Allied dental professional scope of practice
The roles of allied dental professionals can be expanded by increasing the scope of duties they are statutorily allowed to perform and decreasing dentist supervision requirements. Allied dental professionals include dental assistants, community dental health coordinators, dental hygienists, and dental therapists1. Allied dental professionals are often called dental auxiliaries2. In partnership with dentists, dental auxiliaries increasingly provide care in community settings such as schools, nursing homes, community health centers, and Indian health centers3. Dental therapists perform examinations, preventive services, local anesthesia, restorations, and extractions under the indirect supervision of dentists4. Domestically, dental therapists are authorized to practice in 14 states, including Tribal areas of Alaska, in traditional private practices, Tribal health systems, nonprofit community clinics, and other community settings5.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased access to oral health care
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Increased availability of health professionals in underserved areas
Reduced cavities
Increased patient satisfaction
What does the research say about effectiveness?
There is some evidence that expanding the roles of allied dental professionals increases access to oral health care6, 7, 8, 9, 10, 11, 12. A number of studies indicate that allied dental professionals trained to perform restorations and other treatments can perform these treatments as well as dentists1, 2, 3, 11, 12, 13. Additional evidence is needed to confirm effects and determine which role expansions best increase access to care2, 3.
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 incomes11, 14 and to increase the use of dental care by white adults with low incomes10. 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 dentists7. In Minnesota, dental therapists are required to care for under-resourced populations, supporting greater access to oral health care in rural and metropolitan areas15 and expanded access to primary dental care for all ages9. Authorizing and employing dental therapists in Minnesota increased access to preventive, diagnostic, restorative, and oral surgery services7, 8 and allowed dentists to take on more complex, generally adult cases8, while maintaining a high quality of dental health care and patient satisfaction16. 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 high17.
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)6. 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 populations3. 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 care18.
Studies have shown that dentists generally have positive attitudes towards extended scope of practice regulations for dental auxiliaries19. By delegating preventive care and less complicated procedures to allied dental providers within their practice, dentists have additional time to perform complex procedures19. Patients report satisfaction with care provided by dental auxiliaries2, including dental therapists16.
Evidence regarding the effect of expanded function allied dental professionals on private practice income is mixed11, 12, 20, 21; financial effect appears to depend on the functions performed, office composition, and caseload1, 21. 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 practice8. Studies in New Zealand, Australia, and Canada suggest that dental therapists can be cost effective, particularly when treating children4.
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 states22. 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 rates23.
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 levels7, 24.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: supported by some evidence.
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 providers6, 7, 8. 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 incomes8, or live in rural28 or remote areas7.
Expanded practice autonomy for dental hygienists has been shown to increase the use of preventive care in dental HPSAs6. 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 hygienists28.
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 insurance8. 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 areas7, 8, 30. 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 adults7. 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 outcomes31.
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 only10. 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 patients16.
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 graduation30. 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 provider23.
What is the relevant historical background?
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)8; most areas are rural or remote28. 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 solution28. 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 country30.
Dentists have been supported in their work by dental auxiliaries of various scopes of practice since the 19th century32. However, a formal training program for dental hygienists was not established until 191430, followed in 1916 by a law in Connecticut that first described dental hygiene as a practice32. Allied dental education programs soon followed in dental schools, technical colleges, and community colleges32. By 1951, every state and Washington, D.C. legally recognized dental hygiene practice32. 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 state6.
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 System25. 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 HPSAs8, 30.
Equity Considerations
- 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?
Implementation Examples
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 practice25. As of 2021, 42 states allow dental hygienists to initiate patient care outside of traditional dental offices, without the presence of a dentist26. As of 2024, 19 states allow dental hygienists to receive direct reimbursement for care provided to Medicaid eligible patients22 and only eight states explicitly bar independent practice27. 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 settings28.
As of 2024, Alaska Native communities in the Yukon-Kuskokwim Delta region of Southwest Alaska7 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)5, 29. 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 state9.
Implementation Resources
‡ Resources with a focus on equity.
ADTA-Dental therapist - American Dental Therapy Association (ADTA). (n.d.). Get the facts: What is a dental therapist? Retrieved October 21, 2024.
Pew-Expand dental - The Pew Charitable Trusts (Pew). Expanding the dental workforce.
CHAWI-Dental therapy - Children’s Health Alliance of Wisconsin (CHAWI). (2024). Dental therapy: Wisconsin welcomes a new member to the dental team – dental therapists. Retrieved October 22, 2024.
ME-Ch 575 2014 - Eves M. Chapter 575: An act to improve access to oral health care H.P. 870 - L.D. 1230. Augusta: State of Maine Legislature; 2014.
