VDHA Policies regarding LICENSE AND REGULATION

R 12-2020

AUTONOMY OF DENTAL HYGIENE

The Virginia Dental Hygienists’ Association supports autonomy of dental hygiene education, licensure, and practice and accepts the responsibility for serving as the recognized authority for the profession of dental hygiene.

R 1-13/5-09

SELF –REGULATION

Regulation of dental hygiene practice by dental hygienists who define the scope of practice, set educational requirements and licensure standards, and govern dental hygienists.

Dental hygienist autonomy is not a new idea—it is a proven model with nearly four decades of safe and ethical application in states like Colorado, Oregon, California, and Maine. These states have authorized dental hygienists to operate independently within their scope of licensed practice, leading to expanded access, improved health outcomes, and no increase in patient harm or legal complications. Autonomy helps modernize oral health care delivery by reducing unnecessary regulatory barriers, while also creating a more fair and efficient business environment for professionals. 

Autonomy is the ability of a licensed dental hygienist to provide preventive and nonsurgical services without being under the remote, direct or general supervision of a dentist. This includes services such as dental hygiene care and recare appointments, oral health assessments, cancer screenings, fluoride treatments, sealants, tobacco cessation and nutritional counseling, and referrals to other providers. Autonomy does not expand a hygienist’s scope—it simply allows them to deliver their authorized services in settings without the supervision of a dentist; however, collaboration and referrals may still occur.  

Yes. States such as Colorado, Oregon, California, and Maine have safely implemented autonomous practice models for decades. Research and state data consistently show that dental hygienists in these states deliver high-quality care, increase access in underserved communities, and help divert patients from costly emergency room visits. These models have also demonstrated fiscal sustainability and improved workforce retention, all without elevating liability or compromising quality of care. 

Autonomy removes redundant gatekeeping and oversight, improving both efficiency in private practice and access in hard-to-reach populations. It allows hygienists to serve directly in community settings—schools, nursing homes, health departments, mobile clinics, and more—especially in areas with persistent dentist shortages. This model increases access to the dental hygienist’s care, reduces the burden of untreated dental disease, reduces emergency room visits, and ensures timely referrals to dentists for complex or restorative needs. It also supports vulnerable populations who often face logistical, financial, or geographic barriers to traditional dental office models—ensuring care is brought to them. 

No. Hygienists are not performing fillings, extractions, or any surgical or irreversible procedures. Autonomy upholds the licensed scope of dental hygiene practice centering on prevention and education. Dentists and hygienists have complementary roles, and autonomous practice strengthens this relationship by creating more efficient, team-based models of care. 

It frees dentists to focus on complex restorative and surgical procedures, while hygienists handle preventive care. In practice, this can lower overhead costs, improve scheduling efficiency, and expand a practice’s patient reach—particularly in rural or high-volume settings. It also encourages new service delivery models such as tele-dentistry and mobile hygiene care that are financially viable and compliant with state laws. 

Absolutely. Decades of outcomes data show that autonomous hygienists deliver care safely. These providers are well-trained, licensed, and accountable to state regulatory boards, just as their dental counterparts. There is no evidence that autonomy leads to lower care quality or increased harm; in fact, patient satisfaction is often higher due to increased accessibility and continuity of care. 

No. Autonomy is not about competition—it’s about complementing the existing workforce to close gaps in access. Dentists remain the primary providers of surgical and restorative care. Hygienist autonomy simply unlocks the full potential of prevention specialists to contribute to public health and help reduce disease. It promotes an equitable business environment by giving hygienists the same entrepreneurial and professional opportunities available to other licensed health professionals. 

In stark contrast to hygienist autonomy, the American Dental Association (ADA) and several of its state chapters are actively promoting regressive measures that would allow under-educated dental assistants to perform hygiene procedures with minimal training, bypassing the education, licensure, and public accountability that define the dental hygiene profession. These proposals create a dangerous and legally tenuous environment, eroding public trust and potentially violating federal antitrust laws by suppressing competition and preserving control under the guise of delegation. Rather than improving access, these actions jeopardize public safety and lower the standard of care—undermining a profession built on evidence, ethics, and accountability. 

