With the new year comes many changes, and we look forward to spring and summer weather, birthdays and anniversaries, vacations, and barbeques. Dental hygienists also set goals in pursuit of continued professional growth. What we don’t always expect are the legal battles that come with a new year and the changes they may bring to our daily lives.
Montana meets for a 90-day state legislative session every odd-numbered year. The Montana Dental Hygienists’ Association (MDHA) heard whispers last winter that a bill could be introduced in this year’s legislation, proposing that the state allows dental assistants to scale teeth. In early January, the Government Affairs Chair confirmed with the MDHA that this was true.
As a trustee for the MDHA, I noticed that the initial feeling among hygienists in Montana was of insult. The bill assumed our job was so easy any dental staff member could step into the position of a registered dental hygienist. The concern was also for our patients, as we felt that watering down quality dental care was not a reasonable solution to Montana’s dental hygienist shortage.
Currently, the MDHA has nine job postings listed on its website, but a quick Google search shows 75 job postings on Indeed spanning the state of Montana. In Butte, my current town of residence, I know of at least two dental offices looking for a full-time hygienist, and I know there are at least two others looking for part-time hygienists. From what I understand, this is the norm throughout the state.
The language of the bill proposed that “a dental auxiliary may only perform oral prophylaxis… on a medically healthy child 12 years of age or younger with healthy gums or mild gingivitis.” The problem with this wording is that any person employed by a dental office may fall under the title of “dental auxiliary,” and without formal education in medical conditions, how does an auxiliary determine a patient to be medically healthy? Without periodontal charting under the scope of practice, how does auxiliary clinically determine healthy gingiva versus mild gingivitis?
The bill also did not define any strict educational requirements, licensing or board requirements, or continued education requirements for the auxiliary team member.
The other issue Montana’s hygienists had with the proposal was the absence of “subgingival” or “supragingival” scaling within the bill. The bill used “oral prophylaxis” as a large blanket term without listing any specifications or details of the scope of practice for the auxiliary member.
The bill was assigned to the House as HB-411. The MDHA board unanimously agreed not to support the bill, and our association jumped to action with our lobbyist.
The bill was heard by the House Human Services Committee on February 13, 2023, and was tabled with a 17-4 vote.1
Maintain Awareness of Other Efforts Targeting Dental Hygiene
Though HB-411 didn’t make it far, it is probable that similar bills will be presented again in Montana and other states. More push from the bill’s sponsor, Rep. Jane Gillette, would be no surprise to local dentists and hygienists, as the sponsor has a history of opposing the role of dental hygienists in Montana’s communities.
This type of legislation is not uncommon among other states in the United States. Currently, states such as Kansas and Illinois allow dental assistants to coronally scale if the dental assistant has completed the extra educational requirements set by each state.2,3
Washington State’s Dental Hygienists’ Association has also faced and defeated similar bills, not just once, but in Washington State’s last three legislative sessions. This should raise a red flag for hygienists and hygiene associations throughout the United States because Washington has shown that just because one dental assistant scaling bill gets shot down doesn’t mean it won’t be an idea that returns with each legislative session. Hygienists should also fear that dental assistants scaling is an idea that might catch fire and jump from state to state.
Whether you are a hygienist in favor of or against dental assistants scaling, it is important to remain informed, and it’s important to consider what you may or may not support if your state’s dental hygiene association were to have similar conversations and face similar bills. As a dental hygiene community, we all need to be aware of the proposed changes not just in our own state but in each state’s legislature.
What was the MDHA’s initial reaction to HB-411?
I asked some of our members of the MDHA who were active in this year’s legislative session to answer some questions regarding the efforts that went into fighting HB-411. Below, the members share how we organized as an association, what steps the MDHA took to action, what the support for HB-411 looked like, and what these bills represent for the future of our profession.
Clancy: MDHA knew this legislative session was going to be a fight. We felt we were on the defense right from the start.
Diedri: Dental hygienists had heard rumors for months before the legislative session that there would be a bill regarding assistants scaling, so we were not surprised and were very prepared when it was introduced.
