Arizona recently made an innovative change in its scope-of-practice rules governing supervision of dental hygienists to enable hospitals to more easily use these providers to help prevent ventilator-assisted pneumonia (VAP) – the leading cause of death from nosocomial infections in critically ill patients. VAP, the second most common nosocomial infection, increases the duration of hospitalizations by seven days and health care costs by approximately $40,000 per hospitalization.1
Preventing VAP is important to reducing both hospital-acquired infections and health care costs. VAP usually occurs when a patient aspirates oral bacteria. The US Centers for Disease Control and Prevention, in recognizing the importance of oral care to VAP prevention efforts, suggests that hospitals, “develop and implement a comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients in acute care settings or residents in long-term care facilities who are at high risk for health-care-associated pneumonia.”2
Nurses often provide oral-hygiene care to ventilator-dependent hospital patients, but some hospitals prefer to use dental hygienists to provide that service because of hygienists’ expertise and to give nurses more time for other responsibilities. However, hospitals in Arizona encountered challenges to assigning dental hygienists to this task. States’ scope-of-practice laws usually allow dental hygienists to provide care only under the supervision of a dentist. But hospitals may not have dentists on staff, or if they do, the dentist may not be available to order the care when needed.
In May 2019, Arizona enacted HB 2058, which allows dental hygienists working in hospital settings to practice under the supervision of a licensed physician. In addition, the supervising physician must be available for consultation but does not need to be physically present when the care is administered.
Changing the Scope of Practice Required Innovative Partnerships Among Providers
HB 2058 affects how physicians, oral hygienists, nurses, hospitals, and dentists work together. For example, nurses had traditionally provided oral health care in hospitals and they needed to understand that the change would not reduce their role, but rather free up their time to provide other critical services. Also, physicians needed to understand their responsibilities in supervising dental hygienists. As a result, crafting the legislation required partnerships and cooperation among the associations representing these providers. A volunteer project fostered these partnerships and generated real-life examples that confirmed that the scope-of-practice laws needed to be changed to enable hospitals to use dental hygienists to effectively provide dental hygiene in hospital settings.
Remaining Challenges and Next Steps
Although changing dental hygienists’ scope of practice facilitates their ability to practice in hospitals, challenges remain. For example, allowing hygienists to provide services does not obligate public and private insurers to pay for those services. Even before the bill passed, one regional hospital began hiring dental hygienists to work in its intensive care unit and the hospital then sought reimbursement for the hygienists’ services through medical billing — an action made possible by the change in the scope-of-practice rule. However, because Medicare does not recognize dental hygienists as a provider type, the hospital will not receive payment from Medicare. At this time, it is not known whether other payers will choose to pay for oral hygiene services provided to hospital patients by oral hygienists.
State health officials are tracking the results of this new innovation. They plan to assess patient outcomes, including VAP reduction, costs, and whether more hospitals implement this innovation. Depending on the results, officials are considering developing education programs or training to foster the innovation’s expansion. State policymakers are also considering expanding the physician-supervision model to long-term care facilities.
Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank officials with the Arizona Department of Health Services who shared their time and insights. The author also thanks Carrie Hanlon, Elinor Higgins, and Trish Riley of NASHP. She also would like to thank Trenae Simpson, M. Parrish Ravelli, and the DentaQuest Partnership for Advancing Oral Health for funding this project.
 Timsit, J.J., et al. (2017) Update on ventilator-associated pneumonia. F1000 Research. 6:2061. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710313/
 Centers for Disease Control and Prevention (2003). Guidelines for Preventing Health-Care—Associated Pneumonia. CDC Morbidity and Mortality Weekly Report. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm