and preventing costly complications through patient education and outreach are all cost-management strategies provided by CHWs. These efforts help reduce operational expenses while maintaining, or even enhancing, the quality of oral healthcare provided to communities.⁴

Challenges and Considerations

Lack of standardized training and certification requirements, varying scopes of practice between states, and limited professional organizations all present challenges for CHWs. Additionally, there is a lack of clearly defined roles. Many organizations continue to add tasks to CHWs’ job descriptions, blurring distinctions between trained and certified CHWs.¹⁶ This can lead to inadequate compensation and limited career advancement. Many CHWs are underpaids, which can affect motivation and retention. At times, CHWs are not fully recognized as valuable team members by healthcare professionals.

Expanding beyond disease management to address SDOH, integrating CHWs into care teams, clarifying roles, and ensuring proper documentation and reimbursement structures are all common challenges. Success relies on organizational support, team collaboration, and ongoing evaluation.¹⁷ Unclear job descriptions for CHWs can lead to overlooked tasks, missed health interventions, role overlap, and working beyond their competence. This confusion can also hinder collaboration, as partners may not know how to engage or support CHWs.

Clarifying CHW roles through coordinated efforts by policymakers, healthcare organizations, employers, and professional associations is essential to maximizing their benefits.¹⁸ Efforts should focus on establishing standardized scopes of practice, defining core competencies, and developing sustainable reimbursement mechanisms to support effective integration into healthcare systems.

The lack of sustainable funding and reliance on unstable grant-based support continue to create barriers to long-term CHW workforce stability. Schmit et al¹⁹ note that many CHW funding mechanisms depend on state appropriations or short-term grant programs, which limit long-term reliability. Policy and regulatory constraints also restrict CHW roles, especially due to inconsistent terminology and variation in reimbursement eligibility across states. Enabling CHW reimbursement from Medicaid and other public assistance models would create a more sustainable option because they function as entitlement-based funding that can better support long-term CHW integration and service delivery.²⁰

Although standardized CHW training is lacking, reputable websites provide useful resources. In Michigan, MDHHS and the Michigan Community Health Worker Alliance (MiCHWA) offer reliable information on training opportunities.^4,21 MiCHWA training covers CHW roles in public health and health systems, legal and ethical responsibilities, community resource navigation, communication and cultural responsiveness, teaching and capacity-building, coordination, documentation and reporting, promotion of healthy lifestyles, and behavioral health. Additionally, the NACHW provides national training and professional development to support CHW competency and workforce development across the US.⁶

Research demonstrates the success of CHWs. Northridge et al²² found that 98% of the 74 participants agreed or strongly agreed that CHWs helped them take better care of their health. Participants reported that CHWs answered their questions, provided informative content, and demonstrated how to improve oral health. After the intervention, a higher proportion of participants felt more confident in caring for their oral health and in communicating with dental professionals.

Future Direction and Opportunities

National organizations, such as NACHW and the American Public Health Association, advocate for policies that support CHWs, including efforts to secure Medicaid reimbursement for CHW-provided oral health services, a crucial step toward expanding access and ensuring program sustainability. Sharing successful strategies from states that have implemented reimbursement models can provide useful frameworks for broader adoption and more equitable access to CHW support.

Interprofessional training is another key strategy to strengthen collaboration and clarify CHWs’ roles within oral health settings. Joint training opportunities can help oral health professionals better understand how to effectively partner with CHWs in areas such as patient education, care coordination, and referral systems. For example, dental hygienists can support CHWs by providing guidance on evidence-based oral hygiene practices and caries prevention, while CHWs can reinforce these messages within the community and assist with follow-up, appointment reminders, and addressing barriers to care.

Expanding oral health education and fostering collaboration among the safety net workforce are essential strategies for advancing health equity in marginalized communities. By equipping all team members with knowledge of oral self-care behaviors and encouraging effective communication, organizations can help close care gaps. Achieving these improvements will depend on robust educational initiatives led by employers and community leaders as well as the development of strong peer and employer support networks.

Integrating telemedicine into community health also presents opportunities to improve access and patient outcomes. CHWs can help facilitate virtual visits, provide education, and assist with triage and follow-up care. These approaches may be particularly valuable in underserved communities, where barriers to in-person care are more common.

