Dental hygienists in the United States are

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1 Milieu in Dental School and Practice Practicing Dental Hygienists Perceptions About the Bachelor of Science in Dental Hygiene and the Oral Health Practitioner Kelly L. Anderson, R.D.H., M.H.S.; Barbara S. Smith, Ph.D. Abstract: No research data are available about practicing dental hygienists opinions regarding the Bachelor of Science in Dental Hygiene (B.S.D.H.) and the oral health practitioner (OHP), a new professional category in dental hygiene; however, such views would be useful to those implementing these programs in the academic setting as well as those involved in proposing and passing legislation regarding them. The purpose of our study was to gather information from a group of practicing dental hygienists regarding their opinions in three areas: 1) the entry-level B.S.D.H., 2) the OHP, and 3) reasons for being for or against these programs. A survey, sent to 564 dental hygiene graduates, used a five-point Likert scale to evaluate perceptions in various categories. The respondents also ranked perceived benefits and negative impacts. The usable return rate was 33.6 percent. Descriptive statistics were developed, and chi-square tests were used to analyze the data. More than 70 percent of the respondents agreed that an associate s degree sufficiently prepared dental hygienists for their positions and that the OHP would have a positive impact on access to dental care. The majority also said they felt the master s-educated hygienist would be adequately prepared to perform proposed OHP functions. Selected demographic variables were found to be significantly associated with perceptions, including that the B.S.D.H. was viewed more positively by younger respondents. Prof. Anderson is Assistant Professor, Department of Dental Hygiene, and Dr. Smith is Associate Professor, Department of Physical Therapy both at Wichita State University. Direct correspondence and requests for reprints to Prof. Kelly L. Anderson, Department of Dental Hygiene, Wichita State University, 1845 Fairmount St., Wichita, KS 67260; phone; fax; kelly.anderson@wichita.edu. Keywords: bachelor s degree in dental hygiene, oral health practitioner, survey, perceptions Submitted for publication 4/14/09; accepted 7/1/09 Dental hygienists in the United States are educated primarily through entry-level associate degree programs in approximately 250 institutions across the country. Students who seek additional education can choose from forty-eight baccalaureate degree programs and eighteen master s level programs. 1 The scope of professional practice does not change whether one has an associate, baccalaureate, or master s degree. However, the latter degrees, especially the master s, allow a hygienist to pursue career paths other than clinical practice for example, in administration, research, and/or education. The advanced dental hygiene practitioner (ADHP) was introduced by the American Dental Hygienists Association (ADHA) in 2004 as a proposed professional category that requires a master s degree. The curriculum is being developed with the cooperation of organizations such as the ADHA and the Oral Health Practitioner Work Group in Minnesota. 2 On April 17, 2008, the Minnesota State Senate passed an amended Omnibus Higher Education Bill that created the oral health practitioner (OHP) based on the proposed ADHP and assigned a workgroup the responsibility of making recommendations and proposing legislation to define provider scope, supervision, and education. The amendment specified that the OHP will be a licensed, educated health care provider who works under the supervision of a dentist via a collaborative management agreement. It also stipulated that OHPs must practice in underserved areas and cannot begin lawful practice prior to This legislation is the first step in a lengthy, ongoing process. Under general supervision, the OHP is expected to perform procedures such as primary diagnostic, educational, palliative, therapeutic, and restorative care and simple extractions and will have prescriptive authority collaborating with a consulting dentist. 4-8 The goal is to provide cost-effective, easily accessible primary oral care. The concept of this 1222 Journal of Dental Education Volume 73, Number 10

