The case for dental hygienists’ autonomy: The education and credentialing gap

What you'll learn in this article

• Rebutting false premises dismantles faulty arguments and power structures.
• Dentists' oversight of hygienists rests on flawed, outdated assumptions.
• Dental education lacks standardization, especially in preventive training.
• Hygienists face regulation from less-qualified or untrained practitioners.
• Fear and institutional inertia block reform and suppress dissent.
• True advocacy requires evidence, ethics, and unwavering confrontation of falsehoods.

Part 4 of 6

Rebutting the premise

An essential element of debate is rebutting the premise on which an argument rests. Known formally as the false premise fallacy, once the foundation of an argument is shaken, the structure collapses.¹ It mirrors the legal and rhetorical technique reductio ad absurdum—momentarily accepting an opponent’s premise to expose the absurd, even dangerous, consequences that follow.²

This tactic, when applied with precision, resembles a martial arts counterstrike—redirecting the opponent’s force against them. In advocacy, it functions like a courtroom cross-examination, where a crack in testimony exposes the truth.

Organized dentistry has long relied on the public accepting the premise that dentists are the most qualified, objective, and prepared guardians of oral health, uniquely suited to supervise and regulate all others in the field. But what if that premise is false? What if the foundation on which nearly every regulatory restriction placed on dental hygienists is flawed—demonstrably, dangerously flawed?

Unfortunately, many in advocacy circles approach these questions with a dovish temperament, treating compromise as a default stance. Diplomacy, however, is not synonymous with concession. In fact, this tendency is not merely counterproductive, it undermines our professional obligations. Our Code of Ethics requires us to act in the public interest, advance timely and transparent research, and advocate for evidence-based care.³ Anything less is a failure of duty, not a virtue of civility.

Dentistry’s unchallenged assumptions

The narrative we are challenging is the long-standing assumption that dentists, by virtue of their degree and licensure, are the de facto authorities in all aspects of oral health, including preventive care and the management of periodontal disease. This belief is the foundation for the supposed necessity of dentists’ supervision of hygienists, and it has become the rationale behind the dangerous proposals to train dental assistants in-house or deploy foreign-trained dentists to perform hygiene duties. Organized dentistry has now opened dental education to very real scrutiny by promoting the idea that any dentist can train someone off the street to perform the complex, nuanced care that takes licensed dental hygienists years of rigorous education to master.

A curriculum of convenience, not competence

The myth of uniform competence among new dentists quickly unravels under closer examination of clinical and curricular realities. Despite dentistry’s efforts to insulate itself from scrutiny—evident in patterns of restricted access bias that have constrained empirical research⁴—some studies have still managed to emerge.

DeStaffany et al. reviewed 612 patient charts at one dental school and found that 56.7% contained no periodontal diagnosis, 20.4% lacked any periodontal charting, and 61.1% did not include any documented periodontal assessment or clinical management plan.⁵ In other words, more than half the students never identified the presence or absence of periodontal disease, a condition they were expected to evaluate. They thus lacked any documentation that supported an evidence-based approach to care, confirmation that “competence” is neither standardized nor assured.

These disparities are a direct result of CODA’s ambiguous accreditation criteria for dental programs. Standard 2-24 allows each school to craft its own curriculum “based on the school’s goals, resources, accepted general practitioner responsibilities and other influencing factors.”⁶ That bureaucratic wiggle room produces divergent clinical hour requirements.⁷ The result is predictable: inconsistency, corner-cutting, and a deeply concerning conflict of interest stemming from CODA’s structural subordination to the ADA.⁸

The profession’s own educators acknowledge the gap. In the Journal of Dental Education debate on making a postgraduate year one (PGY-1) residency mandatory, proponents concede that four years is “not sufficient time…to fully prepare students with the scientific knowledge and clinical expertise they will need for 21st century practice.”⁹ They argue that a compulsory PGY-1 is the only realistic way to close the competence gap and protect patients, yet most states still treat residency as optional, leaving graduates to enter independent practice after what is, in effect, an extended classroom simulation.

