Direct access and the dental hygienist: State spotlight, Colorado

Direct-access dental hygiene, which can be defined as a dental hygienist’s ability to provide treatment without the onsite supervision or authorization of a dentist, is developing a key place in the dental industry. This article will look at the state of direct-access dental hygiene in America, as well as a spotlight on the state of Colorado and the practice of independently practicing dental hygienist Angie Rhoades.

Direct access and its variations

In the United States, dental hygienists providing direct access to care have numerous titles and definitions—so many, in fact, that things often become confusing for both practitioners and patients alike. Even though no two states are identical in their definition of direct access, at least 40 states currently authorize dental hygienists to provide direct access in one form or another. It is rare to find two states that give direct-access dental hygienists the same title—thanks in part to legislation that establishes direct-access requirements at the state level.

For example, direct-access dental hygienists in Maine function independently and can practice without influence of a supervising dentist, while other states allow direct-access hygienists to provide services only when under general supervision of and when having a written collaborative agreement with a dentist.

The state-by-state variation of direct-access dental hygiene—and the dental hygiene model in general—not only promotes confusion, it also challenges hygienists’ authority as primary care providers. In many instances, state legislation adds constraints to direct access, such as limiting treatment to underserved patients and restricting the types of services allowed. Some states mandate an oral evaluation by a third-party dentist after a designated period of time in order for a hygienist to continue care.

Direct access and oral health in America

How will direct access be even more significant for the future of dentistry? A recent report by the US Department of Health and Human Services predicts a national shortage of dentists by 2025.1 Creative solutions to mitigate this problem are being discussed at the local, state, and national levels. These solutions aim to impact legislation, increase third-party reimbursement rates, and create entirely new health-care delivery models, such as oral care by a dental therapist.

The problem is that it can take decades to strategize, design, fund, and implement a single solution. What will happen to the state of oral health in America while we wait year after year for these solutions to become viable? It’s an important and challenging question to consider. But direct-access dental hygiene may provide the answer. With simple regulatory changes at the state level, the current dental hygiene workforce of more than 211,000 professionals could easily be the most immediate and effective solution.2 In fact, the Department of Health and Human Services also predicts a national surplus of hygienists by 2025 and suggests that a change to oral health delivery and systems within the existing dental workforce is inevitable.1

Think of this: What if every hygienist had the opportunity to provide care precisely where their patients ate, slept, worked, learned, prayed, and played? What if dental hygienists could provide their current scope to anyone, in any place, and at any time without being restricted by the availability of a dentist? What if eliminating supervision requirements for dental hygienists across all 50 states was the most immediate answer to this country’s poor oral health future? These types of questions highlight numerous creative possibilities. But to be effective, it is imperative that the role and scope of direct-access dental hygienists become more universally understood.

Real stories of direct-access dental hygiene

In order to learn more about the differences in dental hygiene practice across the country, I’ll be interviewing hygienists who are providing variations of direct access and present them here in RDH. Each article will explore the statutes, regulations, opportunities, and limitations that shape direct access in a particular state.

Our first state spotlight is one with the longest tradition of complete dental hygiene independence: Colorado. Since the mid-eighties, dental hygienists in Colorado have pioneered independent hygiene practice. They have had the privilege of working unencumbered and unsupervised. They have even enjoyed the opportunity to own their own dental hygiene practices.

Direct access in Colorado has allowed independent dental hygienists to provide mobile services, rent a space in a traditional dental practice, or form a stand-alone practice. Colorado statutes are some of the surprisingly few to specifically recognize and define the dental hygiene diagnosis.2 A summary of Colorado’s definition of direct-access dental hygiene care can be found in Table 1.

Interview with Colorado independent hygienist Angie Rhoades, BSDH