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

April 2004

Appendix C. Detailed DHPPI Calculations

Of primary interest to this study is the question of the effects of the legal scope of practice for dental hygienists on access to care for underserved populations. Traditionally, these oral health professionals have provided services through gatekeeper dentists who supervise hygienists and manage provision of care to the patient.  The roles of dentists in the management of oral health care are described in the dental practice acts and the dental hygiene acts that govern the licensure and the practice of oral health professions.  The statutes in each State are augmented by the regulations promulgated by Boards of Dentistry and Boards of Dental Examiners who regulate the services which may be provided, the locations in which practice may occur, and the circumstances (including supervision requirements and patient affiliation with the dentist) under which care may be provided.

Of interest is the direct effect of legislative and regulatory controls on access to oral health care by populations with marginal or no access to regular dental services. As discussed in this report, the statistical index of scope of practice for dental hygienists was created to provide a numeric indicator to be used in analysis of this question. Initially, it was hoped that a statistical index for the profession could be developed for the year 1992 as well as for the year 2001. Composing an index that accurately reflected the legal conditions of practice for dental hygienists in 1992 proved to be beyond the scope of this study. Statutes are dynamic documents that change incrementally over time and ascertaining the prevailing legal conditions for hygienists in 1992 would require significant expert legal research. In the absence of comprehensive historical documents to inform the creation of an index for 1992, researchers examined available sources to support the investigation into changes over the decade in supervision requirements, tasks allowed to the hygienist, and permission to provide services in a variety of non-traditional settings.  This chapter will detail the findings from this investigation. Each of the areas examined in the index are addressed below. Although this overview of practice across the decade is not as comprehensive as the detailed index for 2001, the thrust of changes that have occurred is clearly evident. In fact, this overview further supports researchers conclusion that change for the profession has been slow. Change has occurred in increments with more change in the later years of the decade than in the earlier ones.

There have been many ongoing legislative initiatives in more recent years (the later years of the 90s and the first years of the new century) that address supervision, settings, and tasks.

In an effort to understand how scope of practice has changed over the decade, researchers examined historical documents published by constituent organizations including the American Dental Hygienists’ Association and the American Dental Association. These documents provide a picture of changing conditions and permit several observations about the quality and quantity of change that has occurred over the decade.

• In South Carolina, the board holds an election from all licensed hygienists in the State to nominate a candidate for appointment by the Governor.^[70]
• In Oklahoma, the dental hygienist board member is elected directly by licensed dental hygienists in the State.^[71]
•  In Illinois, all members of the board are appointed by the Director of the Board of Dentistry from recommendations received from a variety of professional organizations.^[72]
• In some States, the hygienist member(s) enjoy full voting privileges. In others, hygienist member(s) are limited in their powers. In Georgia, “the dental hygienist member of the board may vote only on matters relating to dental hygiene, administration, and policy which do not directly relate to practical or scientific examination of dentists for licensing in this State.”^[73]

In all States, hygiene representation is small when compared to the numbers of dentists on the board with voting privileges. Existing dentist to hygienist ratios on dental boards across States make the hygiene vote somewhat ineffectual in influencing policy since permitted representation by hygienists on boards is universally small. Board structure is somewhat problematic since statutory change would usually be required to alter representation on professional boards. Some State legislatures have provided automatic remedies to this problem by legislating dates for sunset review of one or another professional boards. At review, the effectiveness of the board is evaluated and structure is often reconsidered. The recent legislative mandate for the creation of a dental hygiene board in California is an example of the outcomes of a sunset review process. California reviewers determined that the board structure was ineffectual and that remediation in the form of an independent hygiene board would better serve the profession and the public.

Legislative Statute and Board Regulation

In all fifty States, the profession is governed within State law and regulation. By 1951, hygienists were licensed as a profession in every State.^[74] The profession enjoys universal title protection across all States. The title conferred by passage of the certifying exams is “registered dental hygienist” (RDH). 

In most States, the statute addressing professional practice by dental hygienists is the Dental Practice Act. Often, the mechanism used to enable practice is a joint article within a statute that addresses practice by dentists, dental hygienists, dental assistants, or other auxiliaries and occasionally, dental laboratories and/or denturists. A few examples of the diversity of statutory and regulatory configuration elucidate the different ways in which States enable practice.