MDH-DT and ADT - Office of Rural Health and Primary Care. (2024). Dental therapist (DT) and advanced dental therapists (ADT). Minnesota Department of Health (MDH). Retrieved October 22, 2024.
ADHA-Dental hygiene programs - American Dental Hygienists’ Association (ADHA). Education & careers: Dental hygiene programs.
Footnotes
* Journal subscription may be required for access.
1 Rodriguez 2013b - Rodriguez TE, Galka AL, Lacy ES, et al. Can midlevel dental providers be a benefit to the American public? Journal of Health Care for the Poor and Underserved. 2013;24(2):892-906.
2 Dyer 2016 - Dyer TA, Robinson PG. The acceptability of care provided by dental auxiliaries: A systematic review. Journal of the American Dental Association. 2016;147(4):244-254.
3 Naughton 2014 - Naughton DK. Expanding oral care opportunities: Direct access care provided by dental hygienists in the United States. Journal of Evidence Based Dental Practice. 2014;14(Suppl 1):171-182.e1.
4 Friedman 2014 - Friedman JW, Mathu-Muju KR. Dental therapists: Improving access to oral health care for underserved children. American Journal of Public Health. 2014;104(6):1005-1009.
5 ADTA-Dental therapist - American Dental Therapy Association (ADTA). (n.d.). Get the facts: What is a dental therapist? Retrieved October 21, 2024.
6 Chen 2024 - Chen, J., Meyerhoefer, C. D., & Timmons, E. J. (2024). The effects of dental hygienist autonomy on dental care utilization. Health Economics, 33(8), 1726–1747.
7 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.
8 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.
9 Brickle 2023 - Brickle, C. M., Jacobi, D. A., & Larkin, C. E. (2023). Igniting a movement in a dual-licensed dental workforce: The Minnesota model. International Journal of Dental Hygiene, 21(4), 789–794.
10 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.
11 Bailit 2012 - Bailit HL, Beazoglou TJ, DeVitto J, McGowan T, Myne-Joslin V. Impact of dental therapists on productivity and finances: I. Literature review. Journal of Dental Education. 2012;76(8):1061-1067.
12 Galloway 2002 - Galloway J, Gorham J, Lambert M, et al. The professionals complementary to dentistry: Systematic review and synthesis. London: University College London, Eastman Dental Hospital, Dental Team Studies Unit; 2002.
13 Phillips 2013 - Phillips E, Shaefer HL. Dental therapists: Evidence of technical competence. Journal of Dental Research. 2013;92(7 Suppl 1):11S-15S.
14 Simmer-Beck 2015 - Simmer-Beck M, Walker M, Gadbury-Amyot C, et al. Effectiveness of an alternative dental workforce model on the oral health of low-income children in a school-based setting. American Journal of Public Health. 2015;105(9):1763-1769.
15 Blue 2016 - Blue CM, Kaylor MB. Dental therapy practice patterns in Minnesota: A baseline study. Community Dentistry and Oral Epidemiology. 2016;1-9.
16 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.
17 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.
18 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.
19 Reinder 2017 - Reinders, J. J., Krijnen, W. P., Onclin, P., Van Der Schans, C. P., & Stegenga, B. (2017). Attitudes among dentists and dental hygienists towards extended scope and independent practice of dental hygienists. International Dental Journal, 67(1), 46–58.
20 Beazoglou 2012a - Beazoglou TJ, Chen L, Lazar VF, et al. Expanded function allied dental personnel and dental practice productivity and efficiency. Journal of Dental Education. 2012;76(8):1054-1060.
21 Beazoglou 2012b - Beazoglou TJ, Lazar VF, Guay AH, Heffley DR, Bailit HL. Dental therapists in general dental practices: An economic evaluation. Journal of Dental Education. 2012;76(8):1082-1091.
22 ADHA-Medicaid reimbursement - American Dental Hygienists’ Association (ADHA). (n.d.). Scope of practice: Medicaid reimbursement. Retrieved October 22, 2024.
23 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.
24 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.
25 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.
26 ADHA-Direct access - American Dental Hygienists’ Association (ADHA). (n.d.). Scope of practice: Direct access. Retrieved October 22, 2024.
27 NCSL-Direct access - National Conference of State Legislatures (NCSL). (2024). Oral health providers: Dental hygienists with direct access. Scope of Practice Policy. Retrieved October 22, 2024.
28 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.
29 NPDT - National Partnership for Dental Therapy (NPDT). (n.d.). About dental therapy. Retrieved October 21, 2024.
30 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.
31 Bianchi 2022 - Bianchi, T., Wilson, K., & Yee, A. (2022). Undoing structural racism in dentistry: Advocacy for dental therapy. Journal of Public Health Dentistry, 82(S1), 140–143.
32 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.
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