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

April 2004

Appendix D. Field Work Details

This chapter summarizes the fieldwork conducted as part of this study. It includes the following subsections:

• The Fieldwork Process
• Scope of Practice of Dental Hygienists
• Supervision by Dentists
• Current and Future Issues
• Access to Care
• Professional Concerns
• Professional Relationships
• Best Practices Which Promote Access
• Conclusions

• The scope of practice for dental hygienists as defined in statute and regulation;
• The effects of supervision on hygienists providing oral health care to underserved populations;
• Critical future issues for the hygienist profession;
• Questions about professional practice circumstances and professional relationships with other oral health providers;
• Best practices in States that contribute to access to care for a variety of populations.

• States with expansive scope of practice for dental hygienists;
• States with a variety of dentist supervision requirements – some with direct supervision as a legal requirement, others with a variety of supervisory levels depending on setting and patient, and States that allow more liberal supervision by dentists in public health settings.
• States with special practice provisions for hygienists that permit or encourage provision of care in alternative settings to meet the oral health care needs of populations with limited access.
• States that represent geographic and/or demographic diversity.

Representatives from the following States were invited to attend a total of five discussion groups over a several day period:

• Arkansas
• California
• Colorado
• Connecticut
• Florida
• Georgia
• Kentucky
• Massachusetts
• Minnesota
• Missouri
• North Carolina
• Oregon
• Texas
• Washington
• West Virginia

Project staff also participated in other networking sessions as part of the conference schedule. Staff was able to obtain insights from a variety of informants not included in the formal discussion process.

Other professional hygienists from the following States offered comments on scope of practice for hygienists in several networking discussion groups at the conference:

• Alaska
• Hawaii
• Idaho
• Illinois
• Iowa
• Kansas
• Maine
• Maryland
• Montana
• Nevada
• New Mexico
• Rhode Island
• South Carolina
• Tennessee
• Virginia

The topics covered in fieldwork discussions varied depending on the nature of practice in the particular States in which informing hygienists practiced. In a discussion with hygienists from States with restrictive environments, for instance, the problems attendant on direct supervision were a major focus. In focus groups attended by hygienists practicing in States with more liberal supervisory requirements, reimbursement for hygienists’ services was of concern. Generally, hygienists from States with like practice environments were invited to attend a single session. However, in several cases, the attending hygienists at a session were from a mixture of States with differing characteristics in practice conditions.

This remainder of this appendix summarizes the observations and comments of informants during the various discussion groups. The appendix is divided into several sections:

•  Scope of Practice of Dental Hygienists
• Supervision by Dentists
• Current and Future Issues
• Access to Care
• Professional Concerns
• Professional Relationships
• Best Practices Which Promote Access

The last section is a summary of the discussion from the fieldwork.

• A Health Manpower Pilot Project in California led to the establishment of an extended function role for hygienists in the State. There were 17 hygienists in alternative practice who were licensed in the pilot in 1997, 13 of whom are still practicing. However for several years, there was no funding for the education of expanded function hygienists and the program was effectively defunct. Within the last year, funds were appropriated by the legislature in the State and made available beginning in January 2003 to support an educational program for the Registered Dental Hygienist in Alternative Practice. These hygienists are permitted to work unsupervised in a variety of settings under a patient specific prescription of a dentist, physician, or surgeon when providing oral health services for a client.
• The rules of the Oregon Board of Dentistry permit a limited access permit to be issued to a dental hygienist who qualifies with significant work experience. This permit allows the hygienist to perform several extended function services for patients who, due to “age or infirmity”, are unable to access services in a dental office.^[126] Permitted extended functions include relines of dentures, temporary restorations, and sealants.
• Connecticut permits hygiene practice without a dentist’s supervision in public health facilities such as community health centers, nursing homes, group homes and schools by a “public health dental hygienist” who qualifies by experience and education to perform services for needy patients.^[127]
• Colorado statute provides for practicing “unsupervised dental hygiene” that includes prophylaxis, fluoride application and dental hygiene assessment.^[128] When services are provided to Medicaid eligible children, direct reimbursement is mandated for the hygienist providing the service.^[129]
• South Carolina Code provides for dental hygienists to apply fluorides and sealants under general supervision in a variety of settings such as schools, public health facilities, hospitals, nursing homes and rural clinics. In schools, the services are authorized by permission of the student’s parent or guardian.^[130] South Carolina has had significant success in reaching several thousand children through their programs.

Expanded Functions for Dental Assistants

Hygienists expressed concern about the expansion of scope of practice for dental assistants that is occurring in many States under the guise of increasing access to care. A number of States have legislated extended functions for dental assistants that include services usually provided by licensed hygienists.

• California has several categories of dental auxiliaries – dental assistant, registered dental assistant, registered dental assistant in extended functions, registered dental hygienist, registered dental hygienist in extended functions, and registered dental hygienists in alternative practice.^[131] Each class of provider has a different scope of practice defined in code. In California, a dental assistant can apply topical fluoride,^[132] a registered dental assistant with appropriate education can perform coronal polishing^[133] and a registered dental assistant in extended function can apply pit and fissure sealants,^[134] all tasks within the scope of dental hygiene practice.
• Vermont rules provide for licensure as a dental hygienist, registration for expanded function dental assisting duties for dental hygienists, and registration as a traditional dental assistant, a certified dental assistant, or as an expanded function dental assistant. Each category of professional requires different preparation and education.^[135] Each also has a particular scope of duties.
• Oklahoma statutes list dental hygienist, dental assistant, and dental nurse as qualified dental auxiliaries.^[136] The rules of the State Board of Dentistry define expanded duty as “a procedure for which a dental assistant has received special training..” while an advanced procedure is “ a procedure for which a dental hygienist has received special training..” ^[137] Dental assistants in the State have several expanded duties such as x-rays, coronal polishing, fluoride treatments and placement of sealants.^[138] Hygienists may qualify to administer local anesthesia and nitrous oxide as advanced procedures.^[139]

Hygienists continuously remark that they are highly educated in prophylaxis and that they spend more time in an educational curriculum that teaches those skills than even dental students. They are concerned that the quality of services provided by assistants trained by dentists or trained in abbreviated certificate programs is not the same as those provided by hygienists trained in accredited programs and certified by national and regional exams as having mastered hygiene competencies.

Some State efforts to increase access to care through increased scope of practice for assistants are seen as misguided. To increase the availability of preventive services, Kansas passed legislation that allows dental auxiliaries (dental assistants) to scale and polish teeth supragingivally (above the gum line), also called coronal polishing, after an approved course of instruction.^[140] This is also permitted in California. However, significant gum disease can occur when subgingival (below the gum line) scaling is not performed on a regular basis. Hygienists express concern that patients who receive such superficial services are more likely to eventually develop gum disease. Other States now permit coronal polishing by assistants (Kentucky permits an assistant who has passed an approved course in the State to perform coronal polishing^[141]). In order to accommodate, reimbursement for these services, the national dental association has changed the requirements of the reimbursement code for prophylaxis to allow for either complete prophylaxis, supragingival scaling or for coronal polishing. Although, there is no difference in the reimbursement rate for these services, hygienists indicate there is a difference in the quality and extent of the actual service. Complete prophylaxis is a much more substantial procedure than coronal polishing.

