Transforming Dental Hygiene Education and the Profession ... · Transforming DenTal Hygiene...

28
TRANSFORMING DENTAL HYGIENE EDUCATION AND THE PROFESSION FOR THE 21ST CENTURY 1 EM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM SS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIR ION COLLABORATION COLLABORATION COLLABORATION COLLABORA NTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERP L ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL NG LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELO ONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFO URES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUA OVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CA OLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CU CRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL TH BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER B YER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER E EM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM SS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIR ION COLLABORATION COLLABORATION COLLABORATION COLLABORA NTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERP L ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL NG LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELO ONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFO URES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUA OVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CA OLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CU CRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL TH BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER B YER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM SS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIR ION COLLABORATION COLLABORATION COLLABORATION COLLABORA NTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERP L ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL NG LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELO ONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFO URES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUA OVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CA OLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CU CRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL TH BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER B YER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM SS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIR ION COLLABORATION COLLABORATION COLLABORATION COLLABORA NTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERP L ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL YER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER E Transforming Dental Hygiene Education and the Profession for the 21st Century

Transcript of Transforming Dental Hygiene Education and the Profession ... · Transforming DenTal Hygiene...

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 1

TEM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM ESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRETION COLLABORATION COLLABORATION COLLABORATION COLLABORAINTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERPLL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ING LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELOTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFOSURES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUALOVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CAOLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CUTCRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL THIBUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER ETEM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM ESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRETION COLLABORATION COLLABORATION COLLABORATION COLLABORAINTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERPLL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ING LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELOTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFOSURES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUALOVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CAOLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CUTCRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL THIBUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER E TEM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM ESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRETION COLLABORATION COLLABORATION COLLABORATION COLLABORAINTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERPLL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ING LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELOTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFOSURES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUALOVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CAOLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CUTCRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL THIBUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER E TEM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM ESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRETION COLLABORATION COLLABORATION COLLABORATION COLLABORAINTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERPLL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL YER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER E

Transforming Dental Hygiene Education

and the Profession for the 21st Century

White_Paper_Covers.indd 1 8/17/15 10:58 AM

2 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

Table of ConTenTs03 Introduction

• GoalandPurpose• BackgroundandSettingtheStage• TransformingDentalHygieneEducationSymposium

05 Current State of Dental Hygiene Education• DentalHygieneProgramInfrastructure• AccreditationStandardsforDentalHygieneEducationPrograms• DentalHygieneLicensureRequirements

07 Imperatives for Change• TheAccess-to-CareCrisis• ChangingDemographicsandComplexityofCare• FutureOralHealthWorkforceProjections• EmergingTechnology• TwoSystemsofDelivery• DirectAccess• VirtualDentalHome• ExpandingScopeofPractice• DentalHygieneDiagnosis• HistoryofDentalHygieneDiagnosis• MinnesotaPavestheWay• CODAAdoptsandImplementstheAccreditationProcessforDentalTherapyEducationStandards

• FutureofDentalHygiene• ExpansionofOralHealthServicestoUnderservedPopulations• MovingForward

15 A Framework for Transformation• ADHA’sNationalDentalHygieneResearchAgenda• AdvancingtheProfessionbyLearningfromOthers• FocusonInterprofessionalEducation(IPE)andCompetency• PreparingaFutureGenerationofDentalHygienists• TheRoleofDentalHygieneEducators• ChangeChampionsNeeded• DevelopingNewDomainsandCompetencies• PilotProjectReports:EWUandVTC• PublicPolicyandRegulation

21 Conclusion

ChapTer one

ChapTer Two

ChapTer Three

ChapTer four

ChapTer five

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 3

TheAmericanDentalHygienists’ Association(ADHA),withthesupportofJohnson&JohnsonConsumerInc.,forthedistributionofthispaper,is pleased to provide thiswhite paper supple-mentonthefutureofdentalhygieneeducationandpractice,andhowdentalhygienistswillcon-tributetotheexpansionoforalhealthservices.Thiswhitepaperwill:

• Provide a summary of the “TransformingDentalHygieneEducation, ProudPast,Un-limitedFuture”(“theSymposium”);

• Describethefutureneedsofdentalhygienepractice;

• Outlinestrategiesthatwillcontributetotheexpansionoforalhealthservices tounder-served populations, including mothers andchildren;and

• Identify the future standards of educationandpractice—includingexaminingcurrentdental hygiene curriculum, and offer ideasonpotentialrevisionsandenhancementstopreparedentalhygienistsforfuturepractice.

Theissuesaddressedinthispaperasitrelatestochangesindentalhygieneeducationandtrans-formingthewaygraduatesarepreparedforthefuturehighlighthow,withthesechanges,dentalhygienistswillbebetterequippedtoservethehealthandwellnessneedsoftheentirepopula-tion.

Introduction

cHaPTer one

Goal and purpose

baCkGround and seTTinG The sTaGe

ThecoreideologyoftheADHAistoleadthetransformationofthedentalhygieneprofessiontoimprovethepublic’soralandoverallhealth.In2013,thedentalhygieneprofessioncelebratedits100thanniversary,amilestonethatcontrib-utedasacatalysttochange—infacttransform— theprofession.With recognition thatdentalhygieneeducationrequiredchangesothattheprofession would remain relevant in a chang-ing environment, the ADHA enlisted the helpof the Santa FeGroup (SFG), an organizationcomposed of internationally renowned schol-arsand leaders frombusinessandtheprofes-sionsunitedbyacommitmentto improveoralhealth.TogetherwiththeSFG,ADHAworkedtobringdentalhygieneeducators,researchersand

practitioners together with leaders from otherhealth disciplines, government, philanthropyandbusinesstostrategicallyaddressthisneedforchangeindentalhygieneeducation.

Part of the profession’s responsibility to thepublicincludesevaluatingitsownabilitytopro-videcareandtakingthestepsnecessarytoen-sure itsmaximum effectiveness. The ADHA iscommittedtobestpositioningtheprofessionofdental hygiene to be viewed as an integratedpartofthehealthcaresystemthroughstrategicpartnerships,aswellasmaximizing theabilityofdentalhygieniststotakeadvantageofoppor-tunitiesinmoreintegratedhealthsystems.1TheSFG and ADHA co-developed the Symposiumand invited guests from diverse professionalbackgroundstoexaminethedentalhygieneed-ucationalsystemthroughthelensofitshistori-calbeginning,thecurrentenvironment,andthefuture oral health care needs of the public. Itprovidedtheplatformtoexplorequestionsthathadnotbeenfullydeliberatedbefore.Ultimate-ly,thepurposeofadvancingeducationinden-talhygiene isachievingbetteroralandoverallhealthformorepeople.Tothatend,apartner-shipwasborn.

TransforminG denTal hyGiene eduCaTion symposium

InSeptember2013,theADHA,incollabora-tionwithSFGandtheADHA’sInstituteforOralHealth, convened a Symposium titled “Trans-formingDentalHygieneEducation,ProudPast,Unlimited Future.” The fundamental questionbehindtheSymposiumwashowtobestpreparedentalhygieniststoservethehealthandwell-nessneedsofsocietybytransformingthewaydentalhygienegraduatesareprepared for thefuture. In addition, the Symposium exploredwheredentalhygieneeducationhasbeen,whereitisnow,whereitwillneedtobeinthefutureand how changes to dental hygiene educationcanmovetheprofession forward.TheSympo-sium’slearningobjectivesincluded:

• Exploringhowthechangeinthehealthcareenvironment could inform the transforma-tionoftheprofessionofdentalhygiene.

4 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

• Identifyingthebroadrangeofrolesthatthedental hygiene profession could play andnewmodels of health care within and be-yonddentalcare.

• Considering the broad skills, attitudes andcompetencies needed by dental hygieniststomeetthefutureneedsofthepublic.

Michael Sparer, PhD, JD, Department Chair,Health Policy andManagement,ColumbiaUni-versity School of Public Health, served as theSymposium’skeynotespeaker.Hispresentation,“The Transformation of the U.S. Health CareSystem,”centeredontheimminentchangesun-derwayintheU.S.healthcaresystem,manyofwhichprecededtheAffordableCareAct.“Giventhechangesthataregoingoninthehealthcaresystem today,” Sparer said, “the agenda thatyouhavebeforeyouforthenextcoupleofdayscouldnotbemoreimportant.”2

OverthecourseoftheSymposium,keystake-holdersinhealthcarepolicy,education,financ-ingandcaredeliverydiscussedinnovativeden-talhygieneeducationmodelsthatwouldenabledentalhygienetoincreaseaccesstooralhealthcare.This increasedaccesswouldbeachievedbypreparingdentalhygienistsforanexpandedscopeofpracticeandintegrationintothehealthcaresystemasessentialprimarycareproviders.

The Symposium featured several distin-guishedauthorities.MarciaBrand,PhD,BSDH,MSDH,whowasthenDeputyAdministrator,U.S.DepartmentofHealthandHumanServices,pro-videdthefederalperspective.PamelaZarkows-ki,JD,MPH,BSDH,ProvostandVicePresident,Academic Affairs, University of Detroit Mercy,provided the educational and administrativeperspective.HalSlavkin,DDS,Professor,OstrowSchoolofDentistry,UniversityofSouthernCali-fornia,provided the researchperspective.AnnBattrell,MSDH,Chief ExecutiveOfficer, ADHA,provided organized dental hygiene’s perspec-tive.

The group heard from several health pro-fessions that have advanced their professionaleducationandcurriculum.PanelistMariaDolce,NP, PhD, Interim Director, School of Nursing,BouvéCollegeofHealthSciences,NortheasternUniversity,ascribedtheeducationandpracticetransformations within the nursing professionto thechanginghealthcareneedsof thepub-lic.Thistransformationinnursingeducationledto the incorporation of leadership and profes-sionaldevelopmentcompetenciessothatnurses

arewell-preparedtobecomefullpartnerswithphysiciansandotherhealthcareprofessionals.Competencies incorporated within the nursingcurriculum include leadership, health policy,system improvement, research and evidence-basedpractice.3Thenursingprofessionhassetanexampleforthedentalhygieneprofessiontofollow in response to the increasingly complexhealthcareneedsofthepublic.

PanelistLucindaL.Maine,PhD,RPh;Execu-tiveVicePresidentandChiefExecutiveOfficer,AmericanAssociationofCollegesofPharmacy,discussed the transformation of the pharmacyprofession over the last 40 years. Until 2004,apharmacistrequiredonlyabaccalaureatede-gree;today,adoctoraldegreeistheentrylevelfor the profession.2 Increasing the educationalrequirement for the pharmacy profession oc-curredduetothegrowthandcomplexityofthepharmaceutical industryand increasingchang-es in health care.2 The new doctoral curricu-lum“[incorporated]InstituteofMedicine(IOM)core competencies for the health professions:patient-centered professionals functioning inteam-based care that is evidence-based andemphasizesqualityandhealthinformationtech-nologycompetence.”2

PanelistRuthBallweg,PA,MPHA,Director,ME-DEXNorthwestPhysicianAssistantProgram,de-scribedthesimilaritiesbetweendentalhygieneandthephysicianassistants(PA)profession,es-pecially regarding the lackof clarityabout theidentity of the profession as perceived by thepublic.ThePAs’workingenvironmentsexpand-edfromprimarycareandemergencyroomstoallfieldsofhealthcareasa resultof thepro-fession’s transformation. The speaker encour-ageddentalhygienists toexploreareaswhereservicesareneeded,whether theseneedsaregeographic,economicordemographic.Ballwegrecommended that “dental hygienists consid-erbroader leadership rolesas systemsof oralhealthcareareintroduced,andincasemanage-mentorqualityandcompliancemanagement.”2

ThemesthatrecurredthroughouttheSympo-siumweretheneedforcollaboration,interpro-fessionaleducationandthedemandforawork-force as diverse as the communities it needsto serve.Repeatedly,participants stressed theneedforchangesintheregulatoryandeduca-tional infrastructure to support change. Smallgroupdiscussionsat theSymposium identifiedchallenges andbarriers thatwill affect the fu-tureof dental hygieneeducationandpractice.

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 5

Groups discussed challenges, barriers and op-portunitiesassociatedwithfivekeytopicareas:

• Statepracticeacts.• Accreditationstandards.• Financingandbusinessplans.• Newpracticelocationsandcollaborations.• Interprofessionaleducation.

The SFG attributed difficulty in accessing oralhealthcaretoavarietyoffactors.Amongtheseare the affordability of dental care for low-in-come populations, low health literacy, inad-equate public spending for Medicaid dental

care,theexclusionofdentalcareforMedicarebeneficiaries, themaldistributionand/or short-ages of dental health care providers, and re-strictivescope–of–practicelawsinmanystates.Thegroupbelievesthatinnovationandchangeareneededtoimproveequityinaccesstooralhealthcare.

“TheSantaFeGroupapplaudstheopennessof the ADHA to explore both new educationalparadigmsaswellasalternativepracticemodelsthatmayenhancethepotentialformorepeopletogainaccesstooralhealthcare,”saidtheSFGPresidentRaulGarcia,DMD,MMSc.

