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Cutting the Red Tape

School-based sealant programs are effective in the fight against tooth decay, but state regulations and policies interfere with their implementation.

A strong research base demonstrates that dental sealants are highly effective in preventing tooth decay. Sealants can reduce the risk of decay in permanent molars by 80% in the first 2 years after application and continue to work after more than 4 years post-application.1,2  Given this evidence, the United States Centers for Disease Control and Prevention, Association of State and Territorial Dental Directors, and several other health organizations support sealant programs in schools to deliver preventive care to low-income children. Yet, 61% of low-income children ages 6 to 11 lack sealants.1,2  And the Pew Report released by the Pew Charitable Trusts found that school sealant programs are in fewer than half of high-need schools in 39 states.3

There are numerous reasons for our nation’s underdeveloped school-based oral health prevention infrastructure.  Featuring prominently are a range of state-based regulations or policies that either limit or prohibit dental hygienists from sealing children’s teeth at school or create financial burdens that impede the expansion of school-based sealant programs. These barriers can be found mainly in state practice acts—which define scope of practice for dental hygienists—and Medicaid policies.

Research and experience find that these rules and policies do not protect the public from unsafe dental practice, nor do they promote the efficient use of public resources. Yet still, they exist.  This piece highlights findings from a major report released by the Pew Charitable Trusts Dental Campaign in 2018 that describes such restrictive rules and policies.4 The report was based on surveys done in 2016 with 44 state dental directors as well as a range of other policy stakeholders. The most significant barriers are as follows.

Prior Exam Rules. These require that a student be examined by a dentist before receiving a sealant in school from a dental hygienist. These requirements exist because regulators are concerned that a dental hygienist cannot identify which molars are candidates for sealants, even though they are trained to do so.5 Research finds that labor accounts for about two-thirds of the cost per child of a school sealant program. Program costs are lower when dental hygienists, instead of dentists, are making sealant determinations.6 Currently, prior exam rules still remain in the District of Columbia, Alabama, Delaware, Hawaii, Louisiana, Mississippi, North Carolina, and Texas.7,8

Employment Requirements. In Kentucky and Virginia, only government employees can supervise public health dental hygienists.9  This requirement does not allow for an ample supply of school-based dental hygienists given the history of budget cuts for state and local public health departments. Without this restriction, private practices and nonprofits could participate. Other states place strict limits on the number of public health dental hygienists that any one dentist can supervise. For instance, in North Carolina, a dentist can supervise no more than two public health dental hygienists at a time.10,11  When dentist supervision is a requirement, as it is in nearly all states with public health hygienists, narrowing the pool of available supervisors limits the potential for program growth.

Reimbursement Based on Location. Medicaid is the dental insurer for nearly 80% of all low-income children  and is a major funding source for school-based sealant programs.12 Dental directors in Alaska, Arkansas, Hawaii, and South Dakota said that Medicaid does not reimburse for care delivered outside of a traditional brick-and-mortar dental clinic or office.

Restrictions on Direct Billing. Currently, 32 states and the District of Columbia do not allow dental hygienists to bill Medicaid directly for services.13 Instead, they must bill through their supervising dentists, requiring both clinical supervision and a financial arrangement to sustain the program.  Eighteen of 44 dental directors identified this rule as a barrier. The inability to bill directly in many cases causes payment delays to programs. States also report that dentists are reluctant to supervise school-based hygienists because of lack of administrative capacity to handle billing.

Managed Care. In addition, some states that employ Medicaid managed care for dental services report that contracted insurers are not allowing dental hygienists to bill Medicaid directly, even though they can do so under the state’s Medicaid fee-for-service program.

Regulations are intended to protect the public safety and to promote the efficient use of public resources. It is troubling that these policies identified impede both aims. A more comprehensive review of all state practice acts and related rules would provide a road map for state reform efforts. State lawmakers interested in improving the oral health of low-income children could consider proposals to remove these and similar barriers in their jurisdictions.


  1. Wei L, Gooch BF, Weno K, Espinoza L. Vital signs: dental sealant use and untreated tooth decay among u.s. school-aged children. MMWR Morb Mortal Wkly Rep. 2016;65:1141–1145.
  2. Ahovuo-Saloranta A, Forss H, Walsh T, et al. Sealants for preventing dental decay in the permanent teeth. Cochrane Database Syst Rev. 2014;2:CD000243.
  3. The Pew Charitable Trusts. States Stalled on Dental Sealant Programs: A 50-State Report. Available at: pewtrusts.o/​g/​-/​media/​assets/​2015/​04/​dent_​l_​sealantreport_​final.pdf?la=en&hash=34B595E9DE067F6B63BCD9BA6CE8002814752CD4. Accessed October 8, 2019.
  4. The Pew Charitable Trusts. When Regulations Block Access to Oral Health Care, Children at Risk Suffer. Available at​en/​research-and-analysis/​issue-briefs/​2018/​08/​when-regulations-block-access-to-oral-health-care-children-at-risk-suffer. Accessed October 8, 2019.
  5. Children’s Dental Health Project. Dental Sealants: Proven to Prevent Tooth Decay. Available​resources/​314-dental-sealants-proven-to-prevent-tooth-decay. Accessed October 8, 2019.
  6. Community Preventive Services Task Force. Oral Health: Preventing Dental Caries, School-Based Dental Sealant Delivery Programs—Task Force Finding and Rationale Statement. Available at:​sites/​default/​files/​assets/​Oral-Health-Caries-School-based-Sealants_​0.pdf. Accessed October 8, 2019.
  7. The Pew Charitable Trusts. States Stalled on Dental Sealant Programs: A 50-State Report. Available at:​-/​ media/​assets/​2015/​04/​dental_​sealantreport_​final.pdf?la=en&hash=34B595E9DE067F6B63BCD9BA6CE8002814752CD4. Accessed October 8, 2019.
  8. Langelier M, Baker B,  Continelli T, Development of a new dental hygiene professional practice index by state, 2016. Available​wp-content/​uploads/​2016/​12/​OHWRC_​Dental_​Hygiene_​Scope_​of_​Practice_​2016.pdf. Accessed October 8, 2019.
  9. Virginia Board of Dentistry. Kentucky Administrative Regulations Governing Dental Hygienists, Chapter 27. Available at:​dentistry/​dentistry_​laws_​regs.htm. Accessed October 8, 2019.
  10. North Carolina Dental Hygienists’ Association. Limited supervision rules. Available​limited-supervision-rules/​. Accessed October 8, 2019.
  11. North Carolina Dental Practice Act, Article 16: Dental Hygiene Act, § 90-233, Practice of Dental Hygiene. Available at:​ EnactedLegislation/​Statutes/​HTML/​ByArticle/​Chapter_​90/​Article_​16.html. Accessed october 8, 2019.
  12. Child Trends Databank. Health Care Coverage: Indicators of Child and Youth Well-Being. Available at:childtrends. org/​wp-content/​uploads/​2016/​05/​26_​Health_​Care_​Coverage-1.pdf. Accessed October 8, 2019.
  13. American Dental Hygienists’ Association. Direct Access States. Available​resources-docs/​7513_​ Direct_​Access_to_Care_from_DH.pdf. Accessed October 8, 2019.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental HygieneOctober 2019;6(11):12—13.

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