Permitting dental assistants to provide hygiene services, although promoted as a way of increasing access, is seen by many as an erroneous strategy or a slippery slope. Since assistants work directly with dentists and generally in private practice, patients without traditional access to dentists would not have access to the services of the dentist’s assistant. Hygienists suggest that generally patients are not well served by allowing assistants to provide preventive and prophylactic services. Informants suggest that such a practice might compromise the quality of care that even patients with existing access receive.

Supervision By Dentists

Levels of Supervision

Perhaps no issue evokes more pervasive concern among hygienists than the degree of supervision required from dentists when hygienists are performing oral health procedures or services for patients. As indicated elsewhere in this report, supervision requirements vary in legislation and/or regulation on a continuum from personal supervision requiring both the immediate presence and direction of a dentist to no supervision required for particular hygiene services. The requirements for supervision differ across States and are described in law and regulation in a variety of terms.

Universally, hygienists suggest that the accredited hygiene education programs provide certified hygiene professionals with a substantial skill set that enables the profession to be expert providers of oral hygiene services and preventive hygiene education to patients. Professionals across States comment that certain basic services including oral prophylaxis, dental hygiene screening and assessment, and dental hygiene education should be permitted to the hygienist without direct oversight by dentists. Fluoride treatments and sealant application are also seen as fundamental tasks for the profession. These services frequently require layers of supervision, depending on the State, not incumbent on hygienists when providing other primary oral health preventive services. Level of supervision required for hygiene services is predicated on different circumstances or standards across States. Supervision is characterized variously:

• The hygienist is supervised. (Iowa requires that hygienists perform all authorized services under general supervision of a dentist.^[142] North Dakota Code states that “the practice of dental hygiene is...supplemental and auxiliary to the practice of dentistry.”^[143] The dentist “exercises full responsibility” over procedures he delegates to a dental hygienist “under direct, indirect, general or modified general supervision.”^[144])
• The level of supervision required is determined by the task that is performed. (Ohio statutes provide specific detail about the tasks that are authorized under varying levels of supervision for hygiene services including non-delegable tasks and/or procedures,^[145] procedures that may not be performed by a hygienist when a dentist is not physically present,^[146] and a detailed list of each of the basic remediable intra-oral and extra-oral tasks that can be performed by a hygienist without the physical presence of a dentist.^[147])
• Level of supervision is determined by characteristics of the patient to whom services are provided. (In California, registered dental hygienists in alternative practice provide services to patients on prescription from the patient’s dentist, surgeon or physician.^[148] In Pennsylvania, the level of supervision and the services allowed depend on the American Society of Anesthesiologists’ (ASA) classification of the patient.^[149]
• The level of supervision is determined by the setting in which services are provided. (In South Carolina, hygienists may apply topical fluoride under general supervision in schools, nursing homes, hospitals, and rural clinics and in several other listed settings.^[150] However, South Carolina Code specifically states that general supervision is not permitted in private dental practice.^[151]
• The supervising dentist determines the level of supervision. (Oklahoma rules governing hygienists specifically state that the level of supervision for a list of enumerated hygiene tasks is to be decided at the discretion of the supervising dentist.^[152])

In most States, the level of supervision required is not straightforward. Rather, it is determined by a number of the above factors. This results in a matrix of supervisory requirements within a State depending on setting, task, and patient. A State may require different levels of supervision depending on the services being offered, the setting in which they are provided, and the characteristics of the patient being served. As a result, supervision by dentists is quite various across States and in many cases, rather complicated to decipher and understand.

Supervision and Access

Supervision is seen as a critical factor in limiting or enabling access to care. When a State requires direct supervision for hygienists, services may be provided only when dentists are present and immediately available. This requirement effectively deters the provision of preventive oral health services in settings other than in private dental offices where dentists largely practice. Strict supervision requirements also effectively limit access to oral health preventive services to patients who are able to employ the services of a private dentist. In most cases, those patients would be privately insured or capable of self-payment.

Some examples of how the level of required supervision in a State affects access to care were provided in the following illustrations:

• In Arkansas, there is a requirement for direct supervision of hygienists by dentists. There is an exception in prisons where general supervision is permitted. The services that may be provided in correctional facilities are restricted to those contained in the written directions of the supervising dentist and to prophylaxis, sealants and other standard hygienist functions. Access initiatives in Arkansas are limited by this requirement for direct supervision. According to informants, access is also further constrained by low reimbursement rates from State Medicaid programs that discourage dentists from participating. If dentists do not contract with Medicaid, hygienists are unable, under direct supervision, to provide hygiene services to Medicaid eligible patients.
• Supervision in Hawaii is similarly restrictive. The regulations require direct supervision in private practice and the employing dentist must be present in the office even during brushing and flossing. Some expansion of privilege is permitted in charitable clinics, schools, welfare centers and in governmental facilities in the State where general supervision is allowed.^[153]
• In Colorado, hygienists may provide oral health services unsupervised when services are provided to children on State Medicaid. In fact, under those circumstances, the hygienist may even be reimbursed directly for those services. This enables access for children who might not otherwise receive preventive services.
• Tennessee permits a hygienist to work under general supervision without the presence of a dentist for no more than 15 consecutive days. Although limited in scope, this loosening of the supervision requirement does permit the hygienist some autonomy in practice.
• Maryland requires indirect supervision in private settings but relaxes those requirements in alternative settings such as nursing homes, prisons, and for volunteer endeavors by allowing general supervision in those settings. This permits expanded access for compromised populations.
• Georgia is another example of a State that has dual scope of practice legislation, that is, differing supervision requirements depending on the setting in which services are provided. In dental offices, the direct supervision of a dentist is required. However in certain county, State and Federal dental facilities, this direct supervision requirement is waived to permit more ready access to preventive services. Again, this facilitates increased access by populations who might otherwise not receive preventive oral health services.
• Connecticut hygienists usually work under general supervision in private and public settings. However, there are provisions that permit qualified dental hygienists to work in public health settings unsupervised by dentists. These public health dental hygienists are required by law to refer patients for further dental care if the hygienist makes that determination at the time hygiene services are provided. There are provisions in State statute and regulation that permit direct reimbursement to dental hygienists for the services provided to patients in chronic and convalescent homes^[154] or in a number of other settings including schools, group homes, and community settings.^[155] Connecticut was a leader in providing care to school age children by creating this special class of public health hygienist.

Requirements for levels of restrictive supervision for hygienists are seen as creating obvious barriers to access for some populations. Equally perplexing to hygienists, however, is the rationale that supports a variety of supervisory levels depending on the settings in which services are provided. Hygienists suggest that these variations in State law and regulation are really counter-intuitive.

Many States relax the requirements for supervision in public health settings, in schools, in clinics, and in nursing homes to permit hygienists to work without direct supervision by dentists and thus, increase access. Hygienists remark that patients in these alternative settings are often highly medically compromised and vulnerable. Yet, hygienists are allowed to treat them with more independence than is permitted to them in private practice. Generally, patients who present for hygiene services in private office settings have better overall oral health status and often require only very routine services. Hygienists question why the profession is considered competent to provide services more autonomously to patients who are the most compromised when they are not considered equally qualified to provide the same services with the same autonomy to private clients in optimal oral and medical health. Informants suggest that this is indicative of a dual standard of care.

