The case for dental hygienists' autonomy: Charting the path forward
Key Highlights
- Modernizing dental hygiene is not radical—it is evidence-based, practical, and essential for prevention-focused care.
- Dentistry’s control over hygiene is rooted in monopoly, tradition, and fear—not science or safety.
- The Dental Hygiene Modernization Act proposes the RDH-AP credential, modeled after nurse practitioner-style autonomy.
- RDH-APs would diagnose within scope, provide advanced preventive care, and operate under independent hygiene boards.
- States like Colorado and California prove hygienist autonomy increases access, maintains safety, and supports public health.
Part 6 of 6
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A mass case of Stockholm Syndrome?
In August 1973, a bank robbery in Stockholm, Sweden, turned into a six-day hostage crisis that would leave a permanent mark on psychology and the way we understand power. Two men held four employees captive inside a bank vault, threatening their lives while wielding total control over their every movement.1
Yet when the standoff finally ended, something startling occurred—the hostages resisted rescue, defended their captors, and even raised money for their legal defense afterward. This paradoxical loyalty to one’s oppressor became known as Stockholm Syndrome, a term that has since described the unsettling bond that can form when people subjected to domination begin to accept, rationalize, or even protect the very system that holds them captive.2,3
Dental hygienists, in many ways, have endured a professional parallel. Decades of subordination have conditioned much of the workforce to accept dentists’ control over their licensure, their practice settings, and even their very identity as health professionals. Instead of demanding rightful autonomy, too many rationalize their captivity, persuading themselves that dentists “know best” or “have their back.”
Dentistry’s track record reveals otherwise. Its leadership has been dominantly self-interested—guarding wealth, influence, and monopoly protections—at the expense of society’s health and the advancement of preventive medicine.4 This misplaced trust has allowed an inequitable structure to persist, one in which hygienists’ skills are underutilized, the public’s access to care is needlessly restricted, and the promise of prevention is continually sidelined for the profitability of repair.
Like the Stockholm hostages, too many hygienists have conflated compliance with collaboration. This captivity is not a partnership but a scientifically baseless economic hierarchy that undermines public health. Our profession faces a defining choice: submit to the chains that bind it or break free to claim the autonomy that evidence and justice demand.
The case for modernization
This series has traced the chains that bind dental hygiene, exposing how they were built and why they persist. Part one examined how dental practice acts and the recent actions of organized dentistry are vulnerable to antitrust scrutiny by the Federal Trade Commission. Part two examined the sexism inherent in these statutes, illustrating how restrictions were intended to maintain male-dominated control.
Part three exposed the economic inefficiency of a restorative monopoly that runs counter to sound business practices. Part four uncovered the cracks in dental education, dismantling the view that dentists are fully equipped to control and direct all aspects of oral health practice. And part five revealed a history of regulatory manipulation that has harmed public safety and selective deregulation, revealing where organized dentistry’s priorities truly lie.
The evidence is overwhelming. Restrictions on dental hygiene are not rooted in science, safety, or education; they’re rooted in monopoly, tradition, and fear. Yet, pointing out the chains is not enough. If hygienists are to move beyond captivity, we must move past critique and collectively present a plan for the future, one that replaces the status quo with a modern, responsible, and just framework.
The Dental Hygiene Modernization Act: A blueprint for change
The Dental Hygiene Modernization Act represents that turning point.5 Developed by the American Dental Hygienists’ Association (ADHA) with input from dentists, periodontists, lawyers, educators, and public health advocates, it is a legislative framework grounded in evidence, modeled on proven state successes, and crafted for implementation in every state.
At its core, the Act creates a new designation: the Registered Dental Hygienist in Advanced Practice (RDH-AP). Much like nurse practitioners or physician associates, the RDH-AP credential signals a clear, advanced tier of professional competence. This model ensures that those who seek autonomy meet higher educational and clinical benchmarks, while those content to remain within traditional roles can do so without disruption.
