Modified from the New York State Dental Hygiene Educator’s Association Position Paper March 2025

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Subject: Opposition to ADA Policies 514H-2024, 513H-2024, and 401H-2024 and resulting legislation introduction around the United States

The American Dental Association (ADA) adopted policies in October 2024 in an effort to address dental hygiene workforce shortage issues: policies 514H-2024, 513H-2024, and 401H-2024. However, the Virginia Dental Hygienists’ Association strongly opposes these policies as they do not address workforce shortage issues, undermine the profession of dental hygiene and its educational standards, and directly, negatively impact patient care and outcomes. These policies collectively aim to remove faculty-to-student ratios in dental hygiene programs and allow dental students and foreign-trained dentists to practice dental hygiene in the United States, without passing a state licensing exam. The VDHA strongly opposes the adopted ADA policies 514H-2024, 513H-2024, and 401H-2024. Further, the American Dental Association has endorsed Oral Prevention Assistants (OPA) nationally and several states have now introduced and/or passed legislation for this in their state. The VDHA strongly opposes any legislation that directly impacts the safety of patient care, infringes on the education and scope of practice of dental hygiene, or allows unlicensed individuals to perform services they are not educated or trained to provide. This opposition is grounded in evidence-based concerns regarding educational standards, clinical standards, patient safety, expanding access to care, and ethical imperatives in dental hygiene and dentistry as a whole.

Opposition to Policy 514H-2024 (Foreign Trained Dentists Practicing Dental Hygiene Scope of Practice)

The proposal to expand practice rights for foreign-trained dentists fails to address workforce shortages and the fundamental access to care challenges in dentistry. This policy seriously undermines the education dental hygienists receive in Commission on Dental Accreditation (CODA)-accredited dental hygiene programs in the United States and raises the following concerns:

1. Dental and dental hygiene educational standards vary widely across countries. Internationally-trained dentists, and dental hygienists, are not upheld to the same CODA standards and competencies. Further, internationally-trained clinicians lack the clinical expertise needed to practice dental hygiene scope in the United States.

2. Additionally, there are patient safety concerns without proper CODA-accredited and standardized training and education for clinicians practicing dental hygiene.

3. Foreign-trained dentists wishing to practice dental hygiene scope in the United States should follow established pathways by enrolling in programs that are CODA-accredited to ensure proper education and qualifications for licensure. Routes like the one proposed in this policy directly undermine the dental hygiene profession, its educational standards, and dentistry. Further, many foreign-trained dentists have completed our CODA-accredited dental hygiene programs upon coming to Virginia and it is apparent the educational standards vary greatly in other countries based on their feedback.

Research consistently demonstrates that expanding dental hygienists' scope of practice effectively increases access to care:

1. Dental hygienists have proven track records of improving access in underserved communities through expanded practice acts (Langelier, M., Continelli, T., Moore, J., Baker, B., & Surdu, S. 2016; Moore & Goodwin, 2019; Gadbury‐Amyot, C. C., Simmer‐Beck, M. L., Lynch, A., & Rowley, L. J., 2023).

2. Practice autonomy and portability for dental hygienists has demonstrably increased access to preventive care (Chen, J., Meyerhoefer, C. D., & Timmons, E. J., 2024; Catlett, A, 2016; Gadbury‐Amyot, C. C., Simmer‐Beck, M. L., Lynch, A., & Rowley, L. J., 2023).

3. No empirical evidence suggests that allowing foreign-trained dentists to practice will meaningfully expand access to care.

4. The education of foreign-trained dentists is not subject to CODA accreditation standards and may substantially differ from that provided in the U.S. CODA-accredited dental hygiene programs.

5. There are no guarantees that foreign-trained dentists are trained in non-surgical periodontal therapy and preventive measures comparable to the educational and clinical standards in CODA-accredited programs.

6. The use of powered and manual instrumentation requires proper theoretical training and proper clinical training for both patient safety and practitioner wellbeing. Without adequate instruction in ergonomics and proper technique, practitioners risk causing harm to patients and may develop repetitive stress injuries themselves.

Opposition to Policy 513H-2024 (Dental Students and Residents Practicing Dental Hygiene Scope of Practice)

The fundamental differences in educational evaluation standards between dental and dental hygiene programs and impact to patient care raise serious concerns with this policy:

1. Dental hygiene education emphasizes both process and product evaluation, ensuring comprehensive clinical competency. Dental students and residents do not receive the same comprehensive training in dental hygiene procedures such as non-surgical periodontal therapy and preventive measures.