Supervision requirements in most States are motivated by the need to protect patients. The level of required supervision should also be appropriate to the training and the competence of the professional who is providing services. However, some legislated mandates pertaining to level of supervision by dentists over services provided by hygienists are perceived to be overly protective and in some cases, endangering of appropriate patient access. Hygienists are professional providers who are trained in preventive oral health services in a curriculum that has a strong clinical foundation. The profession feels that their skills should be respected enough to permit some autonomy in practice with prophylaxis, prevention education, and hygiene assessment.

Although the goal for the hygiene profession might be considered to be unsupervised practice for hygiene services provided competently to patients within the scope of education and training for hygienists (i.e. oral health education and prophylaxis), one hygienist suggested that the issue should be framed differently. A main objective in provision of hygiene services should be appropriate patient access. Direct access to preventive oral health services without restrictive levels of supervision is a reasonable goal for the patient, the professional, and the community.

Another comment of informants regarding supervision is that professional practice is generally viewed vertically, as a hierarchy, with a dentist supervising services by those under his direction and in his employ. Hygienists suggest that a better view of practice would be in a horizontal configuration. Services provided by hygienists such as risk assessment, oral health promotion and disease prevention services would be located on one end of the lateral spectrum. Preventive services, at the beginning of this range, could be provided by hygienists with little oversight from dentist professionals whose talents are better used in the provision of more complex restorative care, tasks located further along on the continuum. This would maximize the use of the limited available oral health resources.

Hygienists are limited in their access to patients in the same way that patient access to hygiene services is limited. The conduit for the patient to the hygienist and for the hygienist to the patient is usually a dentist who is the intermediary as the doctor of record and the employer of the hygienist. Elimination of restrictive supervision requirements and creation of direct reimbursement mechanisms for hygienists would permit direct access for patients to preventive oral health services and direct access for hygienists to patients in need of their services.

Preventive care should also be viewed as an entry point to other oral health services. Patients may be referred to dentists who would not necessarily seek restorative dental services without first having an assessment performed by the hygienist. Regular oral hygiene services for those without routine access would also generate cost reductions for expensive restorative care.

Hygienists comment that the most liberal supervision laws are Federal. Hygiene services are provided under generous supervision standards in Federal institutions while State standards for supervision are generally more restrictive. In most States, a hygienist changing jobs from a Federal employer to a private dentist in the same location would encounter limiting changes in the supervision requirements when supplying similar services to patients in a private dental practice.

Supervision and Patient of Record Requirements

Another variation in law and regulation that affects access is the need for the patient to be the patient of record of the supervising dentist. Patient of record is defined in Oklahoma regulations as “an individual who has given a medical history, and has been examined and accepted for dental care by a dentist.”^[156] The requirement that a hygienist only see a patient of record of the supervising dentist further limits access to preventive services to patients who have an established professional relationship with a dentist provider.

• In Texas, a dentist must have a doctor/patient relationship with any patient to whom a hygienist supervised by that dentist provides services.
• In California, the conditions for practice by a Registered Dental Hygienist in Alternative Practice (RDHAP) require only that a patient must have a referring dentist, physician or surgeon. A RDHAP provides services to a patient as authorized by that patient’s dentist or physician for up to eighteen months.^[157] The hygienist must have a documented relationship with a dentist to whom a patient could be referred for needed care but that may not be the dentist of record for the particular patient. This permits the hygienist to treat a patient independent of a supervising dentist’s relationship with that client and promotes access for a variety of populations.
• Florida statutes state that “each patient shall have a dentist of record” who is responsible for any dental treatment provided by the dentist or by a hygienist or assistant under the dentist’s direction. The statute further states the intent of the legislation is to “assign primary responsibility to the dentist for treatment rendered by a dental hygienist or assistant under her or his supervision.”^[158] All applicable levels of supervision in the State require that services performed by hygienists receive prior authorization from the supervising dentist. These conditions for practice limit the hygienist in a dentist’s employ to his/or her patients of record.
• Missouri Dental Board Rules permit direct, indirect or general supervision of the hygienist. All levels of supervision require that hygiene services be provided only to a patient of record of the supervising dentist. This is defined in rule as a person from whom a patient history has been taken and who has been evaluated and examined by the dentist.^[159]

Hygienists offered the perspective that the California provisions are ideal. Supervision of the patient should be the goal rather than supervision of the professional who is providing the services. If achievement of oral health is a primary objective, the needs of the patient must be primary in creating the conditions surrounding provision of services.

Another variation that is considered effective is regulation of the level of supervision according to the complexity of the service that is to be provided. Laws regarding supervision of hygiene services in Colorado focus on supervision of the procedures performed by the hygienist. A hygienist may provide preventive services such as prophylaxis, dental hygiene assessment, and fluoride treatments without supervision in the State while local anesthesia, which is more risky to the patient, requires direct supervision.^[160] Fieldwork informants emphasize that it is important to focus on supervisory conditions that make sense. Permitting a hygienist to work as autonomously as possible within the scope of his/her training to provide optimal care for patients is consistent with this focus.

Hygienists comment that patients may have more frequent interface with their hygienist than with their dentist. Patients receiving proper preventive care are seen every six months by the hygienist. In some States, a dentist is required to examine the patient and approve the work of the hygienist but the length of the dentist’s visit is frequently shorter than the visit with the hygienist. This is especially true for patients who have minimal need for restorative care. The patient may, therefore, be better known to the hygienist provider than to their dentist.

Supervision by Medical Providers

Several informant groups discussed the requirement in most statutes that supervision of a hygienist occur through a licensed dentist. Hygienists expressed strong opinions that provision of oral health care should be limited to those with appropriate education and training such as dentists and hygienists. Supervision by dentists seems most appropriate when supervision is warranted.

However, informants suggest that there might be certain patients and/or settings for whom and in which medical supervision would be advantageous. For instance, dentists do not often see very young children. Baby bottle tooth decay is an example of a condition that manifests at an early age. Permitting a dental hygienist to be employed and supervised by a pediatrician might be an effective mechanism for reaching children who are developing or at risk for developing oral disease. This would permit early remediation as signs of poor oral health become evident in an infant or toddler.

North Carolina began training medical providers including nurses and physician assistants to apply fluoride varnishes on the teeth of infants and toddlers beginning at age 9 months until 3 years. The State is committed to expanding access through this prevention program. Special law was enacted enabling payment for services provided by medical professionals. Several other States have funded medical personnel to be trained in the fluoride program in North Carolina so that similar services could be provided in their home States.

Dental hygienists in the State are concerned that medical professionals are being utilized in the program rather than primarily oral health professionals. Concern was expressed that this is indicative of erosion to the legal scope of practice for hygienists. Fluoride application is traditionally a hygiene service that is now being permitted to medical providers. Informants question the need to train other providers when a professional group is already expert at the task.

In Oregon, pediatricians are being trained to screen young children for oral health disease. This is driven by a concern in the State about a shortage of dentists. One informant suggested however that physicians might find it burdensome having another task like oral health screenings added to their existing substantial obligations for patient care.

Enabling medical providers to perform oral health screenings also introduces the problem of quality of services. Medical doctors are not trained in depth in oral health. Informants expressed concern that a parent might substitute the screening done by a pediatrician for a check-up at the dentist mistaking the screening as equivalent to the more thorough and necessary examination by a dentist. The problem of reimbursement to the physician for the dental screening is also an issue. Professionals generally expect to be paid for the services they perform. Reimbursement is an important incentive to provision of care.