Pareesa: Initially, the language in the bill was a shock. From my perspective as a member of MDHA, the bill initially proposed that dental auxiliaries be allowed to provide “prophylaxis” treatment, and the bill did not have clear guidelines on restrictions, state regulations, or state monitoring. This would have meant that any employee in the dental practice could have performed prophylaxis. The sponsor then walked back this language to allow a dental assistant to perform prophylaxis. Even that proposed language would have greatly increased a dental assistant’s scope of practice. This would have all been allowed with minimal training, licensure, or other regulatory requirements.
What was the first move the MDHA made in response to the bill?
Clancy: We reached out to other states that had similar legislation introduced. Washington state was kind enough to have a Zoom meeting with us to help us understand how they were able to defeat similar legislation in their state for the last three sessions.
Diedri: MDHA sent out mass communications to all hygienists, not just members, alerting them to the threat to their profession and encouraged grassroots efforts to contact their legislators. We developed flyers and social media posts focusing on protecting the safety of Montana’s children.
Pareesa: As a member, I feel like MDHA initially tried to spread the word via Facebook and e-mail as quickly as possible that this bill was in the works. This happened even before the first draft of the bill was released. This was important so hygienists and community members could start spreading the word that this huge change might be coming in Montana.
What was the general feeling of support for HB-411? Were there any hygienists who were supportive of the bill?
Clancy: The general feeling was frustration and lack of support for our education. It is hard, though, MDHA supports increasing access to care, but the providers should be qualified to provide the care needed. It feels like there is a disconnect between the understanding of what schooling looks like for registered dental hygienists.
Diedri: It felt to me like a minority faction of dentists who supported the bill, many of them pediatric dentists and a few rural dentists who are having a hard time finding employees. I heard from several dentists who were not in favor of the bill, dentists who do respect and value our education, testing, and licensure. I know some of those dentists sent written comments to the legislators. However, none gave verbal testimony at the hearing.
Pareesa: The hygienists I spoke to were largely opposed to this bill. However, some were tired of the drama that past legislative sessions created between dentists and dental hygienists. They didn’t feel that placing dental assistants in the middle was fair.
What actions did MDHA take leading up to the hearing of the bill?
Clancy: MDHA gathered as much information as possible. This is one thing that MDHA really prides itself on – using research to prove its point. We have the evidence to back up what we are saying. We gathered as much information as possible on the states that allow assistants to scale, what those programs look like, and the success of those programs.
Montana is a rural state with one dental hygiene program and two dental assisting programs. The dental hygiene program recently expanded from 18 to 25 students a year, with a possibility of 10 additional students every other year, pending approval. In 2019, the Montana legislature passed a 4.25-million-dollar expansion of the dental hygiene program. This is the first year we will see those additional students graduate. In the current dental assisting programs, Great Falls had two students, and Salish Kootenai had five. This was not going to solve our shortage issues in Montana.
Pareesa: From a member perspective, MDHA constantly sent out messages to hygienists about the next steps and encouraged members and nonmembers to reach out to representatives, senators, and public members about this bill. MDHA also spent a day at the capitol to talk and spread the word about the issues that this bill would create if passed into law. MDHA focused on public safety and tried to educate the public on the difference between dental hygienists and dental assistants. When it comes to the scope of practice, this would have been a huge change in Montana dentistry. It quickly became clear that many community members, including our representatives and senators, did not know the difference between a dental hygienist and a dental assistant or the training that dental hygienists are required to complete to perform prophylaxis. This became a major focus of our outreach, education, and testimony in response to this bill.
During the presentation of HB-411 in the House, what did each side of support look like (for or against), and what arguments were heard that day?
Clancy: It can be frustrating during these hearings; often, there is misinformation being heard. It was literally dentists on the side of passing this bill (mainly pediatric dentists) versus dental hygienists trying to defeat it. Most pediatric offices do not employ a dental hygienist. The most important part of these hearings is taking notes of the misinformation so that you can send the correct information to the legislative committee and try to get the information out to the hygienists throughout the state and anyone else who will listen so they can also contact the committee. There were dentists who were against this bill, and we encouraged them to contact their representatives as well.