• New Mexico addresses practice by oral health professionals in a Dental Health Care Act that contains a mixture of separate as well as combined sections on dentistry, dental assistants, and dental hygienists.^[75] 
• Utah has promulgated a Dentist and Dental Hygienist Practice Act.^[76] The statute creates a Dentist and Dental Hygienist Licensing Board rather than a Dental Board.
• Oregon addresses dental hygiene in a separate chapter from dentists but includes the profession of denturist in the same chapter with hygienists.^[77]
• Colorado law has a typical configuration with its statutes addressing professions and occupations in health care containing a separate combined chapter addressing dentists and dental hygienists.^[78]

In a few States, the legislature addresses practice by dental hygienists separate from dentistry in a section of business and professions code:

• Practice in North Carolina is enabled in a Dental Hygiene Act that is a distinct article in the statute.^[79] 
• This is also true in Washington where the profession is enabled in a separate chapter of the Business and Professions Statute.^[80]
• In Delaware dental hygiene is addressed separately in a subchapter of the chapter on dentistry and dental hygiene.^[81]

Statutes vary considerably in the amount of detail contained within them addressing the dental hygiene profession. Some legislatures have passed very definitive and detailed law about the profession while others pass broader legislation that simply enables boards of dentistry to regulate the details of professional practice by hygienists.

California is an example of a State with elaborate statutes^[82] and detailed regulation for practice by dental auxiliaries including dental hygienists.^[83]  The State has legislated a number of different categories of dental auxiliaries including registered dental hygienist, registered dental hygienist in alternative practice, registered dental hygienist in extended functions, registered dental assistant, and registered dental assistant in extended functions.^[84] The conditions required to practice in each of these categories are highly detailed in both code and rule with each category of auxiliary addressed separately under several different topics such as scope of practice and extended functions.

Mississippi  is a State that addresses practice by dentists in lengthy code and regulation with practice by dental hygienists only incidentally addressed within those laws and rules.^[85] Dental hygienists practice under direct supervision of dentists in the State, which requires the direct involvement and direction of the dentist in hygiene practice. An exception is made for hygienists providing oral hygiene instruction and screening in a public school or for the State Board of Health. Hygienists may provide those services in certain settings under general supervision in Mississippi.^[86]  However, these conditions are clearly exceptions to the general rule. Both statute and regulation in the State provide only minimal but definitive guidelines for practice by hygienists in dental offices under dental direction. There is, conversely, expansive detail in both rule and law about practice by dentists in the State.

The level of supervision required for hygienists to work within their scope of practice is a critical element in provision of services. The legislative or regulatory requirements of supervision affect:

The settings in which services are delivered;
The circumstances under which services are provided (i.e. that is in the presence or absence of a dentist);
The kinds of services that can be offered;
And the patients to whom services are supplied.

Variation in supervisory level by settings, variation in supervisory level by task, and variation in supervisory level determined by the health of the patient are all conditions that create a matrix for practice by dental hygienists in some States that is difficult to understand. Particular rules may restrict supervision in a setting while other rules may restrict the actual tasks performed under certain levels of supervision. Understanding this variation is important because practice becomes increasingly convoluted when many detailed legal conditions apply.

The following examples of the significant variation in supervision of dental hygienists required by States elucidate some of the complexities that arise from legislated supervision requirements.

• In Oklahoma a defined list of hygiene services may be provided under direct, indirect or general supervision at the discretion of the supervising dentist.^[87]  This creates individual variation within practice environments for practicing hygienists. A hygienist may practice in one dental office under direct supervision and provide the same service in another office under general supervision.
• In South Carolina, a dental hygienist works under general supervision in hospitals, nursing homes, long term care facilities, rural and community clinics, health facilities operated by the Federal, State, county, or local governments, hospices, education institutions, and in charitable institutions and may provide oral prophylaxis, or apply sealants and fluorides. In school settings, a hygienist may apply fluoride and/or sealants and perform oral prophylaxis with the permission of a parent or guardian under general supervision.^[88] The statute specifically states however that general supervision is not applicable to hygiene practice in a dental office. Prophylaxis, sealants, etc. performed in office settings must be provided under direct supervision.^[89]
• In Pennsylvania, the level of supervision is determined by the service being provided and by the “class” of the patient to whom services are being rendered. The American Society of Anesthesiologists (ASA) created the classification detailed in Pennsylvania Code. For instance, an ASA Class 1 patient is one without systemic disease while an ASA Class V patient is “moribund” and “not expected to survive 24 hours with or without operation.”^[90] Dental hygiene regulations in Pennsylvania stipulate which tasks may be performed on which class of patient under what kind of supervision in particular practice sites.^[91] Such rules create complexity for providers and for patients in determining what services can be provided under what conditions. The potential for variation in practice is high since so many factors determine the circumstances for provision of care.

