Allied dental professional scope of practice

There is some evidence that expanding the roles of allied dental professionals increases access to oral health care (Chen 2024, Hill 2022a, Khan 2024, Brickle 2023, Elani 2022, Bailit 2012, Galloway 2002). A number of studies indicate that allied dental professionals trained to perform restorations and other treatments can perform these treatments as well as dentists (Dyer 2016, Phillips 2013, Rodriguez 2013b, Naughton 2014, Bailit 2012, Galloway 2002). Additional evidence is needed to confirm effects and determine which role expansions best increase access to care (Naughton 2014, Dyer 2016).

Dental therapists provide care with indirect dentist supervision and have been shown to increase access to dental care and reduce cavities, especially via programs for children from families with low incomes (Bailit 2012, Simmer-Beck 2015) and to increase the use of dental care by white adults with low incomes (Elani 2022). Dental therapists are more likely to offer preventive care at the population level (often treating a large number of patients at a school or community-based event) than dentists (Hill 2022a). In Minnesota, dental therapists are required to care for under-resourced populations, supporting greater access to oral health care in rural and metropolitan areas (Blue 2016) and expanded access to primary dental care for all ages (Brickle 2023). Authorizing and employing dental therapists in Minnesota increased access to preventive, diagnostic, restorative, and oral surgery services (Khan 2024, Hill 2022a) and allowed dentists to take on more complex, generally adult cases (Khan 2024), while maintaining a high quality of dental health care and patient satisfaction (Zhao 2024). In Alaska Native communities, oral health care by dental therapists contributed to reduced rates of emergency department visits for dental care by children and adults; however, overall rates are still high (Chi 2020).

Following expanded autonomy at the state level for dental hygienists, the use of preventive dental care such as cleanings, exams, and fluoride applications has been shown to increase in dental health provider shortage areas (HPSAs) (Chen 2024). Dental hygienists who serve in community settings under policies that support a broad scope of practice (i.e., direct access policies) also appear to increase access to care for older adults, individuals with special needs, children, individuals who are minoritized by society, and rural populations (Naughton 2014). An Oregon-based evaluation of a state-approved dental pilot project for children from families with low incomes suggests that Expanded Practice Dental Hygienists (EPDHs) located at school dental clinics or in community settings may improve children’s oral health status, including reduced cavities, and may increase parents’ satisfaction with their children’s dental care (Kohli 2022).

Studies have shown that dentists generally have positive attitudes towards extended scope of practice regulations for dental auxiliaries (Reinder 2017). By delegating preventive care and less complicated procedures to allied dental providers within their practice, dentists have additional time to perform complex procedures (Reinder 2017). Patients report satisfaction with care provided by dental auxiliaries (Dyer 2016), including dental therapists (Zhao 2024).

Evidence regarding the effect of expanded function allied dental professionals on private practice income is mixed (Bailit 2012, Beazoglou 2012a, Beazoglou 2012b, Galloway 2002); financial effect appears to depend on the functions performed, office composition, and caseload (Rodriguez 2013b, Beazoglou 2012b). Analysis of dental therapists in Minnesota with expanded scopes of practice reveal significant returns on investments, beyond that of dentists; return on investment by dentists can initially increase after adding dental therapists to a practice (Khan 2024). Studies in New Zealand, Australia, and Canada suggest that dental therapists can be cost effective, particularly when treating children (Friedman 2014).

Insurance reimbursement policies may not support expansion of auxiliary roles; for example, as of 2021, dental hygienists may be directly reimbursed as Medicaid providers in only 19 states (ADHA-Medicaid reimbursement). Yet, when dental hygienists can provide more complex services (i.e., local anesthesia) at a lesser cost than dentists through expanded scope of practice laws, practices may be more likely to accept patients enrolled in Medicaid whose insurance reimburses providers at lower rates (Nasseh 2024).

Experts recommend that additional evaluation of dental therapy education and implementation of dental therapy practice is needed to inform policy decisions regarding expanded scope of practice at both the state and federal levels (Hill 2022a, Luo 2021).

There is some evidence that expanding scope of practice laws for allied dental professionals has the potential to decrease disparities in access to oral health care between individuals in dental health professional shortage areas (HPSAs) and those in areas with large numbers of dental care providers (Chen 2024, Hill 2022a, Khan 2024). Allied dental professionals are often required by state laws to practice in under-resourced dental HPSAs as a way to make dental care accessible and more affordable for those who are uninsured, have limited incomes (Khan 2024), or live in rural (Akinlotan 2023) or remote areas (Hill 2022a).