2 advanced practitioner in dental hygiene, pioneered by ADHA, is not the first of its kind in the health care industry. Precedent has been set in the nursing profession with the nurse midwife, nurse practitioner, clinical nurse specialist, and nurse anesthetist. The nursing profession moved toward the development of the nurse practitioner through recognition of unmet public health needs. The OHP is also modeled as a mid-level provider, primarily motivated by the need to make dental care more widely available to underserved populations. The American Dental Education Association (ADEA) is another group that promotes innovative and higher level learning for dental hygienists. At the June 2000 ADEA Allied Dental Program Directors Conference, 150 dental hygiene program directors agreed on the following strategies to advance the profession and help meet the need for access to care issues: Establishing higher levels of academic credentials for the practice of dental hygiene, with a strong emphasis on degree programs. Some program directors suggested that the bachelor s degree become the entry point into dental hygiene practice. To accomplish this, more degree completion programs would need to be created. In addition, certificate programs would be needed to retrain faculty, with an increase in faculty with master s degrees and doctorates. Creating greater public awareness of the role of dental hygienists, including the role dental hygienists play in providing improved access to oral health care. An increased role for dental hygiene for improving access to oral health care and reducing oral health care disparities. Expand manpower in rural areas through public clinics and to increase care to a diverse patient pool (e.g., poor, disabled, medically compromised, elderly) through care through nursing home and home health care settings. This expanded access will broaden the scope of dental hygiene while enhancing public perception of the dental hygiene role. 9 In June 2008, Dr. Richard W. Valachovic, executive director of ADEA, stated, There s no question that greater independence for the practice of dental hygiene is the wave of the future. A bill passed in Maryland this spring will allow hygienists, beginning this fall, to provide preventive services in public health settings without a dentist s prior authorization or direct supervision. In some states, hygienists can establish their own practices. In others, under certain circumstances, they can perform restorative functions. 10 ADEA recognizes these advances for allied dental professionals as one way to improve access to oral health care. Currently, baccalaureate programs in dental hygiene comprise only 16 percent of total entry-level dental hygiene programs in the United States, which could indicate that students prefer the associate level of education. One study, however, suggested otherwise. In a study published in 2007, 66 percent of responding dental hygiene students said they were interested in completing their baccalaureate degree. These students reported their highest interest for course topics was in the ADHA focus areas of practice and technology. 6 In another study published in 2007, 47 percent of responding senior dental hygiene students expressed a need for OHPs to enhance access to dental care for underserved populations. 7 In comparing graduates of associate and baccalaureate dental hygiene programs, a study published in 2008 concluded that graduates of baccalaureate programs are more likely than graduates of associate degree programs to be involved in non-private practice positions such as teaching and research. 8 This study also found that graduates from baccalaureate programs become educators, scholars, and leaders in the profession. This is particularly important in recruitment because the number of dental hygiene educators is declining. The OHP initiative is important in at least two ways: 1) providing oral health care to more diverse populations, and 2) advancing dental hygiene career choices. However, dental hygiene programs at the master s level cannot be supported without more opportunities for students to pursue the bachelor s educational level. Although advanced education for dental hygienists has been found to have support among students and educators, limited information is available from those in practice. The only study to examine dental hygiene practitioners views about bachelor s-entry level education was published in At that time, respondents with an associate s degree disagreed that having a bachelor s degree was necessary for practice. 11 No literature is available on practicing dental hygienists opinions about the OHP. Thus, our study s purpose was to gather practicing dental hygienists opinions in three areas: 1) the baccalaureate degree as the entry-level degree, 2) the OHP, and 3) reasons for October 2009 Journal of Dental Education 1223