Virginia faces many of the same challenges as other states: rising untreated dental disease, provider shortages in rural areas, an aging population, and a dental workforce struggling to meet demand. At the same time, Virginia has a strong, highly educated dental hygiene, growing workforce ready to serve. Autonomy offers a safe, tested, and economically sound solution that aligns with national trends, improves public health, and respects the professional integrity of both hygienists and dentists. 

Visit VDHA’s Advocacy and Legislation website pages for policy briefs, annotated bibliography of peer-reviewed articles supporting dental hygiene autonomy, model language, and updates on our campaign to modernize Virginia’s dental laws. You can also contact VDHA directly to speak with association leaders and public health advocates. 

1.        Asadoorian J, Forget EL, Grace J, Torabi M. Can J Dent Hyg.: Exploring dental hygiene decision making: A quantitative study of potential organizational explanations. Canadian journal of dental hygiene. 2019;53(1):5-.

This quantitative study examines the decision-making capacity of dental hygienists in Manitoba to evaluate whether they possess the professional judgment necessary for expanded scopes of practice. Contrary to the researchers’ hypothesis, organizational structure and gender were not the primary influences on decision-making capacity. Instead, the strongest predictors were supportive individual traits (e.g., confidence, assertiveness) and graduating from a 3-year dental hygiene program. These findings provide empirical support for the argument that dental hygienists are equipped to function autonomously. The article undermines claims that close dentist oversight is necessary, reinforcing the case for legislative reform and expanded roles for hygienists, especially in improving access to care.

2.        Beach MM, Shulman JD, Johns G, Paas JC. Assessing the Viability of the Independent Practice of Dental Hygiene - A Brief Communication. Journal of public health dentistry. 2007;67(4):250-254. doi:10.1111/j.1752-7325.2007.00028.x.

This article evaluates the economic feasibility of independent dental hygiene practice by constructing a financial model based on data from practices in Cincinnati, Ohio. The model assumes a permissive regulatory environment and demonstrates that an independent practice can become profitable within 26–30 months, with breakeven occurring sooner under favorable assumptions. It affirms that such practices can sustainably serve populations that may otherwise lack access, particularly Medicaid beneficiaries. The analysis emphasizes the need for regulatory reform, insurance parity, and patient and provider acceptance to make this model scalable. Ultimately, the article supports the argument that, with the right conditions, independent hygiene practice is both economically viable and a potential solution to dental care shortages—thereby advancing the case for autonomy.

3.        Catlett, A. (2016). Attitudes of dental hygienists towards independent practice and professional autonomy. Journal of Dental Hygiene, 90(4), 249–256.

This cross-sectional quantitative study surveyed 360 dental hygienists from eight U.S. states to assess their perceived competence and autonomy using the Dempster Practice Behaviors Scale (DPBS). Despite differing levels of dental supervision across states, respondents across the board reported high autonomy scores, suggesting a strong sense of preparedness and capability to provide preventive services without dentist oversight. The study found that educational attainment, age, and gender were significant predictors of perceived autonomy, but years of experience and employment status were not. Importantly, the results support broader professional jurisdiction for dental hygienists and advocate for regulatory reforms to reduce unnecessary supervision. The study underscores that bureaucratic limitations, not competence, are the true barriers to autonomy—reinforcing the case for expanding dental hygiene scope of practice and self-regulation.

4.        Chen, J., Meyerhoefer, C. D., & Timmons, E. J. (2024). The effects of dental hygienist autonomy on dental care utilization. Health Economics, 33(8), 1726–1747.

