Direct Access Dental Hygiene: How Far It’s Come and Where It’s Going

Irene Iancu first had the idea of opening her own dental practice in Canada about 10 years ago. Her vision was simple back then; it would just be her treating patients, with an office manager to keep everything running smoothly.

That evolved into the fully-functioning dental practice she opened in Toronto last summer. Toothlife Studio is a multidisciplinary dental studio where, as a licensed independent dental hygienist, Iancu is able to handle just about everything a general practitioner can, except permanent restorations and preparations.

The fact that Iancu is a dental hygienist and not a dentist threw people off, making it more difficult for her to get approved for loans and to purchase necessities such as anesthesia and x-ray equipment.

Still, being able to open her own practice is a testament to how far restorative hygiene has come in Canada over the years. While regulations and training requirements differ between Canada and the United States, and even province to province and state to state, direct access in the U.S. also has made great strides.

Currently, 42 states allow direct access, which means dental hygienists can practice without authorization from a dentist or without a dentist being present, according to the American Dental Hygienists’ Association (ADHA). That’s up from 28 states in 2008 and some states, such as Colorado, also permit hygienists to own their own practices.

In some states, however, hygienists can’t do much without dentist supervision. What is permitted depends on the state’s dental practice act. This is frustrating for hygienists who want to practice to their full scope because of the benefits this can provide, from increased practice productivity to improved access to care for underserved populations.

Direct access is defined 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.”

Source: The American Dental Hygienists’ Association (ADHA)

Direct access has changed considerably over the years and continues to be redefined in state practice acts, says Katrina Sanders, RDH, BSDH, Med, RF, a dental hygienist and educator. Over the years, advanced instrumentation protocols have evolved and, in certain states, dental hygienists have been given the green light to perform other tasks on their own, such as administering local anesthetic.

“Expanded functions for the dental hygienist give us more autonomy and independence,” Sanders says, “allowing hygienists the opportunity to be more involved in the clinical aspects of patient care.”

Today, dental hygienists work in various settings and under different levels of supervision, according to the ADHA, with each state having its own laws in place to determine what services they can perform, where they can perform those services and the level of supervision needed. Most dental hygienists only provide supportive restorative services, limited to placing and finishing restorative material, with the dentist required to be present in most states.

Dental hygienists may opt to receive a restorative certificate by completing continuing education approved by the state board. Appling cavity liner/base, placing, carving and finishing amalgam restorations, placing and finishing composite restorations, placing and removing temporary restorations and fabricating temporary crowns are among the restorative services hygienists can provide, depending on state practice acts. With the proper training, some states allow dental hygienists to deliver restorations, Sanders says. Dental hygienists have the education in anatomy and diagnostics for this service, so it makes sense for them and the patients they serve.

“Hygienists are known for being patient advocates and educators,” Sanders says. “Who better to sit and guide the patient through the entire experience of receiving a dental restoration? Who better to explain [the process] than someone trained as a patient advocate? Hygienists can step into their power as educators to make the dental experience more comfortable for the patient as well.”

Depending on state practice acts and training, hygienists also might be able to complete simple extractions; work in nontraditional areas such as mobile dental units, schools, community health care clinics, Native American reservations, and senior living facilities; and own practices.

Although things have been slow going, they are improving. When legislators first began making changes to state dental practice acts, the process was somewhat drawn out. Dental hygienists might first be allowed to provide services in schools, and then nursing homes and community centers would be added later. Now states such as Indiana, which became a direct access state in 2018, are skipping the phased approach and allowing dental hygienists to provide services to the top of their scope.

In recent years, more states, like Minnesota, have begun to introduce the concept of a dental therapist. About half the dental therapists in Minnesota, which became the first state to authorize dental therapy in 2009, are dually licensed as dental hygienists. That continued interest in dental therapy represents an evolution in expanded hygiene, with these dual-licensed providers able to offer both preventive and restorative care.

Number of states that allow direct access

Source: ADHA

Direct access can fill a critical gap for underserved populations. Communities with a shortage of primary, dental, or mental health care providers are known as Health Professional Shortage Areas (HPSAs), according to the Bureau of Health Workforce. HPSAs can represent a shortage of providers for an entire group of people within a defined area (geographic HPSA) or a shortage of providers for a group of people within a defined area (population HPSA). Residents in these communities struggle to find high-quality dental care.

In some states, depending on the scope of practice, dental hygienists can provide that care, which is why direct access is having the biggest impact in community oral health clinics, Sanders says. These clinics can employ 1 doctor as well as several direct access dental hygienists. While the doctor is diagnosing and prepping teeth, hygienists can handle the restorative piece. As a result, more patients are seen at a lower provider cost. Practices that treat mainly Medicare and Medicaid patients are also starting to use this model, but of course only if allowed by the state’s scope of practice.