Current and Future Issues

Self Regulation

Much of the legislation regulating dental hygiene across States is reflective of the professions positioning in relation to dentistry. The North Dakota Dental Hygiene Act clearly states that the “the practice of dental hygiene is hereby declared to be supplemental and auxiliary to the practice of dentistry.”^[161] This subordination to the dental profession is reflected in the legislation that regulates the profession.

States address practice by hygienists most frequently in the Dental Practice Act. In some States, the standards dealing with practice by hygienists are embedded in the dental statutes; in others a separate chapter of a statute on professions and occupations addresses the practice of dental hygiene. The actual regulation of dental hygiene occurs almost universally through Boards of Dentistry or Boards of Dental Examiners. A very small number of States have created separate Dental Hygiene Committees that are autonomous.

An important goal for the dental hygiene profession is self-regulation. Across the country, at the local, State, and national organization level, self-regulation is a priority. Although other scope of practice issues trouble hygienists, the absence of professional control is considered restrictive for the profession and limiting to individual hygienists. Self-governance would allow the profession to manage educational standards and quality, to establish uniform professional practice standards, and would provide the profession with some control over scope of practice. It would also permit the profession to move from a defensive mode to a more proactive position.

The hygienist profession remains in a defensive mode because of the continuing fear that the exclusive scope of practice permitted to them by regulating dental boards might be altered at any time. Hygienists profess to feeling continuous pressure to retain existing scope and a need to demonstrate, on an ongoing basis, the efficacy of their services. They suggest that self-regulation would provide the profession with some professional security, would permit a measure of professional standardization, and would ensure quality in consistent educational standards required of those providing hygiene services.

Hygienists express concern that both educational standards and legal scope of practice for the profession are gradually being eroded in some States by the regulating professional boards. Hygienists are effectively disenfranchised by the composition of dental boards. Although there is hygiene representation on many dental boards, the numbers of seats are minimal and the effect on voting, when permitted, is small. Hygienists indicate that reduction in the exclusive scope of practice for the profession is traceable to regulation by dental boards that determine the extent of allowable services permitted to them and to dental assistants.

Increased scopes of practice for dental assistants have been legislated in a number of States. Dental assistants are variously trained – some in accredited education programs that are formally regulated, some in abbreviated courses, and others by the dentists who hire them. The chairside training of assistants to perform hygiene services, which is permitted in some States, was provided as an illustration of allowable practices that undermine the professional scope of hygiene services. The alternative educational process now allowable in Alabama was also cited as an example of this erosion. Alabama permits dental assistants with a certain level of experience to be trained by a dentist while attending an abbreviated educational program. Once the assistant completes the requirements of the alternative program, the assistant can then be licensed as a hygienist.^[162]

Configuration of Regulatory Boards

Although several State hygienist groups have advocated the creation of independent Dental Hygiene Boards, the profession has been mostly unsuccessful in lobbying efforts to attain self-regulation in States. However, the California legislature recently passed a bill that indicates an intention to create an independent Board of Dental Hygiene to govern the profession in the State. This configuration for governing the profession is a result of a sunset review of the Dental Board in the State that determined that a separate board for hygiene was appropriate. The California Dental Board was placed under sunset review when the board was cited as having an inability to deal with dental hygiene issues in a way that protected consumers in the State. Implementation of this legislation is expected to require about two years.^[163] Informants indicate that financial support for an independent board would probably come from existing revenues and from a potential increase in licensing fees for the profession in California.

Washington State is unique among States in that dentistry and dental hygiene are regulated in separate practice acts. Dentists are regulated by the Dental Quality Assurance Commission that has only licensed dentists and a public representative as members. A Dental Hygiene Examining Committee composed of only hygienists and a public member regulates hygienists.^[164] Although the hygiene committee was originally established to supervise examination and licensure for hygienists, committee responsibilities have evolved to making recommendations about practice regulations for dental hygienists to the Department of Health.^[165] The board functions independently of the dental commission.

Several States have Dental Hygiene Committees which function as part of the State Dental Board. The mandates for these boards differ across States, as does their power to influence regulation.

Iowa has a dental hygiene committee with power to effect hygiene issues. The statute creating the committee empowers it to make recommendations to the Iowa Board of Dental Examiners about practice for dental hygienists. The Board of Dental Examiners must ratify committee recommendations unless there is a justifiable impediment. Passage of a committee recommendation is mandatory unless the record does not support it, unless there is a financial barrier that makes it imprudent or impossible, or unless the recommendation is outside the jurisdiction of the board.^[166] The committee is supported through the budget of the Dental Board.

New Mexico has a New Mexico Board of Dental Health Care that includes two dental hygienist members. Additionally, there is a New Mexico Dental Hygienists Committee that includes five hygienists from representative districts in the State. This committee shares decision-making power on issues related to dental hygiene including examination, licensure and practice.^[167]

Since 1992, during a sunset review of the Dental Board, legislators in Maryland mandated the formation of a Hygiene Committee in the State. There is a large board of Dental Examiners that includes three dental hygienists who also sit on the Dental Hygiene Committee of the Board. The committee reviews all matters pertaining to dental hygiene but not all of the committee’s recommendations are passed by the board. The committee still lacks leverage in the State.^[168]

Texas has a Dental Hygiene Advisory Committee with three hygienists, one dentist and two public members that advises the board on matters relating to dental hygiene.^[169] However, the State Board of Dental Examiners retains ultimate power to regulate the professional practice of hygienists.^[170]

Florida statutes create a Board of Dentistry that includes two members who are dental hygienists. The statute also mandates a Council on Dental Hygiene and a Council on Dental Assisting to advise the board.^[171] Florida hygienists cite their frustration with efforts to implement the dental hygiene council. Although the Board of Dentistry appointed the committee, it has not been convened in over three years. This example was provided to illustrate that even when hygiene advisory committees are legally established, they may in practice be ineffectual.

Access To Care

Factors Affecting Access to Preventive Oral Health Services

Access to preventive oral health services is a concern for the profession. There is strong feeling that as a profession, hygienists have little control over increasing access for “dentally indigent patients”.^[172] Preventive oral health services are mostly provided in private dental practices for several reasons:

• Most States have legal requirements that dentists must supervise hygienists. In some States, hygienists can only practice with direct dental supervision limiting them to the settings and the patient population of their supervising dentists.
• Hygienists are limited in some States to providing services to the patient of record of their employing dentist.
• Dentists practice mostly in traditional models of care (that is in solo or small group practices). Practice in alternative settings is rare.
• Hygienists cannot receive direct reimbursement for hygiene services in most States. In some States, they are specifically prohibited from billing directly for their services.
• Hygienists do not generally procure patients and, in many States, are not permitted to own or establish hygiene practices.^{[173] [174]}

These circumstances limit opportunities to provide care for compromised populations not traditionally able to access services in conventional settings like dentists’ private offices.

Hygienists could certainly provide services more frequently in other settings if regulations permitted practice.

One hygienist suggested that when access is discussed, there is a need to reflect on the provision of oral health services as an allocation of resources. Broader scope of practice for hygienists would allow for a better allocation of existing resources and would create more avenues for access by needy populations. In permitting hygienists some control over providing preventive services, dentists could then focus on restorative services for a broader patient population.

There is also a need to create multiple entry points to the system that provides oral health care. More autonomy for hygiene professionals should generate more opportunity to interface with patients in a variety of settings and circumstances. It would enable alternative access that would enhance patient care.

