The case for dental hygienists' autonomy: The economics of dentistry

Part 3 of 6

Follow the money

They say money is the root of all evil, that it makes the world go round, that if one wants answers, one should follow it.¹ These adages endure because they reflect an unavoidable truth: any policy, no matter how well-intentioned, is destined to fail if it ignores the financial systems in which it operates.

Public health initiatives rarely falter due to lack of merit; they fail because their economic impact is overlooked or undervalued. In the debate over dental hygiene autonomy, it is imperative that the economic advantages are not treated as a side note, but as a central pillar of the conversation.

It is equally important to have a candid conversation about what has historically driven the subjugation of dental hygienists, and more urgently, what now fuels organized dentistry’s regressive and irresponsible proposal of the oral preventive assistant (OPA). This is precisely where a forensic economic analysis proves most revealing, exposing the financial motives masked by professional rhetoric.¹

For decades, organized dentistry has exercised rigid control over the profession of dental hygiene, not in the interest of safety, but for profit.^2,3 By dictating how, when, and where hygienists may practice, dentists have secured a steady stream of preventive services that function as feeders for higher-revenue restorative procedures. This outdated model, rooted in professional dependency and cloaked in the language of supervision, lacks scientific basis and offers no documented safety benefit. Its sole purpose lies in gatekeeping and financial control.

The growing unrest between dentists and hygienists is not a mystery; it is the inevitable fallout of a system built on professional suppression and economic exploitation.⁴ As dentists express frustration over rising wage demands and staffing shortages, what they are truly witnessing is the collapse of a model they constructed, a model that has long depended on controlling and undervaluing the hygiene profession.⁵

The proposed OPA model is not an innovative solution but a desperate attempt to reinforce that failing structure. By lowering educational standards and introducing a cheaper, more compliant labor tier, the OPA model seeks to reestablish the power dynamics dentistry has relied on for decades, replacing skilled, licensed providers with a less expensive alternative. But the more pressing question that must be asked: are there other forces at work?

Insurance companies, whose entire business model depends on paying out less than they take in, have a parallel financial incentive.^6,7 Procedures commonly performed by licensed hygienists, such as scaling and root planing or periodontal maintenance, are more expensive to reimburse but essential for oral health. The OPA model would result in fewer of these procedures being performed, allowing insurers to suppress utilization and retain a greater share of premiums.

Is it possible that dentistry’s economic model, built on gatekeeping and dependency, has now found common cause with insurers seeking to lower payouts? Are we witnessing a coordinated shift to devalue prevention and commoditize care? These are not abstract questions. They are at the heart of a policy debate that threatens to reshape the dental workforce in ways that prioritize revenue over outcomes.

The OPA proposal is more than just misguided—it is a case study in what occurs when short-term financial interests eclipse professional ethics and public health priorities. Organized dentistry engineered the very conditions it now pretends to resolve, only to put forth a “solution” that serves the same interests responsible for creating the problem in the first place.

Autonomy’s economic and operational impact

In stark contrast to the regressive OPA proposal, dental hygiene autonomy offers an evidence-based, ethically grounded solution to the very challenges facing the industry. It is a model that practice owners and DSOs should not resist, but actively embrace—one that realigns incentives, enhances workforce stability, and moves the profession toward a more sustainable, future-oriented model in which prevention holds equal value to restoration.

Autonomy, however, does not imply that every hygienist will, or must, open an independent practice. Just as not all dentists choose to become practice owners, not all hygienists will pursue solo ventures. What autonomy offers is choice: the ability for hygienists to serve as associates, collaborators, or entrepreneurs depending on their goals, training, and clinical setting. Rather than causing fragmentation, it introduces much-needed flexibility, benefiting individual professionals and the practices they support.⁸

For some hygienists, the transition may appear daunting, as autonomy brings heightened accountability, greater clinical responsibility, and operational independence.⁹ However, this should not be viewed as a burden, but a long-overdue acknowledgment of the experience, training, and licensure that define our profession.

The most immediate and measurable impacts of autonomy are seen across five key areas: the transfer of liability, changes to employment classification, greater workforce stability, enhanced financial motivation and efficiency, and the strengthening of dentistry’s collective voice against third-party interference.