Implications for Research

Key gaps identified in the current literature include standardizing and evaluating CHW training and roles; developing evidence-based models for sustainable funding and reimbursement; establishing best practices for integration with oral health professionals; and effectively using teledentistry. More research is needed on the methods that enhance professional recognition and facilitate effective workforce integration.

Conclusion

To help CHWs make a significant difference in oral health, training must be supported, stable funding should be provided, and collaboration with other healthcare professionals needs to be fostered. The future of public health depends on breaking down professional boundaries and utilizing those closest to knowing community needs, making CHWs a vital resource for meaningful, long-term improvement.

References

1. Garcia DT. A scoping review of the roles, training, and impact of community health workers in oral health. Community Dent Health. 2021;38:198-208.
2. Molete MM, Malele-Kolisa Y, Thekiso M, Lang AY, Kong A, George A. The role of community health workers in promoting oral health at school settings: A scoping review. J Public Health Dent. 2024;84:175-186.
3. United States Bureau of Labor Statistics. Occupational Employment and Wage Statistics. Available at bls.gov/oes/2023/may/oes211094.htm. Accessed June 4, 2026.
4. Michigan Health and Human Services. Community Health Workers. Available at michigan.gov/mdhhs/inside-mdhhs/legislationpolicy/2022-2024-social-determinants-of-health-strategy/community-health-workers. Accessed June 4, 2026.
5. Michigan Community Health Worker Alliance. CHW Training & Education Overview. Available at https://michwa.org/training. Accessed June 4, 2026.
6. National Association of Community Health Workers. CHW Networks and Training Programs. Available at https://nachw.org/generalresources/networks-and-training-programs. Accessed June 4, 2026.
7. American Dental Association. Community Health Coordinator. Available at ada.org/resources/community-initiatives/action-for-dental-health/community-dental-health-coordinator. Accessed June 4, 2026.
8. Faisal MR, Mishu MP, Jahangir F, et al. The effectiveness of behaviour change interventions delivered by non-dental health workers in promoting children’s oral health: A systematic review and meta-analysis. PLOS ONE. 2022;17:e0262118.
9. Alyafei A, Easton-Carr R. The health belief model of behavior change. Available at statpearls.com/point-of-care/161679. Accessed June 4, 2026.
10. Miller WR. The evolution of motivational interviewing. Behav Cogn Psychother. 2023;51:616-632.
11. Bischof G, Bischof A, Rumpf HJ. Motivational interviewing: an evidence-based approach for use in medical practice. Dtsch Ärztebl Int. 2021;118:109-115.
12. Ponce-Gonzalez I, Cheadle A, Aisenberg G, Cantrell LF. Improving oral health in migrant and underserved populations: evaluation of an interactive, community-based oral health education program in Washington state. BMC Oral Health. 2019;19:30.
13. Ponce-Gonzalez IM, Cheadle AD, Parchman ML. Correlation of oral health education by community health workers with changes in oral health practices in migrant populations in Washington state. J Prim Care Community Health. 2021;12:21501327211002417.
14. Mobula LM, Okoye MT, Boulware LE, Carson KA, Marsteller JA, Cooper LA. Cultural competence and perceptions of community health workers’ effectiveness for reducing health care disparities. J Prim Care Community Health. 2015;6:10-15.
15. Grant M, Wilford A, Haskins L, Phakathi S, Mntambo N, Horwood CM. Trust of community health workers influences the acceptance of community-based maternal and child health services. Afr J Prim Health Care Fam Med. 2017;9:e1-e8.
16. Olaniran A, Smith H, Unkels R, Bar-Zeev S, Van Den Broek N. Who is a community health worker? – a systematic review of definitions. Glob Health Action. 2017;10:1272223.
17. Johnson SL, Gunn VL. Community health workers as a component of the health care team. Pediatr Clin North Am. 2015;62:1313-1328.
18. Lumsden C, Andrews H, Leu CS, Edelstein B. Changes in knowledge and beliefs of community health workers following an oral health intervention training program. J Prev Interv Community. 2019;47:54-65.
19. Schmit CD, Washburn DJ, LaFleur M, Martinez D, Thompson E, Callaghan T. Community health worker sustainability: funding, payment, and reimbursement laws in the United States. Public Health Rep. 2022;137:597-603.
20. Alvillar M, Quinlan J, Rush CH, Dudley DJ. Recommendations for developing and sustaining community health workers. J Health Care Poor Underserved. 2011;22:745-750.
21. Michigan Community Health Worker Alliance. Michigan Community Health Worker Alliance Training & Certification. Available at https://michwa.org. Accessed June 4, 2026.
22. Northridge ME, Wu Y, Troxel AB, et al. Acceptability of a community health worker intervention to improve the oral health of older Chinese Americans: A pilot study. Gerodontology. 2021;38:117-122.

