According According to the Department of Health and

According to the CDC, 1 in 5 American children aged 5 to 11 years have at
least one untreated decayed tooth (Dye, Li, & Beltrán-Aguilar, 2012). Dental disease is preventable, but dental care is often unaffordable and
inaccessible. Childhood tooth decay disproportionately affects low-income
families and racial or ethnic minorities, and is associated with poor outcomes
including loss of teeth, impaired growth, decreased weight gain, poor school
performance, and poor quality of life (Blackburn, Morrisey, & Sen, 2017). During the 2006-2007 school year, the Alabama Department of Public
Health found that 24% of students examined had untreated tooth decay, which is
higher than the national average (Alabama Department of Public Health, 2007).  

The supply of dentists in the United States is likely to shrink in the
coming years, and Alabama is likely to experience a shortage (The Pew Charitable Trusts, 2013). According to the Department of Health and Human Services, 24.4% of people
in Alabama live in an area that is underserved by dentists (U.S. Department of Health and Human
Services, 2013). In 2009,
37% of dentists were over the age of 55, which means many dentists will soon
retire (The Pew Charitable Trusts, 2013). In the coming years, new dental schools are expected to open across
the country. If future graduates continue the practice patterns of current
dentists—locating in more populated urban and suburban areas and serving mainly
privately insured patients or those who pay out of pocket—the inaccessibility
will persist (The Pew Charitable Trusts, 2013). Between 2010 and
2030, the American Dental Association predicts that the ratio of dentists to
patients in America will decline, despite new dental schools and a potential
increase in graduates (Voinea-Griffin & Solomon, 2016).

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In many states, dental hygienists are able to perform services in
underserved areas to help close some of these gaps. Alabama has some of the
strictest supervision guidelines in the country for dental hygienists.

Hygienists must practice under the direct supervision of a licensed dentist,
meaning a dentist must be physically present during any services rendered by
the hygienist. Alabama is one of only two states with such strict guidelines.

This requirement creates a barrier to dental health care, particularly for
low-income Alabamans (Merritt, 2017).

Reforming the supervision guidelines for dental hygienists would expand
access to dental care. Allowing hygienists to apply topical fluoride, perform
the application of sealants, and oral prophylaxis under general supervision
(meaning a dentist must authorize a procedure, but does not have to be
physically present) in safety-net settings would greatly improve access to oral
healthcare for many underserved populations, and likely also improve oral
health outcomes for these populations (Becker et al., 2015). These
safety-net settings would include hospitals, nursing homes, long-term care
facilities, rural health clinics, federally qualified health centers, health
facilities operated by federal, state, county, or local government, hospices,
family violence shelters, free health clinics, and Title I schools (American Dental Hygienists Association,

In 2016, the Department of Labor estimated
there were 3,380 dental hygienists employed across the state of Alabama. By
2020, this occupation is expected to employ a workforce of approximately 4,350.

This projection shows a 3.68% annual growth rate, which will lead to about 195
job openings each year (Bureau of
Labor Statistics, 2016). If this
legislation is passed, the demand for dental hygienists would increase, which
would encourage more workers to go into the profession. Passing legislation to
change the supervision guidelines for dental hygienists could save the state of
Alabama millions of dollars. While there is no research currently available
about emergency room utilization due to dental problems in Alabama, we can look
to Georgia’s experience for guidance. In 2015, about 66,000 Georgians were admitted
and treated in emergency rooms because of dental problems that could have been
prevented. These emergency room visits cost Georgia $47 million (Salzer, 2016). Research is needed to quantify the burden of dental disease emergency
room utilization, but Alabama likely faces similar costs.

Forty-seven states allow dental hygienists to render limited services
without a dentist being physically on site (Salzer, 2016). Under the proposed legislation, a dentist would still have to approve any
procedures performed by a hygienist; they just wouldn’t physically have to be present.

Dentists in Alabama are concerned that this legislation would allow hygienists
to expand their current scope of practice and increase competition. However, dental
hygienists in safety net settings do not pose a threat to dentists’ practices. Very
few dental clinics in Alabama rely solely on low-income or Medicaid patients to
keep their practice growing. In fact, many practices do not accept Medicaid at
all (Mitchell et al., 2017). Allowing
hygienists to perform basic care under general supervision in the
aforementioned safety net settings will improve dental health outcomes for the
state’s most underserved populations while saving the state millions of



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