The disparity becomes even more troubling in light of the reckless proposal to allow internationally trained dentists to function as dental hygienists. With over 1,200 dental schools across 180 countries—many located in developing economies where cultural and institutional emphasis on prevention may be limited—there is considerable variability in educational standards and clinical orientation.¹⁰

Arbitrarily assigning them to deliver preventive services, reserved for licensed dental hygienists, is an affront to both patient safety and professional standards. It replaces specialized education with expediency, triggering a cascade of misinformation, inadequate care, and regulatory evasion. Such a policy could only emerge from a profession where disregard for competency has become so normalized that it is blind to the very harm it perpetuates.

Unlike physicians and veterinarians, who must complete supervised postgraduate training before practicing independently,^11,12 most states allow dentists to begin unsupervised practice immediately upon graduation. These graduates are licensed to perform procedures such as endodontic therapy, implant placement, and complex prosthetics, without any standardized assurance of clinical experience.¹³

In medicine, competency-based education is the norm; in dentistry, it remains an aspiration. The profession relies instead on continuing education—which is often unregulated, minimally vetted, and sometimes conducted overseas—as a retroactive substitute for structured, demonstrable competence.

Meanwhile, dental hygiene programs operate under far more prescriptive accreditation rules,¹⁴ producing a workforce whose diagnostic and preventive competencies are more uniform. In contrast, dentists graduate under a patchwork of self-defined standards and, too often, without ever proving mastery in foundational areas like periodontics or preventive care.

A periodontist exposes the truth

The implications for hygienists are direct and damning. We are being told that our profession requires oversight from individuals who lack mastery in the very areas we specialize in. Worse, state dental boards, often entirely composed of dentists, are now pushing to delegate hygiene services to individuals with inferior or no formal training. This is not an expansion of access; it is a dangerous deregulation of standards. Framing it otherwise is a disingenuous act of political theater.

Michael Rethman, DDS, a periodontist, former president of the American Academy of Periodontology,and former chair of the ADA Council on Scientific Affairs, warned legislators of this dangerous erosion of quality. In a 2025 letter to the Nevada Senate Health and Human Services Committee, he wrote: “… despite being a highly credentialed specialist in periodontology, my instrumentation skills, compared with the skills required of a dental hygienist, are laughably poor. It is my reasoned estimate that 99% of general dentists have lesser skills.” ¹⁵

The weaponization of fear

Dr. Rethman’s letter exposes what many dental educators quietly acknowledge but rarely voice, because speaking out may cost them their careers. Academia and organized dentistry have benefited from this climate of fear, where enforced conformity protects funding, influence, and institutional stability. The use of intimidation to suppress dissent is a hallmark of institutional decline. Dentistry’s regulatory framework has failed to keep pace with advances in clinical science, and that failure carries real and lasting consequences.

Unfortunately, the legal landscape has only reinforced this stagnation. Unlike medicine, where malpractice suits have exposed systemic flaws and driven widespread reforms,^16,17 dentistry remains largely insulated. Torts are not pursued as frequently in dentistry because the financial stakes are lower, allowing the profession to continue operating under the radar. As a result, glaring gaps in competency, accountability, and transparency are not publicly litigated; they are privately endured. Patients suffer, hygienists are constrained, and the public remains unaware.

Strategy for liberation: Facts, ethics, and action

Where do we go from here? First, we must dislodge the premise: dentists do not possess universal expertise in oral health. Second, we must spotlight the facts: dental schools have variable and often insufficient training in prevention and periodontics. Third, we must draw comparisons: medical and veterinary professions impose higher standards for independent practice. Fourth, we must highlight the stakes: patient safety, public trust, and professional integrity are on the line. Finally, we must recommit to our own ethical mandate: the protection of the public through research, evidence, and policy.