3 being for or against proposals regarding the B.S.D.H. and OHP. It is hoped that results of the study would provide information for recruitment of dental hygiene students and marketing of B.S.D.H. programs. Methods Our survey was based on one conducted with practicing physician assistants (PAs). 12 This survey was chosen as a model because PAs are a mid-level practitioner much like what is proposed for the OHP and, in that study, PAs were surveyed about their perceptions of moving from a master s-entry level degree to a clinical doctorate. The language for our survey was changed to reflect the fact that dental hygiene education is primarily at the associate level and to match our objective of determining the current interest level in moving to the B.S.D.H. or OHP. Questions about the B.S.D.H. and OHP were developed by the authors and reviewed by several dental hygienists. Perceived benefits and reasons for potential interest were also taken from the PA survey. Our entire survey was pilot-tested with twenty local dental hygienists, who made comments and indicated the time needed to complete the survey. An electronic database of Wichita State University s dental hygiene graduates (N=1010) was obtained from its alumni association. Funds were limited, so a randomly selected sample of 564 was used. These individuals were sent a survey, cover letter, and return postage envelope. No follow-up correspondence was done. The university s Institutional Review Board approved the project. Frequency distributions were developed for demographic data and for respondents answers. Chisquare analyses were used to determine if relationships existed between selected demographic variables and respondents perceptions. SPSS v. 13 was used for data analysis. Alpha level was set at.05. Results Surveys were returned by 218 individuals. To be included in the study, respondents had to be currently practicing as a dental hygienist (N=190), so the usable return rate was 33.6 percent. The respondent profile is in Table 1. Most respondents practiced in the same state as the university that granted them the degree (73.7 percent). Figure 1 shows response rates to statements about the B.S.D.H. The major- Table 1. Profile of survey respondents (N=190), by percentage of and mean for total respondents Percent Practice settings Solo dental practice 54.2 Dentist partner/group 33.2 Independent dental hygiene practice 4.8 All others: public health, school, community health, nursing home 7.8 Highest academic dental hygiene credential Associate degree 73.8 Baccalaureate degree 24.7 Master s 1.5 Doctorate 0.0 Member of ADHA Yes 29.1 No 70.9 Mean (standard deviation) Years since graduation Range 0 40 years (11.5) Age Range years (11.6) Percentage of time supervised Supervised (range 0 100%) 86.0 (24.1) Unsupervised (range 0 100%) 14.0 (24.2) 1224 Journal of Dental Education Volume 73, Number 10

4 Figure 1. Frequencies of responses to the eight statements about the B.S.D.H.: SA/A=strongly agree, agree; SD/D=strongly disagree/disagree Statements: 1. An associate degree in dental hygiene sufficiently prepares dental hygienists to provide the full scope of services required to practice in today s health care setting upon graduation. 2. The Bachelor of Science in Dental Hygiene should be the entry-level degree for the practice of dental hygiene. 3. I would leave the field of dental hygiene rather than pursue the necessary requirements to obtain a B.S.D.H. if required. 4. I believe the B.S.D.H. degree is necessary to ensure the highest standards of service delivery in the field of dental hygiene. 5. I believe a B.S.D.H. degree is necessary to increase the economic status of dental hygienists. 6. Those who are educationally disadvantaged (graduates from low-performing high schools) may not be competitive for admission to a B.S.D.H. program. 7. Changing to a B.S.D.H. degree will have no bearing on minorities applying to a B.S.D.H. program. 8. Those who are financially disadvantaged will not be able to afford the B.S.D.H. degree. ity (76.2 percent) agreed or strongly agreed that an associate s degree (AD) sufficiently prepared them for their positions. Over 20 percent strongly agreed or agreed they would leave the field if a B.S.D.H. were required for practice. Chi-square analyses examined the relationship between demographic variables and responses to the B.S.D.H. and OHP statements. The combined answers (strongly agree and agree) were used for analyses. Respondents were divided into four groups by age (twenty-two to thirty, thirty-one to forty-three, forty-four to fifty-one, and fifty-two to sixty-five; each group comprised ~25 percent of the sample) and by years of practice (0 5, 6 15, , and ). They were also divided into groups reflecting membership in ADHA, education level (AD and B.S.D.H./graduate degree), and type of practice setting (solo dental practice and all others). Type of practice setting did not influence the answers to B.S.D.H. or OHP statements. Years since graduation was significantly related to responses to three of the B.S.D.H. statements: an AD sufficiently prepares dental hygienists; the B.S.D.H. should be the entry-level degree; and requiring a B.S.D.H. for practice would compel me to leave dental hygiene (Table 2). Those who graduated most recently were more in agreement with the first and second statements. Respondents who had been practicing the longest agreed more with the third statement. Age grouping was also related to three October 2009 Journal of Dental Education 1225

