Dental Hygienist Considering a Mobile Dental Unit?

Direct Access Overview

This document is intended for informational purposes only and does not constitute a legal opinion regarding dental practice in any state. To verify any information, please contact your state’s dental board. This information is from the American Dental Hygienists Associations and can be found in it’s original format here: Direct Access States

"Eight States currently do not allow Direct Access: Alabama, Delaware, Hawaii, Louisiana, Mississippi, New Jersey, North Carolina, and North Dakota.

However, a few of these states have made some changes toward embracing direct access. Late last year, Alabama’s Board of Dental Examiners proposed to allow infiltration injection by permitted, licensed dental hygienists, following a national trend aimed at addressing access to care issues. Lynch notes that Alabama has become the 45th state to allow dental hygienists to administer local anesthesia.

HB 28 was introduced last year in the Delaware General Assembly. It would expand the number of settings in which a dental hygienist could practice under general rather than direct supervision. It would also update the definition of the practice of dental hygiene services. The bill was last reported to be in the House Administration Committee.

In 2017, Hawaii enacted HB 563, which stipulates that dental hygienists needn’t always practice under direct supervision. Instead, they may operate under general supervision in certain instances, after dentists have examined each patient, formulated a diagnosis, and authorized treatment.

In Louisiana, dental hygienists may provide services at public institutions under general supervision, although nitrous oxide or local anesthesia must be administrated under direct supervision. Dental hygienists may also offer services under general supervision if certain conditions are met. No bills designed to further expand dental hygienists’ scopes of practice, however, appear to be in the works at this time.

Mississippi floated two bills early this year, both of which died in committee. MS S 2899 and MS H 1330 would have provided for the general supervision of licensed dental hygienists under certain conditions.

New Jersey requires dental hygienists to perform certain treatments under direct supervision, or merely under “supervision,” which involves a written order from the dentist.

Dental hygienists in North Carolina may render particular services without direct supervision if they have 3 years of experience and have fulfilled additional prerequisites.

North Dakota law stipulates that dental hygienists may provide services under direct, indirect, or general supervision. ND H 1256, which would have allowed dental therapy, was introduced last year to regulate both dental therapists and dental hygienists. It would have prohibited them from operating independently, though, under a written agreement with a dentist and authorization of a supervising dentist, a dental therapist would be allowed to provide, dispense, and administer analgesic, anti-inflammatories, and antibiotics. The bill failed in the House."

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2018;5(10):16–20.

Direct Access Rules for the 50 States

Alaska 2008
Reference: Sec. 08.32.115
Collaborative Agreement:
A dental hygienist may provide services according to the terms of a collaborative agreement. The dentist’s presence, diagnosis, or treatment plan are not required unless specified by the agreement. Care under the agreement can be provided in settings outside of the “usual place of practice” (i.e. private dental office).

Requirements:
A dental hygienist must have a minimum of 4,000 hours of clinical experience within the preceding 5 years. The agreement must be approved by state board of dental examiners. Dentists are limited to 5 or fewer collaborative agreements.

Provider Services:
The agreement can authorize nearly the entire dental hygiene scope of practice (patient education, prophylaxis, sealants, radiographs, etc).

Arizona 2004/2015/ 2019
Sec. 32-1281, 32-1289
Affiliated Practice Agreement:
A dental hygienist with a written affiliated practice agreement may perform dental hygiene services in specified settings outside the private dental office. The written agreement must be submitted to the state board of dental examiners. The affiliated practice dental hygienist shall consult with the affiliated practice dentist before initiating further treatment on patients who have not been seen by a dentist within 12 months of the initial treatment by the dental hygienist.

Requirements: A dental hygienist must have held an active license for at least 5 years and be actively engaged in dental hygiene practice for at least five hundred hours in each of the 2 years immediately preceding the affiliated practice relationship. Alternatively, a dental hygienist who holds a bachelor's degree in dental hygiene, an active license for at least 3 years, and is actively engaged in dental hygiene practice for at least 500 hours in each of the 2 years preceding the affiliated practice relationship, may also qualify for affiliated practice. In addition, a dental hygienist must successfully complete 12 hours of specified continuing education that hold a current certificate in basic cardiopulmonary resuscitation.

Provider Services:
The agreement must outline the practice settings and services provided. The full dental hygiene scope is permitted with the exception of root planing, nitrous oxide, and the use of local anesthesia unless under specified circumstances. After taking an accredited course and exam the dental hygienist will also be able to: place, contour and finish restorations, cement prefabricated crowns, and place interim therapeutic restorations.

Arizona 2006
Sec. 32-1289

Dental hygienists employed by or working under contract or as a volunteer for a public health agency or institution or a public or private school authority before an examination by a dentist may screen patients and apply topical fluoride without entering into an affiliated practice relationship pursuant to this section.

Arkansas 2010
Sec. 17-82-7

Collaborative Agreement:
Dental hygienist with a Collaborative Care permit I or II who has entered into a collaborative agreement may perform dental hygiene services on children, senior citizens age 65 and older, and persons with developmental disabilities in long-term care facilities, free clinics, hospitals, head start programs, residence of homebound patients, local health units, schools, community health centers, state and county correctional institutions. Dental hygienist must have written agreement with no more than one dentist.

Requirements: Must have malpractice insurance. Collaborative Care Permit I: Dental hygienist must have 1,200 hours of clinical practice experience, or have taught dental hygiene courses for 2 of the preceding 3 years. Collaborative Care Permit II: Dental hygienist must have 1,800 hours of clinical practice experience or taught dental hygiene courses for 2 of the proceeding 3 years and has completed 6 hours of continued education courses.

Provider Services: Collaborative Care Permit I may provide prophylaxis, fluoride treatments, sealants, dental hygiene instruction, assessment and other services in scope if delegated by consulting dentist to children in public settings without supervision or prior examination. Collaborative Care Permit II may provide prophylaxis, fluoride treatments, sealants, dental hygiene instruction, assessment, and other services in scope if delegated by the consulting dentist to children, senior citizens, and persons with developmental disabilities in public settings without supervision or prior examination.