The pathway to RDH-AP is a pragmatically rigorous one. A hygienist seeking the designation must at least hold a bachelor’s degree, complete 2,000 hours of supervised practice serving as a clinical residency, and undertake a 150-hour advanced curriculum that bridges traditional hygiene education with the demands of independent judgment and liability. These requirements mandate a standard of readiness equal to, and in some respects exceeding, other health professions.
What follows is a scope of practice that finally aligns with modern preventive science. RDH-APs will provide diagnosis within their scope, nonsurgical periodontal therapies, and caries management, while also screening for systemic diseases and serving as advocates by directing patients to appropriate dental or medical providers for additional care.
The Act expressly limits this scope to prevention, consistent with the ethos of dental hygiene, and establishes a clear statutory boundary separating preventive services from restorative dentistry. With this distinction, the Act preserves dentistry’s restorative domain while simultaneously laying out the framework to challenge opposition as an unlawful restraint of trade under antitrust principles.6,7
Perhaps the most transformative provision is the establishment of self-governance through independent boards for dental hygiene, as successfully demonstrated in California.8 Hygienists will no longer answer to a profession with a vested interest in restricting them. Oversight will rest primarily with hygienists themselves, joined by one dentist and one public member, ensuring accountability while ending the era of regulatory capture.
This model not only protects the public through transparent and profession-appropriate regulation but also provides the legal remedy to organized dentistry’s anticompetitive dominance. Protected titles—RDH and RDH-AP—further guarantee that the public can trust the integrity of these credentials.
Taken together, the Dental Hygiene Modernization Act is not just a model bill, it’s a blueprint for freedom. It will codify a future where hygienists practice at the top of their training, prioritizing prevention over profit, and where public health finally benefits from a fully unleashed preventive workforce.
Why this model works
Skeptics will ask whether such a model is practical, safe, or sustainable. The answer lies in decades of evidence. In Colorado, hygienists have practiced independently since 1986, expanding access in rural and underserved areas, maintaining strong safety records, and producing no evidence of harm.9,10 Their autonomy is not limited to stand-alone practices; even within traditional dental offices, it has been used to increase efficiency, boost productivity, and free dentists to focus on restorative care.
In California, the RDH-AP model has shown that with additional education and defined practice authority, dental hygiene can coexist with dentistry while improving access.8 These are no longer experiments; they are precedents.
The Dental Hygiene Modernization Act builds on those precedents with greater clarity. It draws a firm boundary between preventive practice and restorative dentistry, avoiding contentious political battles while delivering accessible preventive care. At the same time, it raises standards with a bachelor’s degree minimum, 2,000 hours of supervised practice residency, and a 150-hour advanced curriculum—requirements that together represent more than four years of education and training.
In doing so, the Act strips opponents of their favorite caricatures. They cannot claim hygienists lack education when the requirements exceed those of other health professions. They cannot argue scope “threatens” dentistry when the Act clearly delineates prevention from restoration.
And they cannot rely on fearmongering about sedation or restorative procedures when those areas are deliberately excluded. Autonomy in hygiene is not about cutting corners; it is about raising the bar and protecting the public through evidence-based reform.
Finally, the Act resolves a structural weakness that has haunted the profession for a century—dependence on dental boards for regulation. A dedicated Board of Dental Hygiene would place decisions about scope, ethics, and standards in the hands of hygienists themselves, with public oversight built in. This reform is essential to protect progress from future rollbacks.
The Act is not radical—it is reasonable. It is not untested—it is proven. And it does not undermine dentistry—it stabilizes public health by allowing the preventive workforce to function at full capacity. It works because it already has. The only question is whether the rest of the nation will have the courage to enact these reforms.
Breaking the chains: From captivity to courage
The Stockholm hostages did not walk free until the police stormed the vault and forced separation from their captors. For hygienists, no such rescue is coming. Freedom must be chosen. That choice begins with rejecting the idea that captivity is collaboration, that dependence is partnership, or that subordination is protection.