CurrentStateofDentalHygieneEducation

cHaPTer Two

Dental hygienists are primary oral carepractitionerswhohavecontributedtotheoralhealthofAmericansformorethan100years.The dental hygiene profession was foundeduponthepromotionoforalhealthandthepre-ventionofdiseaseforchildreninschool-basedsettings. While educational changes have oc-curredover time, currentdental hygiene cur-ricula are designed to meet the oral healthneedsofa20th-centurypatientbase—nottherequirements of today’s 21st-century patient.Clinical expertise has remained the primaryeducationalfocusforapplicationintheprivatedental practice setting. Today, dental hygien-istsprovidepreventiveandtherapeuticservic-es specified by their respective state practiceacts.Theseservicesareessential;however,adeliverysysteminwhichdentalhygienistsarepermitted to provide additional services anduseadditionalknowledgecouldincreaseaccesstounderservedpopulationsinalternativeprac-ticesettingssuchascommunityhealthcentersandhealthcareorganizations.

denTal hyGiene proGram infrasTruCTure

Dentalhygienistsareformallyeducatedandlicensedinall50statesandtheDistrictofCo-lumbia.Dentalhygienistsareabletograduatefromoneofthenation’s335accrediteddentalhygieneeducationprograms,andsuccessfullycomplete both a nationalwritten examinationandastateorregionalclinicalexamination.Theaverage entry-level dental hygiene education

programis84credits,oraboutthreeacademicyears,induration.4Approximately6,700dentalhygienists graduate annually from entry-levelprogramsthatofferacertificate,anAssociate’sdegree or a Bachelor’s degree and preparegraduatesfortheclinicalpracticeofdentalhy-giene.Currently,21dental hygieneeducationprogramsofferMaster’sdegrees.4Presentlyin48statesandtheDistrictofColumbia,dentalhygienistsarerequiredtoundertakecontinuingeducationaspartofthelicensurerenewalpro-cess to maintain and demonstrate continuedprofessionalcompetence.5

InMarch2016,Coloradowillalsobeginre-quiringcontinuingeducation.Atthattime,Wy-omingwillremaintheonlystatethatdoesnotrequirecontinuingeducationasaprovisionforlicensurerenewal.

aCCrediTaTion sTandards for denTal hyGiene eduCaTion proGrams

A discussion of dental hygiene educationmustincludetheCommissiononDentalAccred-itation’s(CODA’s)“AccreditationStandardsforDental Hygiene Education Programs” (subse-quentlyreferredtoas“TheCODAStandards”)asareferencepoint.6TheCODAStandardsarethe guidelines and requirements for accredit-ed dental hygiene educational programs. ThecurrentCODAStandards include someessen-tialcontentareasthatprovidekeyfoundationsforfuturedentalhygienepractice.Examplesof

6 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

thesecontentareasincludehealthpromotion,diseaseprevention, clinical practice and com-munityservice.Withchangesinsocietalneeds,advances in technology, new research high-lightingtheoral-systemiclinkandthegrowingcomplexityofthehealthcaredeliverysystem,current educational standards and curricu-larcontentwillneedaugmentation.2Curriculamay need to expand beyond a primary focusonclinicalexpertisetoincludeabroaderfocuson primary care, public health service deliv-ery,populationwellness,culturalandlinguisticawareness,andhealthliteracy.

Specifically,more focus on disease preven-tionandhealthpromotionrelatedtotheoral-systemiclink,theroleofinflammation,andtheuseofnewtechnologytodeterminerisklevelswould enhance current guidelines. Additionalcurriculum time could be made available forphysical, head, neck, and oral cavity assess-mentanddiagnosis through theuseof chair-sidediagnostics,salivarytesting,nanotechnol-ogy, genomic mapping, telehealth, and otherstate-of-the-artmethodologies.7,8

TheCODAStandards,atpresent,provideforentry into theprofessionwitheitheranasso-ciatedegreefromatwo-yearcollegeprogramorafour-yearcollegeoruniversitywithanas-sociatedegree,post-degreecertificateorbac-calaureatedegree;however,theADHA’spolicystatementsupportsabaccalaureatedegreeforentryintotheprofession.9Currently,288den-tal hygiene academic programs award an as-sociatedegree,furtherimpedingmovementtoahigherentry-leveldegree.4Associatedegreeprogramsaremoreattractivethanbaccalaure-ateprograms tomany studentsbecause theyarelessexpensiveandrequirelesstimebeforegraduation.Adilemmaisthatassociatedegreeprogramsmay lack thecurricular timeneces-sary for dental hygiene educational enhance-ment.

denTal hyGiene liCensure requiremenTs

Current clinical licensing examinations pri-marilymeasureadentalhygienist’scompetenceby evaluation of specific clinical skills as wellasthecandidate’scompliancewithprofessionalstandardsduringthecourseoftreatment.Asanexample, the Central Regional Dental TestingServices(CRDTS)examscoringrubricawardsamajorityofitstotal100pointsforScaling/Sub-gingival Calculus Removal and SupragingivalDepositRemoval.Traitsconducivetocollabora-

tivepracticesuchas teamwork, critical think-ing skills and professional judgment are notassessed. TheNational BoardDental HygieneExamination (NBDHE) is a written exam thatassesses the ability to understand importantinformation from basic biomedical and dentalhygienesciences,andtheabilitytoapplysuchinformation in a problem-solving context. Al-thoughtheNBDHEdoesmeasuredidacticandacademic knowledge, a more comprehensivetest would be needed to incorporate the ad-ditionalcontent required for futuredentalhy-gienepractice.

AccordingtotheRobertWoodJohnsonFoun-dation, advanced education benefits patients,employers and communities. To take an ex-ample from the nursing profession, baccalau-reate-prepared nurses tend to contribute tosaferworkingenvironments, to lowerratesofmortalityforhospital-acquiredconditions,andtoprovideareadypipelineofprofessionalstofill leadership and management roles. In thenursingprofession,demandisgrowingforad-vancedpracticeregisterednursespreparedbypost-graduate work for licensed independentpractice. With these credentials, nurses mayassumeadvancedclinicalroles.Likewise,den-talhygienistswithadvanceddegreescouldof-ferparallelbenefitstopatients,employersandthecommunitiestheyserve.10,11

Revisingboththeclinicalanddidacticlicens-ingexaminationsisacomplexendeavorrequir-ing redevelopment of both the administrationandthecontentofthetests.Theprocessesfol-lowedbyotherprofessionsthathaveelevatedtheirterminaldegreesprovidesomeguidance.Stakeholders integral to realizing this changeprocess are regional clinical licensing boards(e.g., Northeast Regional Board), the ADHA,the American Dental Education Association(ADEA), professional and community dentalpublic health advocacy groups, other healthprofessiongroupsandtheJointCommissiononNationalDentalExaminations(JCNDE).

Dentalhygienistscanhelpfulfillthenation’sgoalofprovidingthepublicwithimprovedac-cess to oral and general primary health careservices. The dental hygiene profession’s po-tentialtohelpachievethehealthcaregoalsoftheUnitedStatesdependsonthetransforma-tion of dental hygiene education. Curriculummodification,and inmany instances, reinven-tion, can create a profession ready to acceptthechallengesofthe21stcentury.

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 7

ImperativesforChange

cHaPTer THree

The aCCess-To-Care Crisis

In 2000, the U.S. Surgeon General’s report,“OralHealthinAmerica,”calledforactiontoad-dresstheoralcareneedsanddisparitieswithinthe United States.12 Seven years later, in De-cember2007,12-year-oldDeamonteDriverdiedafter bacteria that spread from an abscessedtoothinfectedhisbrain.Driver’sdeathisanun-fortunateexampleofthepotentialimpactofun-treatedoraldisease.DriverhadbeencoveredbyMedicaidsporadically,buthewasdroppedfromtheprogramduringcriticaltimesduetounfiledpaperwork.At thetimeofhisdeath,his familydidnothaveinsurancebutweremakingrepeatedeffortstofindadentistwhowouldacceptMed-icaid.13

In2012,KyleWillis,a24-year-oldfatherwhowas unemployed and lacked health and dentalinsurance,wenttotheemergencyroombecauseofatoothache.Williswasprescribedpainmedi-cationandantibiotics,butdiedfromatoothin-fectionbecausehecouldn’taffordtheantibioticsheneeded.13Willis’deathisadditionalevidenceoftheimportanceoforalhealthandtheseriousconsequencesforpeoplewithoutaccesstodentalcare.

LackofaccesstodentalcareforcestoomanyAmericans to enter hospital emergency roomsseeking treatment for preventable dental con-ditions that emergency rooms are typically ill-equippedtohandle.Despitethefactthatdentalhygienists,alongwithdentistsandothermem-bersoftheoralhealthcareteam,providecareinprivateofficestoalargeportionofthepopulationin theUnitedStates,millions of people remainunserved.Morethan46millionpeopleintheU.S.currentlyliveindentalhealthprofessionalshort-ageareas(DHPSAs),lackingbasicaccesstoden-talcare.14

The National Governors Association’s (NGA)January 2014 issue brief entitled, “TheRole ofDental Hygienists in Providing Access to OralHealthCare,” found that “Innovative statepro-grams are showing that increased use of den-talhygienistscanpromoteaccesstooralhealthcare, particularly for underserved populations,including children,” and that “such access can

reducetheincidenceofserioustoothdecayandotherdentaldiseaseinvulnerablepopulations.”15

The Centers for Medicare and Medicaid Ser-vices (CMS)hasworkedwith federal and statepartners,thedentalandmedicalprovidercom-munities,andotherstakeholderstocontinuetoimprovechildren’saccesstodentalcare.TheChil-dren’sHealthInsuranceProgram(CHIP)provideshealthcoveragetoeligiblechildren,throughbothMedicaid and separateCHIPprograms.CHIP isadministeredbystates,accordingtofederalre-quirements.InApril2010,CMSlaunchedthena-tionalOralHealthInitiative,whichasksstatestoincreasetheuseofpreventivedentalservicesbychildrenenrolledinMedicaidbyatleast10per-centagepointsoverfiveyears.TheCMSnotedinaninformationalbulletinissuedonJuly10,2014,that, “Although dental disease in children islargelypreventable,andtoothdecayremainsthemostcommonchronicillnessamongchildrenintheUnitedStates,toomanychildrenstilldonothaveaccesstoregularoralhealthcare.ChildrenenrolledinMedicaidandCHIParemorelikelytosufferfromdentaldiseaseandlesslikelytousedental services than privately insured children.Increasinganddiversifyingthedentalworkforcecanbeanimportantpartofastrategytoaddresstheseoralhealthdisparities.”16

AllchildrenenrolledinMedicaidandCHIPhavecoverage for dental and oral health services.However,accordingtothe2014Secretary’sRe-portontheQualityofCareforChildrenEnrolledinMedicaidandCHIP,the2013medianoftotaleligiblechildrenreceivingpreventivedentalser-viceswas48percentandamedianof23percentreceiveddentalservice.17

ChanGinG demoGraphiCs and ComplexiTy of Care

Childrenarenottheonlypopulationthatmightbenefitfromincreaseddirectaccesstodentalhy-gienists.Thegeriatricpopulationisburgeoning,withoneineightU.S.adultsnowaged65orold-er.Inthisagegroup,almost1.5millionresideinlong-term-carefacilities.18Itispredictedthatthenumberofindividualslivinginnursinghomeswill

8 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

doublebetween2000and2050.19Thesechangesinpopulationdemographicsandaccesstoafford-ableoralhealthcaremayprovideopportunitiesfordentalhygienists—whileconcurrentlyoffer-ingimprovedaccessforelderpopulationsfacedwithlimitedoralhealthcareoptionsaswell.

Amyriadofsocietalfactorsandnewresearchsupporttheneedfordentalhygiene’sgrowthandexpansion.DemographictrendsindicatethattheU.S.populationischanging,withanincreaseinunderserved patients and demographic groupsthat are underrepresented in both patient andpractitionerpopulations.Manyoftheunderservedpopulationswillpresentwithcomplexhealthcareneeds including complications that far exceedoralconcerns.Behavioral,financial,culturalandmedicalissueswillhavetobeaddressed,astheyoftencannotbeseparatedfromoralhealthneeds.Allofthesetrendswillbeinstrumentalindefiningfuturedentalhygieneroles,asmeetingsocietalneedswillrequireoralhealthcareprovidersfrommorebackgrounds, inmore roles,and inmoresettingsthanjustthetraditionalprivatepracticedentaloffice.

Asof the lastU.S.Census,40.3millionpeo-pleovertheageof65werelivingintheUnitedStates.Eachday10,000adultsretireintheUnit-edStatesbutonlytwopercentkeeptheirdentalbenefits,and35percentof lower-incomeolderadults have not seen a dental provider in fouryearsormore.20Thesearejustsomeofthesta-tisticshighlightingthefactthattheoralhealthofAmerica’sagingpopulationisinseriousperil.