California 1998
Sec. 1922-1931

Registered Dental Hygienist in Alternative Practice (RDHAP):
RDHAP may provide services to a patient without obtaining written verification that the patient has been examined by a dentist or physician. If the RDHAP provides services to a patient 18 months or more after the first date that he or she provides services, the RDHAP shall obtain written verification that the patient has been examined by a dentist or physician.

Once licensed, the RDHAP may practice as: an employee of a dentist; an employee of another RDHAP; as an independent contractor; as a sole proprietor of an alternative dental hygiene practice; as an employee of a primary care clinic or specialty clinic; as an employee of a clinic owned or operated by a public hospital or health system; or as an employee of a clinic owned and operated by a hospital that maintains the primary contract with a county under the California welfare code. Allowed practice settings include: residences of the homebound; schools; residential facilities and other institutions; hospitals; or dental health professional shortage areas.

Requirements:
Must hold a current and active California license as a dental hygienist; have been engaged in clinical practice as a dental hygienist for a minimum of 2,000 hours during the immediately preceding 36 months (in California or another state); possess a bachelor's degree or an equivalent of 120 semester units; complete 150 hours of an approved educational RDHAP program; and pass a written examination.

Provider Services:
All services permitted under general supervision, including prophylaxis, root planing, pit and fissure sealants, charting and examination of soft tissue.

California 2002
Sec. 1911

Dental hygienist may provide screening, apply fluorides and sealants without supervision in government created or administered public health programs.
Colorado 1987
Sec. 12-35-124

Unsupervised Practice:
There is no requirement that a dentist must authorize or supervise most dental hygiene services. Dental hygienist may also own a dental hygiene practice.

Requirements: None.

Provider Services:
Dental hygienist can provide dental hygiene diagnosis, radiographs, remove deposits, accretions, and stains, curettage without anesthesia, apply fluorides and other recognized preventive agents, topical anesthetic, oral inspection and charting. Local anesthesia requires general supervision.

Connecticut 1999 Sec. 20-126l Public Health Dental Hygienist: Dental hygienist with 2 years of experience may practice without supervision in institutions, public health facilities, group homes and schools.

Requirements:
Dental hygienist must have at least 2 years of experience.

Provider Services:
Dental hygienist can provide oral prophylaxis, remove deposits, accretions and stains, root planing, sealants, assessment, treatment planning and evaluation.

Florida 2011
Sec. 466.003, 466.024

Dental hygienist may provide services without the physical presence, prior examination, or authorization of a dentist, provided that a dentist or physician gives medical clearance prior to performance of a prophylaxis in “health access settings.” A dentist must examine a patient within 13 months following a prophylaxis and an exam must take place before additional oral services may be performed.

Health access settings are: a program of the Department of Children and Family Services, the Department of Health, the Department of Juvenile Justice, a nonprofit community health center centers, a Head Start centers, a federally-qualified health center, a school-based prevention program or a clinic operated by an accredited dental or dental hygiene program.

Requirements:
Dental hygienist must maintain liability insurance.

Provider Services:
Dental charting, take vital signs, record histories, apply sealants and fluorides (including varnish) and perform prophylaxis. The setting operating the program may bill a third party for reimbursement.

Georgia 2017 Article 3 of Chapter 11 of Title 43 General Supervision The requirement of direct supervision shall not apply to the performance of licensed dental hygienists providing dental screenings in settings which include: schools, hospitals and clinics, state, county, local, and federal public health programs, federally qualified health centers, volunteer community health settings, senior centers, and family violence shelters. Requirements: Dental hygienist shall have at least two years of experience in the practice of dental hygiene, shall be in compliance with continuing education and cardiopulmonary resuscitation certification requirements and shall be licensed in good standing. Provider Services: Licensed dental hygienists may apply topical fluoride and perform the application of sealants and oral prophylaxis under general supervision in certain designated settings.

Idaho 2004 Sec. 54-903, 54-904 Extended Access Endorsement (EAE): Dental hygienist can provide services in hospitals, long term care facilities, public health facilities, health or migrant clinics or other board-approved settings, if the dentist affiliated with authorizes services. Requirements: Dental hygienist must be an employee of the facility or obtain extended care permit. EAE requires 1,000 hours experience in last 2 years. Provider Services: As determined by authorizing dentist.

Illinois 2015 225 ILCS 25/18.1 Public Health Dental Hygienist: A dental hygienist may treat patients in specified public health settings without a dentist first examining the patient and being present during treatment, who are Medicaid-eligible or uninsured and with household incomes not greater that 200% of the federal poverty level. Requirements: A licensed dental hygienist must have 2 years of full-time clinical experience or an equivalent of 4,000 hours of clinical experience and have completed 42 hours of additional course work in areas specific to public health dentistry. The dental hygienist must also practice pursuant to a written public health supervision agreement with a dentist. Provider Services: Dental hygienist may provide prophylactic cleanings, apply fluoride, place sealants, and take radiographs. Additional services may be prescribed by the Illinois Department of Financial and Professional Regulation.

Indiana 2018 Sec. 1. IC 25-13-1-10 Access Practice Agreement: A dental hygienist may provide preventive dental hygiene services directly to a patient without a prior examination, presence, or authorization of a dentist. A dental hygienist may practice in any setting or facility that is documented in the dental hygienist's access practice agreement. Requirements:

• Professional licensure

• Has at least 2,000 documented clinical hours of dental hygiene services during 2 years of active practice under the direct supervision of a dentist

• Obtains a national provider identifier number

• Enters into an access practice agreement with a licensed dentist

• Maintains liability insurance

• Before providing dental hygiene services to a patient under an access practice agreement, the dental hygienist has obtained a signed consent form

Provider Services: Dental hygienist may provide preventive dental hygiene services as outlined in the access practice agreement.

