Hygiene's Role in Expanding Oral Care Access

When Alfred Fones graduated from dental school in 1890, his primary role as a dentist was pulling already-rotten teeth. Pediatric patients were coming into their first-ever appointments and were already presenting with decay. Clearly, something needed to change.

Perhaps, Fones thought, the answer would be preventing the problems before they start. From this concept, he recruited his cousin, Irene Newman, to become what would come to be known as the first dental hygienist.

“Dental hygienists were conceptualized and created out of a perceived need within the community at that time for somebody who would be able to increase access to care,” says Katrina Sanders RDH, BSDH, M.Ed, RF. “Fones thought to himself, ‘We need to create some sort of a position, an advocate, someone who can go out into the community and increase awareness and improve oral health as a community advocate before these individuals even come into a private practice setting.’”

Thus began the dental hygienists’ immense impact on preventative oral health care and expanded oral care access. Newman and her colleagues trained patients in good oral hygiene habits, dietary choices, the importance of toothbrushing, and more, to better both their oral and overall health—so successfully, in fact, that 5 years after Dr Fones and Newman founded the first dental hygiene school in Bridgeport, Connecticut in 1913, the city had the lowest death rate of any large city in the world during the 1918 flu.¹

Over 100 years later, dental hygienists continue to make a huge impact on oral health care.

“Given that virtually all dental disease can be prevented, that puts the dental hygienist in a really integral and critical part of the dental delivery team,” says Ann Lynch, director of advocacy for the American Dental Hygienists’ Association (ADHA). “Dental hygienists are right at the front line as the prevention experts.”

Direct Access to Care

Fones’ and Newman’s first dental hygiene program opened the door for hygiene education, and their legacy lives on: Since the University of Bridgeport established the first dental hygiene college, the Fones School of Dental Hygiene, in 1949, there are over 320 entry-level hygiene programs and 17 master’s degree programs in the United States.²

The continuing increase in dental-hygiene programs also means an increase in care access, including a growth in direct access care. According to the ADHA, direct access is “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.”³ In 2008, 28 states allowed direct access. In 2021, that number was up to 42.³

“Today there are 42 states that are direct access states,” Lynch says. “That means that in at least 1 setting and often, in several settings, dental hygienists can see the patient and provide services without the authorization or physical presence of a dentist. That's been really important to increasing access to care and frankly, getting care to where people are, such as school-based programs or geriatric patients that are in skilled nursing facilities.”

Increased direct access greatly benefits underserved communities by giving them access to oral health care and education tools for prevention without the need for dentist oversight. Offsite care allows hygienists to bring dental care to communities instead of requiring the patient to come to them, while teledentistry has opened doors even further.

“There are ways dental hygienists have increased access to care even through doing humanitarian work, helping to serve and support underserved areas, such as going into remote community areas and delivering care to those areas of senior living facilities or special care clinics being educators,” Sanders says. “And certainly, it has been very interesting to see how technology has helped to leverage what dental hygienists are able to do in that telehealth and telemedicine space.”

However, there’s still room for growth, as each state currently has its own restrictions and regulations about a hygienist’s scope of practice. While dental hygiene schools are all accredited by the Commission on Dental Accreditation (CODA), what hygienists are authorized to do with that education varies from state to state.

“I think is possible is there are some states where dental hygienists are not permitted to practice to the fullest extent of their education because of the scope of practice,” Lynch says. “There are national accreditation standards for dental hygiene education programs, so no matter which state you attend a dental hygiene program in, everyone has the same educational accreditation standards. However, depending on the scope of practice, they may or may not be permitted to provide all of the services for which they are educated and trained.”

And these limits on scope can influence access to care. A 2016 study from the SUNY University at Albany’s Center for Health Workforce Studies found that oral health notably improves in states where hygienists are allowed to practice at higher levels and that, despite recent progress in improving access to oral health services, underserved populations continue to suffer from lack of delivery of clinical and community preventive services.⁴

“The scope of practice for dental hygienists is different in every state,” Lynch says. “In the states where there isn’t direct access, they could adopt legislation to remove those frankly archaic barriers and permit dental hygienists to practice to the extent of their education. We are seeing that dental hygienists being able to practice without the physical presence of a dentist, has helped to increase oral health care access, as we've seen in schools, Head Start programs, skilled nursing facilities, and even hospitals in some cases.”

