Future of the Scaling Assistant – Part II

In Part 1 of The Scaling Assistant, the authors discussed the 1998 Kansas House Bill (HB) 2724 authorizing dental assistants to scale teeth supragingivally. The HB was written to address a shortage of dental hygienists in the state and outcomes from the 2007 performance audit report of the Kansas Dental Practice Act. The report indicated dental scaling assistants are only subject to minimal oversight by the Kansas Dental Board and unlike dentists and dental hygienists, they are not required to be licensed.¹

In 2015, Illinois became the second state in the United States to authorize dental assistants to scale teeth supragingivally on children 12 years of age and younger after attending a weekend course.

Although both the Kansas and Illinois scaling assistant bills require a dentist or dental hygienist to complete the prophylaxis after the supragingival work has been completed by the assistant, most of us know that time constraints of the dentist and dental hygienist prevent this from occurring as it is not an effective use of time. This suggests offices utilizing scaling dental assistants typically end up billing the supragingival scaling procedure as a complete prophylaxis. However, there is no CDT procedure code for supragingival scaling because the American Dental Association does not recognize it as a separate therapeutic procedure.

In 2021 approximately 333,942 healthcare providers, including members of the dental field, left their jobs due to the COVID-19 public health crisis. The American Dental Association Health Policy Institute Report on Dental Workforce Shortages identified enrollment in dental assisting programs had been trending downward since 2015, and the pandemic had a negative impact on dental hygiene program enrollment. While there has been some recovery of enrollment in dental hygiene programs, data suggest that dental assisting program enrollment will not rebound in the near future. As a result, workforce shortages are likely to remain an issue for years to come.²

Hence, some states have again begun looking for “solutions” to the dental hygiene workforce shortage by initiating legislation via a scaling dental assistant. In 2021, the Wisconsin Dental Association initiated legislation for an expanded duty dental assistant which included scaling. However, after strenuous opposition and advocacy by the Wisconsin Dental Hygienists’ Association, this section of the bill was removed. In 2022, the Illinois Dental Society passed legislation authorizing dental assistants with 32 hours of instruction to provide coronal scaling on Medicaid children 17 years of age and younger. And in 2023, a House representative and dentist from the Bozeman area introduced HB411 under the premise of the “workforce shortage of dental hygienists that would have authorized dental assistants to provide an “oral prophylaxis” on children aged 12 and under.³ Although Kansas and Illinois allow “coronal scaling” by dental assistants, this bill would have been the first to allow dental auxiliaries to provide a complete prophylaxis.

The bill did not include any language requiring a preprocedural evaluation, a post-procedural check, nor did it contain language that parents be informed that an unlicensed person other than a licensed dental hygienist would be cleaning their children’s teeth.

Meanwhile, the Colorado Dental Association (CDA) has created a Resolution “to direct the CDA to submit a Sunrise Review application to the Colorado Department of Regulatory Agencies to address the expansion of dental assistants’ scope of care to include scaling dental assistants.

In researching data for this article, nothing can be found in any common dental database, research articles or abstracts to indicate supragingival scaling alone (without a complete prophylaxis) increases access to dental care or provides a health benefit to the public. As such, one might suggest that delegation of dental hygiene duties to dental assistants is motivated not by a sincere interest in patient health, but rather to maximize profits. Dental hygiene is the only licensed health care profession regulated by another profession to depreciate the rigors of one’s education, training, and licensure to that of a weekend course.

Although dental hygienists know the value of the oral health services they provide, local state legislators do not. Their job is to provide legislation that benefits the public at large. Without understanding the scope of practice of dental hygienists or their education, state legislators will continue to pass legislation for scaling dental assistants. As licensed oral healthcare professionals, it is our job to inform them of the possibility of incomplete care with little or no health benefit. This takes the form of a grassroots effort which begins with getting to know your local state senator and representative.

The Montana Dental Hygienists Association was able to defeat the scaling dental assistant legislation using 3 “A” pillars to their lobbying efforts: advocacy, accuracy, and all together.⁴ This begins by introducing yourself to your local state legislator and scheduling an appointment to meet them in person to discuss concerns impacting your profession. Provide your legislator with accurate information and data to support your concerns. This should be done now regardless if your state is looking at implementing scaling dental assistant legislation. Become a member of your professional Association as legislators want to know that information and it provides a greater voice to make an impact at the state legislature.

Imagine taking your child to a dental practice with certain expectations from a licensed, primary oral health care professional only to discover that care was provided by a technician who may have completed a weekend course. What happens when this so-called technician or “scaling assistant” uses sharp and/or powered instruments in a child’s mouth with no knowledge of fulcruming and instrument safety? Dental hygienists are educated to solve oral health problems of patients and residents based on a process of care that is well defined by the United States and Canadian Dental Hygienists’ Associations. The dental hygiene process of care serves as a foundation for the dental hygienists’ role as professionals who are primary healthcare providers.⁵ Even in the early 1900s, Dr Alfred C. Fones, educated the first dental hygienist, Irene Newman, for an entire year before she began treating patients in his dental practice.⁶

Do we really want to stand still and go backwards by promoting oral health care interventions by unlicensed scaling assistants? What happens if we do nothing? The Scaling Dental Assistant may be coming to a state near you!

References

1. PERFORMANCE AUDIT REPORT, Kansas Dental Practices Act: Determining the Impact of the 1998 Changes to the Act https://www.kslpa.org/wp-content/uploads/2019/08/r-07-23.pdf
2. ADA HPI Dental Workforce Shortages: Data to Navigate Today’s Labor Market. American Dental Association. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/dental_workforce_shortages_labor_market.pdf?rev=e6025d77df184e6c95dc7cefde4adee3&hash=225FCBBCCB67174AAFC760FE2287322D#:~:text=Vacant%20positions%20in%20dental%20assisting,positions%20is%20a%20contributing%20factor
3. Montana HB 411. LegiScan. https://legiscan.com/MT/text/HB411/id/2683516
4. The Montana experience: Fighting House Bill 411 to protect children. RDH Magazine. https://www.rdhmag.com/career-profession/article/14291305/the-montana-experience-fighting-house-bill-411-to-protect-children
5. Kwak SH, Bae SM, Shin SJ, Shin BM. Definition and Classification of Dental Hygiene Interventions Based on the Dental Hygiene Process of Care: A Delphi Study. Int J Environ Res Public Health. 2023;20(17):6704. Published 2023 Sep 2. doi:10.3390/ijerph20176704
6. The 100 Year of Evolution of the Science and Practice of Dental Hygiene. DentistryIQ. https://www.dentistryiq.com/dental-hygiene/clinical-hygiene/article/16363590/the-100year-evolution-of-the-science-and-practice-of-dental-hygiene