The Impact of Direct Access and Dental Therapy

The dental hygiene profession continues to work toward increasing access to care in the United States through efforts to expand dental hygienists’ scope of practice. Additionally, several states have passed bills allowing for varying degrees of expansion of the midlevel practitioner. However, one of the most significant factors improving the ability of the underserved to receive oral health care services is direct access to patients. Direct access, as defined by the American Dental Hygienists’ Association (ADHA), is the ability of dental hygienists “to initiate treatment based on their assessment of a patient’s needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship.”¹ And in many states, direct access has been legislated into law. Wisconsin Governor Scott Walker signed Assembly Bill 146 into law to expand direct access settings wherein a dental hygienist can provide care. The new law allows Wisconsin dental hygienists to treat patients without the authorization and supervision of a dentist in a variety of settings—from detention facilities to adult day care centers to medical settings. Following suit was Georgia’s passage of HB 154. In January 2018, Governor Nathan Deal made Georgia the 40th state to allow direct access to services provided by dental hygienists under general supervision.

When it comes to direct access, much hinges on what kinds of supervision are required, though exact meanings can vary from state to state, and often depend on the setting, treatment to be performed, and educational parameters. Direct supervision generally means that the dentist must be physically present in the office or even the room where the treatment is occurring, and must perform the initial exam, diagnose the problem, and authorize treatment. Indirect supervision generally means that the dentist must at least be in the office. General supervision often means that the dentist must be available for consultation, but not necessarily in the office. A requirement of direct or indirect supervision can be an impediment to dental hygienists practicing outside of the traditional private practice setting. One of the primary benefits of expanding the scope of practice for dental hygienists is to expand oral health care services to areas lacking dentists.

Most states that allow direct access require some type of agreement between a dentist and a dental hygienist. Such agreements typically allow dental hygienists to provide basic oral hygiene treatments without prior authorization by the dentist in predetermined, high-need settings and without direct supervision. In some states, such as Colorado, California, and New Mexico, dental hygienists may own their own practices. Requirements to perform in such capacities vary.

DIRECT ACCESS EXPANSION CONTINUES

According to Ann Lynch, director of education and professional advocacy for the ADHA, two more states have passed legislation this year, bringing the total number of direct access states to 42. The newcomers are Indiana and Wyoming. In Indiana, dental hygienists may now provide preventive services without prior examination or authorization of a dentist, and without the presence of a dentist. They may operate in any settings that are documented in a practice agreement with a dentist.¹

Wyoming now allows direct access to limited dental hygiene treatments performed by its public health dental hygienists in a broad range of facilities including federally funded health centers and clinics, nursing homes, free clinics, and public and private schools. They work under a collaboration agreement with a dentist, and may provide basic dental hygiene care, treatment, and patient education without prior authorization by a dentist.¹

The other direct access states are: Alaska, Arizona, Arkansas, Connecticut, Florida, Idaho, Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New York, Nevada, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, and West Virginia. Eight states do not yet permit direct access: Alabama, Delaware, Hawaii, Louisiana, Mississippi, New Jersey, North Carolina, and North Dakota. However, a few of these states have made some changes toward embracing direct access. Late last year, Alabama’s Board of Dental Examiners proposed to allow infiltration injection by permitted, licensed dental hygienists, following a national trend aimed at addressing access to care issues. Lynch notes that Alabama has become the 45th state to allow dental hygienists to administer local anesthesia.

HB 28 was introduced last year in the Delaware General Assembly. It would expand the number of settings in which a dental hygienist could practice under general rather than direct supervision. It would also update the definition of the practice of dental hygiene services. The bill was last reported to be in the House Administration Committee.

In 2017, Hawaii enacted HB 563, which stipulates that dental hygienists needn’t always practice under direct supervision. Instead, they may operate under general supervision in certain instances, after dentists have examined each patient, formulated a diagnosis, and authorized treatment.

In Louisiana, dental hygienists may provide services at public institutions under general supervision, although nitrous oxide or local anesthesia must be administrated under direct supervision. Dental hygienists may also offer services under general supervision if certain conditions are met. No bills designed to further expand dental hygienists’ scopes of practice, however, appear to be in the works at this time.

Mississippi floated two bills early this year, both of which died in committee. MS S 2899 and MS H 1330 would have provided for general supervision of licensed dental hygienists under certain conditions.

New Jersey requires dental hygienists to perform certain treatments under direct supervision, or merely under “supervision,” which involves a written order from the dentist.

Dental hygienists in North Carolina may render particular services without direct supervision if they have 3 years of experience and have fulfilled additional prerequisites.