Breaking our chains means confronting uncomfortable truths: that dentists as a profession have prioritized wealth over wellness, that organized dentistry has fought autonomy at every turn, and that passivity has only delayed the inevitable. It means admitting that no profession willingly surrenders power—and that autonomy will never be “granted.” It must be claimed.
Breaking chains also means embracing accountability. Autonomy is not an escape from responsibility—it is its fullest expression, rooted in service to the public good. Prevention belongs to those who have studied it, trained for it, and built their careers upon it. Courage now is not defiance for its own sake—it is fidelity to science, to our patients, and to the mission of preventive health.
The path forward
The path forward is clear. Hygienists must organize around a legislative agenda that advances the Dental Hygiene Modernization Act as the national model. Lawmakers must recognize that outdated restrictions are not only unjust but also anticompetitive, exposing states to FTC scrutiny. Public health advocates must join this effort, seeing hygienists as essential partners in primary prevention. And we ourselves must stop rationalizing our captivity, stop waiting for permission, and start demanding the autonomy we have already proven we can shoulder.
This is not about abandoning dentistry. It is about liberating prevention from its confinement within a restorative monopoly. It is about honoring the public’s right to timely, accessible, evidence-based care. It is about a profession choosing courage over comfort, responsibility over restriction, and justice over tradition.
The chains have been identified. The key has been forged. The door can be opened. The only question that remains is whether we as a profession will walk through it.
Editor's note: This article appeared in the November/December 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
1. Harnischmacher R, Müther J. The Stockholm syndrome. On the psychological reaction of hostages and hostage-takers. Arch Kriminol. 1987;180(1-2):1-12.
2. Namnyak M, Tufton N, Szekely R, Toal M, Worboys S, Sampson E. 'Stockholm syndrome': psychiatric diagnosis or urban myth? Acta psychiatrica Scandinavica. 2008;117:4-11. doi:10.1111/j.1600-0447.2007.01112.x
3. Alshwaiheen N, Saleh D, Alani W. A case of post-traumatic stress disorder (PTSD) complicated by Stockholm Syndrome: a unique psychiatric phenomenon in the context of intimate partner violence. Cureus. 2025;17(4). doi:10.7759/cureus.82307
4. Finley S. Standardizing greed: the real agenda behind SB 495. The Nevada Globe. 2025. https://thenevadaglobe.com/articles/opinion-standardizing-greed-the-real-agenda-behind-sb-495/
5. ADHA Advocacy releases model autonomy legislation. American Dental Hygienists’ Association. September 2025. https://www.adha.org/adha-at-work-for-you/
6. The Antitrust Laws. Federal Trade Commision. 2024. https://www.ftc.gov/advice-guidance/competition-guidance/guide-antitrust-laws/antitrust-laws
7. Liptak A. Justices find antitrust law valid against dental board. New York Times. February 25, 2015. https://www.nytimes.com/2015/02/26/business/justices-find-antitrust-law-valid-against-dental-board.html
8. Background paper for dental hygiene board of California. March 16, 2023. https://abp.assembly.ca.gov/sites/abp.assembly.ca.gov/files/3-16%203.%20Dental%20Hygiene%20Board%20-%20Sunset%20Background%20Paper%20%282023%29.pdf
9. Astroth DB, Cross-Poline GN. Pilot study of six Colorado dental hygiene independent practices. J Dent Hyg. 1998;72(1):13-22.
10. Oral health workforce in Colorado. Colorado Health Institute. 2009. https://www.coloradohealthinstitute.org/sites/default/files/file_attachments/OralHealthReport.pdf
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 November/December 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
About the Author
Derik J. Sven, MBA, MPH, RDH, CDT, FADHA
Derik has nearly two decades of experience as a board-certified lab tech and restorative hygienist. He holds undergraduate degrees in dental hygiene and health care administration, as well as master’s degrees in public health and business administration. He’s currently pursuing his doctorate in health science at George Washington University School of Medicine in Washington, DC, where his research focuses on advancing the autonomy of dental hygienists and the broad integration of dental therapists into the health-care system. He’s an inaugural fellow of the ADHA and president of Virginia's chapter.