Research a Retrospective Comparison of Dental Hygiene Supervision Changes from 2001 to 2011
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Research A Retrospective Comparison of Dental Hygiene Supervision Changes from 2001 to 2011 April V. Catlett, RDH, BHSA, MDH; Robert Greenlee, PhD Introduction Abstract Several factors contribute to the Purpose: The purpose of this study is to evaluate the extent of poor dental health of low-income change in the professional practice environment for dental hy- populations in the U.S. Some of the gienists in the 50 states and District of Columbia by comparing most significant factors that contrib- the state supervision requirements for dental hygienists during ute to this lack of access to care are a 2001 to 2011 to the previous 7 year period, 1993 to 2000. shortage of dentists, poor participa- Methods: A retrospective comparison evaluation was conduct- tion of dentists in public assistance ed using the 2 tables entitled “Tasks Permitted and Mandat- programs and dental hygiene prac- ed Supervision of Dental Hygienists by State, 1993, 1998 and tice acts.1 The dental hygiene prac- 2000” and “Dental Hygiene Practice Act Overview: Permitted tice act supervision requirements, Functions and Supervision Levels by State.” To score the net dictated by state dental boards, lim- change in supervision, a numerical score was assigned to each it the dental workforce conditions. level of alteration in supervision with a +1 or -1 for each level In 2006, the dentist-to-population of change. ratio in the U.S. was 5.8 dentists per 10,000 residents.1 In May 2010, Results: With a 95% confidence level, the mean change in there were over 25% more dental dental hygiene supervision from 2001 to 2011 was 6.57 with a hygienists as general dentists in the standard deviation of 5.70 (p-value=0.002). The mean change U.S.1 Some states are not utilizing of supervision from 1993 to 2000 was 2.61 with a standard dental hygienists to fill the need in deviation of 4.36 (p-value=0.0002). The difference in the mean providing dental health care to their scores for the periods 1993 to 2000 and 2001 to 2011 was 3.96 underserved populations. In a 2010 (p-value=0.06). survey, 1,824 dental hygienists rep- Conclusion: This study shows that the majority of the states resenting 42 states reported frustra- are moving toward a decrease in dental hygiene supervision. tions related to their career growth Study results suggest that the movement appears to be accel- due to the trend of too many dental erating with more states adopting fewer supervision regulations hygiene programs, a reduction in at a faster rate. Therefore, direction is moving toward more ac- benefits and salaries, and a short- cess to dental health care for underserved populations. age of available dental hygiene posi- Keywords: dental hygiene, access to dental care, supervision tions.2 The dental hygiene workforce level, community partnerships, autonomy is available; therefore, it needs to be utilized. This study supports the NDHRA priority area, Health Services Research: Identify how public policies impact the delivery, uti- In addition to the shortage of lization, and access to oral health care services. dentists in the U.S. and a lack of dental participation in public assis- tance programs, public policy plays a substantial pervision confines the dental hygienist to a facility barrier to dental care. In most states the state where the dentist is physically present. Also, there dental boards, which are comprised mostly of den- are state differences in dental procedures that may tists, oversee the regulation of dental hygienists be performed by dental hygienists. Over the past and in some cases have the ability to determine decade several states have passed legislation to which dental hygiene procedures may be legal- allow more dental procedures to be performed by ly performed by dental hygienists and determine dental hygienists without the direct supervision of whether dental hygienists are required by law to a dentist. Other states have not made any changes be directly supervised. Direct supervision limits the in dental hygiene legislation over the past 2 de- conditions and locations in which dental hygienists cades. may provide preventive dental services; direct su- 110 The Journal of Dental Hygiene Vol. 87 • No. 3 • June 2013 According to a study conducted in 2004 by The community water fluoridation.5 Lacking a dental Center for Health Workforce Studies at the Univer- health care provider is a major risk factor for re- sity of Albany, along with other previous studies, ceiving inadequate preventive dental health care. the expansion of dental hygiene professional prac- A 2000 national survey of physicians found that tice acts has been shown to improve the access to 38% of patients enrolled in Medicaid and 55% of and utilization of oral health care services along uninsured patients encountered difficulties in mak- with oral health outcomes.3-7 The findings of these ing a dental appointment