The Professional Practice Environment of Dental Hygienists in the Fifty States and the District of Columbia, 2001

April 2004

Chapter 5. Fieldwork

This chapter summarizes the findings of the fieldwork component of the study. It includes the following subsections:

• Introduction
• Discussion

Additional details about the fieldwork can be found in Appendix D.

• The tasks that are permitted to hygienists in State legislation and regulation;
• The level of supervision by dentists required for the tasks that are permitted;
• The settings in which dental hygienists are permitted to provide preventive and prophylactic oral health services;
• The required relationship between the dentist and the patient and the dentist and the hygienist;
• The ability of the hygienist to be paid for the services provided.

Access to preventive oral health care is also affected by several characteristics of patients or of the environment:

• The geographic location of the patient;
• The ability of the patient to pay for oral health services;
• The availability of insurance coverage for oral health services;
• The physical ability of the patient to access oral health services in private dental practice;
• An adequate understanding or knowledge of the importance of oral health preventive services to general oral and medical health.

Barriers to Access

Supervision requirements in statute and regulation are perceived to create barriers to access to preventive oral health services. Hygienists comment that supervision requirements in many States are a primary impediment to provision of preventive and prophylactic oral health services to populations without traditional access. Most States require supervision by dentists at some level depending on the task, the setting, and the patient being served. In some States, fundamental hygiene services require the direct supervision of the hygienist by the dentist. This level of supervision frequently requires that the dentist see the patient either before or immediately after services are performed. In some States, there is also a prerequisite for the dentist to establish a relationship with the patient (patient of record) and to prescribe the preventive or prophylactic services performed by the hygienist. Direct supervision also limits the hygienist to providing preventive and prophylactic services to periods when a dentist is physically present in the facility where services are performed. Such conditions for practice are perceived to be unnecessarily restrictive to appropriate preventive oral health care when certain hygiene services are provided.

Hygienists understand that supervision requirements are established to protect patient safety. However, direct supervision for basic preventive and prophylactic services is perceived to be overly zealous. Hygienists are concerned that they are not always viewed as a clinical profession even though they are regulated and licensed like other medical and dental professionals. Hygienists emphasize that they have a strong clinical education and substantial clinical training in hygiene assessment and in prophylaxis. Some autonomy in professional practice should be provided considering the required education and certification process. Compelling dental oversight of every hygiene service is probably unnecessary especially since there is little significant inherent danger in most of the services provided.

In fact, hygienists seem confounded by supervision requirements in many States that permit less direct oversight by dentists in alternative settings where patients with limited access might be treated by hygienists. Patients in these alternative settings are often permitted to receive hygiene services under general supervision while patients in private dental offices in the same State may only receive services under direct supervision. Patients who present for care in settings like nursing homes, public health clinics, and community settings are often more compromised medically than those who are capable of paying for private dental services and of accessing care in private settings. Hygienists comment that if patient safety were really the issue driving legislation of levels of supervision, these conditions for practice would not be permitted.

Hygienists comment that the paradigm in which oral health services are provided is a fundamental barrier to access. The structural characteristics of dental practice obstruct care provided in non-traditional settings. There are several features that contribute to decreased access to oral health services:

