Delaware Preventive Oral Health Access Act Policy Proposal

A policy proposal to expand access to preventive dental care by allowing qualified dental hygienists to practice independently for non-surgical preventive services and accept Medicaid directly.

Core idea: Delaware should allow experienced licensed dental hygienists to open preventive oral health practices, mobile clinics, or community-based hygiene sites without requiring a dentist to be physically present on site at all times. The practice would be limited to preventive and non-surgical dental hygiene services, with mandatory referral protocols for patients who need dentist-level care.

Executive Summary

Delaware has a preventable oral health access problem. Medicaid covers adult dental services, including preventive care such as exams, cleanings, x-rays, sealants, scaling, debridement, and periodontal maintenance, but coverage does not automatically create access when too few providers participate or appointment availability is limited.

Current Delaware law generally requires a licensed dental hygienist to practice dental hygiene under the general supervision of a licensed dentist and in the office of a licensed dentist, with limited exceptions for public schools, public institutions, and other State Dental Director-approved public health settings.

Delaware should modernize this framework by creating a new provider category: Independent Preventive Dental Hygiene Practitioner.

This reform would not allow hygienists to drill, fill, extract, prescribe, perform root canals, or replace comprehensive dental care by a dentist. It would allow them to deliver lower-cost preventive care, identify problems earlier, educate patients, and refer patients for dentist-level treatment before dental problems become medical emergencies.

Supporting Facts

- A dental hygienist licensed under Delaware law must generally practice dental hygiene only under the general supervision of a licensed dentist, in a dentist office, or in limited public/public-health settings. Local anesthesia remains subject to direct dentist supervision.

- Delaware Medicaid adult dental coverage began for eligible Medicaid recipients age 21 and older on October 1, 2020. Covered adult dental services include preventive care such as exams, cleanings, x-rays, and sealants, plus basic restorative and limited periodontal care.

- Delaware Medicaid adult dental benefits include a $1,000 annual benefit maximum, with members potentially eligible for an additional $1,500 emergency benefit per year.

- CDC reports more than 2 million emergency-room visits each year for dental emergencies and states that Medicaid pays almost $1,000 for every visit - much more than the cost of a dental visit.

- CDC/NCHS found tooth disorders accounted for an annual average of 1,944,000 emergency department visits during 2020-2022.3

- CDC/NCHS found Medicaid was the most frequent primary expected payer for emergency department visits for tooth disorders in 2020-2022, accounting for 55.4% of such visits.

- CDC reports the United States loses more than $45 billion in productivity each year because of untreated oral disease.

Policy Purpose

The purpose of this Act is to expand access to routine preventive oral health care by allowing qualified licensed dental hygienists to provide preventive dental hygiene services without requiring a dentist to be physically present on site at all times. The policy would allow experienced hygienists to operate independent preventive hygiene practices, mobile hygiene clinics, and community-based hygiene sites, and to enroll as Medicaid providers for covered preventive services.

Problem Statement

Too many Delawareans struggle to obtain routine dental cleanings, screenings, and early intervention. When preventive care is unavailable, untreated oral disease gets worse. A cavity that could have been detected early can become an infection. Gum disease that could have been managed can progress. A patient who needed a cleaning, x-ray, fluoride treatment, sealant, or referral can end up in an emergency room with severe dental pain. Emergency rooms are not designed to provide routine dental care. They can treat pain or infection temporarily, but they usually cannot provide definitive dental treatment. That means the patient may leave with medication while the underlying dental problem remains. The result is worse health, repeated
visits, and higher costs for Medicaid, hospitals, and taxpayers. Preventive dental care is less expensive, more humane, and more effective than waiting until people are in crisis.

Proposed Policy

Delaware should create a new category of licensed provider: Independent Preventive Dental Hygiene Practitioner.

Eligibility Requirements
1) Holds an active Delaware dental hygiene license in good standing.
2) Has completed a minimum number of clinical practice hours or years of experience, as determined by the Board of Dentistry and Dental Hygiene.

3) Maintains current CPR certification.
4) Completes continuing education in medical emergencies, infection control, ethics, Medicaid billing, patient screening, and referral protocols.
5) Maintains professional liability insurance.
6) Operates under written referral protocols with one or more licensed dentists, dental clinics, federally qualified health centers, or other appropriate dental referral partners for patients needing services beyond the hygienist scope of practice.

