In healthcare, a clear hierarchy of providers exists across the spectrum of care, with each team member playing an intricate role. Dentistry, however, has moved to disrupt this structure through programs like the Alabama Dental Hygiene Program (ADHP), which grants full professional credentials with severely reduced educational requirements. Justified by an alleged “access to care” crisis, Alabama was the first to adopt this model. Yet, a review of state statistics shows that implementing the ADHP – a glorified preceptorship – has demonstrably failed to improve access to care or overall dental health.1
The ADHP is fundamentally flawed, based on the premise that the dental hygiene profession is simply scaling teeth. While a program limited to that one task might succeed, the ADHP overlooks the dental hygienist’s comprehensive diagnostic and therapeutic role on the dental team.
My perspective on this issue is informed by direct experience. I worked in Alabama and have friends who are ADHP graduates whom I greatly respect. For a long time, my personal relationships prevented me from publicly comparing the ADHP to a CODA-accredited curriculum. However, given that other states, such as Nevada and South Carolina, have considered or are considering similar models, I realized I had to prioritize the integrity of the profession and the public’s health.
To be clear, I do not blame the ADHP graduates – they simply took an opportunity provided by their state. The problem lies entirely with the program design and the dental board’s policy. I share this personal background to emphasize that, while I encourage all hygienists to be respectful and kind, I must present evidence to stand up for my beliefs.
Comparison of ADHP vs. CODA-Accredited Curricula
First, it is important to distinguish the ADHP from programs that train oral preventive assistants (OPAs) and other dental assistant scaling programs. Assistant scaling programs still classify the assistant as an assistant. In contrast, the ADHP grants assistants a dental hygiene license and the right to use the “RDH” credential. This is a critical distinction because initiatives calling for patients to verify a “registered” dental hygienist is treating them will not distinguish between those who completed a CODA-accredited program and those who completed the ADHP.
To better understand and identify knowledge gaps between the ADHP and CODA-accredited dental hygiene programs, the curricula are compared below.
Alabama Dental Hygiene Program (ADHP)
The sheer difference in the time dedicated to foundational knowledge between the ADHP and a CODA-accredited program is concerning. The ADHP provides only a fraction of the clock hours required to develop comprehensive knowledge, as well as diagnostic and therapeutic skills.
Prerequisites for the ADHP include:
- 24 months of full-time employment as a chairside dental assistant in the 3 years immediately prior to the program application date
- Be at least 19 years of age
- High school diploma or GED
- Proof of hepatitis B titer verification
- CPR certification
- Infectious disease control training2
The infection control “training” requirement is an online self-paced continuing education course. There are two suggested courses: the first provides 1 hour of continuing education in infection control, and the second offers 2 hours.3
Once accepted into the program, students attend 10 months of didactic coursework (1 weekend a month), totaling 184 clock hours of instruction delivered across 23 program sessions (8 hours per session).2,4 This instruction includes, but is not limited to, lectures, interactive classroom activities, and hands-on instrumentation.2
Didactic lecture topics cover:
- Periodontics for the Dental Hygienist
- Periodontal Instrumentation
- Clinical Practice for the Dental Hygienist
- Infection Control
- Office Emergencies
- Pharmacology
- Oral Pathology
- Dental Radiography
- Head and Neck Anatomy
- Cariology and Preventive Dentistry
- Anatomy and Physiology of the Periodontium
- Special Needs, Medically Compromised, and Pregnant Patients
- Laws and Ethics
- Alabama Dental Professionals Wellness Program2,4
In addition to their didactic responsibilities, students must complete 150 prophylaxis treatments (equivalent to approximately 150 clinical hours) on patients with a permanent dentition. Students must maintain a minimum work schedule of 30 hours per week, and prophylaxis treatments must be completed in the practice of the sponsoring dentist. Patients are not required to consent to receive treatment from a student.2
This is where the ADHP structure fundamentally breaks from established healthcare standards.
After a mere 2 months and only 40 hours of classroom instruction, students are issued a “temporary training permit” and immediately begin treating patients in public dental settings.2,4 This permit is very misleading, as it closely resembles a standard Alabama dental hygiene license and is displayed prominently in the student’s operatory. Crucially, patients are not required to provide informed consent for treatment performed by a student who has not completed a comprehensive, CODA-accredited program. This system effectively minimizes the public’s right to informed choice and significantly maximizes patient risk.