According to a 2013 report by Oral HealthAmerica (OHA), “A State of Decay,” while im-provements in oral health have been observedoverthelast50years,significantchallengesre-mainforthe10,000Americansretiringeachday.TheOHAreportfound,“Limitedaccesstodentalinsurance,affordabledentalservices,communitywater fluoridation, and programs that supportoral health prevention and education for olderAmericans are significant factors that contrib-ute to theunmetdental needsandedentulismamongolderadults,particularlythosemostvul-nerable.”21

The report highlights a critical issue — thestraineddentalworkforce infrastructure.Thirty-onestates,or62percent,havehighDHPSAratesand consequently aremeeting only 40 percentorlessoftheneed.AmongtheOHAconclusionswasarecommendationtoaddresstheseshort-ageareasbyimprovingtheprimaryoralhealth

fuTure oral healTh workforCe projeCTions

While demand for oral health care servicescontinues to grow, changes in the availabilityof thosewhoprovide thoseserviceswill putagreaterdemandontheneedfordentalhygien-ists— and for dental hygienists to be able topractice to the fullest extent of their scope inordertoadequatelymeettheoralhealthneedsof the public. The U.S. Department of HealthandHumanServices’HealthResourcesandSer-vices Administration (HRSA) Bureau of HealthWorkforcebrieftitled“NationalandState-LevelProjectionsofDentistsandDentalHygienistsintheU.S.,2012-2025,”statesthatnationally,theincreasesinthesupplyofdentistswillnotmeetthe demand for dentists as they are incorpo-rated intothecurrentoralhealthcaresystem,exacerbatinganalreadyexistingshortage;andthat“All50statesandtheDistrictofColumbiaareprojectedtoexperienceashortageofden-tists.”14

Exploring the changing role of the dentalhygienist as an integratedmemberof the21stcenturyoralhealthcareteam,HRSAstatesthat“Changes in oral health delivery and in healthsystems may somewhat ameliorate dentistshortagesbymaximizingtheproductivityoftheexistingdentalhealthworkforce,”andthat“In-creased use of dental hygienists could reducetheprojecteddentistshortageiftheyareeffec-tivelyintegratedintothedeliverysystem.”14

emerGinG TeChnoloGy

In recent years, extensive advancements indentaltechnology—especiallytelecommunica-tions, digital diagnostics and imaging — havehelped dental professionals collaborate, diag-nose, manage and provide dental services indistant locations. The process of networking,sharinginformation,consultationsandanalysisthroughtechnologyiscalledtelehealth,ofwhichteledentistry is a part.22,23 Teledentistry offersthe potential to improve access to oral healthcare, eliminate health disparities, enhance thedelivery of services and provide specialist ex-pertiseinremoteareaswhereadentalhygienistmaybetheonlyoralhealthcareproviderinthecommunity.24

workforcethroughalternativeworkforcemodels,includingexpandingtheroleofdentalhygienistsanddentaltherapists.

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 9

As teledentistry continues to emerge andevolve,dentalhygieneeducationmustpreparefor the future. Students who are educated touseinformationandcommunicationtechnologyas a part of dental hygiene practice will havethe foundational knowledge to adopt futuretechnologicaladvancementsastheyoccur.Den-tal hygienists with this expertise will functionwithmoreinter-collaborationinclinicaldecisionmaking, casemanagement,provisionofdirectcare,andpatienteducationontreatmentregi-mensandadoptionofhealthylifestylesandoralhealthpractices.

Understanding and utilizing digital informa-tion, patient data and other assessments canprovideablueprintforimprovingaccesstocare.An example of this in use can be found in apracticemodel institutedbyWillametteDentalGroup,alargegroupdentalpracticewithaffili-ateddentalinsuranceandmanagementservicecompanies.TheWillamettemodeldemonstrateshowadentalhygienepractitionercanplayaroleinimprovingaccesstooralhealthcare.Forex-ample,nursesinanemergencydepartmentwhoidentifiesapatientwithadentalissuewillcon-tactaWillamettefacilityandspeakdirectlytoadental hygienist. TheWillametteDentalGroupstrives for their dental hygienist employees tohavedigitalliteracyskillsandtheabilitytoenteressentialdatapointsandriskassessmentsintoelectronicdentalrecords,aswellasunderstandthedivergentneedsofadiversepatientbase—includinghowtocommunicateacrosscultures,ethnicitiesandgenerations.Thispracticemodelalso necessitates interprofessional collabora-tion and collaborationwith other provider set-tings,suchasFederallyQualifiedHealthCenters(FQHCs),medical homes,andhealth systems.Theprocesses in theWillamettemodelare fo-cusedon interprofessional interaction, collabo-ration and the “four dimensions of right:” therightprovider,therightlocation,therighttimeandtherightservices.2,25,26

Two sysTems of delivery

Theoralhealthcaresystemisprimarilycom-posedoftwoseparatedeliverymodelsthatusedifferentfinancingsystems,treatdifferentpopu-lationgroupsandoffercareindifferentsettings.Private dental office care is typically providedinsmallofficesandfinancedprimarily throughemployer-based or privately purchased den-tal coverage and out-of-pocket payments. Thesafetynet,incontrast,ismadeupofadiverseand fragmented group of providers in various

settings.ItisfinancedprimarilythroughMedic-aidandCHIP,othergovernmentprograms,pri-vate grants, and out-of-pocket payments. Thenon-dental health care workforce is becomingincreasingly involved in this provision of oralhealthcare.27

Underservedandvulnerablepopulationsfacemanybarriers to accessing the traditional oralhealthsystem—includinglackofdentalinsur-anceorinabilitytopay,difficultyaccessingser-vicesduetolowlevelsofhealthliteracy,physicaldisabilities, geographic barriers and maldistri-butionoforalhealthcareproviders.Therefore,thoseunderservedpopulations tend to relyonthe “dental safety net.” Generally, the dentalsafetynetiscomposedofavarietyofproviders,including FQHCs, FQHC look-alikes, non-FQHCcommunity health centers, dental schools,school-basedclinics,stateandlocalhealthde-partments,andnot-for-profitandpublichospi-tals.Inspiteofthenumberofdentalsafetynetproviders,theneedsofthosewhoareleftoutoftheprivatesystemarestilloftennotmet,duetoalackofcapacityoftheseprovidersoraper-ceivedlackofaffordableoptionsbyindividuals.

direCT aCCess

Currently,37 stateshaveprovisions in theirstatepracticeacts thatallowdentalhygieniststo provide various levels of direct access ser-vices.28Directaccessallowsadentalhygienisttoinitiatetreatmentbasedontheirassessmentofapatient’sneedswithoutthespecificauthori-zationofadentist,treatthepatientwithoutthepresenceofadentist,andmaintainaprovider-patientrelationship.29Insomeinstances,dentalhygienists must meet specific educational re-quirementsandhavedesignatedexperiencetoworkinfederal,state,schoolorothernon-tradi-tionalsettings.30Often,thedentalhygieneser-vices provided under direct access are limitedandmayrequirepublichealthsupervisionorawrittenagreement,i.e.aCollaborativeManage-mentAgreementestablishedbetweentheden-tal hygienist and the collaborativedentist thatdentalhygienistworkswith.28

One model in Nevada that has been cre-ativeinobtainingfundingforitsoperationsandhas forged community partnerships is “FutureSmiles.”ThisNevadanonprofitcorporationandIRS status 501(c)(3) utilizes the Nevada pub-lichealthspecialtylicensethatmaybeobtainedunderaregistereddentalhygienelicense.Pub-lic HealthDental Hygienistswho hold a Public

10 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

Health Dental Hygiene Endorsement (PHDHE)approvedbytheNevadaStateBoardofDentalExaminers(NSBDE)candeliveravarietyofpre-ventiveservicesthatinclude:oralhealthscreen-ings, prophylaxis, fluoride varnish and digitalx-raysinamultitudeofcommunityandschoolbased settings. Terri Chandler, RDH, FutureSmilesFounder/ExecutiveDirector,hasworkedwithmanygroupstoachievesuccess,withafi-nancial support system that includes solidpri-vate/public partnerships, corporate-sponsoredcommunity grants, philanthropic foundations,localbusinesses,Medicaidreimbursement,andasocialserviceprogramthataddressestheoralhealth needs of the underserved andprovidestechnicalassistance.31

ASouthCarolinabusinessthathasbeeneffec-tivewaslaunchedbyTammiByrd,RDH,calledHealth Promotion Specialists (HPS). HPS em-ploysdentalhygieniststoprovidecaretoschoolchildren.Theschool-basedprogrambringsden-tal hygienists directly to low-income studentsin 413 schools in 45 targeted school districts.Importantly, the program has 20 restorativepartners, dentists who agree to see referredchildrenintheirprivateoffices,thuspromotingthe receipt of comprehensive services. Care-giversareprovidedwithlistsofdentistsinthechild’sneighborhood,notingwhichonesacceptMedicaidpatients.Datafromthestatedemon-stratedthat inthefirstfiveyearstheprogramwas effectively in place, sealant use for Med-icaid children increasedwhile the incidence ofuntreatedcavitiesandtreatmenturgencyratesdecreased for that population. The 2007-2008South Carolina Oral Health Needs Assessmentshowedthattherewerenodisparitiesbetweenblackandwhitethird–gradechildrenforsealantuseinSouthCarolina.32

virTual denTal home

ThePacificCenterforSpecialCareattheUni-versityofthePacific,ArthurA.DugoniSchoolofDentistry(Pacific)hascreatedaneworalhealthdeliverysystemutilizingteledentistry,the“Vir-tual Dental Home (VDH).” The VDH is a com-munity-based delivery system inwhich peoplereceivepreventiveandsimple therapeutic ser-vices. Pacific has partnered with a number oforganizationstobringmuch-neededoralhealthservicestoCalifornia’smostvulnerableandun-derservedcitizens.Careisdeliveredwherepeo-ple live,work, play, go to school, and receiveeducationalandsocialservices.

TheVDHprojectutilizesregistereddentalhy-gienists inalternativepractice(RDHAP), regis-tereddentalhygienistsworkinginpublichealthprograms, and registereddental assistants. InadditiontotheirtraditionalscopeofpracticetheVDH model has also demonstrated the safetyandacceptabilityof twoprocedureswhenper-formedbyallieddentalpersonnel—placingin-terimtherapeuticrestorations(ITR)tostabilizepatientsuntiltheycanbeseenbyadentistfordefinitivecare,and theability todecidewhichradiographstotakeinordertofacilitateanoralevaluationbyadentist.33

Thevirtualdentalhomeprojecthassuccess-fully demonstrated the ability to deploy geo-graphicallydistributed,collaborative,telehealthfacilitatedteamswhoareseeingpatients,per-formingpreventionandearly intervention ser-vices, andmaking and supporting referrals todentistsasneeded.PlansareunderwayinCali-fornia to expand this system throughout thestate.34

expandinG sCope of praCTiCe

Affordingdentalhygieniststheabilitytoprac-ticetothefullestextentoftheireducationisan-otherpathwaythatwouldimprovetheaccesstocare.States’dentalhygienescopesofpracticeand supervision requirements vary consider-ably.35 Even in stateswhere dental hygiene isself-regulating, degrees of self-regulation andsupervision requirements varywidely.30,36 Self-regulationenablesprofessionstoeffectchangeintheirscopesofpracticetoreflecttheirnaturalevolution.37Nursing, physical andoccupationaltherapy, physicians’ assistants, and pharmacyhavemandatedhigherlevelsofeducationwithintheir professions; these mandates transpiredbecausealloftheseprofessionsareself-regulat-edandhavetheirownprofessionalaccreditationbodies.Thesechangeshaveenhancedservicesandbroadenedscopesofpractice.7

In primary care roles, dental hygienists donotworkinisolation,butleveragethecontribu-tionsandexpertiseofotherhealthprofessionalswhileon-siteorthroughtelehealth.Thedentalhygieneprofessioncanlearnfromcurrentprac-ticemodelsthathavebeendevelopedinvariousstatesandcountries.

InJanuary2015,FamiliesUSAreleasedHealthReform2.0,whichoutlinesseveralproposalstoincreasehealthcarecoverageandreducehealthcarecosts.38Manyinsuredfamiliesstillfacebar-

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 11

denTal hyGiene diaGnosis

Discussions related to dental hygiene scopeof practice should also include dental hygienediagnosis. It is imperative that dental hygienediagnosisbeincludedintheeducationandprac-ticeofdentalhygienistsforthesuccessfultrans-formationofthedentalhygieneprofession.Ap-pendixAprovidestheADHApositionondentalhygienediagnosis.

DentalhygienediagnosishasbeendefinedbyADHA as, “The identification of an individual’shealthbehaviors,attitudes,andoralhealthcareneedsforwhichadentalhygienistiseducation-allyqualifiedandlicensedtoprovide.Thedentalhygienediagnosisrequiresevidence-basedcriti-cal analysis and interpretation of assessmentsinordertoreachconclusionsaboutthepatient’sdentalhygienetreatmentneeds.Thedentalhy-gienediagnosisprovidesthebasisforthedentalhygienecareplan.”39

ADHAsupportsdentalhygienecurriculathatleadstocompetencyinthedentalhygienepro-cessofcare:assessment,dentalhygienediag-nosis,planning,implementation,evaluationanddocumentation.40

Statestatutesaremostoftensilentonwhatdegreeofpatient evaluation is included in thedentalhygienescope.In2004and2009respec-tively,Oregon41andColorado42becamethefirststates to specifically authorize the dental hy-gienediagnosisaspartofthedentalhygienists’scopeofpractice.

hisTory of denTal hyGiene diaGnosis

TheCODAwasestablishedin1975andisna-tionallyrecognizedbytheUnitedStatesDepart-mentofEducationasthesoleagencytoaccreditdental and dental-related education programsconductedatthepost-secondarylevel.

On Jan. 1, 2010, the CODA removed “den-talhygienetreatmentplan”and“dentalhygienediagnosis” from the CODA Accreditation Stan-dardsforDentalHygieneEducationPrograms.43The terms dental hygiene treatment plan anddentalhygienediagnosishadbeenapartoftheaccreditationstandardsfordentalhygieneedu-cationprogramssince1998.

