Dental Hygiene: New Perspectives, Unprecedented Solutions

The state of the dental hygiene profession is marked with vast changes, ranging from education to its role in providing solutions to America’s access-to-care dilemma. In an effort to identify and address these issues, in 2009, ADHA commissioned an environmental scan report entitled, “Dental Hygiene at the Crossroads of Change,” which looked at the future of oral health and future opportunities for dental hygienists.

In that report, the ADHA identified key drivers of change, which include new opportunities for dental hygienists in community centers and other locations, expanding access to oral healthcare, an aging workforce, and the scope of practice changes. “Interestingly, collaborative leadership—in which leaders engage people to work toward common goals that surpass their traditional roles, disciplines, past experience, and beliefs—was identified as a game-changing strategy for dental hygienists,” Bowers says. “Dental hygienists who can lead in nontraditional settings such as community health centers, retail clinics, and senior centers will be in high demand.”

Dental hygiene is one of the fastest growing healthcare professions in this country, with a 33% job growth rate expected by 2022, according to the US Bureau of Labor Statistics. The median pay for a dental hygienist is $70,210 per year, or $33.75 an hour. By 2016, the dental hygiene workforce will number more than 200,000.¹ However, government data note that the dental profession, in comparison, is growing more modestly and “suggests that the dental workforce will not be able to keep up with patient need,” Bowers says.

Bowers observes that although the outlook is positive for hygienists, the perception remains that dental hygienists are often underemployed or unemployed. “A 2012 survey of dental hygienists conducted by ADHA revealed a different picture of dental hygiene employment. Survey results showed that 71% of dental hygienists are currently working as many hours in dental hygiene as they would like and only 5% are not working and currently seeking a position that requires a dental hygiene license,” Bowers says.

The American Dental Association (ADA) calls the access-to-care issue “a disturbing dental divide in America.”² It reports that 48% of lower-income Americans have not seen a dentist in a year or more, compared with 30% of middle- and higher-income Americans. In addition, 20% of adults earning less than $30,000 have not seen a dentist in 5 years.² More than 49 million people live in dental health professional shortage areas, according to US Department of Health and Human Services.³ It estimates the country has approximately 4,800 dental health professional shortage areas, meaning these are locations with 5,000 or more people per dentist.⁴ The number of dentists is expected to decline from a peak of 60 per 100,000 in 1994 to 55 per 100,00 in 2020.⁵

Shifting demographics as the baby boomers age and societal demands in the American population are shaping the face of dentistry. As the demand for advanced practices areas for cosmetic and regenerative dentistry increases, dental hygienists should expect to see opportunities to deliver more basic services, which hygienists are trained to provide.⁶ The need for affordable oral care, particularly in underserved communities, continues.

An emerging trend nationwide is direct-access care. In states such as Colorado, it seems to be working. Take, for example, Senior Mobile Dental. In 2009, Michelle Vacha, RDH, BS, began the nonprofit to visit older, underprivileged patients in nursing homes. Colorado is one of 36 states allowing what is known as direct access for dental hygienists. The ADHA defines direct access to mean that a dental hygienist can initiate treatment based on his or her 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. In Colorado, hygienists are allowed to deliver most hygiene services without being under the supervision or authority of a dentist and they may own a dental hygiene practice.

“Our profession is a main artery in addressing this access-to-care issue,” Vacha says. “These people have been underserved for many years due to the lack of the dentist interest or availabilities in serving them. If the hygiene profession is capable of initiating care for the underserved population, care that has not been provided, then why prohibit us from doing it? The focus should be on providing needed care, not control of qualified professionals.”

Vacha observes that the dental hygiene profession has made great strides in addressing the access-to-care issues and is continuing to make improvements. Some states have expanded the functions of dental hygienists to allow them to provide certain basic functions, such as prophylaxis, without the supervision of a dentist. But she notes one caveat for the profession. “Self-regulation is the key as proven by the success of the nursing profession, and until we can achieve this, the public will always be faced with the barriers of access to care,” she says. “Self-regulation will also help us standardize the education criteria. Dental hygiene is more than just the mechanics of cleaning teeth, and we need to represent dental hygiene as educated, articulate professionals, as well as master clinicians.”