Hygienist informants question why there are legal constraints on their provision of prophylactic services to needy populations when dentists have not demonstrated significant interest in meeting the needs of the underserved. Medicaid plans in numerous States have difficulty enrolling participating dentists because the economic incentives are so limited. Reimbursement rates for Medicaid insured patients are typically one-half to one-third of the usual and customary charges in private dental offices.^[175] This results in very little competition for Medicaid eligible patients and is an example of how economic factors affect access.

Hygienists suggest that the delivery of oral health services occurs in a topsy-turvy manner. Unlike medicine where nurses are the frontline workers performing patient triage, dental hygienists are often allowed to see new patients only after a dentist has evaluated and diagnosed them. Hygienists remark that they are educated in programs with substantial clinical subject matter and the curriculum is the equivalent of three years of a college education even though associate degrees are awarded. A high percentage of hygienists do complete bachelor’s education. This positions hygienists at the same educational level as nurses. However, they are not permitted the same freedom to interface initially with patients as are nurses in a variety of medical settings.

Provision of Services in Non-Traditional Settings

Informants suggest that there is a need to think in other than conventional patterns about access to care. Oral health providers work in a practice paradigm in which patients traditionally come to them to receive professional services. However, it is possible for providers to go to patients. This can be an effective strategy with populations who have limited or no access.

Providing oral health services in other than established office settings creates challenges. Although mobile equipment can be somewhat expensive, it is available and does serve a need. Hygienists working in home settings, for instance, use portable units as do volunteer hygienist teams who work in screening clinics.

Dental equipment can also be installed in other than dental offices. A volunteer hygienist commented that the nursing home where she provides services had established a dedicated dental suite to accommodate her and her collaborating dentist in the nursing home setting. Mobile dental vans serve populations by bringing the providers to the patient while providing adequate equipment to perform most preventive and restorative procedures. Some complex surgical procedures need to be performed in more fixed settings, but many preventive and restorative services can be provided with portable units. For those services requiring more extensive equipment, mobile vans that are equipped with fixed apparatus generally meet both provider and patient need.

Teledentistry was cited as an innovation in the practice environment that will permit increased access. It is also a circumstance that may result in the need for changing supervision requirements for dental hygienists across States. The implementation of teledentistry programs will demand some modifications in the supervision requirements for dental hygienists performing hygiene services using electronic media at a distance from the dentist. Demonstration projects include such practices as having a hygienist with the patient taking diagnostic x-rays in one location with a dentist in another location receiving them for diagnosis. These physical circumstances will challenge the legal conditions for practice in several States where direct supervision is required, that is the requirement of the physical presence of the dentist when any service is provided.

Barriers to Access to Dental Services

Geographic barriers to care were of concern. Hygienists from Hawaii commented that the geography of their State created some significant challenges. The State’s population lives on many islands not all of which have an adequate supply of providers. Additionally the requirement for hygienists to work under direct supervision causes some artificial barriers to access since dentists for whom they work are not always conveniently or strategically located to those in need of services.

Rural populations often encounter difficulty with access due to geographic barriers. Patients in rural areas may not have dentists and therefore, probably also have no access to hygienists. Mobile dental vans are an effective strategy for meeting the needs of geographically scattered patients. There are a variety of private and public programs in States that offer mobile oral health programs which contribute to access. However, hygienists indicate there are not enough programs in operation to adequately meet need. Additionally, funding for such programs is often limited to restorative services because programs do not have the needed van space or the required funding to also provide preventive care.

There are also cultural barriers to care which were of concern to hygienists. Professionals from Alaska, for instance, discussed the Eskimo and Native American populations in their State. Hygienists encounter obvious language barriers and also comment on additional cultural barriers to provision of services. Hygienists suggest there is a general apathy about health care among certain groups that is fostered by the culture. One hygienist offered the example of seeing a child who needed full mouth rehabilitation because of significant decay. Health and social services professionals in Alaska followed the case and provided the mother with extensive education about prevention. However, there were four subsequent children born to the same family all of whom developed the same condition, each requiring extensive oral rehabilitation.

Professional Concerns

Education

Educational programs for dental hygienists are accredited by the Commission on Dental Accreditation that functions “under the auspices of the American Dental Association.”^[176] Presently there are 261 accredited programs for dental hygiene education awarding certificates, associate’s, bachelor’s or master’s degrees. The vast majority (231) of these programs grant associate degrees.^[177]

Hygienists recognize that there is some environmental push to elevate the educational level required for the profession. Discussion has occurred in organizational groups about advancement to entry-level bachelor’s education to increase the professional stature of hygienists. Canada will require baccalaureate degree education as the entry-level credential for dental hygienists beginning in 2005.^[178]

However, as with many clinical professions, hygienists struggle with the concept of adding general education requirements to advance the degree awarded when the additional academic courses will not enhance the clinical expertise of the graduate. Presently programs require 90 credit hours of clinical and practical education. There are additional concerns that advancement to bachelor’s level would increase the cost of a hygiene education without a commensurate increase in starting salaries. The clinical skill level of a newly graduated hygienist would remain the same although the educational attainment would be advanced. Many hygienists already complete bachelor’s education. 49 percent of hygienists have completed baccalaureate education while 44 percent have an associate degree. 7 percent of practicing hygienists indicate a certificate program as their most advanced education.^[179]

There is some concern among professional hygienists that a proliferation of educational programs encouraged by dentistry as a strategy to increase supply will actually result in an oversupply of hygienists in some areas. Hygienists from Illinois and North Carolina comment that there has been a proliferation of programs in their States that has affected employment opportunities and salary levels. In general, hygienists feel that dental control over education programs is another strategy that strengthens the hygiene profession’s subordination to dentistry, reinforcing the control of one profession over the other.

Hygienists also express concern that some States are permitting licensure after completion of abbreviated educational programs accompanied by chairside training by dentists. Professionals believe that these alternative programs will reduce the level of competency of the profession through a watering down of the education process. Skill will be diminished and dependence of the hygienists on dentists for direction and supervision will also be increased. A similar concern is that some States, such as North Carolina, do not require graduation from an accredited hygiene education program for certification as a hygienist in the State.

Reimbursement

Unlike medical care, where there is some subsidy built into public reimbursement for care to provide for indigent services, private dental insurance provides no subsidy or offsets for uninsured patients in need of dental services. And unlike medical care, where mid-level providers such as nurse practitioners, physical and occupational therapists, etc. are permitted to bill insurances directly for services, hygienists are generally prohibited from billing directly for their services. In a handful of States, hygienists are permitted to file for direct Medicaid reimbursement. However, this is the exception rather than the rule.

Although several States have no actual stated prohibition in law to hygienists billing directly, payers are perceived to be generally unwilling to offer direct reimbursement for hygiene services to the profession. This may be a function of a strong dentist lobby that encourages reimbursement to dentists for all services provided in dentists’ offices. These established reimbursement mechanisms require the hygienist’s employment by or contract with a dentist when providing services to patients.

Salaries

Several economic factors are cited as contributing negatively to the relationship between hygienists and dentists, particularly in private practice. Dentistry is still configured mainly in solo practice with the dentist as the employer of the hygienist. Hygienists are also not permitted to receive direct reimbursement for services in most States. Hygienists must therefore be in the employ of a dentist or independently contracted to a dentist in order to be paid for their services. Many States actually require in legislation that hygienists be employed by dentists in order to provide services to patients. Some States also permit public or governmental institutions to employ a hygienist as long as there is supervision from a dentist available within the organization.