This econometric study analyzes the effects of expanding dental hygienists’ scope of practice using 2001–2014 Medical Expenditure Panel Survey (MEPS) data across U.S. states. By linking practice autonomy levels to utilization metrics, the study finds that granting moderate autonomy (collaborative agreement) leads to significant increases in total dental visits and preventive care use, particularly in underserved areas. Full independence (level 4 autonomy) is associated with reduced treatment visits, suggesting that increased preventive services may be offsetting the need for restorative procedures. Notably, greater autonomy is linked to improved access in shortage areas and increased use of services typically provided by hygienists, such as cleanings and exams. The findings provide strong empirical validation for autonomy as a cost-effective, access-expanding public health intervention. This article is pivotal in quantifying the impact of scope of practice reform, demonstrating that expanding hygienist autonomy improves preventive utilization without adverse effects.

5.        Dobrow MJ, Valela A, Bruce E, Simpson K, Pettifer G. Identification and assessment of factors that impact the demand for and supply of dental hygienists amidst an evolving workforce context: a scoping review. BMC oral health. 2024;24(1):631-13. doi:10.1186/s12903-024-04392-6.

This scoping review synthesized 148 publications across 13 high-income countries to identify factors impacting the supply and demand of dental hygienists. One of the three major thematic categories focused on scope of practice expansion, direct access, and independent practice, documenting both challenges and opportunities. Articles in the review linked broader scope of practice with improved access, enhanced preventive service delivery, and better population health outcomes, especially for underserved groups. Barriers identified included misunderstanding of the hygienist role, reimbursement obstacles, and inadequate business training. The review emphasized that optimizing dental hygienists’ roles in settings such as public health, primary care, hospitals, and long-term care is crucial to workforce sustainability. It concludes that enabling autonomy through expanded scope and supportive policy is essential to addressing oral health care shortages in high-income jurisdictions.

6.        Hopcraft MS, Morgan MV, Satur JG, Wright FAC. Utilizing dental hygienists to undertake dental examination and referral in residential aged care facilities. Community dentistry and oral epidemiology. 2011;39(4):378-384. doi:10.1111/j.1600-0528.2010.00605.x.

This Australian study evaluated whether dental hygienists can independently perform oral examinations, develop treatment plans, and refer residents to dentists in residential aged care facilities (RACFs). A sample of 510 residents from 31 RACFs were examined by both a dentist and a dental hygienist, with their diagnostic and referral decisions compared. The results demonstrated exceptionally high agreement between hygienists and dentists regarding referral decisions (sensitivity 99.6%, specificity 82.9%), even without additional training in geriatric or special needs care. Hygienists also developed effective preventive and periodontal treatment plans independently. The authors conclude that dental hygienists possess the necessary clinical competencies to be frontline providers in aged care settings, arguing that legal and regulatory constraints—not clinical capacity—are the true barriers to expanding their role. This study provides strong evidence in support of granting dental hygienists independent practice authority, especially in institutional and underserved environments.

7.        Jang Y, Kim N. Influence of job autonomy on job crafting of dental hygienists. International journal of dental hygiene. 2023;21(3):497-504. doi:10.1111/idh.12674.

This cross-sectional study of 411 South Korean dental hygienists explores the relationship between job autonomy and job crafting—defined as proactive efforts to shape job roles and tasks. Using validated Korean versions of the Job Crafting Questionnaire and Job Autonomy Questionnaire, the study found a strong positive correlation between autonomy and job crafting (r = 0.64, p < .001), even after controlling for age, education, and experience. The regression analysis confirmed that job autonomy was the strongest predictor of job crafting (β = 0.58), reinforcing the idea that autonomous professionals are better positioned to innovate, adapt, and deliver care efficiently. This study adds to the growing evidence base that legal restrictions on autonomy—not capability—are limiting hygienists’ potential. It supports restructuring job roles and legal frameworks to promote autonomy, which in turn improves competence, job satisfaction, and oral health outcomes.

8.        Jang YE, Kim NH. Dental hygienist job autonomy depends on the period of dental hygiene education. Indian journal of dental research. 2020;31(1):57-60. doi:10.4103/ijdr.IJDR_212_18.