Yes, this is a confrontation, but one that is principled, evidence-based, and long overdue. Like a cross examination, our role is to bring to the surface the questions dentistry has long evaded. Hygienists must stop playing defense. Progress does not come from appeasement; it comes from taking the metaphorical bull by the horns and confronting falsehoods with clarity and conviction. Challenging the premise is not optional, it is our responsibility to patients, to the profession, and to our collective conscience.

By dismantling the myth that dentists have mastered preventive and hygiene competencies, we dismantle the entire rationale for their oversight. When the foundation collapses, the structures built upon it must fall. The next phase of hygiene advocacy cannot rely on polite requests for reform—it must demand structural change, armed with evidence, ethics, and an unflinching commitment to the truth.

Author’s note: Coming in part 5: As organized dentistry advances regressive policies, we must confront the historical consequences of its actions (or inactions). Part 5 will reveal how regulatory loopholes, which are deliberately exploited by the profession, have compromised public safety, posing urgent questions about whether these failures reflect mere negligence or an intentional coverup.

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 August/September 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Walton D. Informal Logic: A Pragmatic Approach. Cambridge University Press; 2008.
2. Copi IM, Cohen C, McMahon K. Introduction to Logic. Routledge; 2016.
3. Code of Ethics for Dental Hygienists. American Dental Hygienists’ Association. 2024. Accessed June 10, 2025.
4. Teplitskiy M, Acuna D, Elamrani-Raoult A, Kording K, Evans J. The social structure of consensus in scientific review. arXiv. 2018. doi:10.48550/arxiv.1802.01270.
5. DeStaffany AM, Gurenlian JAR, Bono LK. Investigating periodontal diagnosis and treatment at one dental school. Eur J Dent Educ. 2023;27(3):535-540. doi:10.1111/eje.12838.
6. Accreditation standards for dental education programs. Commission on Dental Accreditation. 2023. Accessed June 10, 2025.
7. Nalliah RP, Forman MS, Chavis SE, Timothé P. Variability between credit units dedicated to dental and clinical sciences in dental schools across the USA. J Investig Clin Dent. 2017;8(3). doi:10.1111/jicd.12229
8. DeRossi S. Friday perspective… improving dental accreditation. LinkedIn. Accessed June 10, 2025. https://www.linkedin.com/pulse/friday-perspectiveimproving-dental-accreditation-code-scott-s--2o6nc?utm
9. Dhar V, Glascoe A, Esfandiari S, Williams KB, McQuistan MR, Stevens MR. Should PGY‐1 be mandatory in dental education? Two viewpoints. J Dent Educ. 2016;80(11):1273-1281. doi:10.1002/j.0022-0337.2016.80.11.tb06212.x
10. Scepanovic T, Mati S, Ming ALC, et al. The global distribution of special needs dentistry across dental school curricula. Spec Care Dentist. 2024;44(4):1191-1210. doi:10.1111/scd.12973.
11. Charap MH, Levin RI, Pearlman RE, Blaser MJ. Internal medicine residency training in the 21st century: aligning requirements with professional needs. Am J Med. 2005;118(9):1042-1046.
12. Sykes JE. Lessons learned: Shaping the evolution of veterinary specialty education. J Vet Intern Med. 2024;38(1):375-380.
13. Katsaros T, Allareddy V, Elangovan S. Dental students’ exposure to periodontal and implant placement surgeries in US dental schools. J Dent Educ. 2019;83(8):953-958. doi:10.21815/jde.019.090.
14. Accreditation standards for dental hygiene education programs. Commission on Dental Accreditation. 2022. Accessed June 10, 2025.
15. Rethman M. Letter to the Nevada Senate Health and Human Services Committee Chair. 2025.
16. Agarwal R, Gupta A, Gupta S. The impact of tort reform on defensive medicine, quality of care, and physician supply: a systematic review. Health Serv Res. 2019;54(4):851-859. doi:10.1111/1475-6773.13157.
17. Studdert DM, Mello MM, Brennan TA. Defensive medicine and tort reform: a wide view. J Gen Intern Med. 2010;25(5):380-381. doi:10.1007/s11606-010-1319-8.