Despite holdups in some states, the overall trend is heartening. In 2018, the US Department of Labor’s (DOL) Bureau of Labor Statistics recategorized hygienists as “Healthcare Diagnosis or Treating Practitioners” from “Health Technologists and Technicians.”⁵ This reclassification could open doors for more opportunities for hygienists nationwide and expand the scope of practice to allow for even more comprehensive direct-access care.

Increasing Opportunities, Increased Care

Direct access isn’t the only frontline service increasing access to care. Dental therapy licensure has also provided greater opportunities for populations to receive preventive care, as well as, in some states, nonsurgical extractions, and preparation of teeth for direct restorations.

Because of its benefits to underserved populations, dental therapy has seen growing support from even the federal level. A 2018 report from the U.S. Departments of Health and Human Services (HHS), in conjunction with the Department of Treasury and DOL, released policy recommendations to improve competition and choice in healthcare markets. The report suggested states assess emerging healthcare occupations, including dental therapy, and examine how licensure scope of practice can increase access and decrease consumer costs while ensuring safe care.⁶

Currently, Arizona, Connecticut, Maine, Michigan, Minnesota, Nevada, New Mexico, and Vermont, as well as tribal lands in Alaska, Idaho, Montana, Oregon, and Washington, have embraced dental therapy as a viable model for addressing access to care challenges.7 As of April 2021, nine more states (Florida, Indiana, Kansas, Massachusetts, New Jersey, New York, Oregon, Washington, and Wisconsin are pursuing dental therapy licensures.⁷ The ADHA reaffirmed its commitment to dental therapy in advocating support of new hygiene-based models for oral health care in a statement released by the organization in 2021.⁷

One way the ADHA accomplishes this is by providing continuing education opportunities for hygienists to increase knowledge bases—as it has now been doing for a century. In July 2023, the ADHA will celebrate its 100th anniversary at its annual conference in Chicago from July 7-9.

“The conference is a terrific opportunity for the dental industry to support dental hygienists,” Lynch says. “The dental industry continues to provide new technology and evidence-based research and it really can be a resource for all members of the dental delivery team.”

Another opportunity for dental hygienists to magnify their education is to explore expanded function dental auxiliary programs (EFDAs). EFDA certification allows dental health care professionals, such as hygienists, to perform reversible dental procedures under the direct supervision of the dentist. While about half of US states allow some EFDA duties, as with seemingly all hygiene regulations, the permitted procedures—and the education requirements to perform them—vary wildly from state to state.

Since its development in the 1970s, EFDA certifications have allowed hygienists in some states to perform the placement and carving of amalgam restorations; placement contouring, and finishing of composite restorations; fabrication, cementation, and removal of temporary restorations; and more. While all of this must be performed under a dentist’s direct supervision, it allows for an expansion of efficiency within a practice, allowing more patients to be treated and thus increasing access to care.

Reaching New Populations

While access to care is critical, getting patients into the chair in the first place is another monumental challenge to providing care. A 2019 National Center for Health Statistics survey found that nearly 45% of adults aged 18-64 had not had a dental visit in the past 12 months, and in rural areas, that number grew to almost 63%.⁸

Sanders sees unique opportunities for dental hygienists to reach this population and educate them about the importance of oral health. From social media, YouTube channels and news appearances, to hygienists going into schools or sending letters to parents to educate them, hygienists can have a large impact on their communities.

“Dental hygienists sometimes don't realize the influence they have even on the patients that do not come in to see them,” she says. “Even on social media; you have a large body of individuals—who are not dental professionals—who see hygienists’ posts or the articles they’re cross-posting. And that starts to create a very organic way for the community to metabolize our content. And now we have the opportunity to really leverage a conversation where people, not even the people in our chairs, but the other people who are interacting with our thought leadership pieces or articles—these individuals are also beginning to understand the importance of oral health.”

Because dental hygienists are often the patient-centric faces of oral health care, Sanders says, they have a unique opportunity to serve as conduits to more than just good oral health. Hygienists talk to patients about decay, gingivitis, periodontitis, oral cancer—and even health conditions outside of the mouth. For example, if a hygienist takes vital signs, they can advise a patient about high blood pressure or pulse rates, and suggest they see their primary care physician.