Iowa 2004 Rule 650-10.5 (153) Public Health Dental Hygienist: Dental hygienist may administer care based on standing orders and a written agreement with a dentist. Services can be administered in schools, Head Start settings, nursing facilities, federally-qualified health centers, public health vans, free clinics, community centers and public health programs. Requirements: Dental hygienist must have 3 years of clinical experience and must submit an annual report to the state department of health noting the number of patients treated/services administered. Provider Services: All services in the dental hygiene scope (except local anesthesia and nitrous) may be provided once to each patient. The supervising dentist must specify a period of time in which an examination by a dentist must occur prior to the dental hygienist rendering further dental hygiene services. However, this requirement does not apply to educational services, assessments, screenings and fluoride if specified in the supervision agreement.

Kansas 2003/2012 Sec. 65-1456 Extended Care Permit I, II & III (ECP): Dental hygienist may practice without the prior authorization of a dentist if the dental hygienist has an agreement with sponsoring dentist. Examples of settings are schools, Head Start programs, state correctional institutions, local health departments, indigent care clinics, and in adult care homes, hospital long term units, or at the home of homebound persons on medical assistance. The ECP I permit authorizes treatment on children in various limited access categories, while the EPT II permit is for seniors and persons with developmental disabilities. ECP III permit authorizes dental hygienists to treat a wider range of patients, including underserved children, seniors and developmentally disabled adults and to provide more services than ECP I and II. Requirements: Dental hygienist must have 1,200 clinical hours or 2 years teaching in last 3 years for ECP I; 1,600 hours or 2 years teaching in last 3 years plus 6 hour course for ECP II. Dental hygienist must also carry liability insurance and must be paid by dentist or facility. ECP III requires 2,000 hours clinical experience plus 18 clock hour board approved course. Dentist can monitor a maximum of 5 practices. Provider Services: ECP I and II provide prophylaxis, fluoride treatments, dental hygiene instruction, assessment of the patient’s need for further treatment by a dentist, and other services if delegated by the sponsoring dentist. ECP III can additionally provide atraumatic restorative technique, adjustment and soft reline of dentures, smoothing sharp tooth with handpiece, local anesthesia in setting where medical services available, extraction of mobile teeth.

Kentucky 2010 Sec. 313.040 Volunteer Community Health Settings: A dental hygienist may provide the services listed below without the supervision of a dentist in volunteer community health settings. Provider Services: Dental hygienist can provide dental hygiene instruction, nutritional counseling, oral screening with subsequent referral to a dentist, fluoride application, demonstration of oral hygiene technique, and sealants. Kentucky 2010 201 KAR 8:562 Public Health Dental Hygienist: A public health dental hygienist shall perform dental hygiene services under the supervision of the governing board of health. Settings are limited to local health departments, public or private educational institutions with affiliation agreement, contracted mobile dental health programs, and public or private institutions under the jurisdiction of a federal, state, or local agency. Requirements: Dental hygienist must have 2 years and 3,000 hours of experience. During each renewal period, complete a 3 hour course approved by the board on the identification and prevention of potential medical emergencies, as well as 5 hours of other CE in area of public health or public dental health. A dental hygienist authorized to practice as a public health dental hygienist shall receive a certificate from the board indicating their registration. Prior to performing services, must receive informed consent from patient. The patient must be in the ASA Patient Physical Status Classification of ASA I or ASA II, meaning a normal healthy patient or a patient with mild systemic disease. Provider services: Limited to preventative services.

Maine 2001 Rule 02 313 Chap. 2. Sec. 3 Public Health Dental Hygienist: Dental hygienist may provide services in a public or private school, hospital or other nontraditional practice setting under a public health supervision status granted by the dental board on a case-by-case basis. The dental hygienist may perform services rendered under general supervision. The dentist should have specific standing orders and procedures to be carried out, although the dentist need not be present when the services have been provided. A written plan for referral or an agreement for follow-up shall be provided by the public health hygienist recording all conditions that should be called to the attention of the dentist. The supervising dentist shall review a summary report at the completion of the program or once a year. Reference: A dental hygienist must apply to the board to practice providing such information the board deems necessary. The board must take into consideration whether the program will fulfill an unmet need, whether a supervising dentist is available and that the appropriate public health guidelines and standards of care can be met and followed. Provider Services: All services that can be provided under general supervision. Dentist’s diagnosis for sealants is not needed in public health or school sealant programs. Maine 2008/2015/2017 32 §18345 & 18375 Independent Practice Dental Hygienist: Independent practice dental hygienist means an individual licensed to practice independent dental hygiene without supervision of a dentist. However, a written practice agreement is required when engaging in the taking of dental radiographs pursuant to Chapter 16 of the Board’s rules. Requirements: Verification of 2,000 work hours of clinical practice. For purposes of meeting the clinical practice requirements, the applicant's hours in a private dental practice or nonprofit setting under the supervision of a dentist may be included as well as the applicant's hours as a public health dental hygienist or, prior to July 29, 2016, as a dental hygienist with public health supervision status. Provider Services: An independent practice dental hygienist may perform only the following duties without supervision by a dentist:

• Interview patients and record complete medical and dental histories;

• Take and record the vital signs of blood pressure, pulse and temperature;

• Perform oral inspections, recording all conditions that should be called to the attention of a dentist;

• Perform complete periodontal and dental restorative charting;

• Perform all procedures necessary for a complete prophylaxis, including root planing;

• Apply fluoride to control caries;

• Apply desensitizing agents to teeth;

• Apply topical anesthetics;

• Apply sealants;

• Smooth and polish amalgam restorations, limited to slow-speed application only;

• Take impressions for athletic mouth guards and custom fluoride trays;

• Place and remove rubber dams;

• Place temporary restorations in compliance with the protocol adopted by the board;

• Apply topical antimicrobials, including fluoride but excluding antibiotics, for the purposes of bacterial reduction, caries control and desensitization in the oral cavity.