Interestingly, access to care legislation also contributes to variation within individual States. Several States have enacted laws that enable more expanded practice by hygienists in a variety of public health settings or with special populations.  Connecticut, Missouri, and Oregon are examples of States that have expanded scope of practice legislation for hygienists to enable provision of care to patients with limited or no routine access to oral health care. Even this necessary variation contributes to some confusion in practice circumstances. For instance, in Missouri, a child on Medicaid may receive sealants from an unsupervised dental hygienist in a school setting while another child, whose dental care is funded privately and who is a student in the same school, may only receive sealants from that same hygienist under the direct supervision of a dentist. If a child with Medicaid were in a mental health facility in the State, an unsupervised hygienist could provide prophylaxis to that child while the same service could not be offered to an older patient with Medicaid in the same facility.

Restrictive supervision requirements deter hygienists from practice in alternative settings with underserved patients. In some States, such as Arkansas, restrictions are so explicit that hygienists are confined for most services to direct supervision in a dental office.^[92] This directive significantly diminishes the possibilities for access to preventive oral health care for populations without access to private dental care.  In other States such as Washington, a dental hygienist with clinical experience could effectively practice unsupervised within the scope of traditional duties working in a range of settings with a variety of populations needing oral health services.^[93] This spectrum of supervision for hygiene tasks is obvious within the scoring index that has been created as part of this study demonstrating that variation in practice circumstances is more the rule than the exception across States.  Specific regulation of so many aspects of dental hygiene practice complicates provision of care for hygienists and for their supervising dentists.  It also affects access to care for patients.

The level of legislated supervision is the critical factor in determining if a particular service can be provided by a hygienist without the immediate involvement of a dentist. If direct supervision is required in all settings at all times, as is true in the State of West Virginia, services can be provided only when a dentist is present and has authorized the procedure. Under such circumstances, hygienists can provide services only in locations where dentists choose to practice and only when they are physically present.

The level of required supervision is an area where legislated change within individual States might enhance the opportunities for provision of oral health preventive services by hygienists. If services can be supplied in the absence of dentists, especially to populations with compromised access, then prophylactic and preventive services can be made more immediately available. For purposes of understanding the varying levels of supervision, the following elaboration will help in understanding dental hygiene legislation.

Supervision is defined across States as personal, direct, indirect, general, or unsupervised. In each State, level of supervision is defined in statute or rule as intended by the legislating entity. Although there are differences in how a particular level of supervision is applied across States, there are some common features that permit comparison.