Services Allowed
An Independent Preventive Dental Hygiene Practitioner may provide preventive and non-surgical dental hygiene services within the hygienist training and scope of practice, including:
● Dental cleanings.
● Periodontal maintenance within the hygienist scope.
● Oral health screenings.
● Dental charting.
● X-rays, if otherwise authorized by law and regulation.
● Fluoride treatment.
● Sealants.
● Patient education on brushing, flossing, nutrition, tobacco cessation, and oral disease prevention.
● Referral to a dentist, physician, emergency department, or specialist when needed.

Services Not Allowed
This policy would not allow dental hygienists to perform procedures reserved for dentists, including drilling, fillings, extractions, root canals, crowns, diagnosis beyond authorized screening, prescribing medication unless otherwise permitted by law, surgical treatment, or administration of local anesthesia except as otherwise authorized under Delaware law.

Authorized Practice Settings
Qualified hygienists should be allowed to provide preventive services in independent preventive dental hygiene offices, mobile dental hygiene clinics, schools, senior centers, community health centers, federally qualified health centers, nonprofit clinics, correctional and reentry programs, long-term care facilities, substance use recovery programs, homeless shelters, and other community-based settings approved by regulation.

Medicaid Participation
The Department of Health and Social Services should be directed to allow qualified Independent Preventive Dental Hygiene Practitioners to enroll as Medicaid providers and receive direct reimbursement for covered preventive dental hygiene services. This is essential. Expanding scope of practice will not solve the access problem unless hygienists can also accept Medicaid and be paid directly for covered services. The policy should require Delaware Medicaid and Medicaid managed care organizations to reimburse eligible dental hygiene services when provided by licensed independent preventive dental hygiene practitioners, so long as the services are within the provider authorized scope of practice.

Patient Safety and Referral Guardrails
Every independent dental hygiene practice should maintain written referral protocols. These protocols should include:
1) A process for referring patients to a licensed dentist when decay, infection, pain, oral lesions, advanced periodontal disease, or other concerns are identified.
2) A process for urgent referral when a patient presents with swelling, fever, uncontrolled bleeding, trauma, suspected abscess, or other signs of emergency.
3) A requirement that patients receive a written summary of findings and referrals.
4) A requirement that the hygienist keep appropriate patient records.
5) A requirement that the hygienist disclose to patients that the practice provides preventive dental
hygiene services and does not replace comprehensive dental care by a dentist.
6) A requirement for infection-control compliance, emergency protocols, and malpractice coverage.

Why This Makes Sense
Dental hygienists are already trained and licensed preventive oral health professionals. Delaware should use this workforce more effectively. Allowing qualified hygienists to open preventive care practices would:
● Increase access to cleanings and screenings.
● Help Medicaid patients find care sooner.
● Reduce preventable dental emergencies.
● Lower pressure on hospital emergency departments.
● Support early detection of oral health problems.
● Create small business opportunities for licensed hygienists.
● Expand care in underserved communities without requiring the state to build new dental clinics from
scratch.
This is not anti-dentist. It is pro-patient. Dentists would still provide diagnosis, restorative care, surgical care, and complex treatment. Hygienists would help fill the preventive care gap and refer patients to dentists when higher-level care is needed.

Fiscal Rationale
The cost argument is straightforward: a routine dental cleaning, screening, sealant, fluoride treatment, or early referral is far less expensive than an avoidable emergency room visit for dental pain or infection. CDC reports that Medicaid pays almost $1,000 for every dental emergency-room visit, while CDC/NCHS found nearly 1.94 million annual emergency-department visits for tooth disorders in 2020-2022, with Medicaid as the most frequent primary expected payer. Delaware taxpayers should not be paying more for crisis care because state law blocks lower-cost preventive care from being delivered by qualified licensed professionals.