The independent practice dental hygienist shall follow current manufacturer's instructions in the use of these medicaments;

• Expose and process radiographs, including but not limited to vertical and horizontal bitewing films, periapical films, panoramic images and full-mouth series, under protocols developed by the board as long as the independent practice dental hygienist has a written agreement with a licensed dentist that provides that the dentist is available to interpret all dental radiographs within 21 days from the date the radiograph is taken and that the dentist will sign a radiographic review and findings form; and

• Prescribe, dispense or administer anticavity toothpastes or topical gels with 1.1% or less sodium fluoride and oral rinses with 0.05%, 0.2%, 0.44% or 0.5% sodium fluoride, as well as chlorhexidine gluconate oral rinse. For the purposes of this paragraph, "topical" includes superficial and intraoral application.

Maryland 2010/2014/2019 (effective 10/1/19) Md. Health Occupations Code Ann. § 4-308 General Supervision: Dental hygienist may practice under the general supervision of a dentist in a nursing home, assisted living program, medical office, and a group home or adult day care center. A dental hygienist practicing under the general supervision of a licensed dentist in these facilities shall have a written agreement with the supervising dentist that clearly sets forth the terms and conditions under which the dental hygienist may practice. Requirements: Dental hygienist must hold an active license, hold a current certificate evidencing Health Care Provider Level C Proficiency, or its equivalent, in cardiopulmonary resuscitation, have at least 3,000 hours of active clinical practice in direct patient care, and ensure that the facility where the dental hygienist will practice under general supervision has:

• A written medical emergency plan in place;

• Equipment, including portable equipment and appropriate armamentarium, available for the appropriate delivery of dental hygiene services, unless the dental hygienist provides the equipment; and

• Adequate safeguards to protect the patient’s health and safety.

Provider Services: Initial appointment is limited to dental hygiene tasks and procedures including toothbrush prophylaxis, application of fluoride, dental hygiene instruction, full mouth debridement, and other duties as may be delegated, verbally or in writing, by the supervising dentist.

Massachusetts 2009 Chap. 112, Sec. 51. Public Health Dental Hygienist: Dental hygienist may provide services without the supervision of a dentist in public health settings including, and not limited to, hospitals, medical facilities, schools and community clinics. Prior to providing services, a public health dental hygienist must have a written collaborative agreement with a local or state government agency or institution, or licensed dentist that states the level of communication with the dental hygienist to ensure patient health and safety. Public health dental hygienists shall provide patients with a written referral to a dentist and an assessment of further dental needs. Requirements: Dental hygienist must have at least 3 years of full-time clinical experience practicing in a public health setting and any other training deemed appropriate by the department of health. Provider Services: Dental hygienist can provide full scope of dental hygiene practice services allowed under general supervision in the private office, including prophylaxis, root planing, curettage, sealants and fluoride.

Michigan 2005 Sec. 333.16625 PA 161 Dental Hygienist: Dental hygienist with grantee status can practice in a public or nonprofit entity, or a school or nursing home that administers a program of dental care to a dentally underserved population. Collaborating dentist need not be present for or authorize treatment, but dental hygienist must have continuous availability of direct communication with a dentist to establish emergency protocol and review patient records. Requirements: Dental hygienist must apply to the state department of community health for designation as grantee health agency. Provider Services: Dental hygienist can provide full scope of dental hygiene services allowed under general supervision, including prophylaxis, sealants, and fluoride treatments.

Minnesota 2001/2017 Sec. 150A. 10, Subd. 1a Collaborative Practice: A Collaborative practice dental hygienist may be employed or retained by a healthcare facility, program, or nonprofit organization to perform the dental hygiene services without the patient first being examined by a licensed dentist. Practice setting can be a hospital; nursing home; home health agency; group home serving the elderly, disabled, or juveniles; state-operated facility licensed by the commissioner of human services or the commissioner of corrections; and federal, state, or local public health facility, community clinic, tribal clinic, school authority, Head Start program, or nonprofit organization that serves individuals who are uninsured or who are Minnesota health care public program recipients. Requirements: Has entered into a collaborative agreement with a licensed dentist that designates authorization for the services provided by the dental hygienist and has documented completion of a course on medical emergencies within each continuing education cycle. Provider Services:

• Complete prophylaxis to include scaling, root planing, and polishing of restorations;

• Preliminary charting of the oral cavity and surrounding structures to include case histories, perform initial and periodic examinations and assessments to determine periodontal status, and formulate a dental hygiene treatment plan in coordination with a dentist's treatment plan;

• Dietary analysis, salivary analysis, and preparation of smears for dental health purposes;

• Etch appropriate enamel surfaces, application and adjustment of pit and fissure sealants;

• Removal of excess bond material from orthodontic appliances;

• Replacement, cementation, and adjustment of intact temporary restorations extraorally or intraorally;

• Removal of marginal overhangs;

• Make referrals to dentists, physicians, and other practitioners in consultation with a dentist;

• Administer local anesthesia. Before administering local anesthesia, a dental hygienist must have successfully completed a didactic and clinical program sponsored by a dental or dental hygiene school accredited by the commission on dental accreditation, resulting in the dental hygienist becoming clinically competent in the administration of local anesthesia;

• Administer nitrous oxide inhalation analgesia; and

• Obtain informed consent, according for treatments authorized by the supervising dentist pursuant to the dental hygienist's scope of practice. 

Missouri 2001 Sec. 332.311.2 Public Health Dental Hygienist: Dental hygienist may provide services without supervision in public health settings to Medicaid-eligible children and can be directly reimbursed. Requirements: Dental hygienist must have 3 years of experience. Provider Services: Dental hygienist can provide oral prophylaxis, sealants and fluorides.