• Personal supervision implies the immediate presence and active participation of the dentist in the procedure or services being provided to the patient. Generally, this level of supervision applies when a dentist is the primary provider of a service and the hygienist is assisting. (“Personal supervision is a level of supervision indicating that the dentist or dental hygienist is personally treating a patient and authorizes the dental hygienist…to aid his treatment by concurrently performing a supportive procedure.”^[94]) In Michigan, the hygienist is actually called a “second pair of hands” when providing services under these circumstances.^[95]
• Direct supervision usually indicates that the dentist has prescribed and/or authorized the services being provided to the patient while the dentist is physically present in the office. In some States, this level of supervision requires that the dentist examine the patient after the hygienist has completed the service and prior to the patient’s departure. (“Direct supervision shall mean that the dentist must be in the dental office at the time the duties under his/her supervision are being performed. In order to provide direct supervision of patient treatment, the dentist must at least diagnose the condition to be treated, authorize the treatment procedure prior to implementation, and examine the condition after treatment and prior to the patient’s discharge.”^[96])
• Indirect supervision suggests that the dentist has authorized the work to be performed by the hygienist at some time in his interface with the patient (either immediately or at some prior point) and that the dentist is physically present and readily available to the hygienist. (“Indirect supervision is a level of supervision in which the dentist has authorized the procedure for a patient of record and remains in the treatment facility while the procedure is performed.”^[97])
• General supervision often means that the dentist has authorized a hygienist to perform a hygiene task that is not always a patient specific authorization but may be a task specific one i.e. may perform a dental hygiene assessment on patients. The dentist is not required to be present in the facility where the services are performed but should be available or have dental coverage available to the hygienist as needed. He may also authorize the performance of the task in a setting other than the dental office. In some cases written authorization or a prescription from the authorizing dentist is required for the patient to receive hygiene services. This authorization may need to be patient specific or it may be part of a formal hygiene protocol for treating patients.  In some States, dental boards or legislatures have appended a provision to general supervision that requires that the patient be informed that the supervising dentist is not on the premises.^[98] (“General supervision shall mean the directing of the authorized activities of a dental hygienist or other dental auxiliary by a licensed dentist and shall not be construed to require the physical presence of the supervisor when directing such activities.”^[99])  
• Unsupervised indicates the most autonomous form of practice for a hygienist. When unsupervised practice is described in law, the tasks permitted are usually well defined and focused on special competencies of dental hygienists such as oral hygiene instruction and education, dental hygiene treatment planning, oral prophylaxis, or fluoride treatments. In situations where unsupervised practice is permitted, as is the case in Washington State, there is often a stipulation for the hygienist to refer the patient to a dentist for any needed dental services or dental treatment.^[100]

When addressing conditions of supervision, some States limit the number of hygienists who may be supervised by a dentist at any time.  Ohio statute clearly states, “at no time shall more than three dental hygienists be practicing clinical hygiene under the supervision of the same dentist.”^[101]  Tennessee statutes also limit the number of dental hygienists under general supervision to no more than three at any one time.^[102] California limits the number of dental auxiliaries in “extended functions” that a dentist may supervise to two.^[103]

• “those intraoral tasks which are reversible and do not create unalterable changes within the oral cavity or the contiguous structures and which do not cause an increased risk to the patient.”^[108]

• “those intraoral treatment tasks which, when performed, are irreversible and create unalterable changes within the oral cavity or the contiguous structures or which cause an increased risk to the patient.”^[109]

• Hawaii’s statute indicates “ the licensed dental hygienist may operate in the office of any licensed dentist, or legally incorporated eleemosynary dental dispensary or infirmary, private school, or welfare center or in any building owned or occupied by the State or any county, but only under the aforesaid employment … No dental hygienist may establish or operate any separate care facility which exclusively renders dental hygiene services.”^[110]  
• Oklahoma statutes state that it is unlawful for a dental hygienist to “attempt to conduct a practice of dental hygiene in some other location other than in an office of a dentist and under his supervision.”^[111]
• Louisiana has legislated that “ Any licensed dentist licensed in Louisiana of good standing, public institution, or school authority may employ a licensed hygienist who may perform such duties as may be authorized by the board. A registered dental hygienist may operate only in the office of a licensed dentist under his direct supervision on the premises, except that when employed by a public school or Federal or State institution where health care is provided, the hygienist may operate under the general direction and supervision of a licensed dentist also employed by the public school or Federal or State institution.” The conditions of employment further require that the hygienist keep the board advised of the name and location of the employer.^[112]
• In Colorado, “the group practice of dentistry or dental hygiene is permitted”^[113] so it would be possible for a dental hygienist to be self-employed.
• California permits “the establishment of independent practice by a registered dental hygienist in alternative practice” but the RDHAP must provide documentation of a relationship with a dentist who would provide referral, consultation, and emergency services.^[114]
• New Hampshire statutes specifically state, “nothing in this chapter shall be construed to permit the independent practice of dental hygienists.”^[115]
• New Jersey statute provides a similar admonition. “Nothing in this act shall be construed as permitting a licensed dental hygienist to establish an independent office for the purpose of performing traditional hygienist services whether or not there is supervision or direct supervision of a licensed dentist.”^[116]
• Virginia is also explicit in the prohibition to self-employment. “Dental hygienists. . .shall engage in their respective duties only while in the employment of a licensed dentist or governmental agency and under the direction and control of the employing dentist or the dentist in charge, or the dentist in charge or control of the governmental agency.”^[117]
• Kentucky limits the practice of dental hygiene by including a provision in statute that “it shall be unlawful for a person or corporation to practice dental hygiene in a manner that is separate or independent from the dental practice of a supervising dentist or to establish or maintain an office that is primarily devoted to the provision of dental hygiene services.”^[118]