CODA-Accredited Dental Hygiene Program
In stark contrast, a CODA-accredited dental hygiene program is more didactically and clinically comprehensive. While the ADHP totals roughly 334 clock hours, a CODA-accredited program requires an average of 2,932 clock hours – nearly 9 times the instructional time – built on a foundation of college-level prerequisite courses.2,4-6
Mandatory prerequisite coursework is typically completed before applying to or beginning a CODA-accredited dental hygiene program and often varies, with some programs requiring more than others.6 Programs might also include recommended courses, or the prerequisites themselves may have prerequisite courses of their own, leading to a higher total number of clock and credit hours.7
Prerequisite course examples for a CODA-accredited dental hygiene program include:
- Writing 121: Composition I or higher
- Prerequisites: Writing 115 and Reading 115 or equivalent placement
- Math 65: Introductory to Algebra or higher
- Prerequisites: Math 60 or 62 and Reading 80 or equivalent placement
- Biology 231: Anatomy and Physiology I with lab
- Prerequisites: Math 65 and Biology 112 or Biology 211 and 212
- Biology 232: Anatomy and Physiology II with lab
- Biology 234: Microbiology with lab
- Prerequisites: Biology 112 or Biology 211 and 212
- Chemistry 102: Organic Chemistry or higher
- Prerequisites: Writing 115, Reading 115, and Math 20 or equivalent placement; and Chemistry 100, 104, or 151
- Food and Nutrition 225: Nutrition
- Prerequisites: Writing 115, Reading 115, and Math 65 or 98 equivalent placement; and Biology 1127
- Psychology
- Recommended: PSY 101 Psychology and Human Relations
- Sociology
- Recommended: SOC 204 Introduction to Sociology
- Communication
- Recommended: COMM 111 Public Speaking7,8
The majority of CODA-accredited dental hygiene programs have maximum enrollment caps. Admission is typically highly competitive and often includes the GPA of some or all of the required prerequisite coursework as part of the criteria for consideration of entry.6,7 Applicants may also be required to complete an interview, submit an essay, and/or pass a dexterity test.6
Most CODA-accredited dental hygiene programs include full-time curricula.6,8 In addition to didactic coursework, programs require an average of 681 clock hours of supervised clinical instruction.6
While specific didactic and clinical curricula may vary by state and program, examples include:
- Dental Hygiene Theory I
- Dental Hygiene Practice I
- Oral Health Education Promotion
- Prevention and Management of Medical Emergencies
- Dental Hygiene Theory II
- Dental Hygiene Practice II
- Dental Radiography I
- Dental Radiography Lab I
- Head and Neck Anatomy
- Dental Hygiene Theory III
- Dental Hygiene Practice III
- Cariology
- Oral Pathology
- Dental Radiology II
- Dental Materials I
- Pharmacology
- Community Oral Health I
- Dental Hygiene Restorative Theory I
- Dental Hygiene Restorative Practice I
- Dental Hygiene Restorative Theory II
- Dental Hygiene Theory IV
- Dental Hygiene Practice IV
- Pain Management
- Pain Management Lab
- Dental Hygiene Restorative Practice II
- Community Oral Health II
- Periodontology I
- Dental Hygiene Theory V
- Dental Hygiene Practice V
- Dental Hygiene Ethics and Law
- Dental Hygiene Restorative Practice III
- Research Methods and Issues in Oral Health
- Dental Hygiene Practice VI
- Community Oral Health III8
Unlike the ADHP model, clinical instruction within a CODA-accredited program occurs in a dedicated educational environment. Patients are knowingly participating in a student’s education, which is a major distinction from the ADHP’s model of treating patients in private practice settings, where the “student” status might be less obvious.
Beyond clinical board examinations, every graduate of a CODA-accredited dental hygiene program must pass the National Board Dental Hygiene Examination (NBDHE) to qualify for and obtain state licensure. This comprehensive exam assists state dental boards in determining the qualifications of those seeking licensure by assessing the knowledge, skills, and abilities required for safe practice, including their application in a problem-solving context. Ultimately, the NBDHE serves as a standardized benchmark used by state boards to protect public health.9
The Great Divide
In my experience, a professional divide exists in Alabama, and dental hygienists who graduated from a CODA-accredited program are justifiably frustrated. They are expected to work alongside dental hygienists who hold the same licensure but who lack a fundamental foundation in the full scope of dental hygiene practice. Further, ADHP graduates are not required to pass nor are they eligible to take the NBDHE. The ADHP lacks this external validation entirely, meaning its graduates are never tested against the national standards required of all other dental hygienists in the country.9
Can ADHP hygienists scale teeth? Sure, but scaling is only one component of our preventive and therapeutic role. I considered my time in my CODA-accredited program a solid foundation upon which to build. In contrast, the ADHP provides only a minimal framework for their foundation. This means ADHP graduates must first be self-motivated to construct the missing foundation after leaving the program, and only then can they further build upon it.
For example, the ADHP provides 8 clock hours of oral pathology.4 That would be equivalent to 1 all-day oral pathology course, whereas a CODA-accredited program provides approximately 48 clock hours of oral pathology instruction.4,8 Even with 6 times as many hours as the ADHP provides, this still wasn’t enough for me to fully understand the subject. I had to seek out knowledge of topics such as rare diseases, infectious diseases, and heavy metal toxicity on my own to gain a more comprehensive understanding.