Montana 2003/2017 Sec. 37-4-405 Public Health Dental Hygienist/Limited Access Permit (LAP): Public Health Supervision means the provision of limited dental hygiene preventive services without the prior authorization or presence of a licensed dentist in a public health facility which includes: federally qualified health centers; federally funded community health centers, migrant health care centers, or programs for health services for the homeless; nursing homes; extended care facilities; home health agencies; group homes for the elderly, disabled, and youth; head start programs; migrant worker facilities; local public health clinics and facilities; public institutions under the department of public health and human services; mobile public health clinics; and other public health facilities and programs identified by the Montana Dental Board. Requirements: A dental hygienist practicing under public health supervision shall obtain a limited access permit from the board. The board shall issue a limited access permit (LAP) to a Montana licensed dental hygienist who:

• Possesses an active, unrestricted Montana dental hygiene license;

• Certifies that the dental hygienist has actively practiced either:

• 2400 clinical hours over the last three years; or

• A career total of 3000 hours, with a minimum of 350 hours in each of the last two years;

• Provides the name of the applicant's current liability insurance carrier, policy number, and expiration date;

• Provides the name and address of the public health facility or facilities where the applicant intends to provide services under a LAP;

• Provides certificates of attendance of completion of 12 additional continuing education credits for the three-year cycle immediately preceding LAP application; and

• Submits a completed application and pays all appropriate fees.

Provider Services: A licensed dental hygienist practicing under public health supervision may provide dental hygiene preventative services that include removal of deposits and stains from the surfaces of teeth, the application of topical fluoride, polishing restorations, root planing, placing of sealants, oral cancer screening, exposing radiographs, and charting of services provided, and prescriptive authority limited to fluoride agents, topical oral anesthetic agents, and nonsystemic oral antimicrobials.

Nebraska 2007 Sec. 38-1130 Public Health Dental Hygienist: The Department of Health may authorize an unsupervised dental hygienist to provide services in a public health setting or a health care or related facility. Requirements: Dental hygienist must have 3,000 hours experience in at least 4 of last 5 years. Dental hygienist must also have professional liability insurance. Provider Services: Dental hygienist can perform prophylaxis for a healthy child, pulp vitality testing and preventive measures including fluorides and sealants.

New Hampshire 1993 Rule 302.02(d), 402.01(d) Public Health Supervision: Dental hygienist may treat patients in a school, hospital, institution or residence of a homebound patient. Supervising dentist must authorize dental hygienist to provide services but need not be present for care. Requirements: None. Provider Services: Dental hygienist can provide instruction in oral hygiene, topical fluorides, prophylaxis, assess medical/dental history, periodontal probing/charting, and sealants. New Hampshire 2012 Sec. 317-A:21-e Certified Public Health Dental Hygienist: Dental hygienist may practice in a school, hospital, or other institution, or for a homebound person without the dentist having to be present, provided the dentist has reviewed the records once in a 12-month period. Dental Hygienists may perform any procedure that is within the scope of practice that has been authorized under public health supervision. Requirements: Any dental hygienist shall be considered qualified as a certified public health dental hygienist after obtaining a bachelor’s degree in dental hygiene with a minimum of 6 semester hours in community dental health; obtaining a master’s degree in public health; or after successfully completing specified courses and successful completion of an examination by the course provider. Provider Services: Dental hygienist can perform radiographic imaging limited to bite wings, and occlusal and periapical radiography and provide nutritional counseling for the control of dental disease

New Mexico 1999/2011 Sec. 16.5.17 Collaborative Practice: Dental hygienist can practice in any setting with collaborative agreement and can own or manage a collaborative dental hygiene practice. Dental hygienist must enter into a written agreement with one or more collaborative dentist(s) which must contain protocols for care. Dental hygienist must refer patients for annual dental exam. Requirements: Dental hygienist must have 2,400 hours of active practice in preceding 18 months or 3,000 hours in 2 of the past 3 years. Dentists may not collaborate with more than 3 dental hygienists. Provider Services: Collaborative practice dental hygienist can provide a dental hygiene assessment, radiographs, prophylaxis, fluoride treatments, assessment for and application of sealants, root planing, and may prescribe and administer and dispense topically applied fluoride and antimicrobials, depending on the specific services allowed in agreement with collaborating a dentist. New Mexico 2007 Sec. 61-5A-4-C No supervision required for any dental hygienist to apply topical fluorides and remineralization agents in public and community medical facilities, schools, hospitals, long-term care facilities and such other settings as the board may determine.

New York 2005 Rules Sec. 61.9 General Supervision: General supervision means that a supervising dentist is available for consultation, diagnosis and evaluation, has authorized the dental hygienist to perform the services, and exercises that degree of supervision appropriate to the circumstances. Provider Services: The following services may be performed under the general supervision of a licensed dentist:

• Removing calcareous deposits, accretions and stains, including scaling and planing of exposed root surfaces indicated for a complete prophylaxis;

• Applying topical agents indicated for a complete dental prophylaxis;

• Removing excess cement from surfaces of the teeth;

• Providing patient education and counseling relating to the improvement of oral health;

• Taking and exposing dental radiographs;

• Performing topical anticariogenic agent applications, including but not limited to topical fluoride applications, and performing topical anesthetic applications;

• Polishing teeth, including existing restorations;

• Taking and assessing medical history including the measuring and recording of vital signs as an aid to diagnosis by the dentist and to assist the dental hygienist in providing dental hygiene services;

• Performing dental and/or periodontal assessments as an aid to diagnosis by the dentist and to assist the dental hygienist in providing dental hygiene services;

• Applying pit and fissure sealants;

• Applying desensitizing agents to the teeth;

• Placing and removing temporary restorations;

• Making assessments of the oral and maxillofacial area as an aid to diagnosis by the dentist;

• Taking impressions for study casts. Study casts shall mean only such casts as will be used for purposes of diagnosis and treatment planning by the dentist and for the purposes of patient education; and providing dental health care case management and care coordination services.