As employees of dentists, hygienists require benefits such as health insurance and retirement contributions. Some dentists are cited as being reluctant to provide those benefits to workers who are largely part time. Employing dentists will utilize the strategy of hiring several rather than one hygienist to staff their practices. This allows them to circumvent the need to provide benefits by reducing the number of hours that a hygienist works in the practice thus eliminating any legal responsibility for extending benefits. Hygienists suggest that some dentists will complain that there is a shortage of hygienists when, in fact, the dentist has a retention problem because of a refusal to support the professionals with adequate compensation. Hygiene is unusual in that there is little upward movement in salary available to professionals. The salary level at which a new hygienist enters the profession remains relatively stable throughout a hygiene career.

Compensation levels vary depending on demand. Hygienists from a variety of States offered the following as examples of salaries within States:

• In Massachusetts, a hygienist working in the Boston area might make about $35.00 per hour. A hygienist working in the Berkshire Hills in the western part of the State might only earn about $25.00 per hour. Temporary hygienists work for agencies in the State for about $33.00 per hour. A variety of salary and commission arrangements are also possible when contracting with a dentist for employment.
• California hygienists report that in large metropolitan areas a hygienist can make about $350 per day with a statewide average of about $280 per day.
• Georgia hygienists report that in metropolitan areas a hygienist can earn between $30 and $35 per hour. However, in rural areas, a hygienist may make from $14 to $17 per hour.
• Arkansas hygienists report that the opposite is true in their State. Providers in rural areas make more money than those in urban areas because the demand for providers is so high in more remote areas of the State.
• Rhode Island reports a unique circumstance in that the State borders several other States (Massachusetts and Connecticut) so hygienists can easily leave the State and work in neighboring communities for more competitive salaries than might be available in Rhode Island.
• Salaries in North Carolina were also cited in a range. New graduates might earn $225 per day while a hygienist in a metropolitan area like Charlotte would earn about $320 a day. Salary range was cited as about $40,000 in some more rural locations to about $62,000 in Chapel Hill and about $72,000 in Raleigh for a four-day week. Public health hygienists in the State would earn in a range of $37,000 to $42,000 for full time work.

Professional Relationships

The quality of relationships between dentists and dental hygienists was explored in a number of fieldwork discussions. Although hygienists suggest that at the individual level practice with dentists who appreciate their skills is generally rewarding, tension between professional dental and dental hygiene groups is apparent. As with medical professions, this animosity is most obvious at the organizational level. Hygienists identify the antagonism as ingrained and institutionalized.

There is a demonstrated, adversarial relationship in organized professional circles between dental professionals and hygiene professionals. Although informants to this research seemed to understand many of the reasons for this tension, the professions seem unable to effect any change in the existing relationships. Hygienists continue to encounter difficulties in their attempts to work cooperatively with dental professional organizations to achieve alterations in legal conditions for practice that would benefit the hygiene profession and those to whom they provide care. Hygienists from a wide variety of States recount resistance from State dental associations and State dental regulating boards when seeking expanded privileges or reduction in legislated levels of supervision. This antagonism seems to permeate national, State, and even local organizations for the professions.

Relationships between dentists and hygienists in the public health arena seem less strained than the relationships between professionals practicing in private settings. Contributions to care for a variety of populations are valued differently in public health environments than in private practice. Resources in public health settings are also more limited and the hygienists’ contributions are essential to the efficiencies required. The economic incentives for public and private providers also vary depending on settings and on the patient to whom services are provided. These variations in circumstance may contribute to the observed reduction in tension between the professions in public organizations.

As an indicator of the institutional nature of the adversarial relationship between the professions, one hygienist educator commented she had observed that in her experience, over several years of teaching dental students, this attitude was learned. She commented that initially dental students are receptive to the hygiene profession. As the dental students progress through the educational process they adopt the attitude of the dental faculty which is often less favorable to hygienists.

There is significant political tension between constituent professional organizations in States. The State of Illinois provides an example. After repeated attempts at lobbying for a change in the supervision requirements for hygiene services in the State were unsuccessful, the Illinois Dental Hygienists’ Association recently affiliated with the Illinois Federation of Teachers.^[180] Organizationally, the federation will provide management services as well as political advocacy and lobbying services for the hygienist association. The hygiene association hopes that the level of required supervision might be changed from direct to general in the State. This would then permit practice in alternative settings not presently accessible to hygienists. The American Federation of Teachers has had some success in other States lobbying for change for other healthcare professionals. In the State of New York, the federation effectively advocated for professional regulation of psychologists after their affiliation with the New York State Psychological Association. Hygienists hope that the union’s efforts will have positive results for Illinois hygienists.

Best Practices Which Promote Access

State Initiatives

Many States have initiated Oral Health Task Forces and other initiatives to promote access to oral health services for populations who have limited opportunities to receive dental services. Hygienists credit interest in these initiatives to a greater awareness of oral health issues prompted by the Surgeon General’s Report on Oral Health in America.

Informants from a variety of locales provided the following examples of access initiatives occurring in their home States:

• Nevada has developed an oral health plan for the State that includes a needs evaluation, a resource assessment, and an action plan. Hygienists are involved in both the conceptual stage and in the implementation process. The plan reviews the needs of vulnerable populations like children and the elderly and suggests that one emphasis should be on oral health education.^[181]
• Arkansas has a program called AR Kids First that is administered through the State CHIP program. There is some problem with dentist participation in the program since reimbursement for services is so low. Arkansas has developed an outreach program called Smiles AR US. Arkansas also did an oral health needs assessment in 2000 to investigate the oral health status of Arkansas’ children.^[182]
• In Massachusetts, the governor authorized the formation of a Commission on Oral Health in the Commonwealth resulting in a report on oral health in the State.^[183] .
• The Montana Migrant Health Program of the Montana Primary Care Association has a mobile van staffed by dentists and hygienists that provides oral health services to migrant populations and to residents of Native American reservations in the State.
• The Oregon Health Plan (Oregon Medicaid) Project: Prevention is focusing efforts on the prevention of cavities in young children. The Early Childhood Cavities Prevention Coalition is working on early intervention in children from birth to 24 months.
• The Department of Health and Welfare in the State of Idaho convened an Oral Health Summit to address concerns about access to oral health care particularly for low-income populations.^[184]
• In Colorado, the Governor convened a Commission on Children’s Dental Health. The group recommended that dental hygienists be utilized in provision of preventive oral health services. The recommendations of the commission also included a suggestion that hygienists be allowed to bill State Medicaid for provision of services.^[185] Reimbursement for hygienists was subsequently formalized in law.