Constraints imposed on the hygienist regarding employment represent another barrier to provision of services in non-traditional settings. A required status of employee limits hygienists to practice settings in which their employing dentist is engaged.  Although some States permit employment by a health care facility, legislation often further limits the circumstances under which a hygienist is paid.

Direct Medicaid reimbursement is presently available (in 2001) in only six States. Even when Medicaid reimbursement is permitted, funds are not always mandated to support the law. Missouri is an example of a State where the payment mandate has not yet been funded. This is an example of a circumstance that further deters hygienists from working in underserved settings with underserved populations.

• In Maine, a hygienist who has been approved by the board to practice under Public Health Supervision “may be compensated by salary, honoraria, and other mechanisms by the employing or sponsoring entity. Nothing in this rule shall preclude the entity that employs or sponsors a dental hygienist from seeking payment, reimbursement or other source of funding for the services provided.”^[119]
• In Connecticut, law mandates direct payment to dental hygienists for services provided to patients in chronic and convalescent hospitals and homes. “Payment for dental hygiene care rendered to patients in chronic and convalescent hospitals or convalescent homes shall be made directly to the dental hygienist rendering such care.”^[120]
• In Missouri where qualified hygienists are permitted to provide prophylaxis, fluoride and sealants without dental supervision in public health settings to Medicaid eligible children, there is a statutory provision to permit payment. “Medicaid shall reimburse any eligible provider who provides fluoride treatments, teeth cleaning, and sealants to eligible children.”^[121] This is a relatively new statutory provision that appears not to have been funded at the time of the writing of this report.
• Washington State’s rules for the medical assistance program in the State list a number of licensed professionals and organizational health care providers who are authorized to provide services to clients eligible for medical assistance and then to bill for dental-related services provided to entitled patients. Those who “practice as dental hygienists”^[122] are among the professions enumerated.

The ability to be reimbursed directly for services is of special importance to hygienists practicing in other than traditional settings and under less restrictive supervision requirements than in private dental offices.  Professionals need to be paid for the services that they provide in an equitable fashion. Hygienists providing services to compromised patients or those without regular access could conceivably practice preventive and prophylactic oral health care without direct interface with an employing dentist should reimbursement be available. Direct reimbursement is another aspect of professional practice that affects increased access and one that must receive the attention of State legislators and regulatory boards.

Components of the DHPPI

The following provides a detailed description of each of the scored items on the Dental Hygiene Professional Practice Index.

Legal Scope of Practice (Maximum = 10 points)

The distribution of the score under regulated by supposes that self-regulation through a board of dental hygiene or a dental hygiene committee empowered by a dental board with a mandate to regulate the profession contributes most significantly to a legal scope of practice for the profession that effectively utilizes their skills and education. Although hygiene representation on dental boards is important, the power to influence policy or the conditions of practice for hygienists is minimal when only nominal hygiene representation is the mode. One hygienist working with many dentists may not have the same power to effect change as several hygienists working with one or two dentists.

Other regulatory conditions that affect practice include licensure by endorsement. The profession is licensed based on national standards for education and certification. Hygienists are generally required by statute or regulation to graduate from an education program approved by the Commission on Dental Accreditation. States also require hygienists to be certified through national or regional examinations as qualified for clinical practice. Mandating that a hygienist who has been licensed and has practiced in another State be clinically examined in a new State when applying to transfer license to that State is an impediment to practice. Although passage of a legal examination is a common mandate for all newly licensed professionals in a State, clinical examination is not a universal requirement. Legal conditions for practice do vary across States so examination about legal aspects of practice might be expected. Clinical practice, however, does not vary by locale so clinical re-examination is often extraneous. When licensure by endorsement is available in a State, it is not universally available to all professions. Although licensure by endorsement for dentists may exist in a State, it does not necessarily follow that licensure by endorsement for hygienists is similarly legislated in that same State.

