A century of subordination: The historical barriers to dental hygienists' autonomy
Part 2 of 6
It shouldn’t take a man to say this, but here we are
The irony of a white, cisgender man addressing the entrenched sexism in dentistry is not lost on me. Yet, research suggests that men are more likely to engage in discussions about sexism when another man leads them,1,2 a paradox that only reinforces the very bias this article seeks to expose.
With that in mind, while the women in my profession may find little here that surprises them, my true audience is the legislators, policymakers, and male leaders in dentistry who may be open to an honest evaluation of why systemic change is needed.
This is an unfiltered examination of the structural sexism embedded in dentistry, a profession that has long constrained the autonomy of hygienists under the pretext of safety and oversight.
The gendered origins of dental hygiene
In 1906, Dr. Alfred Fones trained his cousin, Irene Newman, as the first “dental nurse,” introducing the novel idea that a nondentist could provide preventive oral health care.3 Though revolutionary, this concept was quickly gendered. Women were viewed as naturally suited for the nurturing role of health maintenance and prevention, fitting well into the societal norms of the time.
It should be noted that although Fones is credited with founding the first successful dental hygiene program in 1913,3 it was not the first attempt. The earliest known program was established in Ohio in 1910.4 However, it closed quickly due to intense resistance from Ohio dentists,5 foreshadowing the first of many battles between organized dentistry and the emerging dental hygiene profession. Although organized dentistry opposed the idea of dental hygienists, the role’s exclusively female composition made it easier to control.
Parallel struggles: Women’s civil rights
I realize my last statement will make some uncomfortable, but when taken in the context of the time, it’s difficult to deny because the professional subjugation of dental hygienists mirrors the broader historical struggle for women’s civil rights in the US. The 19th Amendment, granting women the right to vote, was not ratified until 1920.6 For decades after, women remained legally and financially tethered to men, unable to open a bank account or secure a mortgage without a male cosigner until the passage of the Equal Credit Opportunity Act in 1974.7
This forced dependency has an uncanny parallel in dentistry. Just as women were deemed incapable of managing their finances, dental hygienists were deemed incapable of managing their own patients and practices. The result? A power structure in which control remains concentrated in the hands of a male-dominated profession, while those doing the bulk of the work operate under artificial constraints.
Systemic barriers: Current and historical
Despite progress in gender equality, dentistry remains one of the slowest professions to shed its patriarchal roots. While women have gained autonomy elsewhere, dental hygienists in most states still need a dentist’s permission to practice, a restriction imposed by male-dominated dental boards intent on preserving control. Even within their own profession, women make up less than 38% of dentists,8 a notable increase, but the field remains male-dominated.
In many ways, the struggle for dental hygiene autonomy mirrors nursing’s fight for professional recognition, with both fields facing systemic efforts to limit their independence under the pretense of patient safety.9 While nurses eventually won the right to diagnose, prescribe, and practice independently in many states, it took years of resistance against organized medicine.10
Dental hygienists now face similar opposition in their push for autonomy,11 reinforcing a pattern that when women dominate a profession, it is systematically suppressed, forcing it to fight for legitimacy and the ability to serve the public fully.
Historically, laws and regulations ensured the profession remained predominantly female, making it easy to dismiss, undervalue, and control. O’Shea states in his 1971 article that hygienists “by state law or custom … can only be female.” 12 Even the American Dental Hygienists’ Association’s own constitution had to be amended in the 1960s to remove the word “female,” paving the way for the first male hygienist in 1965. While these restrictions were lifted, the profession continues to grapple with the lasting impact of its exclusionary history within a broader system that still devalues female-dominated fields.
Economic consequences of professional gatekeeping
The forced dependency of dental hygienists on dentists stifles productivity across the entire dental care system. Requiring hygienists to work only with a dentist’s permission limits their contributions, restricts career growth, and suppresses earning potential.13 More critically, it blocks them from providing the preventive care they’re trained to deliver, care that could reduce the need for costly restorative treatment. This structure prioritizes gatekeeping over both efficiency and public health.
At its core, this model reflects a broader pattern seen in female-dominated professions, where systemic constraints limit autonomy and compensation.14 Framed as oversight, these restrictions functionally devalue a skilled workforce and hinder efforts to expand access to care.
Case study: The Virginia Dental Practice Act
I trained as a dental hygienist in the Pacific Northwest, where the profession operates under one of the broadest scopes of practice in the country. While paternalism still exists there, it is far less overt than in other regions. When I moved to the South for graduate school, I was unprepared for the stark contrast of deeply entrenched sexism still casting its long shadow over dentistry.15
Here, outdated regulations continue to restrict and undermine hygienists. A glaring example is the Codes of Virginia on Dentistry, which still refers to dentists using exclusively male pronouns,16 an outdated linguistic relic that reflects the profession’s deeply ingrained gender bias. But language is merely a surface-level symptom of a much deeper problem.
Under current Virginia law, dental hygienists working under general supervision must first obtain a written treatment order from a dentist and can only provide care if the dentist has examined the patient within the past 10 months.17 They must also inform the patient that a dentist will not be present,17 creating an insulting dynamic that implies their care is somehow less safe.
This outdated requirement is little more than modern-day Victorian-era nonsense. It sends the message that the overwhelmingly female profession of dental hygiene cannot be trusted to do the very work they are licensed and trained to perform unless a dentist grants permission.