From Dimensions of Dental Hygiene. July/August 2026; 24(4):36-39

As of February 2025, the transgender population makes up roughly 2.3 million or 1% of the United States population.¹ As this population grows, oral health professionals are responsible for fostering respectful, affirming, and culturally competent care, which, ultimately, may lead to higher treatment adherence and overall better oral health outcomes.^2,3

Transgender is an umbrella term for those who do not identify with their sex assigned at birth but rather choose their own gender identity. Gender identity refers to people’s individual feelings of gender and how they choose to identify and/or express those feelings. The transgender community includes trans men, trans women, nonbinary, gender nonconforming, and gender queer. Trans men (or trans masc) refer to those who were assigned as female at birth but identify as male. Trans women (or trans femme) refer to those assigned at birth as male but identify as female.⁴ Table 1 provides definitions.^4-6

Transitioning can happen at any stage of life but often begins in childhood with feelings of gender dysphoria. The American Psychological Association defines gender dysphoria as the “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.”5 Individuals seeking gender affirmation can choose several ways to transition such as social, legal, medical, or surgical.

Social transitioning may include changing one’s name, pronouns, or the type of clothing/hairstyles they present with.⁵ For example, changing their name given at birth (dead name) to one that they choose and aligns with their gender identity. Legal transitioning includes changing gender markers on government-issued documents such as a driver’s license or birth certificate.

Medical and surgical transitions may include hormone replacement therapy or surgical procedures such as breast augmentation, masculine chest reconstruction, or facial feminization surgery.⁵ Transitioning is a personal decision and not all transgender individuals will choose to achieve gender affirmation through any of these approaches.^5,6

Affirming Dental Hygiene Care

Marginalized groups, such as transgender individuals, often face unique stressors such as discrimination, victimization, harassment, or prejudice outside of and within healthcare settings.⁷ According to the minority stress theory, these stressors can contribute to poorer physical and mental health outcomes due to financial limitations, barriers to healthcare, fear of seeking care from healthcare professionals who are not culturally competent, and concerns of medical confidentiality.^8,9

Based on the United States 2020 Transgender Survey (N=27, 715), 30% of transgender respondents experienced a form of health discrimination or did not seek care due to cost.¹⁰ Barriers to accessing healthcare often stem from overall cost and lack of coverage, as well as denial of claims due to being transgender. If legal transitioning has not been completed, this can lead to lack of insurance coverage, especially for specific gender-affirming care. Lack of healthcare coverage can lead to diminished preventive services such as check-ups, health screenings for high blood pressure or diabetes, cancer screenings, immunizations, and dental care.

Even when insurance coverage is available, transgender individuals often delay healthcare simply out of fear of discrimination or substandard care. This fear may be related to lack of knowledge and/or bias from providers related to transgender persons.^10,11 Oral health professionals need to be knowledgable about this population to provide more inclusive practice settings and individualized patient-centered care.

Documentation and Communication

Documents within the office, such as medical histories or consent forms, should include affirming language such as space for preferred names and/or preferred pronouns. This can easily be added into existing patient forms, as well as integrated into most electronic health record systems. Most insurance companies will require legal name and legal sex within documentation for filing purposes if legal transition has not occurred.¹² However, dental practices can ensure transgender patients that this information is used only for insurance purposes and that the preferred name/pronouns are what will be used in the office.

In addition to documentation, nonoffensive verbal communication can establish a trusting relationship and rapport that may counteract many of the barriers that transgender individuals encounter in healthcare settings. Establishing inclusive documentation and communication practices at the start of the appointment can improve the delivery of culturally competent care for transgender patients.

Oral health disparities within the transgender population include higher rates of dental diseases, increased dental anxiety/fear, and difficulty accessing or affording necessary care.^8,13 Due to these disparities, oral health professionals should be prepared to identify risk factors and oral conditions commonly seen in this population as well as provide appropriate treatment strategies.