The removal of “dental hygiene diagnosis”from the dental hygiene education standardswas not supported by any evidence and doesnotcorrelatewiththedentalhygieneprocessofcare.Infact,dentalhygienediagnosiswasre-tained in the “definition of terms” used in theCODA dental hygiene education standards.6Dentalhygieneeducationprogramshavebeenincludingandmanycontinuetoincludeassess-ment, dental hygiene diagnosis, planning, im-plementation, evaluation and documentationas education competencies.44 Further, thoseaforementioned competencieswill enable den-talhygieniststoefficientlyandeffectivelybringpeople into the oral health pipeline andmakereferralswhennecessary.

minnesoTa paves The way

In2009,Minnesotabecamethefirststateinthecountrytoauthorizeamid-leveloralhealthprovider,knownastheDentalTherapist(DT)andAdvancedDentalTherapist(ADT).LicensesmaybegrantedinDentalTherapy,permittingapre-scribedscopeofpracticeundereitherthegen-eralorindirectsupervisionofalicenseddentist.Withadditionaleducationandtesting,aDTmaybeeligibleforcertificationasanADT,permittingmany functions tobedelegatedundergeneralsupervisionandallowingadditionalspecifiedre-storative procedures. The delegation of dutiesisgovernedunderaCollaborativeManagementAgreement,essentiallyacontractbetween thecollaboratingdentistandtheDTorADT.

Minnesota State Colleges and Universities(MNSCU) supported the development of theADTprogram.NormandaleCommunityCollege/Metropolitan State University created a dentalhygiene-basedprogram that builds on the ex-pertiseofdentalhygienistsbyofferingamas-

rierstoaccessparticularlyinunderservedcom-munities. The Focus for FamiliesUSA, in part,isensuringthathealthcoverageissynonymouswithaccesstohealthservices.Amongthepro-posalsinHealthReform2.0isuniversaldentalcoverageandtheutilizationofdentaltherapiststo address the access gap. “States should re-visetheirscopeofpracticelawstoallowexistingmid-levelproviders,suchasnursepractitionersanddental hygienists, to practice at thehigh-estlevelallowedbytheirtraining,andtoallowothermid-levelproviders,suchasdentalthera-pists,topracticeatthetopoftheirlicenses.”38Thepublicwillbenefitfromhygiene-basedmid-levelprovidersasthistypeofprovidercandeliv-erboththepreventivescopeofalicenseddentalhygienistandthespecifiedrestorativescopeofadentaltherapist.Increasedaccesswillaffordthepublicgreateropportunitiestoreceivecare,andimproveboththeiroralandoverallhealth.

12 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

Coda adopTs and implemenTs The aCCrediTaTion proCess for denTal Therapy eduCaTion sTandards

Allowingthedentalhygienistdirectaccesstothepatientisastartingpointforenablingthepublic’sgreateraccesstooralhealthcare—atopicthattheUnitedStatesFederalTradeCom-mission(FTC)hasaddressedwithinthecontextof the deliberations on dental therapy. In re-sponse to the CODA’s proposed AccreditationStandards for Dental Therapy Education Pro-grams,theFTCissueda15-pageletterofcom-ment.TheFTC stated, “Expanding the supplyofdentaltherapistsbyfacilitatingthecreationofnewdental therapytrainingprograms... islikelytoincreasetheoutputofbasicdentalser-vices,enhancecompetition,reducecosts,andexpandaccesstodentalcare.Thiscouldespe-ciallybetrueforunderservedpopulations.”46

AtitsFebruary6,2015,meeting,theCODAadoptedtheAccreditationStandardsforDentalTherapy Education Programs.47 Subsequently,the CODA requested additional informationfrom communities of interest. The CODA hadrequestedadditionalinformation,basedonthe“CODAEvaluation&OperationalPolicies&Pro-cedures.”48 The document includes The Prin-ciples and Criteria Eligibility of Allied DentalProgramsforAccreditationbytheCODA,whichoutlinesthecriteriathatmustbemetfornew

allieddentaleducationareasordisciplines.Thecriteriathatrequiredfurthercommentwere:

Criterion2:Has theallieddental educationareabeeninoperationforasufficientperiodoftime to establish benchmarks and adequatelymeasureperformance?

Criterion 5: Is there evidence of need andsupportfromthepublicandprofessionalcom-munitiestosustaineducationalprogramsinthediscipline?

TheFTCprovidedasecondletterofcommentto the CODA regarding adoption of the stan-dards,concludingthat,“Thetimelyadoptionofaccreditation standards by the CODA has thepotentialtoenhancecompetitionbysupportingstatelegislationforthelicensureofdentalther-apists,andalsotoencouragethedevelopmentof dental therapy education programs consis-tentwithanationwidestandard,whichwouldfacilitatethemobilityofdentaltherapistsfromstate to state tomeet consumer demand fordentalservices.”49

On August 7, 2015, the CODA determinedthat the criteria had been met and voted toimplementtheaccreditationprocessfordentaltherapy education programs. Implementationofthedentaltherapyaccreditationprocesswilltakeplaceduringthenextfewyears.Thiswasacriticalstepforwardinaddressingthegrow-ing interest in the potential for dental thera-pists tomeetdentalcareneeds in theUnitedStatesandcreateanewcareerpathfordentalhygienists.

Amoreexpedientapproachtomobilizingthedentalhygieneprofessionandacceleratingac-cesstooralhealthcarewouldbetoacknowl-edgeandutilize thecadreofalready licenseddentalhygienists.Thedentalhygieneworkforceiseducated,preparedandavailable,andbylift-ing restrictionsandallowingdentalhygieniststopracticetothefullextentoftheirscope,thiswouldprovidethepublicwithimprovedaccesstocare.Further, theremovalof theserestric-tions would also allow dental hygienists whowish topursue furthereducationandbecomeamid-leveloralhealthprovidertheopportunitytodoso.Thiswouldprovidethepublictheben-efit of havinggreater access to apractitionerwho can provide both preventive and restor-ativeservices.Severalstatesarenowconsider-ingavarietyofproposalsthatwouldfacilitatelicensed dental hygienists pursing additional

ter’s degree that develops a new career pathandenablesemploymentinsettingsoutsideofprivatedentalofficessuchasschoolsandsafetynetclinics.Graduatesoftheprogramaretheneligibletobeduallylicensedasregistereddentalhygienists(RDH)andADTs.

In February 2014, the Minnesota Board ofDentistry, in consultation with the MinnesotaDepartmentofHealthreleasedapreliminaryre-portontheimpactofdentaltherapists inMin-nesota.45AppendixBlistshighlightsfromitsex-ecutivesummary.

In2014,MainepassedlegislationcreatingtheDentalHygieneTherapist(DHT).DHTsinMainewill be dually licensed as RDHs and DHTs, astheMainestatuterequiresthatapplicantstotheprogrammust possess a license in dental hy-giene.DHTsmustworkunderthedirectsupervi-sionofaMainelicenseddentist,withawrittenpracticeagreement.ItremainstobeseeniftheoutcomeswillbethesameasinMinnesota,duetothedifferentlevelsofsupervision.

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 13

fuTure of denTal hyGiene

A2014 reportonexpandingpreventiveoralhealth services outside dentists’ offices fromtheNGAnotedthatstateshavelookedintoal-tering supervision or reimbursement rules, aswell as creating professional certifications foradvanced-practice dental hygienists. To date,studiesofpilotprogramshaveshownsafeandeffectiveoutcomes.15

The impact of dental hygienists’ expandedrolesinvariouscountriesaroundtheworldhasbeenmeasuredinnumerousreportsandstud-ies, and positive reports from projects imple-mentedindifferentregionsthroughouttheU.S.showthatunderservedpopulationsobtainneed-edcarewhendentalhygienistshaveabroaderscopeofservicesandareabletopractice inavarietyofenvironments.There isaneedforacomprehensivesummaryofsuchdatafromex-ampleswithintheU.S.

expansion of oral healTh serviCes To underserved populaTions

Evidenceofdentalhygienists’ability toalle-viate access barriers can be found across thecountry.Imperativesfortransformationincludetheresponsibilitytoleveragethemomentumofsuccessesas illustrated in the followingexam-ples.

California

In1998,afteranextensivepilotproject,thestateofCaliforniaofficiallyrecognizedtheReg-isteredDentalHygienist inAlternativePractice(RDHAP), with a goal of improving access todental hygiene care among high-need popula-tionswith limitedaccesstocare. In2002, thefirstRDHAPeducationalprogramwasapprovedatWestLosAngelesCollege.

TheRDHAPisalicensedregistereddentalhy-gienistwithadditionaleducationtoallowhimorhertopractice insettingsoutsideofthetradi-tionaldentaloffice,withoutthepriorauthoriza-tionorsupervisionofadentist.Thesepracticesettingsinclude,butarenotlimitedto,schools,residentialfacilities,privatehomesand,insomeinstances,RDHAPoffices.RDHAPsprovide pa-tientsthesametypeofprofessionalpreventivecare theywould receive ina traditional dental

officebutallowspatientswithlimitedornoac-cesstoreceivecareconveniently.

Data indicates that compared to traditionaldental hygienists practicing in California, RD-HAPsseemorepatientsfromunderservedpopu-lations.Theseincludepatientsinclinics,schools,federally-designated dental health professionalshortageareas,aswellashomeboundpatients.ElizabethMertz,PhD,MA;andPaulGlassman,DDS,MS,MBA, report that,given thepracticesettingsofRDHAPs,itisclearthatunderservedpopulationsarebeingreached.50

Kansas

In 2003, Kansas passed legislation that ex-pandedthescopeofpracticefordentalhygien-ists, inanattempt tocombatDHPSAsthataf-fectedmorethan90percentofthecountiesinthe state. Themeasure created the ExtendedCare Permit (ECP), which “allows dental hy-gienists to provide preventive services, to un-derservedandunservedpopulations inexplicitlocations, through an agreementwith a spon-soringdentist.”51In2007,thelegislaturefurtherexpanded the settings and populations that adentalhygienistwithanECPcouldserve.

The ECP I permit authorizes treatment forchildren in various limited access categories,andrequiresthedentalhygienisttohave1,200clinical hours or two years as an instructor atan accredited dental hygiene program in lastthreeyears.TheECPIIpermitauthorizestreat-mentforseniorsandpersonswithdevelopmen-taldisabilitiesandmandates1,600hoursortwoyearsasaninstructorinlastthreeyears,plusasix-hourcourse.ECPIandIIfunctionsinclude:prophylaxis,fluoridetreatments,dentalhygieneinstruction,assessmentofthepatient’sneedforfurther treatmentbyadentist, andother ser-vicesifdelegatedbythesponsoringdentist.

TheECPIIIpermit,whichrequires2,000hoursofclinicalexperienceplusan18-hourboardap-proved course, authorizes dental hygienists totreatawiderrangeofpatientsandtoperformevenmoreexpansivefunctionsincludingatrau-matic restorative technique, adjustment andsoft relineof dentures, smoothing sharp toothwithahandpiece, localanesthesia inasettingwheremedicalservicesareavailableandextrac-tionofmobileteeth.

In a 2011 qualitative study conducted byDelingeretal,therewereatotalof1,750den-

education to administer an advanced clinicalscopeofservices,includingrestorativecare.

14 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

movinG forward

Dental hygiene curriculum must change toprovidedentalhygienistswiththerequisiteedu-cationnecessarytoserveininstrumentalrolesthat address the oral health needs of diversepopulations and also contribute to improvedaccess to care.Advancededucationand train-ingwithin interprofessional teamswill preparedental hygienists to better fulfill these needs.Servicelearningincommunity-basedprograms,long-termcarefacilities,government-runfacili-ties andother locations canenabledental hy-giene students to provide care to the under-served.Theseexperiencesalsocanhelpdevelopexpertiseinaddressingdiversepopulationsina

talhygienistspracticinginKansas,withapproxi-mately124inpossessionofanECP.51Delinger’sstudyinterviewedeightECPdentalhygieniststoinvestigatewhydentalhygienistsappliedforanECP, andwhat barriers they encountered. Notsurprisingly,Delingerfoundthat“ECPdentalhy-gieniststhatwereparticipantsinthisstudyhadaveryentrepreneurial spirit. Their passion forworking with these specific populations was amajordrivingforceforthemtoconsiderapply-ing for an extended care permit.”51 Data indi-catesthatECPdentalhygienistsnotonlyvaluethe permit, but believe it is having a positiveimpact providing preventive dental services.51However, getting these patients’ restorativeneedstreatedcontinuestobechallengingorim-possiblesomoreisnecessarytoaddresstheis-sue.TherehasbeenactivelegislationinKansasfor the past five years to create a RegisteredDental Practitioner (mid-level provider) to ad-dresstheseconcerns.

Oregon

In 1997 Oregon passed legislation to allowdentalhygieniststoobtainalimitedaccessper-mit.52Thislegislationwasrevisedin2012,andcreated the Expanded Practice Permit (EPP).AnEPP“enablesdentalhygieniststoprovideavarietyofdentalhygieneservices,without thesupervisionofadentist,for“limitedaccess”re-gionsorpopulations.”52

The state ofOregondistinguishes these ex-panded practice dental hygienists (EPDHs) asdentalhygieniststhatdonotneedacollabora-tive agreement with a dentist to initiate den-talhygienecareforpopulationsthatqualifyashavinglimitedaccesstocare.EPDHscanobtaintheir EPP through one of two pathways. Path-wayonefocusesondentalhygienistscurrentlyinpossessionofanunrestrictedOregondentalhygienelicensewhohavealsocompleted2,500hoursofsuperviseddentalhygienepracticeand40hoursofcoursesineitherclinicaldentalhy-giene or public health.52 Pathway two allowsdentalhygieniststocompleteacourseofstudyapprovedbytheboardthatincludes500hoursofdentalhygienepractice,completedbeforeoraftergraduationfromadentalhygieneprogramon limitedaccesspatientswhileunder thesu-pervisionofamemberofthefacultyofadentalprogramordentalhygieneprogramaccreditedbytheCODA.52

EPDHsinOregonareabletoworkinavarietyofsettings,suchasnursinghomesandschools,

and many are employed as private businessowners.52Ina2015studyconductedbyCoplenetal,71EPDHsweresurveyed,and21percentwere planning to start their own independentpractice.52

TheimpactofEPDHswasmeasuredinastudyconductedbyBelletal.53Inthisstudy,itwasde-terminedthatmanyEPDHswereprovidingcareintwodistinctsettings—residentialcarefacili-ties, and schools. Themost common servicestheyprovidedalsoindicatedaheavyemphasisonpediatricpopulations.Accordingtothestudy,“Childprophylaxes,childfluoride,fluoridevar-nishandsealantswerethemostfrequentlyre-portedservicesamongpracticingEPDHs.”53ThisdataindicatesthatmanyvulnerablepopulationswouldgowithoutcarewithoutOregon’sEPDHsandtheutilizationoftheEPPpermit.