Public and Private Collaborations

Several fieldwork informants noted the importance of embracing opportunities to create public and private collaborations to meet the oral health care needs of assorted populations. Some examples of successful collaborations were offered:

• The United Methodist Health Ministry Fund (UMHMF) provided funds for the State of Kansas to study access to dental services for Medicaid populations and to develop and implement programs to increase access. The UM Health Ministry Fund was the beneficiary of the dissolution of a not for profit health provider, Wesley Health Systems, and the resulting endowment is being used to fund oral health initiatives in the State. UMHMF has sponsored sealant grants as well as the education of some of Kansas’s medical providers in the North Carolina fluoride varnish program to increase access to fluoride services for infants and toddlers in Kansas.
• Kentucky hygienists have been involved in some private initiatives to increase access to care which are sponsored by Ronald McDonald Charities and the University of Kentucky. The Ronald McDonald Charities donated a mobile dental unit that has been used in a sealant program for children in the State. Presently, Ronald McDonald House Charities funds eight mobile units that provide both pediatric and dental care in Massachusetts, Pennsylvania, North Carolina, Texas, California, and Montana.^[186]
• The Elks Club in Missouri funds a van used by the University of Missouri for a dentist and an assistant to travel to any area of the State where there is a need for oral health services. There is presently only sufficient funding for restorative care with no preventive services being offered. The Elks Club has funded the van since 1967 and has also provided funding for the services offered by the program.^[187]
• The Massachusetts Coalition for Health funded a sealant program at multiple sites that used volunteer hygienists and hygiene students to provide services. Project Stretch is a Massachusetts’ dental initiative that has extended program services both nationally and internationally. The program provided children in Berkshire County with fluoride treatments and oral hygiene education.^[188] Another program in which hygienists have been involved in the State is the Child Ident Program. This is an identification program funded by the Free Masons and the State Dental Association that involves creating a bite impression, a saliva swab and a video of the child.
• Kids in Need of Dentistry (KIND) is a not for profit agency in Colorado^[189] providing oral health care to children who are ineligible for insurance. The program operates in fixed clinic sites. The organization also operates a mobile van program called Miles for Smiles that services the rural areas in the western part of the State. Services provided include both prophylactic and restorative care.
• Crest Toothpaste is collaborating with the American Dental Association, the Boys and Girls Clubs of America and the American Academy of Pediatric Dentistry in educational efforts across the United States to teach children about oral health.^[190]
• The Children’s Aid Society of New York is working with Columbia University School of Dental and Oral Surgery to provide oral health services to children in schools, day care and head start programs in the metropolitan area of New York City through a mobile van equipped for dental services.^[191]

Volunteer Services

Hygienists in various fieldwork discussions indicated that there are a number of active volunteer efforts across States that have been organized to increase access to care. These programs are coordinated by individual hygienists and by professional organizational affiliates in collaboration with a variety of interested private and public community funders. These programs provide services such as oral health screening, hygiene education, and in some cases, sealant and/or fluoride application.

Volunteer services provided by hygienists were discussed in the fieldwork as an important contribution to the oral health of certain populations with limited access, especially for the very young and the elderly. Volunteer services are perceived to be important enough to efforts to increase access that some States actually legislate the conditions under which volunteer services may be provided:

• Maryland’s statutes detail the conditions for a retired volunteer’s license to practice dental hygiene. ^[192] This license permits a hygienist who is not actively employed in a dental practice to provide hygiene services to poor, elderly or handicapped patients in certain facilities administered by government or charitable organizations. The hygienist must agree to provide at least 100 hours of free services in order to be issued a volunteer license.
• The Code of Virginia provides for restricted volunteer licenses for dental hygienists who are willing to provide services in public health or community settings without remuneration and under the direction of a licensed dentist for patients who have been screened and are eligible for treatment.^[193]
• Ohio provides for a volunteer certificate that can be issued to a dentist or a dental hygienist to provide oral health services to indigent or uninsured patients in a non-profit shelter or health care facility without remuneration.^[194]

Volunteers in Health Care, an organization funded by the Robert Wood Johnson foundation cites volunteers as an important resource when considering expanding access. Their publication, “Volunteer Recruitment: Dental Providers”, provides the insight that there are significantly more volunteer programs to provide medical care than dental care despite the fact that there are three times as many people without dental insurance in the United States as there are without medical insurance.^[195]

Conclusions

In summary, discussion with informants suggests that several changes in conditions of practice could potentially increase access to preventive oral health services for those populations with compromised access:

1. Self-regulation would provide hygienists with needed professional control while still ensuring the quality of preventive and prophylactic hygiene services.
2. Levels of supervision required by States should be examined and evaluated in light of not only patient safety issues but also goals for reasonable access.
3. Hygienists should be permitted direct reimbursement from both public payers and private insurers. This will be critical to providing appropriate avenues for access to preventive services.
4. Expanded functions should be encouraged for hygiene professionals who are seeking professional growth and/or new opportunities to interface with a variety of patient populations.
5. Public initiatives, private/public collaborations, and volunteer efforts to provide preventive oral health services should be encouraged. These resources contribute to increased access for a variety of groups who might not otherwise receive prevention services.
6. Oral health services should be offered in other than the traditional paradigm. It is possible to provide services in many settings other than private dental offices.
7. Oral health should be recognized as an issue of significant concern for public health and integrated into future policy initiatives that address the health care needs of Americans.

Appendix E. Background Charts and Tables

The following charts and tables are source documents for the charts and tables presented in Chapter 6 of this report.

Resources
ADA, 1993. Legal Provisions for Delegating Functions to Dental Assistants and Dental Hygienists ADA, 1998.
Survey of Legal Provisions for Delegating Expanded Functions to Chairside Assistants and Dental Hygienists ADA, 2000.
Survey of Legal Provisions for Delegating Intraoral Functions to Chairside Assistants and Dental Hygienists

Chart E-2

Source: ADA Survey of Legal Provisions 1993, 1998, 2000

Sources:
ADA, 1993. Legal Provisions for Delegating Functions to Dental Assistants and DHs, Chicago, IL
ADA, 1998. Survey of Legal Provisions for Delegating Expanded Functions to Chairside Assistants and DHs, Chicago, IL
ADA, 2000. Survey of Legal Provisions for Delegating Intraoral Functions to Chairside Assistants and DHs
Center for Health Workforce Studies, University at Albany School of PH, Scope of Practice for DHs. 2001.

Appendix F: Bibliography

Adesanya RM and Drury TF, “Black/White Disparities in Oral Health Status of American Adults”, National Institute of Dental and Craniofacial Research, NIH

American Dental Association, “Uninsured Persons Record Big Increase in Dental Visits, Remain Far Behind Those with Dental Insurance, Study Says”, http://www.ada.org/public/media/releases/0305_release03.asp.

American Dental Association, 1993 Legal Provisions for Delegating Functions to Dental Assistants and Dental Hygienists, Chicago, IL, 1993.

American Dental Association, 1998 Legal Provisions for Delegating Functions to Dental Assistants and Dental Hygienists, Chicago, IL, 1998.

American Dental Association, 2000 Survey of Legal Provisions for Delegating Intraoral Functions to Chairside Assistants and Dental Hygienists, Chicago, IL, 2001.

American Dental Association, Commission on Dental Accreditation, “Dental Assisting, Hygiene and Laboratory Technology Education Programs”,  http://www.ada.org/prof/ed/programs/dahlt/alliedus.asp.

American Dental Association, http://www.ada.org/prof/ed/accred/whatis /index.html.

American Dental Association, "What Is Accreditation?"  http://www.ada.org/prof/ed/accred/whatis/define.html.

American Dental Education Association et al., The Report of the ADEA President's Commission: “Improving the Oral Health Status of All Americans: Roles and Responsibilities of Academic Dental Institutions,” http://www.adea.org/CEPRWeb/cepr.html

American Dental Hygienists' Association, "Dental Hygiene Participation in Regulation",  May 2002.

American Dental Hygienists' Association, "Licensee Populations and State Board Representation", 2002.