Diedri: The legislator who introduced this bill is a dentist with a long history of being anti-dental hygienist. She gifted each committee member with an unsterilized, over-the-counter hygiene tool kit and said these were the same tools hygienists use and that moms have been flicking stuff off their kids’ teeth for years. So, according to her, it clearly would be safe for a dental assistant to do the same.
Pareesa: The proponents of HB-411 focused their arguments on workforce shortages, stating this bill would allow more children to receive care (and hygienists don’t frequently see children) and that the military has had this model in practice for years. They described the cleanings (prophylaxis) that HB-411 would have allowed as “simple” and “easy” and argued that dental assistants could perform this care.
The opponents of HB-411 focused their arguments on the education, testing, and licensing of dental hygienists. Holding a license allows hygienists to be held accountable by Montana’s Board of Dentistry (BOD). Montana dental assistants are not monitored or licensed by the state; the Montana BOD already voted against this during a past board meeting. The public safety and dental care provided to children sets them up for life, and they should be provided with the same standard of care as anyone else. Care should be provided by a person who has demonstrated professional competency through education requirements and through completing board examinations and state licensure.
What do you believe was the ultimate failure of HB-411?
Clancy: MDHA tried to be as proactive about this legislation as possible. We made videos to share on social media, trying to explain the difference between a dentist, a dental hygienist, and a dental assistant. We tried to get as many people engaged in this legislation as possible. I believe some of these videos helped engage our patients in the legislative process. One of the legislators said that she was happy with the legislative process in this bill; they had heard from people all over the state.
Pareesa: I believe that the representatives realized that this bill would be a large scope of practice change, and they could see that the dental hygienists and dentists did not agree on this change. I also think the representatives heard that the board of dentistry had already voted no on this topic and could see that this was a larger issue than a “simple” change.
Are you concerned that HB-411 might only be the beginning of the fight for Montana’s hygiene community?
Clancy: I believe that we will continue to see bills like this in the future. Montana has grown in a way no one could have predicted; our state still needs educated, qualified health care. We shouldn’t be lowering the standard of care. We should be using all our health care professionals to their full scope of practice.
Pareesa: I think that the scope of practice for dental assistants will come up again. I also believe that workforce shortages in dentistry will come up again. To address these issues, I hope we can encourage increasing the scope of practice for dental hygienists or an expansion of Montana’s Limited Access Permit program. There are many ways dental hygienists can do more for their community members in Montana, but changes in our scope of practice need to occur versus being limited.
Another alternative to address workforce shortages could be to attract more dental hygienists to move to Montana as we continue to train more hygienists at the expanded program in Great Falls. Attracting more dental hygienists could be done by license portability in Montana. License portability for dental hygienists would be a step in the right direction for allowing hygienists to practice in other states more readily.
I also believe that dental assistants could have a larger scope of practice if Montana created a way to regulate them. Plenty of models from other states show how expanded duties dental assistants (EDDA) can be useful in aiding dentists in their practices. However, the states that have created an EDDA function have done so with a system in place for each EDDA to have adequate education, monitoring, and registration with the state, along with other requirements. Dental assisting schools in Montana have very low class sizes right now. But if Montana made changes in this way, there would be more incentive for dental assistants to attend schools with dental assisting programs. In return, they would hope to receive a higher rate of pay that would fairly reflect the higher level of education and training they’d receive.
What advice would you give to other hygiene associations that may be facing similar bills in their coming legislation?
Clancy: Educate anyone who will listen. As a profession, we need to set ourselves apart and educate people on what our schooling and profession look like. Most people outside the dental profession have no idea of the difference between these professions. Dental assistants are an imperative part of the dental team, but our jobs/responsibilities/licensure are very different. I would encourage those states to reach out to states that have had legislation brought forth and try to learn from each other. Making videos for social media can be an easy way to educate many people in a short time. Make sure you hang your diploma in your operatory; it gives your patients a chance to understand that we are highly educated oral health care professionals.