Studiessuchasthosedescribedarethebasisforabodyofevidencesupportingthecontentionthat dental hygienists in a variety of practicesettingscanimprovetheoralhealthofspecificpopulations.Populationsthathavealreadyben-efittedfromaccesstodentalhygienistsincludethe elderly, children, individual communities,special needs groups and those most at-riskandvulnerable.Tocontinueamassingevidencefortransformationofdentalhygieneeducation,areasofstudycouldincludecollaborationswithnon-dental health care providers in assisted-living and long-term care facilities, communi-ty-based education facilities, medical officesor clinics, specialty practices or corporate en-vironments.Outcomesdata couldbegatheredonthesuccessofthesenewpracticelocations,businessplansandinterprofessionalpracticeinthedeliveryofdentalhygieneservicesasback-groundtochangepolicy.

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 15

AFrameworkforTransformation

cHaPTer four

TheADHANationalDentalHygieneResearchAgenda(NDHRA)wasdevelopedin1993bytheADHACouncilonResearch(COR)andreleasedin1994.ADelphi studywasused toestablishconsensusandfocustheresearchtopicsfortheagenda.ThiswasthefirststeptoguideresearcheffortsthatsupporttheADHAstrategicplanandgoals.Aresearchagendaprovidesdirectionforthedevelopmentofauniquebodyofknowledgethatisthefoundationofanyhealthcaredisci-pline.Indentalhygiene,thisbodyofknowledgeisusedtoestablishdentalhygienistsasprimarycareprovidersinthehealthcaresystem.

In2001,theCORrevisedtheagendatore-flectachangingenvironmentbasedontwona-tionalreports:TheSurgeonGeneral’sReportonOralHealth12andHealthyPeople2010.54Inputfromthe2000NationalDentalHygieneResearchConferencesponsoredbytheADHAwasconsid-eredintherevision.ThereviseddocumentwasreleasedinOctober2001andprioritizedthekeyareasofresearch.

In2007,theagendawasrevisedbytheCORto reflect current research priorities aimed at

adha’s naTional denTal hyGiene researCh aGenda

meetingnationalhealthobjectivesand tosys-tematically advance dental hygiene’s uniquebodyofknowledge.Theserevisionswerebasedon aDelphi study thatwas conducted to gainconsensusonresearchpriorities.55

CurrentlytheCORisconductingafurtherre-vision of theNDHRA to align itwith themostcurrentevidenceaswellasfuturenationalandinternational priorities in dental hygiene re-search.Thisrevisionwill integrateglobalfeed-back received from recent interorganizationalresearchmeetings with representatives of theInternationalFederationofDentalHygiene,theCanadianDentalHygienistsAssociation,andTheNational Center for Dental Hygiene ResearchandPractice.Additionally,thisrevisionwillmir-ror the profession’s transformation by viewingdentalhygieneresearchasarelevantandinte-gralcomponentofoverallhealthresearch.

Theroleofdentalhygienistsinresearchandpractice must build on existing research andpractice models and grow beyond reliance onresearch originating from other disciplines toemerge from within dental hygiene itself. The

variety of health care settings. The CODAAc-creditationStandardsforDentalHygieneEduca-tionProgramscurrentlyincludeservicelearningas a required part of the dental hygiene cur-riculum.6 Furthermore, the IOM recommendsincreasing community-based education experi-encestoimproveproficiencyinthissettingandto“reinforcetheprofessionalandethicalroleofcaringforthevulnerableandunderservedpopu-lations.”27

Greater community involvement also wouldbothexposestudentstopopulationsinneedandenableattainmentofcompetenciesthataddresspopulationhealthandprimarycareservicede-liverytoamulticulturalandheterogeneousso-ciety. In addition,withmanyassociatedegreeprograms lacking sufficient time to augmenttheirexpandedlearningexperiences,thebroad-

ercurriculaofferedwithinentry-levelbaccalau-reateprogramswouldprovideasolidfoundationonwhichtobuildthisapproach.

Standardizeddatabasesareneededtoassessthe outcomesof operational andnewexpand-edscopeofpracticemodels.Individualreportsfromdiverseprogramsandprojectsneedtobesummarizedandpublished.Forwardmovementtoincreasethedentalhygienist’sscopeofprac-ticerequiresoutcomesdatathatarerigorouslycollected,analyzed, interpretedandevaluated.Theestablishmentandmaintenanceofthebodyofevidencetosupporttheenvisionedroleofthedental hygienist in the futurehealth care sys-tem is the responsibilityof thedentalhygieneprofession,and fulfilling that responsibilitywillrequireaneducationalpreparationbeyondwhatdentalhygienistsreceivetoday.

16 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

foCus on inTerprofessional eduCaTion (ipe) and CompeTenCy

IPE has been defined as “members or stu-dents of two or more professions associatedwithhealthorsocialcare,engagedinlearningwith,fromandabouteachother.”57IPEprovideshealthcareprofessionalstudentstheopportu-nitytoplacevalueonworkingwithininterpro-fessionalteamsbeforetheybegintopractice.58InadditiontoIPE,theoralhealthprofessionaleducationsystemalsomustfocusonintrapro-fessional teams to better prepare future clini-cians for practice within the new team basedparadigm.

Teamwork training for interprofessional col-laborative practice in education is at variousstagesofdevelopmentamongthehealthprofes-sions.TheAmericanAssociationofCollegesofNursing, forexample,has integrated interpro-fessional collaboration behavioral expectationsinto its “Essentials” for baccalaureate (2008)master’s(2011)anddoctoraleducationforad-vancedpractice(2006).58

Similarly, dental education has also beendeveloping competencies for dentists. Amongthemisfordentiststo“participatewithdentalteammembers and other health care profes-sionalsinthemanagementandhealthpromo-tionforallpatients.”58In2010,thestandardsforpredoctoral dental education programs, found

advanCinG The profession by learninG from oThers

Other health professions such as nursing,pharmacy,andPAshavemovedforwardbyre-definingtheeducationalbasisfortheirpracticeroles. The guiding principles from these pro-fessionsmayprovideroadmapsfordentalhy-gieneeducational transformationwhereparal-lelpathwaysexist.TheIOMConsensusReporton Nursing, “The Future of Nursing: LeadingChange,AdvancingHealth,”hassignificantim-plications for dental hygienists.3 In May 2010theTri-Council forNursing issuedaconsensusstatement calling for all registered nurses toadvance their education in the interest of en-hancing quality and safety across health caresettings.Thisstatementadvocatesforchangesin nursing practice and education to the bac-calaureatelevelandbeyondandcallsforstateandfederalfundingforinitiativesthatfacilitatenursesseekingacademicprogressions.3,56Simi-lartonurses,dentalhygienistscontinuetofaceanumberofbarrierstoadvancinginthehealth

dentalhygieneresearchagendaframeworkdi-rectsdentalhygieneresearchersincontributingtothebodyofknowledgeuniquetodentalhy-giene,andthefiveprimaryobjectivesthatwerethebasisforthecreationoftheNDHRAstillre-mainapplicabletoday:

• Togivevisibilitytoresearchactivitiesthatenhance the profession’s ability to pro-mote the health and well-being of thepublic;

• Toenhanceresearchcollaborationamongthedentalhygienecommunityandotherprofessionalcommunities;

• Tocommunicateresearchprioritiestoleg-islativeandpolicy-makingbodies;

• Tostimulateprogresstowardmeetingna-tionalhealthobjectives;and

• To translate the outcomes of basic sci-enceandappliedresearchintotheoreticalframeworks to form the basis for dentalhygieneeducationandpractice.

Therevisedresearchagendawillallow foron-goinginvestigationofspecificscientificfindingssupportinggrowthoftheprofession.Italsoal-lowsfor investigationandtestingofnewideasthat will further the transformation of dentalhygiene as a profession and as part of an in-terprofessional networkwith other health careprofessionals.

caresystem.Dentalhygienistsmustalsohavetheopportunitytoachievethehighestlevelofeducation with seamless progression and ar-ticulation to higher degrees. More leadershipopportunitiesareneeded fordentalhygieniststopartnerwithotherprofessionalstoredesignhealthcare.

Toachievetransformation,thedentalhygieneprofessionmightalsolooktothePAprofession.Theentry-levelmaster’sdegreewasinitiatedinthelate1980s,withseveralkeyinstitutionsre-structuringtheircurriculatoaccommodatethischangeandawardagraduatedegree.56Allnewprogramsestablishedafter2006mustawardabachelor’sdegreeorhigher.Allcertificate-andassociate-level programs must have articula-tionagreementswithinstitutionsthatawardabachelor’sormaster’sdegree.EntrytopracticeisadvancingtothegraduatelevelwiththePAaccreditingbodyrequiringprogramsaccreditedpriorto2013totransitiontoofferingthegradu-atedegreetoallwhomatriculateafter2020.

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 17

preparinG a fuTure GeneraTion of denTal hyGienisTs

Transformingdentalhygieneeducationisim-perativetoachievingtheADHA’svisionfortheintegrationofdentalhygienists into thehealthcaredeliverysystemasessentialprimarycareproviderstoexpandaccesstooralhealthcare.1Sinceeducationisthefoundationofanyprofes-sion,theenvisionedfutureofthedentalhygieneprofessionwilldependonthetransformationofthe educational preparation required to betterpreparedentalhygieniststopracticewithintheintegrated health care delivery structure andimpactthepublic’soralandoverallhealth.

Advancing education in dental hygiene in-cludesraisingtheprofession’sentryleveltothebaccalaureatedegree,whichhasbeenformallysupportedbytheADHAsince1986.9Inaddition,associatedegreeprogramshavebeenencour-agedbyADHAandADEAtocreatearticulationagreements andutilizedistance learning tech-nologyasmechanismsforcreatingapathwaytoachievingacademicprogressiontoabachelor’s

intheCODAAccreditationStandardsforDentalEducation Programs,were revised to promotecollaborationwithotherhealthprofessionals.59

The dental hygiene accreditation standardsincludetheexpectationthatgraduatesmustbecompetentininterpersonalandcommunicationskillstoeffectivelyinteractwithdiversepopula-tion groups and othermembers of the healthcare team.TheCODAAccreditationStandardsforDentalHygieneEducationProgramsclearlystate:

• “Thedentalhygienist functionsasamem-berof thedental teamandplaysasignifi-cant role in the delivery of comprehensivepatienthealthcare.Thedentalhygienepro-cessofcareisanintegralcomponentofto-tal patient care and preventive strategies.Thedentalhygieneprocessofcareisrecog-nizedaspartof theoverall treatmentplandevelopedbythedentistforcompleteden-talcare.”6

• “The curriculum should include additionalcoursework and experiences, as appropri-ate,todevelopcompetentoralhealthcareproviders who can deliver optimal patientcarewithinavarietyofpracticesettingsandmeettheneedsoftheevolvinghealthcareenvironment.6

• Dentalhygienesciencesprovidetheknowl-edgebasefordentalhygieneandpreparesthestudenttoassess,plan,implementandevaluatedentalhygieneservicesasaninte-gralmemberofthehealthteam.”6

As of 2014, only 23 dental hygiene programswerelocatedwithinadentalschoolandanother37were located onhealth sciences campusesthat also educate nurses, physical therapists,occupational therapists, pharmacists and oth-erprofessionalgroupswhowouldbenefitfromknowingabout the importanceoforalhygieneanditsrelationshiptogeneralhealth.Withonly18 percent of dental hygiene programs beingco-located,eitherwithinadentalschooloronahealthsciencescampus,therearebothatre-mendousgapandsignificantbarrierstomaxi-mizingIPEopportunities.

Anexampleofaninnovative,interprofession-alpracticemodelwastestedbyPatriciaBraun,MD, MPH, Associate Professor, Pediatrics andFamily Medicine at the University of ColoradoAnschultzSchoolofMedicine.Thisexperimen-talprojectaddedanoralhealthcomponenttowell-childvisitsbyco-locatingadentalhygien-

ist inthepediatrician’soffice.Overthecourseof27months,fivepart-timedentalhygienistsprovidedcare to2,071patients.Major factorsfacilitating adoption of the project idea werefunding,recognitionbypediatriciansoftheim-portance of children’s oral health needs, andthedesiretocreatethe”one-stopshopping”ofamedicalhome.Factorshelpingtosustaintheprogramweredevelopmentofapatientbase,rotating dental hygienists through the clinicduring well-child medical visits, and the sat-isfaction of parents or caregivers. Caregiverslikedtheconvenienceofhavingtheservicesallunderoneroof—theysaidthattheywouldbemorelikelytotaketheirchildtoadoctor’sofficewithadentalproviderthanonewithout.Someof thebarriersencounteredduringtheprojectincluded logistical issues and, in some cases,theneedtoeducatestaffatthepediatricofficesiteabouttheimportanceoftheoral-systemicrelationship.Thestudynotedthat“RDHs’con-fidenceinworkingindependentlymayimproveasmoreoftheirpeersexperiencesuccesswiththepracticeandwithmoreeducationonsmallbusinessdevelopmentandmanagement.”60

Co-locating dental hygienists into medicalpracticesisafeasibleandinnovativewaytopro-videoralhealthcare,especially forthosewhohave limited access to preventive oral healthservices.60

18 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

ChanGe Champions needed

“We are at a crossroad where suddenly, the environment seems ready and willing to foster change. The environment is riper than it has ever been before. Oral health care access is be-ing recognized as a social justice issue and den-tal hygienists have an integral role to play in that conversation.”