This cross-national review of 23 countries assesses the relationship between dental hygienists' job autonomy and the duration of formal education in each country. The study found that countries with over 40 years of dental hygiene education history are more likely to permit independent practice, aligning with guidelines from the International Federation of Dental Hygienists (IFDH). The authors argue that autonomy improves public health outcomes—particularly for children and older adults in low-income communities—by increasing access and reducing costs. Autonomy is also associated with higher professional efficacy, job satisfaction, and social responsibility. Countries like the U.S. and Canada are cited as models due to their national certification frameworks and structured pathways to independence. Conversely, countries like Korea and Japan restrict autonomy despite long-standing educational programs, due to cultural and policy factors. The article underscores that independent practice is a natural and necessary evolution of the profession when coupled with strong educational and regulatory systems.

9.        Kleiner MM, Park KW. Battles Among Licensed Occupations: Analyzing Government Regulations on Labor Market Outcomes for Dentists and Hygienists. NBER Working Paper Series. Published online 2010:16560-. doi:10.3386/w16560.

This landmark economic analysis examines how regulatory restrictions affect labor market dynamics between dentists and dental hygienists. The authors find that states allowing dental hygienists to be self-employed—a proxy for professional autonomy—see hygienists earning approximately 10% more than their counterparts in restrictive states, while dentists in those same states experience lower earnings and slower employment growth. These findings are consistent with the presence of monopsonistic control by dentists over hygienists’ labor, enforced through licensing statutes. The study concludes that legal and legislative outcomes over professional independence have tangible economic consequences, supporting policy reform that permits independent hygiene practice. The authors underscore that autonomy for hygienists can rebalance labor markets, improve efficiency, and enhance service delivery—especially in underserved areas.

10.  Langelier M, Continelli T, Moore J, Baker B, Surdu S. Expanded Scopes Of Practice For Dental Hygienists Associated With Improved Oral Health Outcomes For Adults. Health Affairs. 2016;35(12):2207-2215. doi:10.1377/hlthaff.2016.0807.

This study uses multilevel modeling of national Behavioral Risk Factor Surveillance System (BRFSS) data to show that broader scope of practice for dental hygienists is positively associated with improved oral health outcomes—specifically, lower rates of tooth loss due to decay or disease. The authors developed the Dental Hygiene Professional Practice Index to quantify state-level regulatory environments, finding that states with more autonomous hygienist roles scored higher and saw better oral health across adult populations. Between 2001 and 2014, states that expanded hygienist autonomy—particularly through reduced supervision requirements, expanded task allowances, and direct reimbursement—showed statistically significant improvements. The study concludes that regulatory reform enabling hygienists to operate more independently in public health and community settings is a critical strategy to reduce disparities and expand preventive care access. This article provides direct, quantitative evidence linking autonomy to population health improvements.

11.  Manski RJ, Hoffmann D, Rowthorn V. Increasing Access to Dental and Medical Care by Allowing Greater Flexibility in Scope of Practice. American journal of public health (1971). 2015;105(9):1755-1762. doi:10.2105/AJPH.2015.302654.

This policy-focused article explores legal and structural barriers to expanding the roles of health professionals, including dentists and physicians, and discusses how rigid scope-of-practice laws limit access to care. Although it centers primarily on dentists and physicians, it makes a broader argument in favor of expanding the scope of all healthcare providers—including dental hygienists—based on the success of advanced-practice nurses and physician assistants. The article acknowledges that licensing boards often protect economic interests under the guise of public safety and calls for reform through legislative changes, demonstration projects, and updated training models. By critiquing how state practice acts restrict interprofessional collaboration and impede efficient care delivery, the authors strengthen the legal and ethical justification for granting hygienists greater independence and a broader role in improving access to preventive oral health services.

12.  Naughton DK. Expanding Oral Care Opportunities: Direct Access Care Provided by Dental Hygienists in the United States. The journal of evidence-based dental practice. 2014;14:171-182.e1. doi:10.1016/j.jebdp.2014.04.003.