Risk Assessment and Medical History

A thorough review of the patient’s medical history is critical to determine previous health conditions, current medications, and any surgical history. Specific health conditions commonly seen in the transgender population include mental health issues including anxiety/depression, tobacco/alcohol abuse, increased cancer risk, poor cardiovascular health, and higher incidence of sexually transmitted infections (STIs).^14,15 Additionally, common pharmacotherapeutics taken for these conditions, such as anti-anxiety and/or antidepression medications or gender-affirming hormone therapy (GAHT), significantly impact the oral cavity. Anti-anxiety and/or antidepression may raise the risk of xerostomia and caries as well as increase the levels of the periodontal pathogen Porphyromonas gingivalis.^16,17

GAHT is one of the most common medical treatments for transgender individuals and may include hormone replacements or hormone blockers.⁸ For example, a transgender woman may be taking estrogen and anti-androgens to suppress the effects of testosterone and elevate the feminine characteristics provided by the estrogen. These sex hormones have a direct and indirect impact on the periodontium, just like normal hormonal fluctuations can affect patients’ oral health status.¹⁸ Dental hygienists should complete a thorough review of health history and medication use in order to properly educate patients about any oral health risks.

Caries Risk and Periodontal Considerations

Xerostomia is one of the most common side effects of anti-anxiety and anti-depression medications, raising the risk of caries and poor periodontal health.¹³ Treatment considerations for transgender individuals with an increased caries risk include caries risk assessments, in-office fluoride applications, and nutritional counseling. In addition to providing treatment, dental hygienists can educate patients on proper at-home oral health strategies, xylitol use, and product recommendations to reduce xerostomia and caries risk.

Furthermore, fluctuations in sex hormones, such as estrogen, progesterone, and testosterone, can affect the epithelial tissues’ response to bacterial biofilm and increase vascular proliferation, contributing to heightened gingival inflammation and bleeding, regardless of oral hygiene status.^18,19 Many GAHT medications alter sex hormone levels, leading to higher rates of gingivitis and periodontal diseases among the transgender population.¹⁸

Dental hygienists play a critical role in prevention and treatment by providing prophylaxes, scaling in the presence of gingivitis, and initial nonsurgical periodontal therapy. Other possible treatments include frequent (every 3 to 4 months) periodontal maintenance visits, laser therapy, and possible referral to a periodontist for further evaluation. Additionally, thorough oral hygiene instruction can reduce the oral effects of these hormone imbalances.²⁰ At-home oral hygiene care instructions may include selective brushing techniques and interproximal care options with recommendations for oral hygiene aids. Ultimately, oral hygiene education should be tailored to these unique risks.

Oral Cancer and Sexually Transmitted Infection Screening

Due to the high incidence of STIs among the transgender population, oral health professionals should be prepared to identify potential intraoral and extraoral lesions.^21,22 Human immunodeficiency virus (HIV), syphilis, gonorrhea, and human papillomavirus (HPV) are common STIs seen in the transgender population.⁸

Dental hygienists can ensure early detection of potential lesions through comprehensive and routine oral cancer screenings and education for self-screening techniques at home in between routine visits. Possible STI lesions found intraorally may appear as red or white discolorations found near the tongue, soft palate, or tonsillar region and could be palpated during an extraoral exam as swollen lymph nodes. Additionally, patients with oral lesions may require referral to an oral surgeon or other specialist, while those who may be unaware of a possible STI should be referred for appropriate medical evaluation.

Tobacco Cessation

In addition to facing an increased risk of STIs, the transgender community is identified by the US Centers for Disease Control and Prevention as a priority population for tobacco cessation interventions.²³ Rates of tobacco use are higher in the transgender population and dental hygienists should be prepared to address this during oral health education.

Starting with medical history, oral health professionals should allow for open dialogue with their patients to determine if they are currently smoking or have a past history of smoking. For patients who currently smoke, clinicians should assess the frequency and quantity of tobacco use to support accurate periodontal staging and grading, treatment planning, and individualized oral hygiene education, particularly when periodontal disease is present. Additionally, discussing tobacco use with patients may also provide oral health professionals assistance with a differential diagnosis when examining intraoral and extraoral lesions.¹³

Practice Environment and Team Training

Within dental practices, oral health professionals can provide a safe and inclusive environment through easy and minor changes. Providing affirming signage within the office such as displaying lesbian, gay, bisexual, transgender, and queer (LGBTQ+) friendly stickers or flags can alert transgender patients of a safe environment.³