— Pamela Overman, EdD, RDH, Associate Dean for Academic Affairs at the University of Missouri Kansas City School of Dentistry and Se-nior Consultant for the Academy for Academic Leadership (AAL)

FromNovember2013-June2014,theADHA,in collaboration with the AAL, facilitated a pi-lotprojectwithsevendentalhygieneeducationprogramstocreatechangewithintheircurriculaandlearningdomains.Dentalhygieneprogramsthat participated in this pilot project includedEastern Washington University (EWU), IdahoStateUniversity,MiamiDadeCollege,UniversityofDetroitMercy,UniversityofMissouri-KansasCity, University of New Mexico, and VermontTechnicalCollege(VTC).TheAAL’sTobiasRodri-guez,PhD,andOvermanservedasfacilitators.

developinG new domains and CompeTenCies

The new domains as defined by the ADHApilotgroupparticipantsfocusedonthefollow-ingareas:

• FoundationKnowledge:Includesbasic,be-havioralandclinicalscienceknowledgethatcanberecalledandappliedtopatientcare.Asolidfoundationinliberaleducationpro-vides the cornerstone for the practice ofdentalhygienists.

• Patient-CenteredCare:Includesskillsinpa-tientassessment,dentalhygienediagnosisand thedental hygieneprocessof care tofosteroralandsystemichealth.

• ManagementinHealthCareSystems:Workswithin the oral care system and with theoverall health care system to foster opti-

The role of denTal hyGiene eduCaTors

Transforming the education and preparationofanewgenerationofdentalhygienistswillre-quire facultywhohave the leadershipandde-termination to integrate change into the cur-riculum.Topreparegraduateswhoareadeptataddressingthecomplexneedsoftoday’spatientpopulationsandareabletoworkeffectivelywithotherhealthcareproviders,facultymustshareavisionoftheprofessionfunctioninginhigher-level clinical, administrative and public healthpositions.Thetransformationofdentalhygieneeducationbeginswithfaculty—educatorswhodemonstrate afirm commitment to dental hy-gieneleadership,lifelonglearningandthepur-suitofadvancededucation thatqualifies themtoteachothers.

Asaresultof theSymposium,a jointwork-group of the ADHA and ADEA Commission onChange& Innovation (CCI)wasestablished tocreate leadership in dental hygiene educationthat can adapt to change and transformation.Thechargeoftheworkgroupistoincreaseandenhanceprofessionaldevelopmentand leader-shipopportunitiesfordentalhygieneprofession-alstopreparethemforthefuturetransforma-tionofthedentalprofession.

Theinitialprojectofthejointworkgroupwillbethedevelopmentofaseriesofwebinarsde-

degree.Progress isbeingmade,as100oftheentry-level dental hygieneeducationprogramsreported to the ADHA that they have existingarticulation agreements to enable students totransition from a community college to a uni-versity.61

Dental hygiene education leaders and re-searchershavediscussedthevalueofdoctoralprogramsdifferentiatedbyfocusarea.Optionsmightincludeadoctoraldegreefocusedonre-searchinaPhDprogram,adoctorateindentalhygiene education (EdD), or a practice-basedDoctorate of Dental Hygiene Practice or Doc-torate of Clinical Science for dental hygienistswhowanttoprovideadvancedclinicalpracticein a variety of health care delivery settings.62Aproposedcurriculumforadoctorateindentalhygienecurriculumwassubmittedinearly2015to theExecutiveDeanandViceProvost in theDivisionofHealthSciencesatIdahoStateUni-versitybyJoAnnGurenlian,RDH,PhD,GraduateProgramDirector,DentalHygiene.Programap-provalispending.

signed to empower adjunct faculty and newmaster’s level graduates with leadership skillsnecessary to take the next step professionallyand toprepare them formoreadvanced lead-ershipprograms.Topicsmayincludeleadershipskills, assertiveness, conflict resolution, work/lifebalanceandadvocacy.

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 19

AddedBioethicsasarequiredcourse.Thiswasoriginallyanelective.Expanded Community Oral Health (COH)course to be two semesters instead of one(COHIandCOHII).COHIfocusesonclass-roominstruction.COHIIrequiresstudentstocompletea community–basedoutreachproj-ect.Added two semesters of weekly 90–minuteclinicalseminarlectures.Thisprovidesforin-creased lecture time for ethics, personal re-sponsibility, leadership, advocacy, advancedinstrumentationskills,motivationalinterview-ing, cultural competence, interdisciplinarywork models, alternative practice settings,and evidence–based decision making/criticalthinking.Implemented an Interprofessional Educationformatwhichincludes:

Business/PracticeManagementAffordableCareActHealthInformaticsElectronicHealthRecordsInterprofessional Education and Interpro-fessionalPracticeAdvocacyLeadership

Expandedpracticemanagementcontenttoin-clude tracking, analyzing, and implementingstepstoimproveproductivityintheclinic.Deletedadentalanatomylabcourseandre-placed it with a new course entitled: OralHealthLiteracy.Decreased the number of credits for Nutri-tionalCounselingandaddedacourseentitled:Inter–ProfessionalEducation.Added Leadership/Health/Policy/Advocacy/Ethics/Law.Added Practice/Business Management/RiskManagement.Removed topics that are only tested on thenational boards, but not clinically relevant.Plan to providehandouts to the students onthosetopics.

Figure1:TransformationalOutcomes

piloT projeCT reporTs: ewu and vTC

Faculty from thepilotgroupswereasked tohave their respectivedentalhygieneprogramsfocusonpreparingdentalhygienestudentsforfuture practice environments. The pilot pro-grams selected represent diverse geographiclocations, patient populations and academicprofiles. The two examples that follow— onea community college in theNortheastand theotherauniversity-basedprogramon theWestCoast—illustratethetypesofcurriculartrans-formationsinitiatedbythepilotgroups.

InVermont,VTCapproveda“threeplusone”dentalhygieneprogramtoreplacethetradition-altwo-yearAssociateDegreeprogram.Thenewprogramisathree-yearAssociateDegreepro-gramandaone-yearBachelorofScienceinden-talhygiene(BSDH)onlinecompletionprogram.The first three years of coursework are com-pletedoncampuswherestudentsutilizeVTC’shigh-techdentalhygiene lab.Thefinalyearof

malhealth.Includesbusinessmanagementskills,advocacy,andchangeagentskillstointegrateoralhealthintohealthsystems.

• Interpersonal Communication and Inter-professional Collaboration: Communicationskills with patients andwithin health careteams, including cultural sensitivity andfosteringhealthbehaviors.Communicationand collaboration are essential to the de-liveryofhighqualityandsafepatientcare.

• Critical Thinking: Use of knowledge andcriticalevaluationof theresearchandevi-dence–basedskillsandclinicaljudgmentinprovidingdentalhygienecare.Professionaldentalhygienepractice isgrounded in thetranslation of current evidence into one’spractice.

• Professionalism: Inculcates thevaluesandethicsneededfortheprovisionofcompas-sionate, patient-centered, evidence basedcarethatmeetsstandardsofquality.

As dental hygiene roles in each entry-levelpractice setting change, the competencies ineachdomainmustchangetokeeppace.Thesealterationswillhelp toensurethatcompeten-ciescontinuetoaddressdiversity,linguisticandculturalcompetence,healthcarepolicy,healthinformatics and technology, health promotionand disease prevention, leadership, programdevelopmentandadministration,integrationoforal health intohealth systems, andbusinessmanagement(Figure1).

20 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

publiC poliCy and reGulaTion

A2015reportfromthePewCharitableTrustsattributeslackofaccesstocareforchildrentorestrictivestatelaws.In13statesandtheDis-trictofColumbia,adentalhygienistinaschool-based program may not place a sealant untila dentist has examined the child. The reportstates, “This rule runscounter togrowingevi-dencethatadentist’sexamisnotnecessarybe-foreasealant isput inplace.”Withrespect todentalhygienistsplacinginterimrestorationsinchildren,thereportnotesthatstate lawshavenotkeptupwithscience,andthatbychanginglaws toallowdentalhygienists toperformthisservice,statescouldmakeprogressinarrestingdentaldecay.63

In a 2013 qualitative case study Dollins, etal,64 discussed the legislative process of a hy-gienist-therapistbill.Thestudynotedaminimallevelofawarenessandunderstandingoftheoralhealthaccessissue,bothwithinthedentalcom-munityandthegeneralpublic.Insomecases,thesuddencomprehensionofthescopeoftheaccess-to-careproblem led legislators andad-vocatestobecomeengaged.

The Center for HealthWorkforce Studies at

the program is completed online, after whichstudentsearnaBachelorofSciencedegree.

Changesmadeto theAssociateDegreecur-riculuminclude:

• Addition of Bioethics as a required course(wasoriginallyanelective).

• Two semesters of Community Oral Health(COHIandCOHII)inplaceofonesemes-ter.ThisallowsVTCtoteachcontentinCOHIandhavestudentsdoacommunity-basedoutreachsemester-longprojectinCOHII.

• An additional two semesters of weekly90-minuteclinicalseminarlectures.

VTC is not anticipatinganyadditional changestotheirdentalhygienedegreeprogram,butareactivelyplanningondevelopingadentaltherapyeducationprogram.TheVermontstate legisla-tureiscurrentlyreviewinglegislationthatwouldestablish mid-level oral health practitioners,knowninthestateaslicenseddentaltherapists.

EWU is also making significant strides intransforming their curriculum. Currently, theschool offers two baccalaureate-level dentalhygienepaths—anentry-levelprogramandadegree-completionoptionforalreadypracticingdentalhygienists.Theprogramsareinthepro-cessoftransitioningfromaquarter-systemtoasemester-basedprogram.

Changesmadetothecurriculuminclude:

• Addition of a course focused on leadershipdevelopment, health policy, advocacy andethics.

• Additionofacoursefocusedonbusinessandriskmanagement.

• Removalofunnecessaryitemsfromthecur-riculum to focus on themost clinically rel-evanttopics.

Forexample,EWUremovedcourseworkonalgi-nateimpressions,impressionmaterialchemicalsandcomponents.InWashingtonstate,RDHsdonotperformthesefunctions,andwhilethena-tionalboardexamstillteststhesubjectmatter,EWUelectedtoprovideabriefhandouttostu-dentsinstead.

TheEWUdentalhygienefacultymetwiththeinstructors responsible for teaching pre-requi-sitecoursesandthoroughlyreviewedthecurric-ulum.Thisapproachallowedthedentalhygienefacultytoremoveredundancywithin individual

courses,andalsoholdstudentsmoreaccount-able forwhat theyhavealready learned.Spe-cifically,EWUidentifiedanutritionpre-requisitecoursethatsatisfiedmuchofthenutritiontopicscoveredinthesubsequentdentalhygienenutri-tioncontent.Thisperiodicreviewofcoursecur-riculumacrossthedentalhygieneprogramhashelpedEWUaddressinstancesofteachingcon-tentalreadycovered.

According to Professor Rebecca Stolberg,RDH, BS, MSDH, Dental Hygiene DepartmentChair at EWU, as administrators and facultydevelop course content and syllabi, the Sym-posiumandthepilotprojecthavehelpedguideEWU’sdentalhygieneprogramtofocusonthefuture as dental hygienists becomemore fullyintegratedintothehealthcaredeliverysystemasessentialprimarycareproviders.

SimilartoVermont,theWashingtonstateleg-islaturealsohaspendinglegislationthatwouldcreate amid-level dental hygiene practitioner.In anticipation of the bill’s passage, EWU hasalreadytakenstepstodevelopacurriculumandispositionedtomoveforwardwhenthelegisla-tionpasses.

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 21

Conclusion

cHaPTer five

Transformationofaprofessionandthenec-essary educational pathway require profes-sional and educational vision and leadership,collaborationwithotherstakeholders,andnav-igation of the changing regulatory, legislativeandoverallhealthcareenvironment.TheADHAhasbegunthisprocessbyenvisioningtheedu-cational preparation necessary to ensure thatfuturedentalhygieneprofessionalswillbepre-paredtorespondtosocietalneed.Theprimarygoal of advancing the dental hygiene profes-sionistoimprovethepublic’soralandoverallhealth.