5 Table 2. Survey respondents agreement with statements regarding the B.S.D.H. according to years since graduation, by percentage of total respondents (N=184) Years Agree or Disagree or Since Agree Neutral Disagree Statement Graduation (%) (%) (%) 1. An associate degree in dental hygiene sufficiently prepares dental hygienists to provide the full scope of services required to practice in today s health care setting upon graduation.* The Bachelor of Science in Dental Hygiene should be the entry-level degree for the practice of dental hygiene.* I would leave the field of dental hygiene rather than pursue the necessary requirements to obtain a B.S.D.H. if required.* I believe the B.S.D.H. degree is necessary to ensure the highest standards of service delivery in the field of dental hygiene I believe a B.S.D.H. degree is necessary to increase the economic status of dental hygienists Those who are educationally disadvantaged (graduates from low-performing high schools) may not be competitive for admission to a B.S.D.H. program Changing to a B.S.D.H. degree will have no bearing on minorities applying to a dental hygiene program Those who are financially disadvantaged will not be able to afford the B.S.D.H. degree *significant relationship p.05 Note: Percentages may not total 100% because of rounding. of the B.S.D.H. statements: requiring a B.S.D.H. for practice would compel me to leave dental hygiene (statement 3); those who are educationally disadvantaged may not be competitive for B.S.D.H. admission (statement 6); and those who are financially disadvantaged will not be able to afford the B.S.D.H. (statement 8) (see Table 3). The oldest age group (fifty-two to sixty-five years) was in the most agreement that they would leave the field if a B.S.D.H. were required for practice. This age group was also positively associated with statements regarding disadvantaged students (statements 6 and 8). The respondents could select multiple statements regarding their lack of interest in pursuing a B.S.D.H. The statement checked most frequently was no personal benefit (seventy-two respondents). Too expensive was checked by thirty-two; not enough time by forty-seven; and B.S.D.H. is not necessary by fifty-four. In addition, the respondents ranked five statements about the perceived personal benefits of the B.S.D.H. from most to least important. Improve professional competence was the item considered the most important (32.1 percent). The least important was to enhance earning power (41.4 percent). Data are found in Table 4. Some written comments included these: No dentist will pay more for a B.S.D.H. graduate because it wouldn t increase production, and During all of my years working, I 1226 Journal of Dental Education Volume 73, Number 10

6 Table 3. Survey respondents agreement with statements regarding the B.S.D.H. according to age group, by percentage of total respondents (N=184) Age Agree or Disagree or Group Agree Neutral Disagree Statement (in years) (%) (%) (%) 1. An associate degree in dental hygiene sufficiently prepares dental hygienists to provide the full scope of services required to practice in today s health care setting upon graduation The Bachelor of Science in Dental Hygiene should be the entry-level degree for the practice of dental hygiene I would leave the field of dental hygiene rather than pursue the necessary requirements to obtain a B.S.D.H. if required.* I believe the B.S.D.H. degree is necessary to ensure the highest standards of service delivery in the field of dental hygiene I believe a B.S.D.H. degree is necessary to increase the economic status of dental hygienists Those who are educationally disadvantaged (graduates from low-performing high schools) may not be competitive for admission to a B.S.D.H. program.* Changing to a B.S.D.H. degree will have no bearing on minorities applying to a dental hygiene program Those who are financially disadvantaged will not be able to afford the B.S.D.H. degree.