New York 2013 Sec. 6606 Collaborative Practice: A collaborative arrangement is an agreement between a registered dental hygienist working for a hospital and a licensed and registered dentist who has a formal relationship with the same hospital. Requirements: A registered dental hygienist providing services pursuant to a collaborative arrangement shall:

• Only provide those services that may be provided under general supervision as specified in subdivision (b) of this section, provided that the physical presence of the collaborating dentist is not required for the provision of such services;

• Instruct individuals to visit a licensed dentist for comprehensive examination or treatment;

• Possess and maintain certification in cardiopulmonary resuscitation in accordance with the requirements for dentists set forth in section 61.19 of this part and the following:

At the time of his or her registration renewal, the dental hygienist shall attest to having met the cardiopulmonary resuscitation requirement or attest to meeting the requirements for exemption as defined in clause (b) of this subparagraph. A dental hygienist may be granted an exemption to the cardiopulmonary resuscitation requirement if he or she is physically incapable of complying with the requirements of this subparagraph. Documentation of such incapacity shall include a written statement by a licensed physician describing the dental hygienist’s physical incapacity. The dental hygienist shall also submit an application to the department for exemption which verifies that another individual will maintain certification and be present at the location where the dental hygienist provides dental hygiene services, pursuant to a collaborative arrangement, while the dental hygienist is treating patients. Each dental hygienist shall maintain for review by the department records of compliance with the cardiopulmonary resuscitation certification requirement, including the dental hygienist’s cardiopulmonary resuscitation certification card; and provide collaborative services only pursuant to a written agreement that is maintained in the practice setting of the dental hygienist and collaborating dentist. Provider Services: The following services may be performed pursuant to a collaborative arrangement:

• Removing calcareous deposits, accretions and stains, including scaling and planing of exposed root surfaces indicated for a complete prophylaxis;

• Applying topical agents indicated for a complete dental prophylaxis;

• Removing excess cement from surfaces of the teeth;

• Providing patient education and counseling relating to the improvement of oral health;

• Taking and exposing dental radiographs;

• Performing topical anticariogenic agent applications, including but not limited to topical fluoride applications, and performing topical anesthetic applications;

• Polishing teeth, including existing restorations; 

• Taking and assessing medical history including the measuring and recording of vital signs as an aid to diagnosis by the dentist and to assist the dental hygienist in providing dental hygiene services;

• Performing dental and/or periodontal assessments as an aid to diagnosis by the dentist and to assist the dental hygienist in providing dental hygiene services;

• Applying pit and fissure sealants;

• Applying desensitizing agents to the teeth;

• Placing and removing temporary restorations;

• Making assessments of the oral and maxillofacial area as an aid to diagnosis by the dentist;

• Taking impressions for study casts. Study casts shall mean only such casts as will be used for purposes of diagnosis and treatment planning by the dentist and for the purposes of patient education; and

• Providing dental health care case management and care coordination services.

Nevada 1998 Sec. 631.287 Public Health Dental Hygienist: Dental hygienist may obtain approval to work as public health dental hygienists in schools, community centers, hospitals, nursing homes and such other locations as the state dental health officer deems appropriate without supervision. Requirements: Special endorsement from the dental board. Submissions of protocol to describe the methods a dental hygienist will use to provide services. Provider Services: May provide most hygiene services and may administer local anesthesia and nitrous oxide in a facility with certain equipment and dentist authorization.

Ohio 2010/2014/2017 Sec. 4715.363 Oral Health Access Supervision Permit Program: Dental hygienist who possess an oral health access supervision permit may provide dental hygiene services through a written agreement with a dentist in public health settings including, and not limited to a healthcare facility, state correctional institution, residential facility, school, shelter for victims of domestic abuse or runaways, foster home, non-profit clinic, dispensary or mobile dental clinic. Prior to providing services, a dental hygienist with an oral health access supervision permit must have a written agreement with a dentist, who possesses an oral health supervision permit, that states the dentist has evaluated the dental hygienist’s skills and the dentist has reviewed and evaluated the patient’s health history. The dentist need not be present or examine the patient before the dental hygienist may provide care. The collaborating dentist must perform a clinical evaluation of the patient before the dental hygienist may provide subsequent care. The evaluation may be done using electronic communication. Requirements: One year and a minimum of 1,500 hours of clinical experience, minimum of 24 continuing education credits during the two years prior to apply for the oral health access supervision permit including an eight hour course as required by the board. Provider Services: Prophylactic, preventive and other procedures a dentist can delegate to a dental hygienist except definitive root planing, definitive subgingival curettage, administration of local anesthesia and other procedures specified in rules adopted by the board. Ohio 2013 Sec. 4715.22 The requirement for a dentist to perform an examination and diagnose a patient prior to the patient receiving dental hygiene services through a program operated by a school district or other specified entity does not apply when the only services to be provided are the placement of pit and fissure sealants.

Oklahoma 2003 Sec. 328.34 General Supervision: Dental hygienist may provide services outside of the private dental office for a patient not examined by the dentist. Dentist must authorize care in writing. Requirements: Dental hygienist must have at least 2 years of experience. Provider Services: Most dental hygiene services, including sealants, fluorides, and prophylaxis, to a patient one time prior to a dental exam.

Oregon 1997 Sec. 680.200, Rule 818-035-0065 Limited Access Permit (LAP): Dental hygienists who have obtained a limited access permit (LAP) may initiate unsupervised services for patients in a variety of limited access settings such as extended care facilities, facilities for the mentally ill or disabled, correctional facilities, schools and pre-schools, medical offices or offices operated or staffed by a nurse practitioner midwives or physicians assistants, and job training centers. Dental hygienist must refer the patient annually to a licensed dentist available to treat the patient. Requirements: Dental hygienist must have 2,500 hours of supervised dental hygiene practice and complete 40 hours of board-approved courses in an accredited dental hygiene program or completed a course of study approved by the board that includes at least 500 hours of dental hygiene practice on limited access patients while under direct faculty supervision. Dental hygienist must also have liability insurance. Provider Services: LAP dental hygienists can provide all dental hygiene services, except several (local anesthesia, pit and fissure sealants, denture relines, temporary restorations, radiographs and nitrous oxide) which must be supervised by a dentist. Dental hygienist may prescribe fluorides and assess the need for sealants. Oregon 2011 Sec. 680.205 Expanded Practice Dental Hygienist (EPDH) Replaces Limited Access Permit. Adds services to patients below federal poverty level and other settings approved by the board to EPDH practice settings. Adds limited prescriptive authority, local anesthesia, temporary restorations and dental assessments to unsupervised EPDH scope if EPDH has agreement with a dentist. Requires insurance reimbursement of EPDHs.