Suggested Legislative Language
Section 1. Amend Title 24, Chapter 11 of the Delaware Code by creating a new section as follows:
§ 1133. Independent Preventive Dental Hygiene Practice.
(a) A dental hygienist licensed under this chapter may apply to the Board for authorization as an Independent Preventive Dental Hygiene Practitioner.
(b) The Board shall issue such authorization to a licensed dental hygienist who: (1) holds an active Delaware dental hygiene license in good standing; (2) has completed the minimum clinical experience required by Board regulation; (3) maintains current CPR certification; (4) completes continuing education required by Board regulation for independent preventive dental hygiene practice; (5) maintains professional liability insurance in an amount established by Board regulation; and (6) maintains written referral protocols for patients requiring dental, medical, emergency, or specialty care outside the dental hygienist scope of practice.
(c) An Independent Preventive Dental Hygiene Practitioner may provide preventive and non-surgical dental hygiene services without the on-site presence or prior examination of a dentist, provided that such services are within the dental hygienist lawful scope of practice and consistent with Board regulations.
(d) Services authorized under this section may include, but are not limited to: dental prophylaxis; periodontal maintenance within the dental hygienist scope of practice; oral health screening; dental charting; radiographs, if otherwise authorized by law and regulation; fluoride treatment; sealants; oral health education; and referral for diagnosis, restorative care, surgical care, emergency care, or specialty care.
(e) Nothing in this section shall authorize a dental hygienist to practice dentistry, perform irreversible dental procedures, diagnose dental disease beyond the hygienist authorized scope, perform extractions, perform restorations, perform root canals, prescribe medication unless otherwise authorized by law, or administer local anesthesia except as otherwise permitted under this chapter.
(f) An Independent Preventive Dental Hygiene Practitioner may own and operate a preventive dental hygiene practice, mobile dental hygiene clinic, or community-based preventive oral health practice, subject to applicable laws, regulations, infection-control standards, recordkeeping requirements, and patient safety standards.
(g) The Board shall promulgate regulations to implement this section, including requirements for clinical experience, continuing education, patient records, informed consent, referral protocols, infection control, emergency protocols, and professional liability coverage.

Section 2. Medicaid Enrollment and Reimbursement.
The Department of Health and Social Services shall seek any state plan amendment, waiver, managed care contract amendment, or other federal approval necessary to allow Independent Preventive Dental Hygiene Practitioners to enroll as Medicaid providers and receive direct reimbursement for covered preventive dental hygiene services provided within their authorized scope of practice.

Section 3. Reporting Requirement.
Within two years of implementation, the Department of Health and Social Services, in consultation with the Board of Dentistry and Dental Hygiene, shall submit a report to the General Assembly evaluating: (1) the number of Independent Preventive Dental Hygiene Practitioners authorized; (2) the number of Medicaid patients served; (3) the geographic distribution of services; (4) the number of referrals made to dentists or other providers; (5) patient access outcomes; (6) any patient safety complaints or disciplinary actions; and (7) any measurable impact on dental-related emergency department utilization.

Policy Message for Legislators
Delaware should stop forcing preventable dental problems to become expensive emergencies. By allowing qualified dental hygienists to practice
independently for preventive services and accept Medicaid directly, Delaware can expand access, reduce costs, support small health care businesses, and
improve oral health for working families, seniors, people with disabilities, and low-income residents across the state.

Citations
1. Delaware Code Online, Title 24, Chapter 11, Subchapter II, § 1121, lines describing dental hygiene supervision and State Dental Director protocols: https://delcode.delaware.gov/title24/c011/sc02/.
2. State of Delaware Medical Assistance Program, Adult Dental Program Benefits brochure, Rev. 07/2023, describing adult Medicaid dental coverage, covered preventive services, and the annual benefit maximum: https://medicaidpublications.dhss.delaware.gov/docs/Search?Command=Core_Download&EntryId;=1528.
3. Schappert SM, Santo L, Mykyta L. Emergency Department Visits for Tooth Disorders. National Center for Health Statistics Data Brief No. 531, June 2025. CDC/NCHS. https://www.cdc.gov/nchs/products/databriefs/db531.htm.
4. Centers for Disease Control and Prevention, Preventing Oral Diseases and Conditions in Communities, noting dental emergency-room visits, Medicaid cost per visit, productivity loss from untreated oral disease, and savings from preventive
interventions: https://www.cdc.gov/oral-health/prevention/index.html.

Note: This document is a policy draft and bill concept, not legal advice. Statutory language should be reviewed by the
Delaware General Assembly Division of Research, Legislative Council, the Department of Health and Social Services, and
the Board of Dentistry and Dental Hygiene before introduction.