* *significant relationship p.05 Note: Percentages may not total 100% because of rounding. have never once been asked if I had a bachelor degree or associate degree. It has never stopped me from getting a job or had any effect on salary. Responses to OHP statements are found in Figure 2. The majority (>64 percent) agreed with three statements about positive impact on access, to increase economic status, and master level hygienist would have adequate training. Over 50 percent disagreed with the statement OHP would be a direct threat to dentists. Respondents agreed that the most positive reason to pursue the OHP is to improve professional competence (44.9 percent); see Table 5. Much less important were enhance earning power (18.2 percent) and professional recognition (12.5 percent). In addition, 7 percent of the respondents chose other as their number 1 choice, and all identified improved access to care as the most beneficial reason for the OHP. Age group (Table 6) and ADHA membership (Table 7) were associated with the first OHP statement: I believe the OHP would have a positive impact on the lack of access to oral health care in the U.S. The only other OHP statement significantly associated with any of the demographic variables was statement 2: I believe the OHP would be one way to increase the economic status of dental hygienists. A greater percentage of ADHA members agreed with this statement. October 2009 Journal of Dental Education 1227

7 Table 4. Ranking of perceived benefits of the B.S.D.H. as the entry-level dental hygiene degree, by percentage of total respondents (N=157) Most Least Important Important Benefit Professional recognition among other professionals Economic: will enhance earning power Improved professional competence Self-esteem Professional identity/public identification Figure 2. Frequency of responses to statements about the Oral Health Practitioner (OHP): SA/A=strongly agree, agree, SD/D=strongly disagree, disagree Statements: 1. I believe the OHP would have a positive impact on the lack of access to oral health care in the U.S. 2. I believe the OHP would be one way to increase the economic status of dental hygienists. 3. I believe the OHP would be a direct threat to dentists. 4. I believe a master s level-trained hygienist would have adequate training for the scope of practice of an OHP. The respondents could check multiple statements regarding their lack of interest in pursuing a master s level OHP degree. The statement checked most frequently was not enough time (fifty-nine respondents). Too expensive was checked by forty; no personal benefit by thirty-eight; and OHP is not necessary by twenty-five. Discussion Bachelor of Science in Dental Hygiene The majority of the survey respondents agreed that the associate degree is sufficient to practice dental hygiene. However, older respondents disagreed 1228 Journal of Dental Education Volume 73, Number 10

8 Table 5. Ranking of perceived benefits of the oral health practitioner (OHP), by percentage of total respondents (N=147) Most Least Important Important Benefit Professional recognition among other professionals Economic: will enhance earning power Improved professional competence Self-esteem Professional identity/public identification Note: Percentages may not total 100% because of rounding. Table 6. Agreement with statements regarding the oral health provider (OHP) according to age group, by percentage of total respondents (N=184) Age Agree/ Disagree/ Group Agree Neutral Disagree Statement (in years) (%) (%) (%) 1. I believe the OHP would have a positive impact on the lack of access to oral health care in the U.S I believe the OHP would be one way to increase the economic status of dental hygienists I believe the OHP would be a direct threat to dentists I believe a master s level-trained hygienist would have adequate training for the scope of practice of an OHP Note: Percentages may not total 100% because of rounding. Table 7. Agreement with statements regarding the oral health provider (OHP) according to ADHA membership, by percentage of total respondents (N=184) Agree/ Disagree/ ADHA Agree Neutral Disagree Statement Member (%) (%) (%) 1. I believe the OHP would have a positive impact on the lack of access Yes to oral health care in the U.S. No I believe the OHP would be one way to increase the economic status Yes of dental hygienists. No I believe the OHP would be a direct threat to dentists. Yes No I believe a master s level-trained hygienist would have adequate training Yes for the scope of practice of an OHP. No Note: Percentages may not total 100% because of rounding. October 2009 Journal of Dental Education 1229

9 that the AD provided enough education to sufficiently prepare graduates. Older respondents, in general, have more clinical experience than their younger colleagues; this may be one reason they believe an AD is not sufficient preparation. While more recent graduates said they believe the AD adequately prepared them for clinical practice, they also believe that the B.S.D.H. should be required for entry into practice. One respondent stated, It is my opinion that my dental hygiene program should be changed to a B.S.D.H. as each student basically spends four years in college: two years for general education requirements, and two years in dental hygiene program. Most students who complete a two-year associate degree enter their programs with at least one year of prerequisites. Completion of a B.S.D.H. was of interest to 66 percent of dental hygiene students in the Barnes et al. study. 