Dentalhygieneprogramdirectorsandfacultywillneedtoworktogethertocreatenewedu-

theSchoolofPublicHealth,UniversityofAlbanySUNY,conductedastudyofstakeholderslookingat oral health inMichigan and analysis of rel-evantstateandnationalsurveillancedata.Sev-eralthemesemergedfromtheirstudy,includingthelackofproviderandpolicymakerknowledgeabout the barriers to oral health services en-

counteredbyunderservedpopulations.There-port found that policymakers needed a betterunderstandingoftheimpactofpoororalhealthoutcomes on employability, absenteeism fromschoolandwork,and theabilityofchildren tolearn,aswellasthesystemicbarrierstoobtain-ing oral health services, including low fundingfororalhealthinMedicaid.65

Onbehalfof theAmericanDentalHygienists’Association,itiswithgreatpleasurethatwebringyouthiswhitepaper.Basedonthe2013sympo-sium, “TransformingDentalHygieneEducation:ProudPast,UnlimitedFuture,”thisdocumentwillserveasaninvaluableresourcenowandinyearsto come. Many important stakeholder groupswere involved in the2013TransformingDentalHygiene Education Symposium and we thankthemfortheirsupportofthedentalhygienepro-fessionandADHA.Wealsothankourmembersandstaffwhowere involvedinthisprojectandresponsibleforseeingitcometofruition.Inpar-ticular,thankyoutoJohnson&JohnsonConsum-erInc.,fortheirsupportinthedistributionofthis

cationalcurriculumanddeliverystrategies foradvancingtheprofession.Dentalhygienelead-erswillneedtofocusontherelevanceoforalhealthtosystemichealthforabroadaudienceincluding other health professionals, consum-ers, corporate entities, academic communi-ties and the public at large. Clear leadershippairedwithaboldandcomprehensivestrategicplan areneeded to drive and sustain forwardmovement.TheADHAremainssteadfastinitscommitmenttotransformingtheprofessionofdental hygiene and continuing this conversa-tion.Theideasinthispaperwillpavethewayforthoseconversationsandultimatelycontrib-utetotheimprovementofthepublic’soralandoverallhealth.

acknowleDgmenTs

landmark publication. The ADHA is leading theeffort to transformtheprofessionofdentalhy-gieneandthiswhitepaperisatestamenttothemomentumandinterestinmovingtheprofessionupward! I hope the ideas in this paper inspireandchallengeyoutothinkaboutthepossibilitiesfor the futureofourprofession. Joinus in thisjourneytobetterservetheoralhealthneedsofallindividuals.WelookforwardtocontinuingthisconversationandinviteyoutointeractwithusataskADHA@adha.net.JillRethman,RDH,BA2015-2016PresidentAmericanDentalHygienists’Association

22 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

PositionItisthepositionoftheAmericanDentalHygienists’Association(ADHA)thatdentalhygienedi-agnosisisanecessaryandintrinsicelementofdentalhygieneeducationandscopeofpractice.1

ADHAsupportsdentalhygienecurriculathatleadstocompetencyinthedentalhygieneprocessofcare:assessment,dentalhygienediagnosis,planning,implementation,evaluation,anddocu-mentation.2

DentalHygieneDiagnosis:Theidentificationofan individual’shealthbehaviors,attitudes,andoralhealthcareneedsforwhichadentalhygienist iseducationallyqualifiedandlicensedtoprovide.Thedentalhygienediagnosisrequiresevidence-basedcriticalanalysisandinterpretationofassessmentsinordertoreachconclusionsaboutthepatient’sdentalhygienetreatmentneeds.Thedentalhygienediag-nosisprovidesthebasisforthedentalhygienecareplan.3

BackgroundTheCommissiononDentalAccreditation(CODA)wasestablishedin1975andisnationallyrec-ognizedbytheUnitedStatesDepartmentofEducationasthesoleagencytoaccreditdentalanddental-relatededucationprogramsconductedatthepost-secondarylevel.TheCODA’smissionistoservetheoralhealthcareneedsofthepublicthroughthedevelopmentandadministrationofstandardsthatfostercontinuousqualityimprovementofdentalanddentalrelatededucationalprograms.

AsaresultofaresolutionbroughtforthbytheAmericanDentalAssociationHouseofDelegatesin2007,onJanuary1,2010,theCODAremoved“dentalhygienetreatmentplan”and“dentalhygienediagnosis”fromtheCODAeducationaccreditationstandardsfordentalhygiene.Thesetermshadbeenapartofthestandardssince1998.DentalHygieneDiagnosisinStateLawsIn2004and2009respectively,OregonandColoradobecamethefirststatestospecificallyautho-rizethedentalhygienediagnosisaspartofthedentalhygienists’scopeofpractice.Oregonstatestatutespecificallyincludesdiagnosiswithinthedefinitionofdentalhygiene.Oregonstatestat-utepermitsdentalhygieniststo“diagnose,treatmentplanandprovidedentalhygieneservices.”UnderColoradostatestatute,“dentalhygienediagnosis”meanstheidentificationofanexistingoralhealthproblemthatadentalhygienistisqualifiedandlicensedtotreatwithinthescopeofdentalhygienepractice.DentalHygieneTheADHArepresentstheprofessionalinterestsofdentalhygienistsintheUnitedStates.Dentalhygieneisthescienceandpracticeofrecognition,preventionandtreatmentoforaldiseasesandconditionsasanintegralcomponentoftotalhealth.Thisincludesassessment,diagnosis,plan-ning,implementation,evaluationanddocumentationandistheprofessionofdentalhygienists.4Adentalhygienistisaprimarycareoralhealthprofessionalwhohasgraduatedfromanaccred-iteddentalhygieneprograminaninstitutionofhighereducation,licensedindentalhygienetoprovideeducation,assessment,research,administrative,diagnostic,preventiveandtherapeuticservicesthatsupportoverallhealththroughthepromotionofoptimaloralhealth.5

AppendixA:DentalHygieneDiagnosis

1. ADHAPolicyManual[6-09].Chicago,Ill.AmericanDentalHygienists’Association.http://www.adha.org/resources-docs/7614_Policy_Manual.pdf

2. ADHAPolicyManual[16-15/16-93].Chicago,Ill.AmericanDentalHygienists’Association.http://www.adha.org/resources-docs/7614_Policy_Manual.pdf

3. ADHAPolicyManual[1-14/SCDHP/18-96].Chicago,Ill.AmericanDentalHygienists’Association.http://www.adha.org/resources-docs/7614_Policy_Manual.pdf

4. ADHA PolicyManual [3-14/14-83]. Chicago, Ill. AmericanDental Hygienists’ Association. http://www.adha.org/resources-docs/7614_Policy_Manual.pdf

5. ADHA PolicyManual [4-14/19-84]. Chicago, Ill. AmericanDental Hygienists’ Association.http://www.adha.org/resources-docs/7614_Policy_Manual.pdf

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 23

• Thedentaltherapyworkforceisgrowingandappears to be fulfilling statutory intent byserving predominantly low-income, unin-suredandunderservedpatients.

• Clinicsemployingdentaltherapistsaresee-ingmorenewpatients, andmostof thesepatients are public program enrollees orfromunderservedcommunities.

• Benefitsattributabletodentaltherapistsin-cludedirectcostssavings,increaseddentalteam productivity, improved patient satis-factionandlowerappointmentfailrates.

• Start-upexperienceshavevaried,andem-ployers expect continuing evolution of thedentaltherapistrole.

• DentaltherapistsofferpotentialforreducingunnecessaryERvisitsfornon-injurydentalconditions.

• Dental therapists appear to be practicingsafely,andclinicsreportimprovedqual-

ityandhighpatientsatisfactionwithdentaltherapistservices.

• Dentaltherapistshavemadeitpossibleforclinicstodecreasetraveltimeandwaittimesforsomepatients,increasingaccess.

• Savingsfromthelowercostsofdentalther-apistsaremakingitmorepossibleforclin-icstoexpandcapacitytoseepublicprogramandunderservedpatients.

• Mostclinicsemployingdentaltherapistsforatleastayearareconsideringhiringaddi-tionaldentaltherapists.

• With identical state public program reim-bursementratesfordentistanddentalther-apistservices,thereisnotnecessarilyanim-mediatesavingstothestateoneachclaimpaid;however,thedifferentialbetweenDHSratesandclinics’ lowerpersonnelcosts fordentaltherapistsappearstobecontributingtomorepatientsbeingseen.

AppendixB:EarlyImpactsofDentalTherapistsinMinnesota

Source:MinnesotaDepartmentofHealth,MinnesotaBoardofDentistry.EarlyImpactsofDentalTherapistsinMinnesota.ReporttotheMinnesotaLegislature.MinnesotaDepartmentofHealth[Internet].2014Febru-ary[cited2015February2].Availablefrom:www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf

1. American Dental Hygienists’ Association StrategicPlan.AmericanDentalHygienists’ Association[Internet].2015March3[cited 2015 August 28]. Available from: http://www.adha.org/resources-docs/ADHA_Strategic_Plan_2015.pdf

2. U.S.DepartmentofHealthandHumanSer-vices, Health Resources and Services Ad-ministration. Transforming Dental Hygiene Education, Proud Past, Unlimited Future: ProceedingsofaSymposium.Rockville,MD. USDepartment ofHealth andHumanSer-vices[Internet].2014[cited2015July28]. Available from: http://www.hrsa.gov/publichealth/clinical/oralhealth/transformingdentalhygiene.pdf

3. InstituteofMedicine.TheFutureofNursing: LeadingChange,AdvancingHealth.iom.edu [Internet].2010Oct5[cited2014May8]. Available from: from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.

4. American Dental Hygienists’ Association. Dental Hygiene Education: Curricula, Pro-gramEnrollment,andGraduateInformation. AmericanDentalHygienists’Association[In-ternet]. 2014 Oct 21 [cited 2015 August 28]. Available from: http://www.adha.org/resources-docs/72611_Dental_Hygiene_Education_Fact_Sheet.pdf

5. Overview of CE Requirements for DentalHygieneLicensureRenewal.AmericanDen-tal Hygienists’ Association [Internet]. 2015July[cited2015August28].Availablefrom:http://www.adha.org/resources-docs/7512_CE_Requirements_by_State.pdf

6. CommissiononDentalAccreditation.Accred-itationStandardsforDentalHygieneEduca-tionPrograms.AmericanDentalAssociation[Internet].2013January[cited2015August28].Availablefrom:http://www.ada.org/~/media/CODA/Files/dh.ashx

7. Davies K. The $1,000 Genome. New York,NY.FreePress.2010.

referenCes

24 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

8. GlickM.TheOral-SystemicHealthConnec-tion:AGuideToPatientCare.Chicago, IL.QuintessencePublishingCo,Inc.2014.

9. ADHAPolicyManual[14-86].AmericanDen-tal Hygienists’ Association [Internet]. 1986 [cited 2015 July 20]. Available from:https://www.adha.org/resources-docs/7614_Policy_Manual.pdf

10.PittmanP,HortonK,KeetonA,HerreraC.In-vestinginNurseEducation:IsThereaBusi-nessCaseforHealthCareEmployers?RobertWood JohnsonFoundation [Internet].2012April 11 [cited2015February2].Availablefrom: http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/04/investing-in-nursing-education.html

11.The Case for Academic Progression: WhyNursesShouldAdvanceTheirEducationandtheStrategiesthatMakethisFeasible.Rob-ert Wood Johnson Foundation [Internet].Sep2013[cited2015February2];21:1-8.Available from:www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf407597

12.U.S.DepartmentofHealthandHumanSer-vices.OralHealthinAmerica:AReportofthe SurgeonGeneral.U.S.DepartmentofHealth and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health [Internet]. 2000 [cited 2015 July 28]. Available from: http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Report/ExecutiveSummary.htm

13.GavettG.TragicResultsWhenDentalCare IsOutOf Reach. PBS.org [Internet]. 2012 June26[cited2015June5].Availablefrom: http://www.pbs.org/wgbh/pages/frontline/health-science-technology/dollars-and-dentists/tragic-results-when-dental-care-is-out-of-reach/

14.U.S.DepartmentofHealthandHumanSer-vices, Health Resources and Services Ad-ministration, National Center for Health Workforce Analysis. National and State-LevelProjectionsofDentistsandDentalHy-gienists in theU.S., 2012-2025 [Internet]. 2015 [cited 2015 July 28]. Available from: http://bhpr.hrsa.gov/healthworkforce/supplydemand/dentistry/nationalstatelevelprojectionsdentists.pdf

15.National Governors Association. The RoleofDentalHygienists inProvidingAccess toOralHealthCare.NationalGovernorsAsso-ciation.2014[cited2015July20].Availablefrom: http://www.nga.org/files/live/sites/NGA/files/pdf/2014/1401DentalHealthCare.pdf

16.U.S.DepartmentofHealthandHumanSer-vices.UpdateonCMSOralHealthInitiative andOtherOral Health Related Items. U.S. DepartmentofHealthandHumanServices [Internet].2014[cited2015July28].Avail-able from: http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-10- 2014.pdf

17.U.S.DepartmentofHealthandHumanSer-vices.TheDepartmentofHealthandHuman Services2014AnnualReportontheQuality of Care for Children inMedicaid and CHIP. U.S.DepartmentofHealthandHumanSer-vices[Internet].2014[cited2015July28]. Available from: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/2014-child-sec-rept.pdf

18.U.S.BureauofCensus.TheNext FourDe-cades. The Older Population in the UnitedStates: 2010 to 2050. Population Esti-matesandProjections.U.S.BureauofCen-sus [Internet]. 2010 [cited 2015 July 28].Available from: https://www.census.gov/prod/2010pubs/p25-1138.pdf

19.AARP Public Policy Institute. Across the State: Profiles of Long-Term Services and Supports. aarp.org [Internet]. 2012 [cited 2014 Aug 6]. Available from: http://www.aarp.org/content/dam/aarp/research/public_policy_institute/ltc/2012/across-the-states-2012-full-report-AARP-ppi-ltc.pdf

20.Older Americans Not Receiving The OralHealthCareTheyNeed.OralHealthAmerica[Internet].2013[cited2015July20].Avail-able from: http://oralhealthamerica.org/wp-content/uploads/Fall-for-Smiles-Press-Release-9-3-13.pdf

21.OralHealthAmerica.AStateofDecay:Are OlderAmericansComingofAgeWithoutOral Healthcare? ToothWisdom [Internet]. 2013 [cited2015July20].Availablefrom:http://b.3cdn.net/teeth/1a112ba122b6192a9d_1dm6bks67.pdf

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 25

22.Bhambal A, Saxena S, Balsaraf SV. Tele-dentistry: potentials unexplored. J Int OralHealth [Internet]. 2010 [cited 2015 July28];2(3):1-6.Availablefrom:http://ispcd.org/userfiles/rishabh/jioh-02-03-01.pdf

23.ReddyKV.Using teledentistry forprovidingthespecialistaccesstoruralIndians.Ind JDent Res [Internet].2011[cited2015July28];22(2):189.Availablefrom:http://www.ijdr.in/text.asp?2011/22/2/189/84275

24.BoardonHealthCareServices;InstituteofMedicine.TheRoleofTelehealthinanEvolv-ing Health Care Environment: WorkshopSummary. Washington DC: The NationalAcademiesPress.2012.