Pennsylvania 2007 Sec. 2 (Definitions), Sec. 11.9 Public Health Dental Hygiene Practitioner: Dental hygienists who are certified as public health dental hygiene practitioners may provide care in a variety of public health settings without the supervision or prior authorization of a dentist. Requirements: Dental hygienist must have 3,600 hours experience and liability insurance. Dental hygienist must also complete 5 hours of continuing education in public health during each licensure period. Provider Services: Dental hygienist may perform educational, preventive, therapeutic and intra-oral procedures which the hygienist is educated to perform and which require the hygienist’s professional competence and skill.

Rhode Island 2006 Sec. 5-31.1-6.1 General Supervision: Dental hygienists working under a dentist’s general supervision can initiate dental hygiene treatment to residents of nursing facilities. Dental hygienists working in nursing facilities can treat patients, regardless of whether or not the patient is a patient of record, as long as documentation of services administered is maintained and necessary referrals for follow-up treatment are made. Requirements: None. Provider Services: Dental hygienist can initiate dental hygiene services, including oral health screening assessments, prophylaxis, fluoride treatments, charting, and other duties delegable under general supervision. Rhode Island 2015 Sec. 5-31.1-39 Public Health Hygienists: Any public health dental hygienist may perform dental hygiene procedures in a public health setting, without the immediate or direct supervision or direction of a dentist. Public health settings includes, but are not limited to, residences of the homebound, schools, nursing home and long-term care facilities, clinics, hospitals, medical facilities or community health centers. Requirements: A public health dental hygienist shall enter into a written collaborative agreement with a local or state government agency or institution or with a licensed dentist. Any public health dental hygienist shall provide to the patient or to the patient's legal guardian a consent form to be signed by the patient or legal guardian. The consent form shall also inform the patient or legal guardian that the patient should obtain a dental examination by a dentist within ninety days after undergoing a procedure. Provider Services: Any procedure or service that is within the dental hygiene scope of practice that has been authorized and adopted by board as a delegable procedure for a dental hygienist under general supervision in a private practice setting.

South Carolina 2003 Sec. 40-15-110 (A) (10) General Supervision: Dental hygienist employed by, or contacted through, the Department of Health and Environment Control may provide services under general supervision that does not require prior examination by a dentist in settings such as schools or nursing homes. Requirements: Dental hygienist must carry professional liability insurance. Provider Services: Dental hygienist employed by, or contacted through, the Department of Health and Environment Control may provide prophylaxis, fluorides, and sealants.

South Dakota 2011 Rules 20:43:10 Dental hygienist may provide preventive and therapeutic services under collaborative supervision of a dentist in a school, nursing facility, Head Start program, non-profit mobile dental clinic, community health center or government program. Requirements: Dental hygienist must possess a license to practice in the state and have 3 years of clinical practice in dental hygiene and a minimum of 4,000 practice hours. A minimum of 2,000 of those hours must have been completed within 2 of the 3 years preceding application. Dental hygienist must have a written collaborative agreement with a dentist and satisfactorily demonstrate knowledge of medical and dental emergencies and their management, infection control, pharmacology, disease transmission, management of early childhood caries and management of special needs population. Provider Services: Any services that can be provided under general supervision.

Tennessee 2013 Sec. 63-5-109 Dental hygienist may apply dental sealants or topical fluoride to the teeth of individuals in a setting under the direction of a state or local health department, without requiring an evaluation by a dentist prior to such application, under a protocol established by the state or a metropolitan health department.

Texas 2001 Sec. 262.1515 General Supervision: Dental hygienist may provide services for up to 6 months without dentist seeing the patient. Services may be performed in school-based health center, nursing facility or community health center. Dental hygienist must refer the patient to a dentist following treatment and may not perform a second set of services until the patient has been examined by a dentist. Requirements: Dental hygienist must have at least 2 years of experience. Provider Services: No limitations. Dentist must authorize services in writing.

Utah 2015 Sec. 58-69-801 Public Health Dental Hygienist: A dental hygienist may treat patients in specified public health settings pursuant to a written agreement with a dentist. The settings include a homebound patient’s residence, a school, a nursing home, an assisted living facility, a community health center, a federally qualified health center and a mobile dental health program that employees a dentist. Requirements: Must be a licensed Utah dental hygienist and have a written agreement with a collaborating dentist. The agreement provides that the dental hygienist shall refer a patient with a dental need beyond the dental hygienist's scope of practice to a dentist. Each patient must complete an informed consent form that provides that treatment by a dental hygienist is not a substitute for a dental examination by a dentist. Provider Services: All general supervision preventive functions in scope of practice. Local anesthesia and nitrous oxide administration are not permitted.

Vermont 2008/2019 § 582 & 624 Public-Health Hygienists: Dental hygienist may provide services in out-of-office settings under general supervision agreement with a dentist, including residences, schools, nursing home and long-term care facilities, clinics, hospitals, medical facilities, community health centers licensed or approved by the Department of Health, Head Start programs, and other locations deemed appropriate. The agreement authorizes the dental hygienist to provide services, agreed to between the dentist and the dental hygienist. The agreement does not require physical presence of the dentist but it stipulates that the supervising dentist review all patient records. Requirements: Dental hygienist must have 3 years licensed clinical practice experience. Provider Services: Dental hygienist can provide sealants, fluoride varnish, prophylaxis and radiographs. Periodontal maintenance is allowable to patients with mild periodontitis.