2. CODA has developed distinct approaches for its educational standards. The Dental Hygiene Program Standards are highly detailed and specific, encompassing non-surgical periodontal therapy requirements based on age, disease severity, and other patient considerations. The standards for DDS/DMD programs take a different approach, utilizing broader guidelines that allow for more flexibility in implementation. This difference reflects the unique educational needs and scope of practice for each profession.

3. Individuals being employed in positions they are not licensed for can have serious health and ethical consequences for patients. To maintain safety for our patients and to uphold integrity, a clear line of qualifications for licensure in healthcare should be maintained. Professional standards associated with each profession should be maintained that ensure quality and comprehensive patient care for all patient populations.

Opposition to Policy 401H-2024 (Remove Faculty-to-Student Ratios)

The proposal to remove faculty-to-student ratios and to align with predoctoral education programs ignores crucial distinctions in educational approaches:

1. Dental hygiene education's structured faculty-to-student ratios ensure consistent,high-quality clinical instruction that upholds CODA standards for dental hygiene education. Additionally, these ratios protect the patients and the care they receive in this setting. Clinical dental hygiene faculty are tasked with the following in any given clinic session:

a. Evaluating the comprehensive assessment and periodontal evaluation of five patients,

b. Development of the individualized homecare plan and homecare instruction of five patients including implications of the oral-systemic link,

c. The non-surgical periodontal therapy and/or maintenance of five patients, andd. Adjunctive services of five patients including sealants, Arestin placement, silver diamine fluoride application, laser procedures, nutritional counseling, tobacco cessation, topical Fluoride treatment applications, and more. Timely and constructive feedback to five students

2. The comprehensive evaluation of both process and product in dental hygiene education necessitates maintained faculty-to-student ratios

3. Removing these ratios risks compromising the quality of clinical education and patient safety.

4. Removing these ratios does not result in increasing student enrollments in dental hygiene programs and may even decrease appeal of attending certain programs with less faculty interaction. Further, dental hygiene programs in Virginia have implemented enrollment increases in recent years in efforts to increase dental hygienists entering the workforce and access to care.

5. Educator burnout is well documented in the literature (Suedbeck J., Ludwig E., & Tolle L., 2021; Hinshaw, K. J., Richter, L. T., & Kramer, G. A. 2010; Kentar, L., Boyd, L. D., Vineyard, J., & McCarthy, J., 2025). and eliminating these ratios may exacerbate educator burnout and further increase dental hygiene educator shortages and retention efforts.6. CODA has already determined, through several workgroup efforts and research endeavors, that existing faculty-to-student ratios in dental hygiene programs are critical for maintaining educational standards and patient safety. Recent recommendations indicated no changes were needed to faculty-to-student ratios at this time.

Opposition to Oral Preventive Assistant (OPA) and Similar Legislation

Many states have begun proposing and adopting legislation allowing Oral Preventive Assistants as well as legislation related to the ADA approved policies outlined previously (See “Proposed Legislation on OPAs, Foreign Trained Dentists, and Dental Students to practice as Dental Hygienists” in Appendix). The VDHA strongly opposes legislation of this nature as:

1. There is a significant reduction in patient safety allowing individuals without proper licensure and CODA-accredited dental hygiene education to perform a licensed dental hygienists’ scope of practice

.2. Much of the passed and proposed legislation does not address true workforce shortages and will not expand access to care to safe and comprehensive dental hygiene care.

Recommendations

Based on empirical evidence and established educational standards, we recommend:

1. Rejection of the implementation of any of these three policies in state dental practice acts, educational institutions, and legislation.

2. Focus on proven solutions for expanding access to care through dental hygiene scope of practice expansion and dental hygiene professional autonomy.

3. Maintenance of rigorous educational standards that prioritize both process and product evaluation and value patient safety.

4. Protection of faculty-to-student ratios that ensure quality clinical education and patient safety.

5. Policy development that ensures dental hygienists are responsible for developing educational standards and regulations for their licensed profession.

6. Rather than lowering professional standards in the profession of dental hygiene, the VDHA believes efforts should be directed to improving the environment of the workplace, enhancing professional development and growth opportunities, offering competitive benefits, and measures to retain qualified, elite oral healthcare practitioners. These efforts would increase attraction of new talent and retain seasoned talent without undermining the dental hygiene profession, its education, and the safety of our patients.

The VDHA remains committed to evidence-based approaches to expanding access to care while maintaining the highest standards of dental education and patient safety.

Signed:

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