“Dental hygienists being trained and coached in these things really helps to position them to be true preventive specialists,” Sanders says. “Not that we're looking for disease, but that we are actually looking for those risk factors that could lead us to disease, and ultimately be able to support our patients in that right. The current statistics indicate about 27 million Americans will see a dentist this year, but not see a primary care physician. Dental hygienists can be not just the preventive specialists in dentistry, but also true preventive specialists in the healthcare space.”

Sanders feels the COVID-19 pandemic opened doors to more conversations about oral-systemic health; many of which put hygienists on the front line.

“Our patients absolutely saw us positioned to be able to support in a lot of those ways during a pandemic, when they would say, ‘I'm 65 years old, I'm a diabetic, I have a respiratory condition; I'm scared that by coming to see you that I could get COVID.’ And for a dental hygienist, that was an opportunity to partner with a patient and both reassure and educate. You could say, ‘I hear you, and I’m just concerned as you are. But let’s talk about risk factors.’”

This, Sanders says, opened the door to a lot of important discussions.

“Let's talk about why inflammation in your mouth actually becomes a far more concerning risk factor for you and how we can do everything we need to do to ensure that we're protecting you,” she says. “Let's talk about the infection-control steps that we take in our practice. Let's talk about the aerosol mitigation strategies that we've employed. That allows dental hygienists to position themselves as true patient advocates to form a patient-centric, personalized care plan before the patient even sat down in our chair.”

Spurring conversations like these, the pandemic shined a light on the link between oral and bodily health—and many people started to understand that they are not mutually exclusive. More and more people began to notice, understand, and embrace the concept of oral-systemic health, due in part to education from people like dental hygienists.

“It has long been that medicine and oral health been viewed as being not connected,” Lynch says. “Now we know with a growing body of research how [oral health] is connected to the body, and if you don't have a healthy mouth, you don't have good overall health. There has been increasing interest and increasing growth in medical-dental integration—and that's a really good thing.”

Ultimately, hygienists are situated uniquely in their ability to reach patients and broaden access to care, with ever-increasing opportunities to do so.

“It’s incredible now, over 100 years after the advent of dental hygiene, as we look over the balcony at where dental hygienists are today, that there are so many ways in which dental hygienists have been able to step into roles to be able to increase that access,” Sanders says. “Whether that is through delivering direct care, like in mobile dental clinics; through telehealth or telemedicine; through patient counseling; or even working with various technologies like salivary diagnostics that allows dental hygienists to look at the oral DNA of the patient and counsel them on appropriate predicaments, etc. It's really amazing to look at the level of influence hygienists have in providing access to care. And it’s only going to continue.”

References

1. Lehman ED. Alfred Fones, Irene Newman, and the dental hygiene revolution. Bridgeport History Center. Accessed December 8, 2022. https://bportlibrary.org/hc/education/dr-alfred-fones/
2. Dental hygiene by the numbers. American Dental Education Association. Accessed December 8, 2022. https://www.adea.org/GoDental/Future_Dental_Hygienists/Dental_hygiene_by_the_numbers.aspx.
3. Advocacy: Direct access. American Dental Hygienists’ Association. Accessed December 8, 2022. https://www.adha.org/direct-access
4. Langelier M, Continelli T, Moore J, Baker B, Surdu S. Expanded scopes of practice for dental hygienists associated with improved oral health outcomes for adults. Health Affairs. 2016;35(12):2207-2215. Accessed December 8, 2022. https://doi.org/10.1377/hlthaff.2016.0807
5. 2018 Standard occupational classification system. United States Department of Labor Bureau of Labor Statistics. Published November 2017. Accessed December 8, 2022. https://www.bls.gov/soc/2018/major_groups.htm
6. Reforming America’s healthcare system through choice and competition. https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf. Published 2018. Accessed December 8, 2022. doi.org/10.1377/hlthaff.2016.0807
7. Expanding access to care through dental therapy. American Dental Hygienists’ Association. Published April 2021. Accessed December 8, 2022.
8. Cha AE, Cohen RA. Urban-rural differences in dental care use among adults aged 18−64. National Center for Health Statistics. Published July 7, 2021. Accessed December 8, 2022. https://www.cdc.gov/nchs/data/databriefs/db412-H.pdf