Beyond providing care to underserved populations, dental hygienists also can spend time educating patients and putting an emphasis on prevention, as dental hygienists are the prevention experts.

“Preventive dentistry is ingrained in us,” Iancu says. “We try to save teeth as best we can. Dentists are taught to treat more than to prevent. That’s where our skills could be more focused and used to help these communities in need.”

Probably the biggest barrier to direct access lies in states’ dental practice acts, Sanders says. Every state is different, and some have been slow to make the changes necessary to allow hygienists to perform to the top of their scope of practice using the full extent of their education.

Then there is the dental community itself. Many dentists are hesitant, concerned that hygienists don’t possess the skills necessary to perform restorative work at the same level as they do, Sanders explains. Some also may feel threatened, if basic dental work can be handled by a provider with a lower salary.

“It’s an interruption of the normal workflow in dental practices,” Sanders says. “It takes training for the doctor and hygienist to work in tandem and to have a structured schedule, yet it makes sense from a clinical and financial standpoint for these practices.”

Some dentists struggle with relinquishing control and putting faith in another person, Iancu says, which keeps them from giving hygienists more autonomy, even in provinces or in the U.S. states where it’s allowed. But there are dentists who support direct access and see these providers as a resource and an ally, not as competition.

Education is another obstacle. Some hygiene programs include restorative training, but right now many don’t. And although there are programs available to hygienists who want to expand their skills, they often cost thousands of dollars, Sanders notes. If there is no financial support from the dentist, many hygienists simply can’t afford it.

The level of education required for certain functions depends on what state, or in Iancu’s case, province, you live in. Iancu is working to get her restorative dental hygiene license, which will give her the ability to perform fillings, temporaries, and permanent restorations in her Toronto practice. Her 6-month program is fairly intense and difficult to get into, but when she has finished, she’ll have a new skill set and a new focus. So, it’s not only about managing the expense but about balancing your time and committing to practicing in a new way.

Incorporating direct access hygienists into a practice does require a new way of working and will look different in every state.

First, both dentists and dental hygienists must determine what their state allows, Sanders says, then evaluate which steps in a procedure dental hygienists can take on. Once the diagnosis is made, what are they able to do? Can they deliver anesthesia or place a restoration?

“What you’re doing is evaluating the best opportunities within the patient appointment flow chart,” Sanders says. “What are the best opportunities to bring a hygienist in to perform certain functions? When the dentist and hygienist are working in tandem, it’s almost like ships passing in the night, with the hygienist performing the vast majority of the direct patient care.”

Of course, there are dentists who are already embracing this model in their practices. Some clinicians bring direct access hygienists on rather than hiring associate dentists and giving part of their patient base away, Iancu says. Instead, they opt to work in tandem with their hygienist, giving them the ability to see more patients each day.

“The idea is not for the hygienist to be stepping into the role of a dentist,” Sanders says. “We very much respect our doctors for the skills and talents they bring to the practice. But onboarding highly trained clinicians who can [provide] support in the restorative piece and provide high-level care gives doctors the opportunity to expand the quality of care in their practice, and to do so while optimizing their overhead.”

A lot of progress has been made over the years, but more work needs to be done. As a growing number of community oral health programs turn to direct access dental hygienists to help fill gaps in patient care, programs in other states will take note and begin to do the same. That’s when people will really start to see change, Sanders says.

“One state will look at what’s successful in another and learn from that, and then slowly other states will begin to adopt the pieces that worked as well,” Sanders says. “It really starts with the community oral health programs. This is where we’ll see eyes opening across the industry.”

Additionally, practices serving patients with a lower socioeconomic status will turn to the community health care model, Sanders says. They will employ more direct access dental hygienists to optimize patient care while keeping overhead low. Eventually, these providers will become a normal part of any dental practice, and there will also be an increase in the number of dental hygienists who opt to open offices of their own.

Standardizing guidelines would also help, Iancu says, making it easier for hygienists to practice to their full scope while also allowing them to move freely. Currently, if Iancu goes to another province, her license may not transfer. The same situation exists in the United States. In one state, hygienists can own their own practice and work without dental supervision, whereas in others, they can’t practice independently at all.

So, although progress has been slow, it has been steady, and continues to gain momentum.

“If dentists are onboarding highly trained clinicians who can support the restorative piece and provide high-level care, that provides an opportunity to expand the quality of care in the practice, and to do so while optimizing overhead,” Sanders says. “It’s important for dentists to learn what these providers can do to help support their practices.”