Pharmacology is another excellent example. There is no question that pharmaceuticals and polypharmacy play an essential role in oral health. Are we to believe that 8 contact hours are enough to fully understand the role of pharmaceuticals on oral health?4 CODA-accredited programs require approximately 48 clock hours of pharmacology.8 Yet, it’s highly likely you could still learn something new every time you take a pharmacology continuing education course.
The ADHP simply does not scratch the surface of the foundational knowledge required to provide comprehensive care to patients. This would be like saying that, because I have 20 years of experience in dental hygiene, I could take a few courses on restorative treatment and become a dentist. If that sounds wild to you, it should. It is just as wild as the ADHP implying that the education and training are equivalent to those of a CODA-accredited program.
ADHP Failed to Improve Access
The ADHP was implemented to improve access to care, but it has failed. Hygienists in the state of Alabama must work under direct supervision, meaning a dentist must be on site for the hygienist to provide care. As of 2022, there are 2 counties in Alabama with no dentist serving the county, 1 county with a single dentist serving the entire county 2 days a week, 1 county with the only dental care available through a federally qualified health center (FQHC), and 2 counties with 2 dentists serving the entire county.1
Among all states, Alabama ranked last in dentists per 100,000 people in 2022.1 This is significant because no matter how many hygienists are pumped out of the ADHP, they can’t practice without dentists directly supervising them. Additionally, when ranked from best to worst, Alabama is listed 43rd among the states for overall dental health.10 The fact that many of the states proposing to implement this model, as well as the President of the American Dental Association (ADA), point to Alabama as a success is either misinformed or the result of an effort to mislead.
In Closing
There is currently a nursing shortage in healthcare. Yet, no one is proposing to add a few didactic courses over several weekends for licensed practical nurses (LPN) to earn the credentials of “registered nurse.”
The ADHP has long been a public health disaster. Moving to implement it in other states will only cause further damage to oral and overall health of the U.S. population. The education of dental hygienists evolved from short, unstandardized courses to a college degree for a reason. Reversing that progress is detrimental. We should be pushing to increase educational requirements, not reduce them, to meet the standards of modern comprehensive care. The solution to the access crisis is not reducing educational standards. It is a strategic investment in the profession.
There are reasonable solutions, such as tuition reimbursement, opportunities for career development and advancement (i.e., dental therapists), and expanding recruitment efforts. Additionally, altering the requirements for employment in dental hygiene education would allow for more eligible instructors, which would result in a higher graduation rate. Ultimately, this will increase the number of well-educated dental hygienists in the job market. Despite the potential of these solutions, the ADA is on board with reducing the education requirements for dental hygienists, yet holds firm on the requirements for dental hygiene educators. This is counterintuitive.
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References
- Oral Health in Alabama: Unveiling the Burden and Pathways to Improvement. (2024). Alabama Public Health. https://www.alabamapublichealth.gov/oralhealth/assets/burden-oral-disease-2024.pdf
- Alabama Dental Hygiene Program: Instructor/Sponsoring Dentist and Student Program Overview and Information Handbook. (2025, March 3). Board of Dental Examiners of Alabama. https://dentalboard.org/wp-content/uploads/2025/03/BDEAL-ADHP-Instructor-Student-Handbook-REV-03052025.pdf
- ADHP Current Program Information. (2025). Board of Dental Examiners of Alabama. https://dentalboard.org/adhp-copy-2/
- Alabama Dental Hygiene Program: 2025-2026 Lecture/Exam Schedule. (2025, March 4). Board of Dental Examiners of Alabama. https://dentalboard.org/wp-content/uploads/2025/03/2025-2026-ADHP-Lecture-Exam-Schedule-FINAL_03042025.pdf
- Dental Hygiene Curriculum. (n.d.). American Dental Education Association. https://www.adea.org/godental/explore-dental-hygiene/dental-hygiene-programs/dental-hygiene-program-curriculums
- Dental Hygiene Education: Curriculum, Program, Enrollment, and Graduate Information. (2015, October 1). American Dental Hygiene Association. https://mymembership.adha.org/images/pdf/Dental_Hygiene_Education_Fact_Sheet_October12015.pdf
- Portland Community College. (2025). Dental Hygiene: Career and Program Description. 2025-2026 Catalog. https://catalog.pcc.edu/programsanddisciplines/dentalhygiene/
- Dental Hygiene: Associate Degree. (2025). Portland Community College. https://www.pcc.edu/programs/dental-hygiene/aas-dental-hygiene/
- National Board Dental Hygiene Examination (NBDHE): 2025 Candidate Guide. (2024, September 24). Joint Commission on National Dental Examinations. https://jcnde.ada.org/-/media/project/ada-organization/ada/jcnde/files/nbdhe_candidate_guide.pdf
- McCann, A. (2025, January 30). States with the Best and Worst Dental Health (2025). WalletHub. https://wallethub.com/edu/states-with-best-worst-dental-health/31498