In addition, oral health providers should receive cultural competency training and maintain it through ongoing continuing education courses and workshops. The Commission on Dental Accreditation (CODA) requires cultural competence as part of its accreditation standards to ensure oral health professionals are providing safe and inclusive care for diverse populations.²⁴ All providers within the dental office should receive and maintain cultural competency training specific to the transgender population after completion of a CODA-accredited program through continuing education and workshops.²⁵

Oral health professionals can also keep other colleagues within the office accountable by correcting any noninclusive comments or language. The entire office is responsible for providing a safe environment for all patients, therefore maintaining office education is essential for providing care to transgender patients.

Conclusion

In a 2020 survey by the Center for American Progress, 54% of transgender respondents stated being in poor health and 68% of respondents reported experiencing a form of discrimination or mistreatment by healthcare providers.²⁶ To reduce health and dental disparities within the transgender population, oral health professionals should be well informed about providing equitable, patient-centered care through affirming documentation, communication, clinical assessment, treatment planning and practice environment.

References

1. USAFacts. What Percentage of the US Population Is Transgender? Feb 2025. Available at https://usafacts.org/articles/what-percentage-of-the-us-population-is-transgender. Accessed June 5, 2026.
2. United States Department of Health and Human Services. Healthy People 2030. Available at https://odphp.health.gov/healthypeople. Accessed June 5, 2026.
3. Tamrat J. ‘Trans-forming’ dental practice norms: Exploring transgender identity and oral health implications. Can J Dent Hyg. 2022;56:131-139.
4. American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol. 2015;70:832-864.
5. American Psychiatric Association. What Is Gender Dysphoria? Available at psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria. Accessed June 5, 2026.
6. American Psychological Association. Understanding Transgender People, Gender Identity, and Gender Expression. Available at apa.org/topics/lgbtq/transgender-people-gender-identity-gender-expression. Accessed June 5, 2026.
7. Falck F, Branstrom R. The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. BMC Pub Health. 2023;23: 1-15.
8. Macri D, Wolfe K. My preferred pronoun is she: Understanding transgender identity and oral health care needs. Can J Dent Hyg. 2019;53:110-117.
9. Frost D, Meyer I. Minority stress theory: Application, critique, and continued relevance. Cur Opinion in Psy. 2023;51: 1-6.
10. Kachen A, Pharr J. Health care access and utilization by transgender populations: A United States transgender survey study. Transgend Health. 2020;5:141-148.
11. Macdonald DW, Grossoehme DH, Mazzola A, Pestian T, Schwartz SB. Oral health care experiences of transgender adolescents and young adults. J Am Dent Assoc. 2019;150:748-754.
12. National LGBT Health Education Center Fenway Institute. Providing Inclusive Services and Care for LGBT People: A Guide for Health Care Staff. Available at lgbtqiahealtheducation.org/wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People.pdf. Accessed June 5, 2026.
13. Discepolo K, Aquino N. Considerations for transgender patients requiring dental rehabilitation. J Dent Children. 2022;89:46-51.
14. Manpreet K, Ajmal MB, Raheel SA. Oral health status among transgender young adults: a cross-sectional study. BMC Oral Health. 2021;21: 1-6.
15. Azagba S, de Silva G, Ebling T. Examining general, physical, and mental health disparities between transgender and cisgender adults in the US. Int J Equity in Health. 2025;24: 1-11.
16. Kisely S. No mental health without oral health. Canad J Psych. 2016;61:277-282.
17. Alcazar-Hernandez J, Pecci-Loret MR, Guerrero-Girones J. Oral manifestations in patients in treatment with antidepressants: A systematic review. J Clin Med. 2024;13: 1-15.
18. Patil SN, Kalburgi NB, Koregol AC, et al. Female sex hormones and periodontal health-awareness among gynecologists – a questionnaire survey. Saudi Dent J. 2012;24:99-104
19. Markou E, Eleana B, Lazaros T, et al. The influence of sex steroid hormones on gingiva of women. Open Dent J. 2009;9:146-156.
20. Sathish AK, Varghese J, Fernandes AJ. The impact of sex hormones on the periodontium during a woman’s lifetime: A concise-review update. Current Oral Health Reports. 2022;9:146-156.
21. McNulty A and Bourne C. Transgender HIV and sexually transmissible infections. Sex Health. 2017;14:451-455.
22. Samuel SR, Muragaboopathy V, Patil S. Transgender HIV status, self perceived dental care barriers, and residents’ stigma, willingness to treat them in a community dental outreach program: Cross-sectional study. Spec Care Dent. 2018;38:307-312.
23. Jamal A, Philips E, Gentzke AS, et al. Current cigarette smoking among adults – United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67:53-59.
24. Commission on Dental Accreditation (CODA.) Dental Hygiene Standards. Available at https://coda.ada.org/-/media/project/ada-organization/ada/coda/files/dental_hygiene_standards.pdf?rev=796e0c03f5ee4abca777ac02f9ee83ae&hash=EF22294B07B4E03B065210C5A68D459A. Accessed June 5, 2026.
25. Ludwig DC, Morrison SD. Should dental care make a transition? J Am Dent Assoc. 2018;149:79-80.
26. Center for American Progress. Discrimination and Experiences of LGBTQ People in the US: 2020 Survey Results. Available at americanprogress.org/article/discrimination-experiences-among-lgbtq-people-us-2020-survey-results. Accessed June 5, 2026.