Dental hygienists’ scope of practice is typically determined by states, which may mandate that hygienists perform their work under the supervision of a dentist. Most hygienists work in dental offices, typically part-time. State laws vary widely, regarding the level of supervision of common tasks, which include prophylaxis, taking x-rays, and applying sealants or fluoride.

“Dental hygienists are uniquely positioned to transform the oral health delivery system and shape the future of the profession by practicing in health professional shortage areas, which range from isolated rural communities to densely populated low-income urban areas, where access to care is decidedly lacking,” says Bowers.

A 2014 report on expanding the provision of affordable preventive services outside dentists’ offices from the National Governors Association noted that states have looked into altering supervision or reimbursement rules, as well as creating professional certifications for advanced-practice dental hygienists. To date, studies of pilot programs have shown safe and effective outcomes.⁷

“Innovative state programs are showing that increased use of dental hygienists can promote access to oral healthcare, particularly for underserved populations, including children,” conclude the authors of the report. “Such access can reduce the incidence of serious tooth decay and other dental disease in vulnerable populations, which suffer disproportionally from untreated dental problems.”

“Unfortunately, many states continue to harbor antiquated regulations and institutional resistance that prevent the public from directly accessing dental hygienists,” Bowers says. “Direct-access policies allow for new entry points into the oral healthcare system—patients can access care in a wider variety of settings like schools, clinics, and hospitals. Offering additional entry points will provide the public with more options to access preventive care and serve as an entrance point into the healthcare delivery system.”

Carol A. Jahn, RDH, MS, senior professional relations manager for Water Pik Inc., agrees. “Growth in dental hygiene jobs is likely to come from direct-access opportunities, not private practice. The majority of dental hygienists will still work in private practice, and the majority of dental services will still be delivered in a dental office,” she says. “However, lack of access to dental services is an issue that is now recognized by our legislators and the public. No one strategy will be able to solve this complex problem or ensure that every child will have a prophylaxis, fluoride treatment, and dental sealants. But dental hygienists do deliver those services, and those services are crucial in helping a child have good oral health for life.”

As more states allow direct access, continuing-education offerings will reflect those changing needs. “Direct access may also involve collaborative agreements between dentists and hygienists,” Jahn says. “This is a wide-open area for continuing education. It can help alleviate the fears and concerns that some dental professionals have about this. We are certainly used to courses on practice management. As more opportunities for direct access grow, the new practice management course is sure to be ‘how to design and carry out collaborative agreements.’”

In recent years, the creation of dental therapists have stirred debate among the dental community as to whether they might help address access-to-care issues or make it more difficult for other dental professionals to compete in the marketplace. Dental therapists are practicing in 50 countries and have been practicing for decades in Canada, New Zealand, Australia, and Great Britain.⁸

In 2009, Minnesota lawmakers were the first to approve licensing of this professional in the United States. The Pew Center on the States published a case study in 2014 of a clinic in Montevideo, Minnesota, and found that employing a dental therapist resulted in a 38% increase in the number of new patients, particularly those on Medicaid, and a $24,000 rise in profits.⁹ These professionals are licensed to perform cavity filling and tooth extraction.

Bowers reports that as of February 2014, Minnesota had 32 licensed dental therapists, with six certified as advanced dental therapists (ADTs). The six ADTs maintain two licenses as registered dental hygienists and ADTs.

“This midlevel provider is quite agile and able to flow freely back and forth delivering the services of the dental hygienist and the advanced dental therapist, based upon the needs of the patient. Scheduling changes are readily accommodated and the provider can adjust workload and assignments as needed,” Bowers says.

Children’s Dental Services in Minneapolis reports that it is able to continue offering its same level of services to its patients because they have been able to hire dental therapists instead of dentists. The nonprofit pays a dental therapist approximately $45 per hour, compared with an average of $75 per hour for a dentist.¹⁰ The median hourly wage for a dental hygienist in Minnesota is $36 an hour.

“Just as we have seen the growth of midlevel providers like nurse practitioners, we will see growth in midlevel providers in dental hygiene. The demand for oral care will increase in the future,” says Rebecca S. Wilder, RDH, MS, professor and director of faculty development for the University of North Carolina at Chapel Hill School of Dentistry and director of the Master of Science Degree Program in Dental Hygiene Education. “We all know that access to care is a growing issue, so it makes sense for dental hygienists to perform advanced functions and provide advanced preventive care if educated appropriately. Even if we see a growth in midlevel providers, I do not see it impacting the amount of care that will be needed by dentists.”