American Dental Hygienists' Association, "Accredited Dental Hygiene Programs", http://www.adha.org/careerinfo/schools.htm.

American Dental Hygienists' Association, "Dental Hygiene Legislative Activity 1985 to 2001", October 2001, Chicago, IL.

American Dental Hygienists' Association, "Dental Hygiene Participation in Regulations", September 2001.

American Dental Hygienists’ Association (ADHA), "Educational Standards Position Paper, 2001", Chicago, IL, p. 2, http://www.adha.org/profissues/education_standards.htm.

Amyot C, Darby M, and Wilder R, "Taking Dental Hygiene to the Next Level: Advanced Degrees in Dental Hygiene", Presentation ADHA Annual Session, from Bureau of Labor Statistics, Bureau of The Census 2000, Current Population Survey-Basic Monthly.

An Oral Health Plan for Nevada, http://health2k.state.nv.us/oral/class/Plan.pdf.

Arkansas Year 2000 Statewide Oral Health Needs Assessment Survey, http://www.healthyarkansas.com/Oral_Health/pdf/needs.pdf.

Barnett WS and Brown KC, “American Dental Association, Dental Health Policy Analysis Series: Issues in Children’s Access to Dental Care Under Medicaid”, Chicago, IL, April 2000, (citation from a study by Mueller et al. “Access to Dental Care in the United States: Estimates from a 1994 survey”, Journal of the American Dental Association, 129, 429-437.)

Center for Policy Alternatives, State of the States, Overview of 1999 State Legislation on Access to Oral Health, http://www.cfpa.org/cpa/publications/pdf/legbrief.pdf.

Colorado Commission on Children’s Dental Health, Addressing the Crisis of Oral Health Access for Colorado’s Children, December 2000, http://www.cdphe.state.co.us/pp/oralhealth/cccdhrpt.pdf.

Committee on Dental Auxiliaries of the Dental Board of California, "Supplemental Sunset Review Report on Auxiliary Scopes of Practice", October 5, 2002, http://www.comda.ca.gov/sunset2002supplemental.pdf.

Community Voices, "Disparity Cavity", (citation: Division of Shortage Designation Bureau of Primary Health Care, HRSA). http://bphc.hrsa.gov/databases/newhpsa/newhpsa.cfm).

Community Voices, "The Disparity Cavity: Filling America’s Oral Health Gap", http://www.communityvoices.org/Uploads/fiok23y4gwhfkg45ksbde3jb_20020826095615.pdf.

Community Voices: Healthcare for the Underserved, “Oral Health for All: Policy for Available, Accessible, and Acceptable Care”, p. 1 (citation from Helberg H, “Health for All or for Some Only?” 1994) http://www.communityvoices.org/Uploads/vgon0eagtnzfjwbujlpvmb55_20020813104505.pdf.

Crest Dental Resource Net, http://www.dentalcare.com/.

Drury TF, Garcia I and Adesanya M, “Socioeconomic Disparities in Adult Oral Health in the United States”, National Institute of Dental and Craniofacial Research, NIH.

Drury TF and Corrigan JG, “Going Beyond Poor/Non-Poor Comparisons in Studying Oral Health Inequalities”, National Institute of Dental and Craniofacial Research.

Drury TF, Redford M, Garcia I and Adesanya M, “Identifying and Estimating Oral Health Disparities Among U.S. Adults”, National Institute of Dental and Craniofacial Research, NIH, Bethesda MD

"History of Dental Hygiene", http://www.askadentalhygienist.com/hst/defalut.asp.

"History of Fones School", University of Bridgeport, School of Dental Hygiene, http://www.bridgeport.edu/dental/history.html

Illinois State Dental Society, "News and Notes, Hygienists Seek to Boost Political Clout from the Chicago Tribune", 10/09/02, http://www.isds.org/News-1102_1f.htm.

"Improving Oral Health Care Systems in California", Chapter 4, Dental Safety Net in California, http://www.futurehealth.ucsf.edu/pdf_files/CDAP/CDAP%20Ch4.pdf.

Isman R and Isman B, “Access to Oral Health Services in the U.S. 1997 and Beyond”, Oral Health America, http://www.oralhealthamerica.org/Access%201997%20and%20Beyond-Isman.pdf

Ripa LW, “A Half-Century of Community Water Fluoridation in the United States: Review and Commentary”, Journal of Public Health Dentistry 1993:52(1): 17-44.)

Kaiser Family Foundation, “ Congressional Prevention Coalition Oral Health Policy Briefing”, September 24, 2002, Washington, DC. Comments by Dr. Burton Edelstein, Founding Director, Children’s Dental Health Project of Washington, D.C., http://www.kaisernetwork.org/admin/healthcast/uploaded_files/Transcript_OralHealth.doc.pdf.

“Kids In Need of Dentistry”, http://www.kindsmiles.org/.

"Legislation and Regulation 2002-2003", California Dental Hygienists Association, http://www.cdha.org/lesis/legupdate.htm.

Manski R and Moeller J, “Use of Dental Services; An Analysis of Visits, Procedures and Providers 1996”, Journal of the American Dental Association 133: February 2002 167-175; Medical Expenditure Panel Survey 1996

"Mobile Dental Van", The Children’s Aid Society, http://www.childrensaidsociety.org/locations_services/servicesindex/healthservices/dentalvan/.

National Center for Health Statistics, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey III, 1988-1994. Hyattsville MD.

National Cancer Institute, NIH, SEER Cancer Statistics Review 1973-1996. Bethesda, MD 1999.  www.seer.ims.sci.nih.gov/Publications/CSR1973_1996. June 15, 1999.

Oral Health America, “Keep America Smiling: Oral health in America”, The Oral Health America National Grading Project 2003, http://www.oralhealthamerica.org/Report%20Card.htm, p. 2.

“Project Stretch”, http://www.sanjuandelsur.org.ni/community/stretch.html.

"Regulations of Connecticut State Agencies, Department of Social Services Concerning Requirements for Payment of Public Health Dental Hygienist Services", http://www.cga.state.ct.us/2001/pub/Chap379a.htm.

Ronald McDonald House Charities, "News & Events", http://www.rmhc.com/news/news_recent_4/index.html.

State of Idaho, Department of Health and Welfare, "Oral Health Summit Seeks to Better Idaho’s Smile", http://www2.state.id.us/dhw/news/2001/01nov02_oral_health.htm.

The Canadian Dental Hygienists Association, "Policy Framework for Dental Hygiene Education in Canada 2005", http://www.cdha.ca/content/newsroom/pdf/PolicyFramework2005.pdf.

The Oral Health Crisis in Massachusetts: Report of the Special legislative Commission on Oral Health, February 2000, http://www.oralhealthcommission.homestead.com/.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, "Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2001", www.cdc.gov/nchs/data/series/sr_10/sr10_218pdf.

U.S. Department of Health and Human Services, Healthy People 2010, Volume II, http://www.healthypeople.gov/document/tableofcontents.htm,

U.S. Department of Health and Human Services, U.S. Oral Health in America: A Report of the Surgeon General, Public Health Service, Rockville, MD, 2000",

United States General Accounting Office, "Oral Health: Dental Disease is a Chronic Problem Among Low-Income Populations, April 2000", http://www.gao.gov/

Volunteers in Health Care, "Volunteer Retention and Recruitment: Dental Providers",

http://www.volunteersinhealthcare.org/Manuals/ddsrecruit.manual.pdf.