7 Overall, the most important benefit in the opinion of all age groups was improvement in professional competence. Physician assistants also ranked improving professional recognition high and improved competence as their second choice with regard to moving their professional entry-level degree from the master s level to the doctorate. 12 Oral Health Practitioner Perceptions about the OHP were strongly related to access to care. The respondents either strongly agreed or agreed (72.7 percent) that the OHP would increase access. Demographics played a role in perceptions. Respondents in older age groups and those who are ADHA members were more positive about the OHP. A statement from one of the older respondents illustrates perceptions about how OHPs could alleviate the access to care problem: I have worked in private practice for 30 years. I began working in a public health clinic one year ago. The need for children s dentistry is great. I feel with additional education, I could provide help. The respondents to our survey felt the main barriers to pursuing an OHP were limited time and expense. In addition, respondents who were members of ADHA strongly agreed or agreed (85.5 percent) that the OHP could impact dental hygienists economic status. Reimbursement guidelines are currently unclear, but members view this as a potential additional income source. Perhaps one issue with dentists is the threat of competition. An OHP could only practice in areas without the services of a dentist, but a supervising dentist would be required to review patient records retrospectively and would receive reimbursement for this. Currently, the proposed guidelines stipulate that collaborating dentists must be actively engaged with oral health practitioners with whom they have a collaborative management agreement and must undertake at a minimum a half-day, quarterly on-site review. Collaborating dentists would periodically observe the oral health practitioner providing treatment and would routinely conduct chart reviews. 4 The most volatile issue surrounding the OHP is different perceptions of ensuring patient safety. Over 70 percent of the respondents to our survey strongly agreed or agreed that a master s level hygienist could adequately provide care under the proposed legislation. Since our survey respondents averaged sixteen years of clinical experience, they have insight into the scope of practice that OHPs could undertake. However, the often expressed opinion of dentists that performing a higher level of oral health care with any education below a D.D.S. might jeopardize patient safety also came up in one written comment. This respondent (a former dental hygienist who is now a dentist and thus excluded from the statistical analysis in this study) commented, I already have my D.D.S. and anyone who wants to do what an OHP does can earn it the correct way by going to dental school as I did! [The OHP] is a short cut, [but] without all my chemistry, physics, etc., I would not be as good of a dentist. A series of articles commissioned by the ADEA Commission on Change and Innovation in Dental Education and published in the Journal of Dental Education reflected on various problems in dental education, including the profession s apparent loss of vision for taking care of the oral health needs of all components of society. 13 Many dental hygienists agree and feel that working to improve access by mid-level providers has been met with multiple obstacles and resistance to new models of dental hygiene practice from practicing dentists. Responses to our survey suggest that dental hygienists like the concept of the OHP even though they feel that the AD has prepared them for the current scope of practice. Recruiting students for the master s level OHP will be difficult without a pool of graduates with bachelor s degrees. If OHP educational programs are to be successful, the B.S.D.H. will have to be promoted as an entry-level degree, or programs will need to find ways to offer credit hours toward the B.S.D.H. through a variety of educational opportunities Journal of Dental Education Volume 73, Number 10