Diedri: I believe one of the most important actions is to be a member of your professional association. There is power in numbers, whether that power is needed to defend our profession (to defeat bills like HB-411) or advance it (administer Botox, for example). You don’t need to agree with everything the association does or every policy, but know that bills like HB-411 will keep coming. Without an organized, robust voice, our profession is in jeopardy. Each state’s dues are different, but for the most part, one day of work will pay for your year’s membership. To me, knowing my profession has been advanced and protected and could be advanced further, that one day’s pay is totally worth it.
Pareesa: I think it’s important to start working with the Board of Dentistry (BOD) within your own state. Those states may also have workforce shortage issues that can be addressed in different ways. This is the argument that the sponsors of these types of bills are using for why these bills are necessary. Dental hygiene associations that work proactively with the BOD might have a better chance of crafting and directing state legislation than if they don’t.
In Closing
In the answers above, one of my co-hygienists mentioned Montana’s Limited Access Permit (LAP) Program. The program allows Montana’s dental hygienists to practice outside of the operatory following the completion of a separate application with an annual LAP fee, the purchase of liability insurance, and the expectation to complete an extra 12 continuing education credits per three-year licensure cycle.
This program was designed as an answer to oral health care needs in Montana’s rural and underserved communities; 44% of Montanans live in communities considered to be rural (2,500 or less). This program was passed in Montana’s 2003 legislative session and served as a prime example of how giving more to hygienists is synonymous with giving more to our communities.4
As we continue to face new challenges as a profession, I believe it is important to understand what strengths and skills we bring to the table. What unique role do we play as registered dental hygienists? What motivated us to become hygienists in the first place? If we can’t answer these questions for ourselves, those who feel we no longer have a place in the dental field have us by our loupes and polishers.
Maybe an important question to ask is: Why is there a shortage of dental hygienists? Just from speaking with hygienists in my community, I know that many hygienists who were considering retirement or career change took the plunge when the COVID-19 pandemic put us to a screeching halt. I also know there are many dentists who abuse their hygienists and do not foster a healthy workspace or provide fair benefits and compensation. Do these offices really think they play no part in their not being able to find employees? Sometimes, their reputations precede them!
I believe an answer to the hygiene shortage is to give to and inspire our dental hygienists without compromising the quality of care provided to patients. We are well-educated, clinical health care professionals who have more potential to grow than a dental assistant, if given the opportunity.
I have spoken with hygienists who don’t fear that our profession is in jeopardy, and I have read comments online aligning with the same beliefs that our profession isn’t being threatened. I hope this article has assured readers that changes are already in motion.
The amount of energy you’re willing to give to the profession is unique to the individual dental hygienist, but it could be as simple as joining your state association or as big as joining the board and participating at the state level. Whatever action you may or may not take, I encourage you to think about what dental hygiene means to you, to consider the value of our education, and to imagine the potential of bills like HB-411 to reshape our profession.
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References
- HB-411: Revise Laws Relating to Dentistry. (2023, June 30). Montana Free Press. https://apps.montanafreepress.org/capitol-tracker-2023/bills/hb-411/
- An Act Allowing a Dental Auxiliary to Perform Oral Prophylaxis Under Certain Circumstances; Providing for Education and Exam Requirements; Allowing for Relevant Training and Experience; Extending Rulemaking Authority; and Amending Section 37-4-408, MCA [House Bill No. 411, 68th Congress]. (2023). Montana Legislature. https://leg.mt.gov/bills/2023/billpdf/HB0411.pdf
- Kansas Dental Assistant Requirements. (n.d.). Dental Assisting National Board. https://www.danb.org/state-requirements/kansas-dental-assistant-with-expanded-duties-training
- Illinois Dental Practice Act [225 ILCS 25]. (n.d.). Illinois General Assembly. https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1296&ChapterID=24#top
- Limited Access Permit – LAP. (n.d.). Montana Dental Hygienists’ Association. http://www.montanadha.org/limited-access-permit-lap-2/