This comprehensive review documents the legal, historical, and clinical evolution of direct access care by dental hygienists across the United States. It defines “direct access” as the ability of hygienists to initiate treatment without dentist supervision and traces its growth from 5 states in 1995 to 36 by 2013. Drawing from state laws, professional interviews, and historical records, Naughton showcases examples of successful independent practices in underserved settings—such as nursing homes, Head Start programs, and mobile units. The article highlights that these hygienists are meeting public health needs, achieving positive outcomes, and operating within fully legal and accountable business frameworks. It emphasizes that barriers to wider adoption are political and economic—not clinical. With data from Michigan’s PA 161 and Kansas’s School Sealant Program, Naughton demonstrates improved access, cost-effectiveness, and population health impact. This article is a powerful resource for policymakers and stakeholders advocating for expanded scope of practice.

13.  Reinders JJ, Krijnen WP, Onclin P, van der Schans CP, Stegenga B. Attitudes among dentists and dental hygienists towards extended scope and independent practice of dental hygienists. International dental journal. 2017;67(1):46-58. doi:10.1111/idj.12254.

This systematic review and meta-analysis synthesizes quantitative survey data from 14 international studies examining professional attitudes toward both extended scope and independent practice of dental hygienists. The results show that while 54% of dentists support expanded hygiene functions, only 14% support full independence. In contrast, 81% of hygienists favor expanded duties and 59% favor independent practice, highlighting a pronounced professional divide. The study suggests dentists’ resistance is rooted in status preservation, economic concerns, and fears of losing control over treatment and billing. Conversely, hygienists’ support is linked to professional identity, job enrichment, and service efficiency. The authors emphasize that autonomy could improve care accessibility and cost-effectiveness, and that resistance is more political than evidence-based. This study is especially valuable for policymakers as it quantifies support for autonomy across stakeholders and nations, revealing that most objections are ideological rather than clinical.

14.  Turner, S., Ross, M. & Ibbetson, R. Dental hygienists and therapists: how much professional autonomy do they have? How much do they want? Results from a UK survey. Br Dent J210, E16 (2011). https://doi.org/10.1038/sj.bdj.2011.387.

This UK-wide survey investigated the degree of clinical autonomy among dental hygienists and their attitudes toward expanded independent practice. Of the 150 hygienist respondents, over 80% reported independently performing a range of clinical activities, including periodontal assessments (BPEs), medical histories, soft tissue exams, and recall interval planning—without requiring a dentist’s referral. Hygienists also expressed strong confidence in expanding their clinical responsibilities, though some reported less confidence in diagnosing caries, interpreting radiographs, and identifying suspicious lesions. The study concludes that dental hygienists possess the skill, confidence, and willingness to practice more independently than current regulations allow. The authors call for regulatory reform to align legal authority with clinical capability, asserting that restrictions on hygienist autonomy are outdated and limit workforce potential. This article reinforces the argument that dental hygienists are competent to operate autonomously in preventive and diagnostic care, particularly in primary care settings.

15.  Wing P, Langelier MH, Continelli TA, Battrell A. A Dental Hygiene Professional Practice Index (DHPPI) and access to oral health status and service use in the United States. Journal of dental hygiene. 2005;79(2):10-10.

This study introduced the Dental Hygiene Professional Practice Index (DHPPI), a composite score evaluating the legal and regulatory environment for dental hygienists across all U.S. states. The index incorporates regulation, supervision, permitted tasks, and reimbursement. Findings showed that states with higher DHPPI scores—indicating broader autonomy—had better oral health outcomes and higher utilization of dental services, including preventive care. The study also found a significant positive correlation between higher DHPPI scores and dental hygienist salaries, suggesting economic value in professional independence. While not proving causality, the data strongly support the argument that expanded scope and reduced supervision improve access to care and public health outcomes without compromising safety. The authors recommend aligning laws with hygienists’ demonstrated competencies to expand access in underserved regions and reduce preventable disease burdens.