The ADHA sees this as a positive change; however, the ADA expresses reservations, specifically in regard to allowing non-dentists to perform surgical procedures. In a 2012 press release, the ADA called into question the findings of another Pew Report on the topic of midlevel providers, stating that: “Dental therapist models would take large financial commitments while returning questionable results.”¹¹ A 2013 ADA scientific literature review found no evidence of disease prevention or cost-effectiveness associated with midlevel providers.¹²

Bowers says, “Dental hygienists are educated, licensed providers in every state. Utilizing the dental hygiene workforce in a manner that allows them to work up to the level that they are educated will further open the doors of access.”

Dental hygiene education will continue to build as marketplace demand builds in the coming years. “Many changes are happening to dental hygiene education,” Wilder says. “On one level, we are seeing more programs opening at the associate degree community college level.” Wilder says in most states, the number of associate-degree programs is ample to graduate hygienists for traditional practice. However, with changing practice patterns and expansion of oral care services, dental hygienists with advanced degrees (ie, bachelor’s, master’s, and doctoral) will be needed.

She notes that the country has more than 335 dental-hygiene education programs with 55 available for dental hygienists to complete their baccalaureate degrees. In addition, the United States has 22 master’s of science degree programs in dental hygiene or master’s degrees in related disciplines, which prepare dental hygienists for advanced roles in teaching, research, business management, public health, and other fields, she observes, adding that she hopes a doctoral program in dental hygiene is coming. A more competitive world places demands on dental hygienists to evolve and hygienists are up to the task.

“Dental hygienists of the future need to be prepared for all aspects of oral care, including working with professionals from other disciplines,” Wilder says. “Already, we are seeing collaboration between dentistry and dental hygiene with nursing, pharmacy, physicians, etc. Dental hygiene educators of the future will need to have advanced knowledge in oral care and also exceptional communication skills and the ability to collaborate with all healthcare professionals. These skills will be needed to prepare future dental hygienists for expanded roles in healthcare.”

“Not unlike other professions, dental hygienists are concerned about being gainfully employed,” Bowers says. “The misconceptions surrounding the dental hygiene profession plague our members. The outdated public perception of dental hygienists as ‘teeth cleaners’ may limit our recognition as essential primary healthcare providers. Similarly, articles that list dental hygiene as a ‘low education/high pay’ job drastically oversimplify the requisite training and rigors of the profession.”

Vacha notes, “As more attention is drawn to the need for overall healthcare, and the important role oral healthcare plays in this, our dental hygiene profession is instrumental in addressing the oral–systemic relationship. We are in a great position as we are able to step away from direct supervision to have the capacity to work within medical healthcare settings and be able to bring medical and dental care together.”

The American Dental Association has identified key barriers in access to care.

• Funding from government programs: Although the dental sections in Medicaid and the State Children’s Health Insurance Programs were designed to provide healthcare to disadvantaged Americans, funds have not always been available. Many states do not provide dental care to underprivileged adults. Not all dental providers accept federally funded insurance plans, providing another barrier.

• Physical barriers to care: Patients on low budgets may have issues getting transportation to dental appointments and may not be able to afford to miss work.

• Health literacy: Too many Americans lack a basic understanding of how to brush, floss, eat a healthy diet, and drink water with fluoride in it.

• Water fluoridation: Despite the fact that for 65 years water fluoridation has been proven to be a safe and effective way to protect against tooth decay, one third of public water systems are not fluoridated.

Source: Oral Health Topics: Access to Dental Care/Oral Health Care. https://www.ada.org/2574.aspx. Accessed July 11, 2014.

The ADHA continues to create and update policy regarding the creation and development of advanced dental hygiene practice. Policies defining advanced dental hygiene practice were established at the 2013 House of Delegates during ADHA’s 90th Annual Session.

The ADHA defines advanced practice dental hygiene as:

• Provision of clinical and diagnostic services in addition to those services permitted to an entry-level dental hygienist, including services that require advanced clinical decision-making, judgment, and problem solving.

• Completion of a clinical and academic educational program beyond the first professional degree required for entry-level licensure, which qualifies the dental hygienist to provide advanced-practice services and includes preparation to practice in direct-access settings and collaborative relationships.

• Documentation of proficiency such as professional certification.