From Dimensions of Dental Hygiene. July/August 2026; 24(4):40-45

Q

When I perform localized scaling and root planing on one to three teeth within a specific quadrant, may I also charge for a prophylaxis in the remaining quadrants?

Updated annually, the Code on Dental Procedures and Nomenclature (CDT) provides a way to document patient services.1 CDT 4342 is described as periodontal scaling and root planing for one to three teeth per quadrant. This procedure involves instrumentation of the crown and root surfaces to remove plaque biofilm and calculus and root planing for cementum and dentin removal that is rough, permeated by calculus, or contaminated with toxins or microorganisms. Code D1110 is for removal of plaque biofilm, calculus, and stains from teeth and implants in the permanent and transitional dentition; as well as for controlling local irritational factors.1

Generally, scaling and root planing and oral prophylaxis should not be coded together on the same day for the same patient because each is a distinct procedure. Scaling and root planing and oral prophylaxis are designed for different disease states. Scaling and root planing is therapeutic in nature; bone loss and clinical attachment loss are present. Oral prophylaxis is preventive in nature for patients with no bone loss or clinical attachment loss.

One option is to provide the needed care in two appointments. In patients who need both scaling and root planing and oral prophylaxis, scaling and root planing can occur in the one quadrant during an appointment. If this appointment is an initial contact or recare, the scaling and root planing could be combined with health and assessment, care planning, patient education ,and informed consent. Then the patient can be rescheduled for oral prophylaxis. The most appropriate time for rescheduling would be 4 to 6 weeks post-scaling and root planing. At this time, care planning should include reevaluation of the quadrant where scaling and root planing was performed and oral prophylaxis. After treatment, consider periodontal maintenance for site-specific scaling and root planing at appropriate intervals.

Some insurers may permit billing of scaling and root planing and oral prophylaxis on the same day. Most likely thorough documentation, including a narrative, comprehensive periodontal charting, and appropriate radiographs, will be required. Also, documentation should include the location where the scaling and root planing and the oral prophylaxis occurred. For example, D4342 in the maxillary right quadrant on teeth #2-4. In the quadrant to be scaled and root planed (maxillary right) documentation should at least include bleeding on probing, bone loss on radiographs, and clinical attachment loss. No bone loss and healthy probing depths will be present in the other quadrants cared for with oral prophylaxis. Therefore, radiographs will reveal bone loss in the one quadrant treated with scaling and root planing and no bone loss in the other three quadrants. Patient-informed consent will include this care plan. The record of services (notes) will include the procedures, time spent on the procedures, and the patient’s conditions.

In similar situations, Code D4346 may be considered. This code is indicated for patients with generalized moderate to severe gingival inflammation with no loss of attachment when gingivitis is present and periodontitis (clinical attachment loss and bone loss) is not present. Refer to periodontal staging and grading for a complete review of disease states.

In conclusion, contacting the third-party payer is the best first step for the optimal outcome for both the patient and provider.

Reference

1. American Dental Association. Coding Education. Available at www.ada.org/publications/cdt/coding-education. Accessed June 2, 2026.

From Dimensions of Dental Hygiene. July/August 2026;24(4):46