Liability shift

Autonomy transfers clinical liability to the professional rendering care, aligned with the legal doctrine respondeat superior (“let the master answer”).¹⁰ Currently, practice owners are liable for their employees' actions within the scope of employment. When hygienists practice autonomously—whether as independent contractors, sole proprietors, or owners of a hygiene-focused practice—they become the primary responsible party for their clinical decisions, just like associate dentists or nurse practitioners in private practice. Another licensed professional's oversight no longer shields them.

Employment classification

Worker classification is a common source of confusion in dentistry. Under IRS and US Department of Labor guidelines, dental hygienists who work under any form of dentist supervision, whether direct, indirect, or general, must be classified as W-2 employees. This includes temporary assignments and working interviews, regardless of how the worker or practice prefers to structure payment.¹¹

However, autonomy creates a pathway for legitimate 1099 classification. In states where dental hygienists are licensed to practice independently, without any form of mandated supervision, they may meet the federal criteria for independent contractor status. When hygienists control their own clinical decisions, schedules, and business operations, they may lawfully operate as 1099 contractors under IRS and Department of Labor guidelines.

Workforce stability

Autonomous hygienists are inherently more invested in their work.¹² Much like associate dentists, they are more likely to remain in their roles when they have meaningful control over their schedules, treatment decisions, and patient relationships.¹³ This sense of ownership fosters stronger clinical engagement, reduces turnover, and enhances continuity of care.

The result is a more cohesive team environment and a more predictable staffing model, both of which are especially valuable in today’s increasingly competitive labor market. For practice owners and DSOs, this translates into reduced recruitment costs, better team morale, and a workforce that is aligned not only with the mission of the practice, but with the long-term success of the business.

Financial efficiency and motivation

A hygienist compensated based on collections, just like an associate dentist, is naturally motivated to be productive, thorough, and clinically efficient. Eliminating the requirement for a dentist to conduct a mandatory exam at every hygiene visit unleashes a powerful source of untapped productivity, often reclaiming 10 to 20 minutes per patient. That time savings alone can increase daily patient volume by 15% to 30%, all without compromising the quality of care. Fewer bottlenecks, smoother appointments, and improved patient satisfaction are the direct result.

In contrast to the OPA model, which dilutes care and lowers standards under the guise of access, this autonomy-based framework maintains clinical excellence while addressing the growing backlog of patients in a scalable, ethical, and evidence-driven way. If the goal is to see more patients without sacrificing care quality, this model is not only more effective, but it is the only responsible path forward.

Strengthening the collective voice

Perhaps most critically, autonomy strengthens the collective voice of dental professionals by moving the focus away from internal hierarchies and toward shared external challenges. For too long, the professions have diverted energy into gatekeeping and control rather than collaboration. By functioning as independent, allied providers, hygienists and dentists can unite to confront the real threat to patient-centered care: third-party payors whose interference devalues treatment and undermines clinical judgment.^6,7 Autonomy creates the foundation for a stronger, more unified profession, better equipped to advocate for both provider integrity and patient access.

A responsible path forward

Autonomy’s success depends on thoughtful implementation anchored in well-defined standards, supported by sound legislation, and upheld through shared professional accountability. Autonomy represents evolution, not division. It requires more from hygienists: legal literacy, increased responsibility, and business acumen. It also challenges practice owners to move beyond hierarchy and recognize dental hygiene as a core clinical discipline, not a subordinate function.

It improves patient care, enhances business performance, and rebalances a profession long overdue for structural reform. Dentistry cannot afford to cling to outdated models; workforce dynamics are shifting, costs are rising, and patients expect more. Dental hygiene autonomy is not a threat; it is a strategic, ethical, and economic solution. The time for control has passed. The time for collaboration is now.

Editor's note: This article appeared in the July 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

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10. Respondeat superior. Cornell Law School. Accessed April 27, 2025. https://www.law.cornell.edu/wex/respondeat_superior
11. Guignon A. Strategies to avoid 1099 workplace woes: why misclassification is a dangerous pathway. Hygienist Hub. 2024. Accessed April 27, 2025. https://www.adha.org/hygienist-hub/avoid-1099-workplace-woes/
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