The definition of scope of practice in law or regulation is important to a profession. Although a particular scope of practice may not be completely exclusive to a profession, definition of the tasks that can be performed and the conditions under which practice can occur within the skill set and competencies of the practicing professional is important to establishing a standard for the professional group.

A broad definition in law of scope of practice is optimal. A scope that defines the hygienist as the professional provider of preventive and prophylactic oral health services is preferable to one that defines each separate task that can be provided to patients. Too much definition can be as restrictive as too little. Lack of appropriate definition positions the profession too dependently and limits hygienists to providing services as delegated by a dental professional. Too much definition may restrict the profession to specifically stated tasks. More loosely defined scopes permit oral health professionals, both dentists and hygienists, to work together to provide services within a framework of basic competencies. There may be services other than those enumerated in legislation that the hygiene professional might provide to patients. A legal scope that permits some independence or latitude in practice is the most desirable.

Another aspect of legislated scope of practice is the issue of patient of record. Requiring that a hygienist be confined to the patient of record of an employing dentist when providing prophylactic and preventive services is a barrier to access to care. Hygienists should be viewed as threshold professionals to the oral health care system. If legally enabled, hygienists might potentially access patients in other than traditional settings who are in need of services but who do not have a formal dentist provider. A requirement that hygienists provide services only to a patient of record of an employing dentist confines the professional and the patient. In States where the hygienist has access to patients regardless of the patient’s relationship to a dentist, the protection of the patient is addressed in legislated requirements for referral. The hygienist must assess the patient and if it is determined that the patient is in need of restorative or corrective dental work, the patient must be provided with a referral to a dentist.

Supervision (Maximum = 47 points)

There is perhaps no greater impediment to provision of preventive oral health services in non-traditional settings for patients without traditional access than the degree of supervision required by a dentist in State law and/or board regulation. As discussed in other parts of this report, supervision requirements vary greatly across States along the spectrum from direct or personal supervision requiring the immediate involvement of a dentist in the provision of any oral health service to unsupervised practice that requires the involvement of a dentist only upon referral by the hygienist providing prophylactic, preventive, assessment, or educational services to a patient.

Supervision requirements across States cannot be considered exclusive of limitations on settings in which services can be provided. Statutes and regulations across States are quite specific about supervisory levels in a variety of enumerated settings. In some States, a loosening of requirements occurs in a wide variety of public settings while a small number of States are universally permissive in the settings where services can be provided. Other States are quite restrictive in permission for hygiene services stating that they may be provided only in dental offices, in schools, in correctional facilities, or in specific public health settings, etc. The settings selected for scoring on the instrument include dentists’ offices, long term care facilities, schools, public health agencies and federally qualified health clinics, correctional facilities, public institutions and mental health facilities, hospitals including rehabilitation hospitals and convalescent settings, and homes of patients. These settings were chosen to be inclusive of places where oral health services might be provided to patients with and without traditional access. Unsupervised practice in any setting is considered optimal, general supervision is favorable while direct supervision creates an impediment to access. However direct supervision is scored since it still provides an opportunity to work in a non-traditional setting even if it is a restricted opportunity. The scoring reflects this assessment.

An additional feature of the legislation and regulation affecting provision of prophylactic and preventive oral health services is the requirement in some States that a patient have a prior examination by a dentist before the hygienist can provide any service. This mandate is an impediment when services are needed by a patient who is without access to a dentist. This legal condition precludes a hygienist from providing prophylaxis, hygiene assessment and screening services, and hygiene education to a patient without prior agreement from a dentist. It prevents the hygienist from acting as an entry point to the oral health system and can result in missed opportunity for patients to interface with oral health services through a hygiene professional.