Expanded practice autonomy for dental hygienists has been shown to increase the use of preventive care in dental HPSAs (Chen 2024). In contrast, states which grant dental hygienists less autonomy have significantly higher rates of preventable dental-related emergency department visits for rural residents compared to states that allow greater autonomy to dental hygienists (Akinlotan 2023).

Dental therapists have a broader scope of practice than dental hygienists; dental care clinics in states that allow both types of providers can have greater operational efficiency along with the capacity to treat additional patients, especially those without insurance or with public insurance (Khan 2024). While the number of states authorizing dental therapists to practice remains limited (only 14 states as of 2024), employing dental therapists in these states reduces disparities in access to dental care for patients living in under-resourced areas (Hill 2022a, Khan 2024, Mertz 2021). A Tribal health organization in Southwest Alaska established the first dental therapist training program in the U.S., which increased access to oral health care and reduced cavities among local Native children and adults (Hill 2022a). Furthermore, most dental therapists trained in this program are members of the community they later serve, improving trust between patients and providers as well as increasing access to care and improving oral health outcomes (Bianchi 2022).

A Minnesota-based study indicates that authorizing dental therapists to treat patients increases access to dental care for adults with low incomes; however, racial and ethnic disparities in oral health care continue, as improvements were among white patients only (Elani 2022). However, another study suggests that non-white patients in Minnesota may have a greater intention to return for care by a dental therapist than white patients (Zhao 2024).

Expanded scope of practice laws for allied dental professionals can support a more diverse dental workforce. Training programs for dental auxiliaries are shorter and more affordable than those to become a dentist, and often meant for local students intending to practice in the area following graduation (Mertz 2021). When dental hygienists can provide more complex services (i.e., local anesthesia) at a lesser cost than dentists through expanded scope of practice laws, practices may be more likely to accept patients whose insurance reimburses providers at lower rates, making it easier for patients with Medicaid to locate a provider (Nasseh 2024).

As of 2024, more than 74 million people in the U.S. reside in one of approximately 7,400 federally designated dental health professional shortage areas (HPSAs) (Khan 2024); most areas are rural or remote (Akinlotan 2023). Newly graduated dentists are less likely to practice in rural areas than urban ones and those who do care for rural communities are approaching retirement age; expanding the scope of practice of allied dental professionals who may be more likely to find rural practice appealing could be one piece of the solution (Akinlotan 2023). The Surgeon General’s report on oral health in 2000 called for an improved dental workforce with greater capacity and diversity in provider types to address oral health inequalities across the country (Mertz 2021).

Dentists have been supported in their work by dental auxiliaries of various scopes of practice since the 19^th century (Haden 2001). However, a formal training program for dental hygienists was not established until 1914 (Mertz 2021), followed in 1916 by a law in Connecticut that first described dental hygiene as a practice (Haden 2001). Allied dental education programs soon followed in dental schools, technical colleges, and community colleges (Haden 2001). By 1951, every state and Washington, D.C. legally recognized dental hygiene practice (Haden 2001). To this day, dental hygienists must maintain state-specific licenses which may mean pursuing additional training, as the scope of practice and educational requirements can vary greatly by state (Chen 2024).

Dental therapists first began to practice in the U.S. through the federally authorized Alaska Community Health Aide Program in 2003, established by the Alaska Native Tribal Health System (Simon 2021). In 2009, Minnesota became the first state to authorize dental therapy practice through legislation as a way to reduce disparities in access to oral care by requiring dental therapists to practice in dental HPSAs (Khan 2024, Mertz 2021).

• Who experiences poor oral health outcomes (e.g., cavities) in your community? Is your community considered a dental health professional shortage area (HPSA)?
• Do training programs for allied dental professionals exist locally? If not, can partnerships between dental providers and local universities and community colleges establish programs, generate funding, and support pathways to licensure?
• How can your community raise public awareness of allied dental professionals as a workforce that can increase access to oral health care, particularly for those in dental HPSAs? How can community voices champion legally expanded scopes of practice at the state and local levels?

Many states have revised or considered revising their allied dental professional scope of practice laws in the last decade; minimum educational requirements, manner of supervision by dentists, and billing options continue to limit where dental auxiliaries may practice (Simon 2021). As of 2021, 42 states allow dental hygienists to initiate patient care outside of traditional dental offices, without the presence of a dentist (ADHA-Direct access). As of 2024, 19 states allow dental hygienists to receive direct reimbursement for care provided to Medicaid eligible patients (ADHA-Medicaid reimbursement) and only eight states explicitly bar independent practice (NCSL-Direct access). Kansas, Maine, Minnesota, South Carolina, and Vermont expanded dental hygienists’ scope of practice to include risk assessments, the placement of basic tooth restorations, sealant applications, supervision of dental assistants, and the ability to maintain independent dental hygiene practices in communities with limited access to dental care, along with care in public health settings (Akinlotan 2023).

