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Inside Dental Hygiene
September 2018
Volume 14, Issue 9

Removing Barriers to Preventive Oral Healthcare

Michele Braerman, RDH, BS President, American Dental Hygienists’ Association

The goal of optimal oral health for every American depends on the ability of the public to access preventive oral health services. Dental hygienists are ideal providers of such services, and the American Dental Hygienists' Association (ADHA), in working to unite, empower, and support the dental hygiene profession, ultimately seeks to position hygienists in roles and settings that alleviate barriers to access. ADHA has prioritized its current focus and activity on a number of key areas.

Direct Access

Oral health is a fundamental component of total health. As prevention specialists, dental hygienists can help alleviate health access disparities and ensure that preventive oral healthcare is available to all Americans. Key in determining the effectiveness of dental hygienists in achieving these goals is their direct access to the patient, defined as the ability to initiate treatment based on their assessment of a patient's needs without the specific authorization of a dentist, treat the patient without the dentist present, and maintain a provider-patient relationship.1

Direct access looks different from state to state.2 Some states specify the settings in which dental hygienists may access patients directly and/or the services they may provide. Some allow dental hygienists direct access by means of a collaborative agreement with a dentist. Some establish an advanced dental hygiene credential requiring that specific criteria be met. As of this writing, 42 states permit some form of direct access.3

Interdisciplinary Focus and Dental Support Organizations

ADHA's vision is that dental hygienists are valued and integrated into the broader healthcare delivery system to improve the public's oral and overall health. Interprofessional education and collaboration provide the foundation and opportunities to locate dental hygienists outside the private dental practice where they can access more patients directly.

One way to integrate dental hygienists into the overall healthcare system is to employ them in new settings. For example, dental hygienists have been integrated successfully into pediatricians' offices in Colorado, where they have been effective in reducing barriers to preventive oral healthcare for underserved children and pregnant women.4,5 As highlighted in a recent article in ADHA's news and features magazine that contains interviews with some of these dental hygienists, their experiences and the effects they have on the populations they serve are highly impactful.6

Another path to integration is to leverage dental hygienists' educational preparation within a larger context. Dental support organizations offer dental hygienists clinical roles,7 as well as leadership roles in administration and education, and a pathway from the former to the latter should the clinician choose to pursue it.8

Dental Therapy

A third way that dental hygienists are being integrated into the larger healthcare picture is by using their education as a basis for additional preparation as a mid-level provider, commonly known as dental therapists. Several states recognize a dental therapist role, and others have pending legislation to create one.9 ADHA policy supports oral healthcare workforce models that culminate in graduation from an accredited institution, professional licensure, and direct access to patient care.10Evidence continues to support the benefit of dental therapists in alleviating access disparities and improving oral health outcomes for patients.11,12

All these mechanisms for integrating dental hygiene into the larger health system require the ability to communicate with and work alongside professionals in other disciplines. Current dental hygiene curriculums already provide much of the preparation for such practice. In addition, the increasing numbers of programs that coeducate dental hygiene students with students in nursing and other disciplines are preparing teams for a successful future in which all Americans have access to optimal total healthcare.

Clinical Examination for Dental Hygiene Licensure

Since 2008, ADHA has had policy supporting research to identify and implement a valid, reliable alternative to the use of human subjects in clinical licensure examinations for candidates who are graduates of accredited dental hygiene programs and who are eligible to take the National Dental Hygiene Board Examination.13 Survey research published in the association's journal of record found that dental hygiene educators nationwide believe that the determination of clinical competence for licensure should be made based on the student's performance over time rather than a single clinical examination. Only 20% of survey respondents said that the use of live patients as test subjects was essential to proving competency.14


1. American Dental Hygienists’ Association. Policy manual: Glossary. Direct Access, 13-15. Chicago, IL: ADHA; 2016.
2. American Dental Hygienists’ Association. Direct access states. Accessed April 24, 2018.
3. American Dental Hygienists’ Association. Direct access states 2018. Accessed April 24, 2018.
4. American Dental Hygienists’ Association. Transforming dental hygiene education and the profession for the 21st century. White paper. Chicago, IL: ADHA; September 2015:17.
5. Braun PA, Cusick A. Collaboration between medical providers and dental hygienists in pediatric health care. J Evid Based Dent Pract. 2016;16(suppl):59-67.
6. Biazar J. The dental hygienist in the medical setting. Access. 2018;32(6). In press.
7. Association of Dental Support Organizations. Toward a common goal: the role of dental support organizations in an evolving profession. Arlington, VA: ADSO; July 1, 2014. Accessed April 24, 2018.
8. Lebeau J. Dental hygiene beyond the traditional pra0ctice model. Access. 2016;30(5):4-5.
9. American Dental Hygienists’ Association: Expanding access to care through mid-level oral health practitioners (information sheet). Chicago, IL: ADHA; March 2018.
10. American Dental Hygienists’ Association. Policy manual: ADHA Policy 4S-09. Chicago, IL: ADHA; 2016.
11. Minnesota Department of Health, Minnesota Board of Dentistry. Early impacts of dental therapists in Minnesota. Report to the Minnesota legislature. Minneapolis, MN: Minnesota Department of Health; 2014. Accessed April 24, 2018.
12. Koppelman J. Dental therapists can provide cost-efficient care in rural areas. The Pew Charitable Trusts web site. March 12, 2018. Accessed April 24, 2018.
13. American Dental Hygienists’ Association. Policy manual: ADHA Policy 1-08. Chicago, IL: ADHA; 2016.
14. Fleckner LM, Rowe DJ. Assuring dental hygiene clinical competence for licensure: a national survey of dental hygiene program directors. J Dent Hyg. 2015;89(1):26-33.

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