10 Limitations of This Study and Future Research Needs Since most respondents to our survey lived in the Midwest, they may not be representative of dental hygienists across the United States. In fact, the results may be indicative of more conservative views of the survey s topics. Expanding the geographical demographic would give a more comprehensive view. In addition, meaningful analyses using educational level will remain difficult because 84 percent of dental hygiene educational programs graduate ADprepared individuals. Many practicing dental hygienists may know very little about the new oral health practitioner supported by the ADHA. Even though almost 30 percent of our survey s respondents were ADHA members, membership does not guarantee knowledge of this important issue. As more dental hygienists become more informed about the OHP and the educational requirements, more may be interested in the B.S.D.H. A survey of dental hygienists specifically seeking to identify their knowledge level about the OHP may be helpful to the ADHA and other stakeholders. Dentists should also be subjects of this type of research since it would prove interesting to learn more about the perspective of those who would oversee this midlevel provider. The usable response rate to our survey was 33 percent, which was lower than expected. A reminder postcard was not sent due to lack of funds. Other reasons for the lower than expected response rate could be lack of interest or knowledge of the topic and/or lack of time to complete the survey. However, the OHP is currently a controversial topic in the dental community, so a response rate of greater than 50 percent was expected. Finally, no reliability or validity data are available for our survey or from the survey of PAs from which most of our survey statements were taken. 12 Conclusion Our survey of practicing dental hygienists educated at a Kansas university found that an entrylevel B.S.D.H. was a desired outcome for the younger group of hygienists. The two main reasons identified in the survey for pursuing a B.S.D.H. were to improve professional competence and professional recognition among other professionals. The respondents strongly disagreed that a B.S.D.H. would increase their economic status. Those who had been practicing the longest said they would leave the profession if a B.S.D.H. were required for practice. Overall, respondents in our study viewed the OHP as having the potential for a positive impact in advancing the dental hygiene profession. The main objective for the OHP was seen as providing care to the underserved. They saw the OHP as neither a direct threat to dentists nor a danger to patient safety. The main barriers they identified to becoming an OHP related to time and expense in pursuing the necessary master s degree. As progress is being made toward defining the role of the OHP and developing supporting legislation at the state level, it is essential to understand the goals and concerns of all those involved. To understand the values of practicing hygienists in these matters should provide valuable information to expand the dental hygiene profession to help meet society s needs and provide the opportunity for some members of the profession to become mid-level practitioners. REFERENCES 1. American Dental Hygienists Association. Dental hygiene programs. At: Entry_Level_Schools_for_Web_Site.pdf. Accessed: April 14, American Dental Hygienists Association. Competencies for the advanced dental hygiene practitioner. At: www. adha.org/downloads/competencies.pdf. Accessed: April 14, American Dental Hygienists Association. ADHP legislation in Minnesota: update. At: news/ adhp-mn.htm. Accessed: September 2, Minnesota Department of Health, Minnesota Dental Board. Oral health practitioner recommendations: report to the Minnesota legislature. Minneapolis: Minnesota Department of Health, January 15, American Dental Hygienists Association. American Dental Hygienists Association adopts official policy to address U.S. oral health disparities (press release, July 8, 2004). At: Accessed: April 14, Monson AL, Engeswick LM. ADHA s focus on advancing the profession: Minnesota s dental hygiene educators response. J Dent Hyg 2007;81(2): Barnes WG, Gamcarz-Gojgini A, Kemdloms S, Arruda J, Neeley J. ADHP and access to dental care: the dental hygiene student s perspective. J Dent Hyg 2007;81(1): Rowe DJ, Massoumi N, Hyde S, Weintraub JA. Educational and career pathways of dental hygienists: comparing graduates of associate and baccalaureate degree programs. J Dent Educ 2008;72(4): October 2009 Journal of Dental Education 1231

11 9. Haden NK, Morr KE, Valachovic RW. Trends in allied dental education: an analysis of the past and a look to the future. J Dent Educ 2001;65(5): Valachovic RW. Positioning allied dental education for disruptive change. Charting Progress (American Dental Education Association newsletter), June At: www. adea.org/about_adea/documents/ %20cp.mht. Accessed: April 15, Tobian MS. Relationship between educational level of dental hygienists and their perceptions regarding postcertificate/postassociate degree programs. J Dent Hyg 1989;63(9): Ohlemeier L, Muma R. Perceptions of U.S. physician assistants regarding the entry-level doctoral degree in PA education. J Phys Assist Educ 2008;19(2): Pyle M, Andrieu SC, Chadwick DG, Chmar JE, Cole JR, George MC, et al. The case for change in dental education. J Dent Educ 2006;70(9): Journal of Dental Education Volume 73, Number 10