The fight for independence

Collaborative Practice Dental Hygienist. Registered Dental Hygienist in Alternative Practice. Expanded Practice Dental Hygienist. Regardless of which title applies, they are in reference to a hygienist who initiates treatment based on their assessment of a patient’s needs without the specific authorization of a dentist, who treats the patient without the presence of a dentist, and who maintains a provider-patient relationship is considered independent and providing direct access to care.¹

As of June 2017, 40 states authorize direct access to hygienists, up from 28 states in 2008.² This drastic increase is the direct result of clinicians, associations, and their allies tirelessly advocating for the advancement of the dental hygiene profession.

Of the states that allow for a variation of direct hygiene services, there are no two states that are identical in title or definition. For example, independent hygienists in Colorado are unique as they practice without restrictions and can even own a dental business. In other states, a written agreement with a collaborating dentist allows hygienists to provide direct care in alternative practice settings. In one state, hygienists are permitted to provide direct access for only five days each year. In less progressive states, hygienists are mandated to practice only with the onsite supervision of a dentist.

The struggle for independent hygiene practice will continue to be a long, hard road with many uphill battles. Is independent dental hygiene practice worth this fight?

This inconsistency in hygiene models not only creates confusion among dental professionals and the public, but also challenges the hygienists’ rightful authority as a primary care provider.

A report by U.S. Department of Health and Human Services predicts a shortage of dentists and surplus of hygienists by 2025, and suggests that “changes in oral health delivery and in health systems may somewhat ameliorate dentist shortages by maximizing the productivity of the existing dental health workforce.”⁶ To expand our large existing dental hygiene workforce to offset the impending shortage, we must advocate together for necessary regulatory changes at the individual state level:

• The elimination of supervision requirements

• Direct reimbursement by third-party payers

• The authority to prescribe medicaments

• The legal recognition of a dental hygiene diagnosis.

• To track what legislative changes are currently proposed in each state, visit ADHA.org.^3,5

The views of professionals

To gauge current attitudes regarding independent hygiene practice, I surveyed a sample of professionals on a popular dental social media site that has over 20,000 members. Two days and 500 comments later, it became apparent that the thought of hygienists practicing independently is a very emotional topic.

The majority of those who commented identified themselves as dentists, and their comments ranged from one-sentence thoughts to full statements ranging from passionate quips to formal discussion. The overwhelming number of those commenting quickly opposed even the suggestion of independent practice by questioning economic viability, citing public safety concerns, arguing that the in-office hygiene department is the sole source of patients for dentists, and highlighting fears about potential competition for patients. Dentists who supported independent hygiene practice suggested that it may initiate a new dental model fostering improved oral health literacy and patient-provider relationships.

Many hygienists unanimously agreed it would increase access to care and health equity throughout communities and even provide further options for patients in private practice. After voicing concerns of being “overworked and underpaid,” hygienists felt that independent practice will create additional career opportunities.

Surprisingly, many commenters were not aware that independent and direct access to hygiene services already exists in 40 states, not to mention the confusion that arises due to state-to-state variations.

If the emotional reaction unearthed by this unscientific poll is at all indicative of popular thought, then the struggle for independent hygiene practice will continue to be a long, hard road with many uphill battles. Is independent dental hygiene practice worth this fight?

Minnesota’s case study

In my own practice, I have been fortunate to provide clinical dental hygiene care in multiple states—both with progressive and restrictive regulations. After spending my early years in a state requiring onsite dentist supervision, I longed for the freedom to provide quality care where and when patients need it most.

At the time, Minnesota was just launching the first dental therapist program and I decided to pursue dental therapy out of a desire for the freedom to practice independently and expand care. I arrived in Minnesota as the first wave of dental therapists were integrating themselves into the landscape of clinical practice. I soon realized that I did not want to expand my scope of practice to become a dental therapist; instead, I simply wanted the autonomy to provide unrestricted direct hygiene services to patients who need it. I came on the scene at the pivotal time when hygienists and other stakeholders were fighting persistently against the restrictive state regulations hampering those very hygienists who practiced direct patient care in alternative settings.

Minnesota hygienists finally moved one giant step closer to independence in 2017 when legislative changes announced a new direct access model called Collaborative Dental Hygiene Practice. This new model expands services by sanctioning the full scope of hygiene practice, permitting licensed dental assistants to work under hygienist supervision, and freeing individual hygienists from minimum clinical hour requirements prior to obtaining a collaborative agreement.⁴ Although collaborative hygienists still practice under general supervision and require a written agreement with a dentist, a simple regulatory change to existing legislation has drastically increased the number of available hygienists providing independent and direct services in alternative practice settings.

How does Minnesota’s direct access hygienist function in the real world? Consider my role as a collaborative hygienist for Operation Grace MN, a mobile dental organization providing free care to underserved students in both rural and urban high schools. This nonprofit charity uses volunteer dental professionals to operate clinics and had its program previously limited by the unpredictable availability of volunteer dentists.

With the introduction of the 2017 regulatory changes, Operation Grace MN has now launched a new program in which teams of hygienists and dental therapists, practicing with collaborative agreements, utilizing teledentistry services and providing direct patient care. Employing industry advances such as silver diamine fluoride, intraoral cameras, and HIPAA-compliant live video streaming software, these teams now offer a wide-range of care whether or not a dentist is available to volunteer.

Minnesota’s subtle legislative change has the potential to drastically transform Operation Grace’s outreach to the communities that need their services the most.

Is the fight for independence worth fighting?

Absolutely. In the case of just one Minnesota dental organization, even the seemingly small victories of subtle regulatory changes are having an unprecedented impact and are allowing dental hygienists to reach the communities who face the most barriers to care. With a predicted shortage of dentists and surplus of hygienists by 2025, it has never been more necessary to continue advocating together for your state to move one step closer to independent hygiene practice. Will you join me?