with a dentist.6 studies confirm that a decrease in dental hygiene supervision requirements in the U.S. could allow Public policy has attempted to address the short- an expansion in professional practice opportunities ages in access to dental health care by providing for dental hygienists. By expanding dental hygiene incentives to dentists who serve low-income popu- practice regulation, access to preventive dental lations (thereby increasing the supply of dentists care could be made more available in underserved in rural areas), by using medical health care pro- populations, including non-traditional settings such viders to provide dental health care services (such as schools, prisons, nursing homes and private as fluoride varnish treatments) and by encouraging homes, for homebound individuals. Some states, foreign dental school graduates to become licensed such as Colorado, Washington, Oregon, Califor- dentists in the U.S.5,8-10 These attempts have re- nia and New Mexico, have had more lenient scope sulted in little or no success in an increase in den- of practice and dental supervision laws which has tal health care access. The National Conference resulted in more access to dental health care for of State Legislatures has recommended that each their underserved populations.3 By allowing dental state consider dental hygiene licensing arrange- hygienists to serve individuals in nursing homes, ments that will improve access to dental health public health clinics and rural areas there is a high- care for underserved families.6 A study performed er access to dental care with no effect on the num- by the National Center for Health Workforce Stud- ber of patients seen in dental offices since these ies suggests that there is a positive correlation be- individuals are not accessing care in a private den- tween access to dental health care and the auton- tal office. Mandating dentists’ physical presence for omy of dental hygienists.3 the provision of dental hygiene care is unnecessary since there is little possible danger in most dental Methods and Materials hygiene services provided.3 And states that have allowed dental hygienists to provide unsupervised A retrospective comparison evaluation was con- services to more medically compromised individu- ducted using the 2 tables. “Tasks Permitted and als in long-term facilities, dental hygiene programs Mandated Supervision of Dental Hygienists by and to homebound patients have determined den- State, 1993, 1998 and 2000,” was developed in tal hygienists should be allowed to serve patients a study funded by the National Center for Health who are less medically compromised in all dental Workforce Analysis Bureau of Health Professions settings unsupervised.3 Health Resources and Services Administration in April 2004. “Dental Hygiene Practice Act Overview: According to the previous Surgeon General Da- Permitted Functions and Supervision Levels by vid Satcher, oral health is an integral part of gen- State” was developed by the American Dental Hy- eral health, and in his 2000 report, Oral Health in gienists’ Association in June 2011 (Tables I, II).3,11 America, he stated that dental caries is a “silent The scoring instruments were designed by the ini- epidemic.”4 Most dental conditions may not be life tial researchers to quantify particular aspects of threatening and may be easily treated, but there the legal practice acts and board regulations for are some dental conditions that result in pain, loss dental hygienists within each state which permit of teeth, infection, severe disability or even death. greater access to dental hygiene services partic- Early diagnosis and treatment of dental conditions, ularly for underserved populations.3,11 The com- such as oral cancer, are important to ensure a good parison of these 2 tables details the net change in quality of life.5 Studies have shown how the preva- the state supervision level required for 11 dental lence of dental caries is historically higher among hygiene tasks from 2001 to 2011. The 11 dental those who live in poverty and rural areas and in mi- hygiene tasks selected were intended by the ini- nority groups.4,6,7 Low-income and minority families tial researchers to capture characteristics of pro- experience 80% of all dental conditions, but only fessional dental hygiene practices that enable den- account for approximately half of the total number tal hygienists to provide dental services and were of dental visits in the U.S.6 In 2005, almost 3 out based on conditions that are perceived to affect of 4 shortage areas of dental health profession- access in a variety of dental hygiene settings.3,11 als were in rural areas where families experience In order to score the net change in state dental transportation barriers and had reduced access to hygiene supervision, a numerical score, which was Vol. 87 • No. 3 • June 2013 The Journal of Dental Hygiene 111 Table I: Change in Supervision Levels for Dental Hygienists by State, 1993 to 2000 Coronal Apply Apply Perio.