As of 2024, Alaska Native communities in the Yukon-Kuskokwim Delta region of Southwest Alaska (Hill 2022a) along with 14 states (Alaska, Arizona, Colorado, Connecticut, Idaho, Michigan, Minnesota, Maine, New Mexico, Nevada, Oregon, Vermont, Washington and Wisconsin) have authorized dental therapists to practice in some or all settings (i.e., traditional dental offices and clinics, schools, mobile clinics, or nursing homes) (ADTA-Dental therapist, NPDT). As of July 2023, in Minnesota, 141 licensed dental therapists and 99 certified advanced dental therapists offer oral health care services in under-resourced areas across the state (Brickle 2023).

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* Journal subscription may be required for access.

ADHA-Direct access - American Dental Hygienists’ Association (ADHA). (n.d.). Scope of practice: Direct access. Retrieved October 22, 2024.

ADHA-Medicaid reimbursement - American Dental Hygienists’ Association (ADHA). (n.d.). Scope of practice: Medicaid reimbursement. Retrieved October 22, 2024.

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Akinlotan 2023* - Akinlotan, M. A., Ferdinand, A. O., Maxey, H. L., Bolin, J. N., & Morrisey, M. A. (2023). Dental hygienists’ scope of practice regulations and preventable non‐traumatic dental emergency department visits: A cross‐sectional study of 10 U.S. states. Community Dentistry and Oral Epidemiology, 51(2), 274–282.

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Chi 2020 - Chi, D. (2020). Supply of care by dental therapists and emergency dental consultations in Alaska Native communities in the Yukon-Kuskokwim Delta: A mixed methods evaluation. Community Dental Health, 37(3), 190.

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Elani 2022 - Elani, H. W., Mertz, E., & Kawachi, I. (2022). Comparison of dental care visits before and after adoption of a policy to expand the dental workforce in Minnesota. JAMA Health Forum, 3(3), e220158.

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Haden 2001* - Haden, N. K., Morr, K. E., & Valachovic, R. W. (2001). Trends in allied dental education: An analysis of the past and a look to the future. Journal of Dental Education, 65(5), 480–495.

Hill 2022a* - Hill, C. M., MacLachlan, E. W., Mancl, L. A., Lenaker, D., & Chi, D. L. (2022). Secular trends in dental services provided by dental therapists and dentists in southwest Alaska. The Journal of the American Dental Association, 153(12), 1145–1153.

Khan 2024* - Khan, M., Catalanotto, F., Singhal, A., & Revere, F. L. (2024). Integration of dental therapists in safety net practice increases access to oral health care in Minnesota. Journal of Public Health Dentistry, 84(3), 281–288.

Kohli 2022* - Kohli, R., Clemens, J., Mann, L., Newton, M., Glassman, P., & Schwarz, E. (2022). Training dental hygienists to place interim therapeutic restorations in a school‐based teledentistry program: Oregon’s virtual dental home. Journal of Public Health Dentistry, 82(2), 229–238.

Luo 2021* - Luo, Y. L., Simon, L., Leiviska, K., Seyffer, D., & Friedland, B. (2021). A survey of dental therapists’ practice patterns and training in Minnesota. The Journal of the American Dental Association, 152(10), 813–821.

Mertz 2021 - Mertz, E., Kottek, A., Werts, M., Langelier, M., Surdu, S., & Moore, J. (2021). Dental therapists in the United States: Health equity, advancing. Medical Care, 59(Suppl 5), S441–S448.

Nasseh 2024* - Nasseh, K., Bowblis, J. R., & Wing, C. (2024). How do dental practices respond to changes in scope of practice regulations? Health Economics, 33(11), 2508–2524.

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Simon 2021* - Simon, L., Donoff, R. B., & Friedland, B. (2021). Dental therapy in the United States: Are developments at the state level a reason for optimism or a cause for concern? Journal of Public Health Dentistry, 81(1), 12–20.

WI-DHA - Wisconsin Dental Hygienists’ Association (WI-DHA). (n.d.). Learn about the profession: Dental hygienists help people maintain healthy smiles and healthy bodies. Retrieved October 22, 2024.

Zhao 2024* - Zhao, Y., Surdu, S., & Langelier, M. (2024). Safety net patients’ satisfaction with oral health services by provider type and intent to return for more care. Journal of Public Health Dentistry, 84(3), 289–299.