Trends in Restorative Procedures provided by a Dental Hygienist
Dental hygienists may qualify for a restorative certificate by completing a state dental board approved continuing education course and obtaining a restorative certification.
As of 2019, 35 states authorize dental hygienists to perform some or all of the following restorative functions:
Apply cavity liners and bases
Place or remove temporary crowns
Place or remove temporary restorations
Place, carve, finish amalgam restorations
Place and finish composite resin silicate restoration
Place, contour, and adjust glass ionomer restorations
Each state enacts its own laws determining the services dental hygienists can perform, the settings in which they can practice, and the supervision under which they practice. However, the typical restorative services provided by dental hygienists are limited to supportive services where the dentist prepares a tooth for restoration and the dental hygienist places and finishes the restorative material. Typically the dentist must be present while the restorative services are administered.
A new trend for dental hygienists working with underserved population groups is to provide “Interim Therapeutic Restorations” also known as (ITR’s), which helps to temporarily stop the progression of decay in a tooth until the patient is able to see a dentist for permanent treatment. In 2006, the American Dental Association (ADA) initiated a pilot project to educate, train and deploy a new dental worker to focus on patient education, disease prevention and patient navigation to work in the community called a
Community Dental Health Coordinator (CDHC).
According to the 2012 ADA Statement on CDHC’s, part of their skill set is to have the knowledge and skill to
temporize dental cavities in preparation for restorative care by a dentist.
The procedure is done by:
Using hand instrumentation to remove debris within the tooth to prepare it for a temporary restoration
Place a temporary restoration such as glass ionomer cement. This procedure has been called a “Scoop and Fill”
As of 2013, the CDHC no longer offers a restorative clinical portion to their program.
ITR’s, for caries stabilization are recognized by the ADA Code on Dental Procedures And Nomenclature (CDT) and are endorsed by the American Academy of Pediatric Dentistry (AAPD). Training for placement of ITR’s requires additional didactic and hands on training. In 2018, the Fresno City College dental hygiene class was the first graduates of the school to receive didactic and clinical training in placing ITRs through their core curriculum. This procedure is now offered as a service in the dental hygiene clinic.
CODA Standards for Dental Hygiene Education in CA requires all California dental hygiene programs to add the ITR didactic and clinical instruction to the curriculum to ensure appropriately educated and trained graduates who would be ready to perform this procedure without needing additional education.
Restorative Function Education or Certification for dental hygienists may be obtained via:
The dental hygiene core curriculum in states that authorize restorative functions in their state practice act.
Restorative functions in WA State are required for dental hygiene licensure.
A restorative expanded functions course.
The type of restorative functions permitted and requirements for certification are dependent on each states practice act.
Dental Hygienists in GA may provide:
Application of cavity liners and bases.
Place or remove temporary crowns.
These functions are permitted by virtue of inclusion in the GA dental assistant scope of practice.
There is no formal process in place at the Commission on Dental Accreditation (CODA) at this time to recognize or accredit a specific course of study in restorative skills. CODA develops overall standards for and accredits entry‐level dental hygiene education programs, rather than individual classes within a program or continuing education classes.
In April 2007, the Idaho Legislature authorized the "Extended Access Restorative Endorsement" for qualified dental hygienists. Idaho also provides for an "Extended Access Dental Hygiene Endorsement." These two endorsements are separate endorsements and vary with duties and supervision requirements.
Dental Hygienists Restorative Duties – State Chart
Silver Diamine Fluoride (SDF)
Another trend for caries management provided by dental hygienists working with underserved populations, is the use of Silver Diamine Fluoride (SDF), which has been shown to be more effective than fluoride varnish for caries control.
SDF is a non-invasive, interim inexpensive medicament that is applied topically. It is 38% SDF, a silver fluoride salt made soluble in water through the addition of ammonia. SDF received Food and Drug Administration approval in 2014 as a device for treating dental hypersensitivity.
Similar to its predecessor fluoride varnish, SDF has not been approved as a dental caries arrest medicament and is administered in children and adults as an off-label use for caries control. It has a high LD50 value indicative of low toxicity. To date, no toxic adverse events have been reported.
SDF has been used internationally for decades to arrest dental caries in primary and permanent teeth. In a recently published meta-analysis, two-thirds of all dentinal caries lesions studied (those that had progressed into the dentin) were found to be arrested after treatment with SDF.
When teeth with arrested dental decay are not subsequently restored with dental fillings or full coverage crowns, studies show it is advisable to reapply SDF every six months.
With a fluoride concentration of 44,800 parts per million, SDF is nearly twice the strength of commercially available 5% sodium fluoride varnishes used in primary care.
In the 2019 Journal of Public Health Dentistry article "Projecting the Economic Impact of Silver Diamine Fluoride on Caries Treatment Expenditures", co-authored by Dr. Nicoleta Serban, a Professor at Georgia Institute of Technology, the article reported that application of SDF as a caries management strategy could save Medicaid Programs money by averting expensive caries treatment options.
Dr. Serban compared the cost savings from NC (since it is very similar in terms of demographics to GA ) and estimated an expenditure reduction for GA’s Medicaid Program can be anywhere from 15 million to 48 million over a 3 year period.
Patients who may benefit from SDF include those:
With high caries risk who have active cavitated caries lesions in anterior or posterior teeth;
Presenting with behavioral or medical management challenges and cavitated caries lesions;
With multiple cavitated caries lesions that may not all be treated in one visit;
With dental caries lesions that are difficult to treat; and
Without access to or with difficulty accessing dental care.
Criteria for tooth selection include:
No clinical signs of pulpal inflammation or reports of unsolicited/spontaneous pain.
Cavitated caries lesions that are not encroaching on the pulp. If possible, radiographs should be taken to assess depth of caries lesions.
Cavitated caries lesions on any surface as long as they are accessible with a brush for applying SDF. (Orthodontic separators may be used to help gain access to proximal lesions.)
SDF can be used prior to restoration placement and as part of caries control therapy.4 Informed consent, particularly highlighting expected staining of treated lesions, potential staining of skin and clothes, and need for reapplication for disease control, is recommended.
Training for SDF placement may be dependent on requirements by each state Board of Dentistry. According to the May 2018 Board of Dentistry Minutes, Dental Hygienists in GA may use SDF, but as a fluoride only.
If the supervising dentist would like SDF used as a caries arresting agent they must apply the initial application, and the dental hygienist may use it as a fluoride agent thereafter.