I strongly oppose Virginia's expansion of dental assistant duties to include supragingival scaling. I recognize that this authority was enacted by the Virginia General Assembly and that the Board of Dentistry must now operate within that law. However, significant concerns remain regarding patient safety, clinical competency, oversight, accountability, and the economic impact on dental workers.
1. This law increases the labor of both RDHs and DAs without fairly increasing their pay, while patients would see little or no financial benefit.
This law could create an unfair pay imbalance for both professions. A DA may now take on the added clinical responsibility of supragingival scaling without receiving additional fair pay.
More importantly, a DA and an RDH may now perform the same supragingival scaling work as part of a prophylaxis, but the DA may be paid significantly less than an RDH for performing that same portion of the clinical work. If two workers are performing the same clinical task, why should one worker's labor be valued significantly less?
At the same time, the RDH could be expected to treat more difficult SRP and periodontal patients without receiving additional pay for the increased difficulty and workload.
The DA may perform the same supragingival scaling work for lower pay. The RDH may be given harder periodontal work for the same pay. The dental office receives more clinical labor from both workers without necessarily paying either worker more.
There is also an important concern for patients: Where does the saved money go? If a dental assistant is paid less to do the same cleaning work that a dental hygienist used to do, the dental office may spend less money. But that does not mean the patient's bill or dental insurance cost will go down.
Patients and insurance plans could continue paying the same fees even though the office's labor cost is lower. If overall dental charges continue to rise, those costs can ultimately affect patients through higher out of pocket costs, deductibles, copayments, benefit limits, or pressure on insurance premiums. Therefore, Virginia should not assume that using a lower-paid worker to perform scaling will automatically make dental care less expensive for patients.
If the purpose of this change is to improve access and reduce workforce costs, Virginia should ask a simple question: Will patients actually pay less, or will the financial savings remain with the dental practice?
A dental workforce shortage should not be solved by increasing the workload and clinical responsibilities of both DAs and RDHs, paying less for comparable clinical labor, and assuming that the savings will benefit patients.
The bold question near the end is especially useful because it forces the economic issue without making an unsupported claim that this law itself will raise insurance premiums.
2. Scaling is a clinical procedure, not simply the mechanical removal of visible calculus.
Knowing how to hold a scaler or operate an ultrasonic instrument is only one part of providing safe care. Scaling requires an understanding of oral anatomy, periodontal tissues, calculus, inflammation, instrumentation, medical considerations, and the clinical significance of what is encountered during treatment.
3. Technical ability is not the same as clinical judgment.
Someone can be trained to physically remove calculus without having the education needed to understand why the calculus is present, whether the surrounding tissues are healthy or diseased, or whether additional treatment is necessary. Knowing how to scale is not the same as knowing when, where, and why to scale.
4. Twenty supervised full-mouth scalings should not automatically equal clinical competency.
Completing 20 procedures proves that 20 procedures were completed. It does not automatically demonstrate mastery of calculus detection, instrumentation, adaptation, tissue management, ultrasonic scaling, recognition of disease, clinical judgment, or knowing when treatment must stop.
5. The 1,800 hours of clinical experience should not be confused with scaling education.
At 40 hours per week, 1,800 hours equals 45 weeks, or approximately 10½ months of full time clinical experience. More importantly, those 1,800 hours are not necessarily 1,800 hours of scaling, periodontal assessment, or periodontal-care experience.
6. Competency should be evaluated using consistent and objective standards.
Virginia patients should receive the same minimum protection regardless of which dental practice they visit. When training and certification depend heavily on individual practices and supervising dentists, Virginia should ensure that competency standards are consistent throughout the Commonwealth.
7. The certification structure creates an oversight concern.
The supervising dentist certifies that the statutory requirements were completed and maintains the certification documentation. Virginia should ensure there is meaningful accountability and objective evidence that an assistant is clinically competent before being allowed to use hand and ultrasonic scalers on patients.
8. Dental hygiene education exists for more than learning instrumentation.
Dental hygienists receive formal education and supervised clinical training in periodontal assessment, anatomy, pathology, pharmacology, radiography, infection control, medical history, instrumentation, prevention, patient education, and other areas necessary for comprehensive patient care. They must also satisfy formal licensure requirements.
9. Patients have a right to know who is treating them and what care they are receiving.
A patient who is told they are receiving a “cleaning” may reasonably believe they are being treated by a licensed dental hygienist. Patients should be clearly informed when a dental assistant will perform supragingival scaling and should understand the limits of that assistant's authorized scope. Limited supragingival scaling should also not be represented as complete care when additional subgingival or periodontal treatment is necessary.
10. A dental hygiene workforce shortage should not be solved by lowering patient safeguards.
If access to dental hygienists is a problem, Virginia should address the underlying causes through recruitment, retention, educational capacity, licensure mobility, geographic workforce distribution, workplace conditions, and other barriers preventing qualified hygienists from entering or remaining in the profession.
11. The supervising dentist's responsibility must be unmistakably clear.
Because Virginia permits this procedure under indirect supervision, the dentist must remain responsible for appropriate delegation, patient selection, supervision, recognition of conditions requiring additional treatment, documentation, and ensuring that patients receive appropriate follow up care.
Teaching someone how to operate a scaler is not the same as educating a clinician to understand when, where, why, and whether scaling is appropriate.
Virginia patients deserve more than proof that an assistant completed 1,800 hours of general clinical experience and 20 supervised scaling procedures. They deserve assurance that the person providing clinical care has the education, competency, and judgment necessary to recognize when that care is appropriate and when it is not.