North Dakota law stipulates that dental hygienists may provide services under direct, indirect, or general supervision. ND H 1256, which would have allowed dental therapy, was introduced last year to regulate both dental therapists and dental hygienists. It would have prohibited them from operating independently, though, under a written agreement with a dentist and authorization of a supervising dentist, a dental therapist would be allowed to provide, dispense, and administer analgesic, anti-inflammatories, and antibiotics. The bill failed in the House.

Dental hygienists have made great strides in their ability to apply silver diamine fluoride (SDF), a relatively new, low-cost, noninvasive, and effective liquid used to arrest caries lesions, especially in underserved populations. Today, most states and the District of Columbia allow dental hygienists to apply SDF. In some states, such as North Carolina and Kentucky, SDF can only be applied by dental hygienists under direct supervision. Due to the novelty of SDF, many states are working on updating their practice acts to address SDF and dental hygienists’ abilities to apply it under general supervision.

DENTAL THERAPISTS GAIN TRACTION

Often compared to nurse practitioners, dental therapists, depending on the state in which they practice, are typically allowed to perform both preventive and limited restorative procedures. Some states have passed legislation to enable these professionals to perform routine restorations in settings outside of the dental office. They are commonly hired by dentists and community clinics to expand oral health care services, usually practicing under a collaborative agreement.

In this regard, Arizona took a major step in May 2018, when Governor Doug Ducey signed HB 2235 into law. For Arizona’s licensed dental hygienists who have undertaken the recommended education and fulfilled a set of requirements, the passage of the bill means they are allowed to practice as dental therapists in underserved settings such as tribal lands, community health centers, and federally qualified health centers (FQHC).

According to Lynch, the law stipulates that dental therapy education must be accredited by the Commission on Dental Accreditation (CODA). “The scope of practice includes preventive and limited restorative procedures and is based primarily on those services identified in the CODA Standards for Dental Therapy Education Programs,” says Lynch. “In addition to completing the necessary dental therapy education, an applicant for licensure must also be a licensed dental hygienist. A last-minute agreement hammered out between proponents and opponents produced a bill that legislators could get behind.”

Lynch notes that some of the most significant changes made in this compromise agreement include:

• Allows dental therapists to work under direct supervision OR pursuant to a collaborative practice agreement after practicing 1,000 hours under direct supervision
• Limits dental therapists to practicing in FQHCs or FQHC look-alikes, community health centers, nonprofit dental practices that provide care to low-income and underserved populations, and private dental practices that provide care for community health center patients of record
• Requires that dental therapists perform nonsurgical extractions of permanent teeth only under direct supervision
• Reduces, from five to four, the number of dental therapists per supervising dentist.

Arizona joins Minnesota, Maine, Vermont, and tribal lands in Alaska, Oregon, and Washington in allowing dental therapists, or “dental health aide therapists” in the case of Alaska and Oregon, to provide midlevel dental care, which can include preventive and limited restorative services.

Michigan has also been making headway in allowing the practice of dental therapy within its borders. According to Pew Charitable Trusts, Michigan has an uneven distribution of dentists; there is at least one dental shortage area in 77 of its 83 counties.² Last fall, Michigan’s State Senate passed SB 541 by a 21 to 15 margin, which would allow a dental therapist to perform expanded practice under an agreement with a supervising dentist. It is hoped that the creation of this midlevel model will help bridge a fairly significant access-to-care gap in that state. The bill has moved on to the House and was last seen in the House Health Policy Committee.

According to Lynch, states that have introduced legislation to authorize dental therapists include Connecticut, Florida, Kansas, Maryland, Massachusetts, Michigan, Mississippi, Ohio, and Washington (to expand beyond Native communities). In the case of Massachusetts, the state’s dental society and the state legislature were at odds over a bill that would green light dental therapists until educational requirements were elevated. The legislation is awaiting further review and must pass the House and Senate before it can reach Governor Charlie Baker’s desk, who, it is predicted, would likely sign it to address his state’s oral health care access problems.⁴

MOVING FORWARD

Much of this expansion of scope of practice is fueled by tremendous need in underserved areas of this country. Though they are hired and generally supervised by dentists, expanded-practice dental hygienists and dental therapists may not only broaden access to oral health care in communities and settings that would otherwise go without, but they also expand the reach of dental practices, which is beneficial to practices’ bottom lines. And because dental therapists’ education is not as lengthy and expensive as dentists’ and their salaries are lower, they offer a practical way for dentists and clinics to accommodate patients covered by Medicaid.

While increasing numbers of dentists profess support for the expanded role of dental hygienists and dental therapists, many state and national dental associations are opposed. Some are lobbying against senate bills, expressing concern about proposed legislation that will allow dental therapists to perform irreversible, surgical procedures without a dentist present.³ Some of the proposed procedures that dental therapists would be allowed to perform include: suturing and suture removal, nonsurgical extractions, preparation and placement of crowns on primary teeth, administering local anesthesia and nitrous oxide, indirect pulp capping on primary teeth, and indirect and direct pulp capping on permanent teeth.

While two 2018 polls indicate that Minnesota offers the best oral health care of all 50 states,^4,5 (though it does drop to number 13 when it comes to children),⁶ some dental organizations assert that only nine out of all licensed dental therapists in Minnesota are practicing in rural underserved areas, noting that a federal warning was issued to Minnesota in May 2017 to improve dental care for children on Medicaid.⁷ Sheri Solseng Trif, RDH, ADT, of the Minnesota Dental Therapy Association, acknowledges the pressure to increase services to low-income children in her state to avoid losing federal funding. But, she notes that the problem is a little more complex than the claim that expanded roles in the form of dental therapists are not working.

“Minnesota has a low state reimbursement rate, which negatively affects access to dental care for children,” says Trif, adding that the pressure from federal government in regard to reimbursement may actually result in an increased reimbursement rate and, ultimately, improve access to care for the state’s children.

“Dental therapy focuses heavily on improving access to care for children, as 42% of those between the ages of 2 and 11 have experienced carious lesions in primary teeth,” notes Trif.⁸ She explains that dental therapists provide care in both urban and rural health care provider shortage areas, private practices, and community clinics, and that Minnesota law requires these practitioners to provide care in clinical practices in which 50% of the patients qualify as uninsured, underserved, and/or low income.⁹

A 2014 study on the early impacts of dental therapists in Minnesota conducted by the Minnesota Department of Health and the Minnesota Board of Dentistry found that dental therapists were: working in underserved settings; providing care mostly to patients on public insurance programs; administering quality care in a safe manner; positively impacting a clinic’s patient load; decreasing travel and wait times for patients; improving cost savings, dental team productivity, and patient satisfaction; lowering appointment fail rates; freeing up dentists’ time to dedicate to more complex procedures; increasing efficiency; and reducing unnecessary emergency department visits for noninjury dental conditions.¹⁰

CONCLUSION

In essence, despite the inevitable roadblocks along the way, it seems fairly certain that the momentum for expanded roles in the profession of dental hygiene is accelerating. Indeed, as Lynch points out, even the classification for dental hygienists under the Bureau of Labor Statistic’s Standard Occupational Classification (SOC) has been revised in 2018 in response, at least in part, to recommendations from the ADHA. Now the profession falls under the “Healthcare Diagnosing or Treating Practitioners” classification. Says Lynch, “Dental hygienists are in the same grouping as dentists. This contrasts with the 2010 SOC, in which dental hygienists were classified under ‘Health Technologists and Technicians.’”

As more states realize what they stand to gain by embracing new work models, more dental hygienists will be able to practice at the top of their license and the dental therapy movement will continue to grow—with the ultimate goal of improving the oral health of all Americans.

REFERENCES

1. American Dental Hygienists’ Association. Direct Access States. Available at: adha.org/resources-docs/7513_Direct_Access_to_Care_from_DH.pdf. Accessed September 18, 2018.
2. Pew Charitable Trusts. Michigan Senate Advances Dental Therapy Legislation. Available at: pewtrusts.org/en/research-and-analysis/articles/2017/11/01/michigan-senate-advances-dental-therapy-legislation. Accessed September 18, 2018.
3. Michigan Dental Association. Dental Therapist Toolkit. Available at: michigandental.org/Dental-Therapist-Toolkit. Accessed September 18, 2018.
4. Wallethub. 2018’s States With The Best And Worst Dental Health. Available at: wallethub.com/edu/states-with-best-worst-dental-health/31498/. Accessed September 18, 2018.
5. Toothbrush.org. Which States Have The Best Oral Health in 2018? Available at: toothbrush.org/2018-us-oral-health/. Accessed September 18, 2018.
6. Wallethub. 2018’s Best And Worst States For Children’s Health Care. Available at: wallethub.com/edu/best-states-for-child-health/34455/. Accessed September 18, 2018.
7. Howatt G. Feds warn Minnesota: improve kids’ dental care in Medicaid. Star Tribune. May 1, 2017.
8. National Institute of Dental and Craniofacial Research. Dental Caries (Tooth Decay). Available at: nidcr.nih.gov/research/data-statistics/dental-caries/children. Accessed September 18, 2018.
9. Hiring a Dental Therapist or Advanced Dental Therapist. Available at: mchoralhealth.org/mn/dental-therapy/practice-settings.html. Accessed September 18, 2018.
10. Minnesota Department of Health. Early Impacts of Dental Therapists in Minnesota. Available at: mn.gov/boards/assets/2014DentalTherapistReport_tcm21-45970.pdf. Accessed September 18, 2018.

 

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2018;5(10):16–20.