25.Quality at Willamette Dental Group. Willa-mette Dental Group [Internet]. April 2015 [cited2015July14].Availablefrom:https://www.willamettedental.com/our-care-standards.htm

26.Rodriguez JA. The Development of DentalTherapyEducationPrograms.Access[Inter-net].2014[cited2015July28];28(5):20-23. Available from: http://pubs.royle.com/publication/?i=212001&p=22

27.InstituteofMedicineandNationalResearchCouncil.Improvingaccesstooralhealthcareforvulnerableandunderservedpopulations.Washington DC: The National AcademiesPress.2011.

28.Direct Access. American Dental Hygienists’Association [Internet]. 2014 June [cited2015 Feb2]. Available from:https://www.adha.org/direct-access

29.ADHAPolicyManual[13-15].AmericanDen-tal Hygienists’ Association [Internet]. 2015 [cited2015July20].Availablefrom:https://www.adha.org/resources-docs/7614_Policy_Manual.pdf

30.DentalHygienePracticeActOverview:Per-mittedFunctionsandSupervisionLevelsbyState.AmericanDentalHygienists’Associa-tion[Internet].2013November[cited2015February 3]. Available from: http://www.adha.org/resources-docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf

31.EveryChildDeservesaSmile.FutureSmiles[Internet]. 2015 [cited 2015 February 2].Available from: http://www.futuresmiles.net/index.html

32.Martin AB, Olatosi B. 2008 South CarolinaOralHealthNeedsAssessmentData.SouthCarolinaRuralHealthResourceCenter [In-ternet].2008[cited2015July20].Availablefrom: http://www.scdhec.gov/Health/docs/OHNA%202008%20Report.pdf

33.Policy on Interim Therapeutic Restorations (ITS). Adopted 2001. Revised 2004, 2008, 2013.AmericanAcademyofPediatricDen-tistry [Internet].2001[cited2015July20]. Availablefrom:http://www.aapd.org/media/Policies_Guidelines/P_ITR.pdf

34.TheVirtualDentalHome.Children’sPartner-ship[Internet].2015March[cited2015June 5]. Available from: http://childrenspartnership.org/storage/documents/OurWork/Dental/VDH_FactSheet_Formatted_Updated_02.26.15.pdf

35.Rhea M, Bettles C. Dental Hygiene at the CrossroadsofChange:EnvironmentalScan 2011-2012.AmericanDentalHygienists’As-sociation [Internet]. 2011 [cited 2014 May 7]. Available from: http://www.adha.org/resources-docs/7117_ADHA_Environmental_Scan.pdf

36.Dental hygiene participation in regulation.AmericanDentalHygienists’Association[In-ternet].2015[cited2015July20].Availablefrom: https://www.adha.org/resources-docs/75111_Self_Regulation_by_State.pdf

37.Dower C, Moore J, Langelier M. It is time to restructure health professions scope-of-practice regulations to remove barriers to care.Health Aff [Internet]. 2013 [cited 2015July28];32(11):1971-1976.Available from: http://content.healthaffairs.org/content/32/11/1971.abstract

38.HealthReform2.0ACalltoAction.Families USA [Internet]. 2015 January [cited 2015 June 5]. Available from: http://www.familiesusa.org/sites/default/files/product_documents/HealthReform-20_final_web.pdf

26 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

39.ADHA Policy Manual [1-14/SCDHP/18-96].AmericanDentalHygienists’Association[In-ternet].2014[cited2015July20].Availablefrom: https://www.adha.org/resources-docs/7614_Policy_Manual.pdf

40.ADHAPolicyManual[16-15/16-93].Ameri-canDentalHygienists’Association[Internet].2015 [cited2015 July 20].Available from:http://www.adha.org/resources-docs/7614_Policy_Manual.pdf

41.Oregon State Statute §679.010(2). Ore-gonStateLegislature[Internet].2013[cit-ed 2015 July 20]. Available from: https://www.oregonlegislature.gov/bills_laws/lawsstatutes/2013orLaw0310.pdf

42.C.R.S. §12–35–128. LexisNexis [Internet].2014 [cited2015 July 20].Available from:http://www.lexisnexis.com/hottopics/colorado?app=00075&view=full&interfint=1&docinfo=off&searchtype=get&search=C.R.S.+12-35-128

43.Commission on Dental Accreditation Meet-ing Minutes. American Dental Association[Internet]. 2009 July 31 [cited 2015 July13].Availablefrom:http://www.ada.org/~/media/CODA/Files/CODA%20Minutes%20July%202009.ashx

44.American Dental Hygienists’ Association, Dental Hygiene Program Directors Survey, 2012, American Dental Hygienists’ Asso-ciation, Chicago, IL [Internet]. 2012 [cited 2015 July 28] Available from: http://www.adha.org/resources-docs/adha2012surveyofPD.pdf

45.MinnesotaDepartmentofHealth,MinnesotaBoardofDentistry.EarlyImpactsofDentalTherapistsinMinnesota.ReporttotheMin-nesota Legislature. Minnesota Departmentof Health [Internet]. 2014 February [cited2015 February 2]. Available from: www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf

46.Gavil AI, Gaynor MS, Feinstein D. Re-sponse - FTCStaff Comment on theCom-missiononDentalAccreditationConcerning Proposed Accreditation Standards. Federal Trade Commission [Internet]. 2013 [cit-ed 2015 July 28]. Available from: https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-comment-commission-dental-accreditation-concerning-proposed-accreditation-standards-dental/131204codacomment.pdf

47.CommissiononDentalAccreditation.Accred-itationStandardsforDentalTherapyEduca-tionPrograms.AmericanDentalAssociation[Internet].2015February6[cited2015Au-gust 28]. Available from: http://www.ada.org/~/media/CODA/Files/dt.ashx

48.CommissiononDentalAccreditation.Evalu-ation & Operational Policies & Procedures. American Dental Association [Internet]. 2015 February [cited 2015 August 13]. Available from: http://www.ada.org/~/media/CODA/Files/eopp.ashx

49.Gavil AI, Lafontaine F, Feinstein D. Re-sponse - FTCStaff Comment on theCom-mission on Dental Accreditation Concern-ing Proposed Accreditation Standards. Federal Trade Commission. 2014. Available from: https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-commission-dental-accreditation-concerning-proposed-accreditation-standards-dental/141201codacomment.pdf

50.Mertz E, Glassman P. Alternative practicedental hygiene inCalifornia: past, present,and future. J Calif Dent Assoc [Internet].2011 [cited 2015 July 28]; 39(1):37-46Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325901/

51.DelingerJ,Gadbury-AmyotCC,MitchellTV, WilliamsKB.AQualitativeStudyofExtended Care Permit Dental Hygienists in Kansas. J Dent Hyg [Internet]. 2014 [cited 2015 July 28]; 88(3):160-172.Available from: http://www.ncbi.nlm.nih.gov/pubmed/24935146

Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury 27

52.Coplen AE, Bell KP. Barriers Faced by Ex-pandedPracticeDentalHygienistsinOregon.J Dent Hyg[Internet].2015[cited2015July28]; 89(2):91-100. Available from: http://jdh.adha.org/content/89/2/91

53.Bell KP, Coplen AE. Evaluating the Impactof Expanded Practice Dental Hygienists inOregon: An Outcomes Assessment. J DentHyg [Internet].2015[cited2015July28];89(1):17-25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25690062

54.OfficeofDiseasePreventionandHealthPro-motion.HealthyPeople2010.U.S.Depart-mentofHealthandHumanServices[Inter-net]. 2000 [cited 2015 July 29]. Availablefrom: http://www.healthypeople.gov/2010/Data/

55.Gadbury-Amyot CC, Doherty F, Stach DJ,Wyche CJ, Connolly I, Wilder R. Prioritiza-tionoftheNationalDentalHygieneResearchAgenda: 2000 – 2001. J Dent Hyg. 2002;76(2):157-166.2002[cited2015July29].Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Prioritization+of+the+National+Dental+Hygiene+Research+Agenda

56.Boyleston ES, Collins MA. Advancing ourprofession:arehighereducationalstandardsthe answer? J Dent Hyg [Internet]. 2012[cited2015July28];86(3):168-178.Avail-able from: http://www.ncbi.nlm.nih.gov/pubmed/22947839

57.Fried J. Interprofessional Collaboration: If NotNow,When?J Dent Hyg.SpecialCom-memorative Issue [Internet]. 2013 [cited 2015July30];87(suppl1):41-43.Available from: http://jdh.adha.org/content/87/suppl_1/41.full

58.Interprofessional Education CollaborativeExpert Panel. Core competencies for inter-professionalcollaborativepractice:Reportofanexpertpanel.InterprofessionalEducationCollaborative [Internet]. 2011 [cited 2015July 20]. Available from: http://www.aacn.nche.edu/education-resources/ipecreport.pdf

59.Commission on Dental Accreditation. Ac-creditation Standards For Dental EducationPrograms.AmericanDentalAssociation[In-ternet].2010[cited2015July10].Availablefrom: http://www.ada.org/~/media/CODA/Files/predoc.ashx

60.BraunPA,KahlS,EllisonMC,LingS,Widmer-RacichK,DaleyMF.Feasibilityofcolocatingdentalhygienistsintomedicalpractices.J Pub-lic Health Dent.2013;73(3):187-194.2013[cited2015July29].Availablefrom:http://www.ncbi.nlm.nih.gov/pubmed/23516970

61.SmithM.Personalcommunication.2014Oc-tober.

62.Walsh M. Raising the Bar. Dimensions of DentalHygiene[Internet].2014[cited2015 August 28]. Available from: http://www.dimensionsofdentalhygiene.com/2014/Perspectives_Supplement/Education/Raising_the_Bar.aspx

63.States stalled on dental sealant programs:a 50-state report. Pew Charitable Trusts[Internet].2015April[cited2015July20].Available from: http://www.pewtrusts.org/en/research-and-analysis/reports/2015/04/states-stalled-on-dental-sealant-programs

64.Dollins HE, Bray KK, Gadbury-Amyot CC.AQualitativeCaseStudyof the LegislativeProcess of the Hygienist-Therapist Bill in aLargeMidwesternState.J Dent Hyg[Inter-net].2013[cited2015July28];87(5):275-288. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24158661

65.Langelier M, Moore J. Interviews of Oral Health Stakeholders in Michigan. Michigan Council for Maternal and Child Health [In-ternet].2015[cited2015July20].Available from: http://www.mcmch.org/resources/Interviews_of_Oral_Health_Stakeholders_Final.pdf

28 Transforming DenTal Hygiene eDucaTion anD THe Profession for THe 21sT cenTury

TEM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM ESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRETION COLLABORATION COLLABORATION COLLABORATION COLLABORAINTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERPLL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ING LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELOTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFOSURES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUALOVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CAOLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CUTCRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL THIBUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER ETEM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM ESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRETION COLLABORATION COLLABORATION COLLABORATION COLLABORAINTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERPLL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ING LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELOTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFOSURES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUALOVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CAOLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CUTCRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL THIBUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER E TEM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM ESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRETION COLLABORATION COLLABORATION COLLABORATION COLLABORAINTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERPLL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ING LIFELONG LEARNING LIFELONG LEARNING LIFELONG LEARNING LIFELOTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY AUTONOMY ATION TRANSFORMATION TRANSFORMATION TRANSFORMATION TRANSFOSURES QUALITY OUTCOMES MEASURESQUALITY OUTCOMES MEASUREQUALOVIDER PRIMARY CARE PROVIDER PRIMARY CARE PROVIDER PRIMARY CAOLOGY CUTTING EDGE TECHNOLOGY CUTTING EDGE TECHNOLOGY CUTCRITICAL THINKING CRITICAL THINKING CRITICAL THINKING CRITICAL THIBUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BUSINESS OWNER BYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER E TEM INTEGRATED HEALTH CARE SYSTEM INTEGRATED HEALTH CARE SYSTEM ESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRECT ACCESS DIRETION COLLABORATION COLLABORATION COLLABORATION COLLABORAINTERPROFESSIONAL EDUCATION INTERPROFESSIONAL EDUCATION INTERPLL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL ACCESS FOR ALL YER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER EMPLOYER E

444 N. Michigan Ave. Suite 3400Chicago, IL 60611312-440-8900www.adha.orgCopyright 2015 American Dental Hygienists’ Association

White_Paper_Covers.indd 2 8/17/15 10:58 AM