Legislature & lobbyists lack critical understanding on just how important the role of dental hygienists is.
It’s never a dull moment when you’re a Registered Dental Hygienist. The profession of dental hygiene rarely gets to relax and, instead, is constantly being challenged by those individuals who don’t understand dental hygiene and the contribution the profession makes to the oral health of the general public.
This year, the Illinois legislature was considering measures to expand the dental hygiene practice act to allow dental hygienists to provide preventive dental services for patients in prisons, nursing homes, and mobile dental vans without the dentist first conducting a dental exam or being physically present in the treatment facility. However, after the Illinois State Dental Society (ISDS) met with key lawmakers, the bills never made it out of committee.1
The ISDS did not support the legislation for “patient safety reasons”; however, there is no data available to indicate dental hygienists initiating treatment put patients at harm. Rather, dental hygienists are educated and licensed to provide appropriate care based on their assessment of a patient’s needs without the specific authorization of a dentist.2
Dave Marsh, a lobbyist for the Illinois Dental Society said, “I just don’t feel anybody with a 2-year associate’s degree is medically qualified to correct your health”. “They’re trained to clean teeth. They take a sharp little instrument and scrape your teeth. That’s what they do. That’s all they do.”He also stated there was a “scarcity of research” on the benefits of dental hygienists having more professional freedom.1 Had Mr. Marsh done his homework he would have known there is a plethora of data over a 20-year period to support expanding delivery of oral health care by dental hygienists. In fact, this particular data was divulged in the first 2000 Surgeon General’s Report on Oral Health in America. The data was further extrapolated and appeared in the 2014, National Governors Association (NGA) Brief on “The Role of Dental Hygienists in Providing Access to Oral Health Care” and the 2018 report “Reforming America’s Healthcare System Through Choice and Competition”.3
What Mr. Marsh didn’t say, was that in 2015, the Illinois General Assembly passed legislation to allow dental hygienists employed in public health settings the authorization to provide basic dental hygiene services for Medicaid and low-income patients prior to a comprehensive exam by a dentist. The quid pro quo from the ISDS for not killing the bill was a provision included for dental assistants to provide “coronal scaling” for low-income patients up to 12 years of age.
Although Mr. Marsh erroneously suggested there was a lack of research on the benefits of dental hygienists having more professional freedom, research data indicating patient benefits for dental assistants scaling above the gumline is non-existent. Like coronal polishing, supragingival scaling is part of a complete prophylaxis but it does not replace it, nor does it increase access to care for underserved population groups.
Every State in the U.S. has charted a different course with the scope of practice laws for dental hygienists, which vary widely. In 2014, Newkirk and Slim noted that states on the West Coast function with more progressive practice acts, while several states in the Deep South lag far behind.4 The Northeastern U.S. and the Midwest have been catching up, and in 2016, the State of Maine enacted a new Dental Practice Act establishing independent dental hygiene practice, the second state in the country to do so.5
Dental hygienists are not dental assistants. According to the U.S. Office of Management and Budget, the Standard Occupational Classification for dental hygienists is “Healthcare Diagnosing and /or Treating Practitioners”, which is in the same broad grouping as dentists, physicians, pharmacists, registered nurses, physical therapists, and other health care providers and diagnosticians.6
Dental hygienists are licensed oral health care providers that have met rigorous educational standards and competencies required by the Commission on Dental Accreditation (CODA), the same accrediting body that sets the educational standards for all U.S. post secondary dental programs. Like dentists, dental hygienists are required to pass a written National Board Examination, a clinical examination that tests their competency, and any additional education required by the jurisdiction they are seeking licensure in.7
Dental hygiene is a relatively young profession and its lifespan is just over the 100-year mark. Developing dental hygiene licensure was a gradual process which began in 1917 when Connecticut became the first State to pass a licensure law. In 1921 the University of Michigan began offering a one-year dental hygiene program that was extended to two years in 1938.8
Today, there are 327 entry-level dental hygiene programs throughout the U.S. that grant an Associate of Applied Science in Dental Hygiene degree upon graduation, 51 dental hygiene Bachelor degree completion programs and 17 Master’s degree programs.9 Similar to licensed medical and dental professionals such as doctors, nurses and dentists, dental hygienists must also have a high GPA and a strong science background of college level courses to meet the stringent pre-requisites to be considered a dental hygiene program candidate.
Illinois Lobbyist Hits a Nerve with Dental Hygienists Nationwide
On October 19, 2021, the Kaiser Family Foundation, the Chicago Tribune, and the Chicago Sun Times published articles on how the ISDS killed dental hygiene legislation that would have increased access to basic dental hygiene services for the Illinois underserved.For many dental hygiene associations working at the state level to increase access to preventive dental care, this is nothing unusual.
Dental associations frequently use the deep pockets of their Political Action Committee to leverage state legislators to kill dental hygiene bills. In July 2017, the Washington Post reported on “The unexpected political power of dentists” which cited “a political force so unified, so relentless and so thoroughly woven into American communities that its clout rivals that of the gun lobby”.10
Although the American Dental Association (ADA) agrees that too many Americans get inadequate dental care, when it comes to limiting competition (even perceived competition by dental hygienists who want to provide care for low income and Medicaid recipients), Dental Super PACs are the ones who pull the strings with legislators and state dental boards.
IDHA President and Public Health Dental Hygienist Sherri Foran, RDH, BSDH, MPA, had this to say regarding Mr. Marsh’s statement about dental hygienists with a 2-year degree being unqualified to care nursing home residents: “Registered nurses also have a two-year associates degree. Does this mean that registered nurses (RNs) are also unqualified to care for the elderly?Of course not! This is just another clear example of how the ISDS continues to battle licensed dental hygienists to suppress their ability to work to their highest scope”. Foran added “Illinois dentists claim they cannot afford to provide care for citizens who have state funded dental insurance, are uninsured or poor. Yet they do not want dental hygienists to care for them either. And who suffers?The most vulnerable citizens of Illinois, that’s who.”
Sadly, for the approximately 60 million Americans living in dental deserts this situation is far too familiar.11
Dental Hygiene’s Future
The COVID-19 pandemic has profoundly affected the delivery of all healthcare services worldwide. We’ve seen reports over past decades of limited access to emergency oral health care and limited oral health care to Medicare and Medicaid recipients. Throughout rural America, there are simply not enough dentists to serve low-income areas so dental hygienists have stepped up to address some of these system-wide failures. Emergency room visits for preventable oral conditions continue to rise annually and account for 1.15 and 2.5 % of all emergency room visits. These emergency room visits cost taxpayers, hospitals and the government about $2 billion each year.12
Integration of oral care into the wider medical care system is welcomed and dental hygienists are positioned to remedy oral health inequalities. Illinois and Minnesota are separated by about 500 miles, yet dentists in Minnesota discovered that dental therapists (many of whom are dental hygienists with additional training) have successfully impacted their shortage of care. Over the past decade, dental therapists in Minnesota have helped to increase dental practice caseloads and gross revenues in rural areas that serve the low-income and uninsured.13
There is nothing inherently wrong with professional lobbyists and they are protected by the U.S. First Amendment. However, when a lobbyist such as Dave Marsh only presents ONE SIDED representation of interests, as was the case in Illinois, lobbyists earn a very bad reputation and one that makes a dental hygienist’s hair stand on end. When he says that the only role of a dental hygienist is that of a tooth scraper with a sharp instrument, he deserves the profession’s unleashed fury. Now is not the time for States like Illinois to go backwards; reform of oral health care systems is necessary and we expect ongoing progress from our political and professional leaders.