• Most dentists practice in solo or small group private practice with only a few practicing in public health settings. This limits access to oral health services to only those patients who have dental insurance or who are capable of paying for dental or hygiene services.
• More than three times as many patients are dentally uninsured as are medically uninsured. Additionally, there is no subsidy in dental insurance to help defray the costs of providing care to the uninsured as happens with medical insurance.
• Most State laws require that a dentist examine the patient either prior to or subsequent to the provision of preventive services, limiting hygienists to settings where dentists are available or requiring an established relationship between dentists and hygienists and dentists and patients.
• Oral health services are provided in a hierarchical model of care in which the dentist directs and supervises both the patient and the hygienist. The dentist is the vehicle through which patients access hygienists and hygienists access patients. Hygienists encourage viewing the provision of oral health care on a continuum with prevention and prophylaxis at one end and restorative and surgical care at the other end. Hygienists suggest that a more appropriate model for the distribution of oral health resources would permit reduced utilization of dentist resources for prevention education and services. Dental resources are better allocated to provision of restorative services to more patients.
• Hygienists are not generally permitted initial interface with patients exclusive of a dentist. States may require that patients be seen first by the dentist before the hygienist can provide any education, assessment or prophylactic services. Unlike nurses who are often the first professional encounter for patients seeking medical services, hygienists are dependent on a dentist for diagnosis and determination of the need for hygiene services.
• Oral health services are primarily accessed in private dental offices. This is unlike medical services that are accessed at multiple entry points in addition to physicians’ private practices. Oral health services should be more available in alternative settings where patients in need of care might access both dentists and hygienists.
• The equipment needed to provide oral health services is more extensive than that needed for basic medical care. Although it is possible to provide oral health services in alternate settings, the equipment required creates an additional barrier to provision of oral health services. Mobile dental vans or dedicated dental suites in alternative settings such as nursing homes address this concern. Portable dental equipment is also available that permits the provision of basic services in homes, schools, and in other public settings.
• The importance of preventive oral health care is not always understood despite the significant ramifications to general health of poor oral health status. Poor oral health significantly impacts attendance at school and work. Additionally, certain systemic diseases manifest in oral symptoms. Oral disease can often be easily prevented or treated if oral health professionals are actively involved. The public needs more education about the importance of oral health and especially about regular preventive oral health care.

Hygienists were clear that there are State initiatives and many private/public collaborations that are increasing access to oral health services. Many States have convened oral health task forces or commissioned studies of oral health status within the State. There are many volunteer initiatives in which dentists and hygienists engage that contribute to increasing access. Of particular concern to hygienists are the very young and the very old who do not receive regular oral health care because of access issues. Dentists do not usually see infants and toddlers. School age children are particularly vulnerable to decay. Much preventable disease occurs in that age cohort. Older people are often limited by mobility issues and by the settings in which they live. Hygienists suggest that there are many opportunities to interface with these populations in alternative settings. However, even when hygienists are willing to work in these settings there are impediments to care in the form of supervision requirements, limitations on tasks that are permitted (specifically, services like sealants, fluorides, assessment, and referral), and the inability to be paid directly for the services provided.

Hygienists suggest that a differentiated model of practice for the profession would contribute to access for compromised populations. The nursing model was cited as an example. Licensed vocational nurses, registered nurses and advanced practice nurses provide services within different scopes of practice under varying levels of delegation and supervision depending on their educational and clinical preparation, certification, and licensure. Implementation of a similar professional model would provide additional opportunities for hygienists and would contribute to access. Several States already provide for extended functions or advance practice for hygienists in their statutes and/or regulations. (See Appendix C for details).

Hygienists express concern that their profession is singular among clinical professions in that another clinical profession regulates it. A fundamental goal for the profession is self-regulation through independent Boards of Dental Hygiene or Dental Hygiene Committees with powers of determination for the profession. It is incumbent for the profession to have some control over scope of practice, requirements for supervision, establishing educational standards, and licensing requirements. Self-regulation would permit more standardization of practice across States as well as provide a measure of security and control for the profession.

Several changes in practice conditions for hygienists would further encourage practice that would meet the needs of the underserved:

• Levels of supervision required for hygienists in States should be evaluated in light of not only patient safety issues but also with a focus on goals for reasonable patient access to preventive oral health services.
• Self-regulation through Dental Hygiene Boards or Committees within States would permit hygienists to have some needed professional control while still ensuring the quality of preventive and prophylactic services provided to patients.
• Expanded functions and advanced practice options for hygienists would provide new opportunities for interested professionals to interface with a variety of patient populations and to increase access to services.
• Legislated direct reimbursement for preventive and prophylactic services to hygienists from both public payers and private insurers would further enable access to care.
• Supporting creative programs that offer oral health services in other than the traditional settings should be encouraged. It is possible to provide safe, effective services outside the traditional paradigm for oral health care. More varied points of entry to the oral health care system must be available.
• Public initiatives, private/public collaborations, and volunteer efforts to provide oral health services are important contributors to increased access for a variety of populations who might not otherwise receive prophylactic oral health services. These activities should be encouraged at the community, State, and National levels.
• Finally, increasing public awareness of the importance of preventive oral health services will be critical to any initiatives to increase access to services. The public must acquire a fundamental understanding of oral health and its impact on overall health and be educated to the need to seek regular preventive oral health services. Once that is achieved it will be the responsibility of the system to provide the opportunities for access to support the care to be provided.