Hygienists suggest that the nursing paradigm is an ideal model in which to enable care. Nurses are usually the first health professional encountered by a patient at entry to the medical system. The nurse provides education and assessment services, takes a history, and supplies some basic medical services prior to the patient’s encounter with the physician. In the oral health system, the hygienist is often prevented from accessing patients until a dentist has first seen the patient. This may not be the most efficient process or pathway for either the patient or the provider. Hygienists are educated in a clinical curriculum that prepares them to assess oral health conditions that need more extensive evaluation and treatment. Hygienists should be positioned to provide care as patients enter the oral health system. Permitting this initial contact with a hygienist could significantly impact the entry points to the system. It is conceivable that hygienists could provide services in a number of health care settings and refer patients for care to dentists in other settings, such as private dental practices.

No limits on settings enable hygienists to practice wherever patients present. This category was scored in one of two ways. If statute and regulation are not specific about practice in any particular setting and simply detail conditions for practice in all settings, no limits are considered to exist. If a comprehensive list of settings is specifically enumerated in statute, then a score is also applied since the listing is inclusive. Provision of services outside the traditional office setting is considered optimal in meeting the needs of patients who might not have access to private dental practices but who could conceivably receive services in other settings like schools and nursing homes.

Dental Hygienist Tasks Allowed in Legislation (Maximum = 28 points)

Hygienists are almost universally required to graduate from accredited educational programs. There is consistency in the standard academic content of these programs and the practical clinical training of hygienists. Professionals who graduate from those programs must also become nationally or regionally certified. Hygienists are considered expert providers of prophylactic oral health services including cleaning of teeth, application of sealants and fluoride varnishes, hygiene assessment and prevention education. As oral health professionals, their ability to provide services to patients unencumbered by restrictive supervision levels would be considered the optimal conditions for provision of services. Prophylaxis, sealants, fluorides, x-rays, hygiene screening and assessment are basic hygiene skills for which the hygienist is fundamentally trained and which could be provided without direct supervision. A score is awarded in this category if a State permits provision of these services without the direct intervention of a dentist.

There are extended functions for which hygienists are often trained through their basic education program including placing amalgam restorations, administration of local anesthesia and administration of nitrous oxide. Some States require that any basic education in these skills be supplemented through continuing education or through dedicated certification programs in a State before a hygienist can perform them in practice. The ability to provide these services enables hygienists to practice more efficiently. A score is awarded in these categories if the hygienist is permitted to perform these functions at all in a State. A score was allowed regardless of the various educational requirements imposed by a State or a regulating board for the privilege and also regardless of the level of supervision required.

If a State permits extended functions to a hygienist or provides a hygienist with the ability to work in extended practice in a variety of settings under less restrictive or minimal supervision, extra points were awarded within the index for a contribution to increased access to oral health services for patients. Extended functions and/or practice permit a hygienist to provide services with more autonomy than is usually allowed in States.

There are several conditions for practice that contribute to access to care by offering the practicing hygienist more autonomy within the scope of practice and also enhancing the quality and/or the quantity of care that is provided. These conditions include the ability of the hygienist to refer a patient for other oral health services, the ability of the hygienist to supervise a dental assistant in providing oral health services, and the ability of the hygienist to be supervised by a medical provider such as in hospitals or pediatricians’ offices. The ability to be self-employed is also a feature of practice that would contribute to access to preventive services. It minimizes the need for any unnecessary involvement of a dentist. Dentists in many States are the only permissible conduits for patients to access the services of a hygienist just as in many States, the dentist must also act as the agent for the hygienist to whom he refers patients for prophylactic services. This positioning as an intermediary may be unnecessary when basic preventive services are being sought or provided.

Reimbursement (Maximum = 15 points)

In order to continue to practice, professionals must be able to be paid for the care that is provided to patients. Hygienists are not permitted in most States to seek direct reimbursement for their services from private or public payers. Payment for the preventive services that they provide is dependent on employment by or contract with a dentist or a legally contracting entity. Limiting payment options for hygienists is a significant constraint to expansion of practice to other than office settings and is an impediment to practice in alternate settings. Direct Medicaid reimbursement and the ability to be paid directly by other third party insurers or patients would enable expanded practice for the profession.

This appendix summarizes the detailed point allocations for the DHPPI for each of the fifty States and the District of Columbia. Detailed notes and statutory and regulatory sources are provided for all of the scoring.

Table C