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    How direct access is expanding treatment options for patients

    With more patients requesting after-hours appointments or mobile dental care, hygienists in direct access states are making a difference.

    About 10 years ago, only 28 states allowed direct access. Compare that with today where 42 states allow it – and the support for direct access is continuing to grow.

    The American Dental Hygienists’ Association defines direct access as “the ability of a dental hygienist to initiate treatment based on their assessment of a patient’s needs without the specific authorization of a dentist, treat the patient without the presence of a dentist and maintain a provider-patient relationship.”

    “As the hygiene association, we really promote that dental hygienists are integrated into the healthcare delivery system, and so through that direct access system that provides for that,” says Ann Lynch, director of education and professional advocacy for the American Dental Hygienists’ Association.

    While rules and regulations for direct access vary per state, most allow for “general supervision” duties on patients of record, according to the California Dental Association. These duties include such procedures as scaling and root planing, sealant application and oral prophylaxis, among others. 

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    Other states are trailblazers, allowing hygienists to perform a full scope of care. Take Colorado, for example, which has been allowing dental hygienists to practice without the direct supervision of a dentist since the early 1980s. According to the state practice act, hygienists can perform unsupervised procedures such as taking X-rays, doing periodontal charting and even providing dental hygiene diagnosis. Indirect supervision, which means that a dentist doesn’t need to be present but must have prior knowledge and consent of the procedure, covers things like local anesthesia, silver diamine fluoride, interim therapeutic restoration and lasers.

    “Not everybody is able to come to a brick-and-mortar practice in a metropolitan area,” says Alyssa Aberle, a registered dental hygienist practicing in Colorado and executive administrator of the Colorado Dental Hygienists’ Association. “I think when hygienists are able to practice either unsupervised or under general supervision and provide direct access, you really open up the options for patients of how and where they can get care.”

    What direct access means for hygienists

    Hygienists who are interested in performing general supervision duties must be aware of specific continuing education requirements, which vary from state to state. In Colorado, for instance, hygienists must perform 30 hours of continuing education every two years. Some procedures, such as local anesthesia and silver diamine fluoride, require their own separate permit, Aberle says.

    In other states, like Oregon, hygienists can obtain an expanded practice permit and enter into a collaborative agreement with a dentist to provide such services as administering local anesthesia, administering temporary restorations without excavation, and prescribing prophylactic antibiotics and nonsteroidal anti-inflammatory drugs.

    “Clinicians who desire this additional responsibility have a few requirements,” says Tina Clarke, a registered dental hygienist practicing in Oregon and a previous president of the Oregon Dental Hygienists’ Association. “They must provide documentation for a certain number of hours (about 2,500) of patient care and have very specific continuing education courses. In Oregon, the normal CE requirements are 24 hours every two years. For EPP hygienists, they need to have 40 hours every two years. EPPs must also carry professional liability insurance as well as have a current BLS (basic life support) for the healthcare provider card.”

    For hygienists looking to be their own boss, Colorado allows dental hygienist to open up their own dental hygiene practice, which can be either a mobile clinic or a brick-and-mortar office.

    Aberle says allowing hygienists to practice unsupervised is especially helpful for school-based settings and rural areas.

    Direct access hygienist“Colorado is one of the states where we definitely don’t have a shortage of dentists. We have an abundance of dentists, but they’re all in the metro areas. So we have the other three-quarters of the state that’s rural and no dentists are moving there, but there are hygienists who live there and are willing to provide care. That really opens up options for them,” she says.

    Another path to provide direct access is through dental therapists. In 2009, Minnesota became the first state government to authorize the licensing of dental therapists and required that these providers primarily serve underserved patients. Other states such as Alaska, Maine and Vermont have since followed suit.

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    “Dental therapy is another way that dental hygienists can take their education and experience and provide further services with additional education,” Lynch says.

    In terms of providing greater access to care, dental therapy seems to be making a difference. Lynch notes a study done by the Minnesota state department and the Minnesota Board of Dentistry that showed the total number of new patients served by dental therapists at study clinics over an almost two-year period was 6,338.

    “I think it’s reasonable to correlate that many of those patients perhaps would not have received care without having the dental therapists as a part of that team,” Lynch says.

    Up next: What direct access means for patients...

    Kristen Mott
    Kristen Mott is the associate editor for Dental Products Report and Digital Esthetics.


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