The restrictions go even further in remote or underserved areas, where hygienists can only provide care if the patient sees a dentist within 180 days.16 This paternalistic rule undermines patient autonomy and wrongly suggests hygienists cannot deliver preventive care independently or refer to a dentist themselves. Imagine if nurse practitioners were forced to send every patient to a doctor after routine care. The idea would be unacceptable, yet this is exactly what Virginia imposes on dental hygienists.
A movement is growing
Despite these barriers, the tide is slowly turning. The brazen attempts by organized dentistry to undermine our profession—whether by pushing for untrained assistants to perform hygiene duties or attempting to hand over our scope of practice to foreign-trained dentists—have ignited a long-overdue reckoning within the field. These aggressive efforts to diminish dental hygiene have only galvanized the profession, strengthening advocacy and legislative momentum.
More states are now considering legislation to separate dental hygiene from dentistry, establishing it as the independent profession it must be. Expanded practice laws are gaining attention, following past movements for gender and professional equality.
However, real change requires more than policy shifts; it demands a cultural transformation in how dental hygiene is perceived. The profession must no longer be seen as an auxiliary service but as a cornerstone of preventive health care. This means dismantling the entrenched biases that have kept dental hygienists in a subordinate position for more than a century and ensuring that the future of oral health care is built on evidence, equity, and autonomy.
The question should no longer be whether dental hygienists can practice autonomously; science and public health data have already settled that. The real question is for dentistry itself: is the ongoing control over hygienists genuinely about patient safety, or is it about preserving a legacy power structure that no longer fits within modern health care?
Author’s note: Part three will critically examine how dental hygiene autonomy functions economically, outlining its advantages and disadvantages for both hygienists and dentists. The evidence presented may pleasantly surprise practice owners while also critically evaluating the workforce models hygienists have grown accustomed to.
Disclaimer: The views and research presented in this series, while they may align with the policies of the American Dental Hygienists’ Association, do not officially represent it or its tripartite structure.
Editor's note: This article appeared in the June 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
1. Czopp AM, Monteith MJ. Confronting prejudice (literally): reactions to confrontations of racial and gender bias. Pers Soc Psychol Bull. 2003;29(4):532-544. doi:10.1177/0146167202250923
2. Cihangir S, Barreto M, Ellemers N. Men as allies against sexism: the positive effects of a suggestion of sexism by male (vs. female) sources. Sage Open. 2014;4(2):2158244014539168. doi:10.1177/2158244014539168
3. Fones AC. The origin and history of the dental hygienists. J Dent Hyg. 2013;87 Suppl 1:58-62. https://jdh.adha.org/content/87/suppl_1/58.short
4. Milling LA. Dental hygiene’s grad history. RDH. 2010. Accessed March 30, 2025. https://www.rdhmag.com/career-profession/article/16407684/a-history-of-the-dental-hygiene-profession
5. Timeline of dental hygiene. Sindecuse Museum. University of Michigan. Accessed March 30, 2025. https://www.sindecusemuseum.org/timeline-of-dental-hygiene
6. 19th Amendment to the U.S. Constitution: Women's Right to Vote. National Archives. Accessed March 30, 2025. https://www.archives.gov/milestone-documents/19th-amendment
7. Blakely SS. Credit opportunity for women: the ECOA and its effects. Wisc Law Rev. 1981;1981(4):655-696. https://wrlc-gwahlth.primo.exlibrisgroup.com/permalink/01WRLC_GWAHLTH/1c5oj26/cdi_proquest_miscellaneous_59210723
8. U.S. dentists demographic dashboard. American Dental Association. https://www.ada.org/resources/research/health-policy-institute/us-dentist-demographics
9. O'Brien JM. How nurse practitioners obtained provider status: lessons for pharmacists. Am J Health Syst Pharm. 2003;60(22):2301-2307. doi:10.1093/ajhp/60.22.2301
10. Moore C, Kabbe A, Gibson TS, Letvak S. The pursuit of nurse practitioner practice legislation: a case study. Policy Polit Nurs Pract. 2020;21(4):222-232. doi:10.1177/1527154420957259
11. Preshaw PM, Minnery H, Dunn I, Bissett SM. Teamworking in dentistry: the importance for dentists, dental hygienists and dental therapists to work effectively together–a narrative review. Int J Dent Hyg. 2024;(11). doi:10.1111/idh.12874
12. O'Shea RM. Dentistry as an organization and institution. Milbank Mem Fund Quar. 1971;49(3):13-28. doi:10.2307/3349416
13. Chen J, Meyerhoefer CD, Timmons EJ. The effects of dental hygienist autonomy on dental care utilization. Health Econ. 2024;33(8):1726-1747. doi:10.1002/hec.4832
14. Hoff T, Lee DR. The gender pay gap in medicine: a systematic review. Health Care Manage Rev. 2021;46(3):E37-E49. doi: 10.1097/HMR.0000000000000290
15. Kerwin KC, Guryan J, Pan J. The effects of sexism on American women: the role of norms vs. discrimination. National Bureau of Economic Research. August 2018.
16. Code of Virginia. Accessed March 30, 2025. https://law.lis.virginia.gov/vacodefull/title54.1/chapter27/
17. Administrative Code. Accessed March 30, 2025. https://law.lis.virginia.gov/admincode/title18/agency60/chapter21/section120/