Virginia 2009/2016/2017/2019 Sec. 54.1-2722 Remote Supervision: Remote Supervision means that a supervising dentist is accessible and available for communication and consultation with a dental hygienist during the delivery of dental hygiene services, but such dentist may not have conducted an initial examination of the patients who are to be seen and treated by the dental hygienist and may not be present with the dental hygienist when dental hygiene services are being provided. Requirements: Complete a continuing education course designed to develop the competencies needed to provide care under remote supervision offered by an accredited dental education program or from a continuing education provider approved by the Board and have at least two years of clinical experience, consisting of at least 2,500 hours of clinical experience. A dental hygienist practicing under remote supervision shall have professional liability insurance with policy limits acceptable to the supervising dentist. A dental hygienist shall only practice under remote supervision at a federally qualified health center; charitable safety net facility; free clinic; long-term care facility; elementary or secondary school; Head Start program; mobile dentistry program for adults with developmental disabilities operated by DBHDS; or women, infants, and children (WIC) program. Provider Services: A dental hygienist practicing under remote supervision may:

• Obtain a patient's treatment history and consent;

• Perform an oral assessment;

• Perform scaling and polishing;

• Perform all educational and preventative services;

• Take x-rays as ordered by the supervising dentist or consistent with a standing order;

• Maintain appropriate documentation in the patient's chart;

• Administer topical oral fluorides, topical oral anesthetics, topical and directly applied antimicrobial agents for treatment of periodontal pocket lesions, and any other

• Schedule VI topical drug approved by the Board of Dentistry under an oral or written order or a standing protocol issued by a dentist or a doctor of medicine or osteopathic medicine; and

• Perform any other service ordered by the supervising dentist or required by statute or board regulation.

No dental hygienist practicing under remote supervision shall administer local anesthetic or nitrous oxide. After conducting an initial oral assessment of a patient, a dental hygienist practicing under remote supervision may provide further dental hygiene services following a written practice protocol developed and provided by the supervising dentist.

Washington 1984/2009 Sec. 18.29.056 Unsupervised and Off-Site Supervision: Dental hygienist may be employed, retained or contracted by health care facilities to perform authorized dental hygiene services without supervision, provided the dental hygienist refers patient to a dentist for dental planning and treatment. Health care facilities are limited to hospitals; nursing homes; home health agencies; group homes serving the elderly, individuals with disabilities and juveniles; state operated institutions under the jurisdiction of the department of social and health services or the department of corrections; and federal, state, and local public health facilities, state or federally funded community and migrant health centers and tribal clinics. Specifically in senior centers, dental hygienist may provide limited dental hygiene services with under the “off-site supervision” of a dentist. Requirements: Dental hygienist must have 2 years clinical experience within the last 5 year with a dentist. Written practice plan required in certain settings. Provider Services: Dental hygienist may provide prophylaxis, application of typical preventive or prophylactic agents, polishing and smoothing restorations root planing and curettage. Washington 2001 Sec. 18.29.220 Public Health Dental Hygienist: Dental hygienist who is school endorsed may assess for and apply sealants and fluoride varnishes and perform prophylaxis in community-based sealant programs carried out in Schools. Requirements: Sealant/Fluoride Varnish Endorsement from Department of Health. Dental hygienist must submit data to the Department of Health concerning patient demographics, treatment, reimbursement and referrals.

West Virginia 2008 Sec. 5-1-8.5 Public Health Dental Hygienist: A dental hygienist may provide care in hospitals, schools, correctional facilities, jails, community clinics, long-term care facilities, nursing homes, home health agencies, group homes, state institutions under the Department of Health and Human Resources, public health facilities, homebound settings, and accredited dental hygiene education programs. A dentist must authorize dental hygienists to provide care but need not be present or have previously seen the patient. Requirements: A dental hygienist must have 2 years and 3,000 hours of clinical experience and take six additional continuing education hours. Dental hygienists and dentists must submit annual written reports of care to the state board of dental examiners. Provider Services: A dental hygienist can provide patient education, nutritional counseling, oral screening with referral to a dentist, apply fluoride, sealants, and offer complete prophylaxis (pursuant to a collaborative agreement or written order.)

Wisconsin 2007/2017 Sec. 447.06 In settings other than a dental office, the authorization and presence of a licensed dentist is not required for the practice of dental hygiene. Under prior law, the authorization and presence of a licensed dentist were required in most cases. in addition to a dental office setting, a dental hygienist may practice dental hygiene in any of the following settings, in accordance with conditions specified in the statutes:

• Federal, state, county, or municipal correctional or detention facilities and facilities established to provide care for terminally ill patients;

• Charitable institutions open to the general public or members of a religious sect or order;

• Nonprofit home health care agencies;

• Nonprofit dental care programs serving primarily indigent, economically disadvantaged, or migrant worker populations;

• Nursing homes, community-based residential facilities, and hospitals.

• Facilities that are primarily operated for the purpose of providing outpatient medical services;

• Adult family homes;

• Adult daycare centers; and

• Community rehabilitation programs. A community rehabilitation program is defined to mean a nonprofit entity or governmental agency providing vocational rehabilitation services to disabled individuals to maximize the employment opportunities of such individuals.

Provider Services: A dental hygienist can provide prophylaxis, root planing, screening, treatment planning, sealants, and delegable duties. Public Health Dental Hygienist The Wyoming Dental Board adopted regulations allowing the public to directly access limited dental hygiene services from a Public Health Dental Hygienist. A public health dental hygienist may provide public health services at facilities to include, but not limited to:

• federally-funded health centers and clinics

• nursing homes

• extended care facilities

• home health agencies

• group homes for the elderly, disabled and youth

• public health offices

• Women, Infants, and Children (WIC)

• Head Start programs

• child development programs

• early intervention programs

• migrant work facilities

• free clinics

• health fairs

• public and private schools

• state and county correctional institutions

• community school-based prevention programs

• public health vans

Requirements: The public health hygienist must submit a Collaboration Agreement with a Wyoming licensed dentist. The hygienist must have a current Wyoming dental hygienist license with a minimum of two years of clinical experience. Lastly, the dental hygienist must carry liability insurance. Provider Services: Public health services solely consist of prophylaxis, fluoride varnishes, oral health education, and dental screenings. These services can be provided by the hygienist without prior authorization of the dentist. All patients seen shall be referred to a dentist annually.