Dentist and Dental Hygienist Compact

There appears to be some confusion, misunderstanding, and unfounded concern about state governments being asked to adopt the recent initiative from the U.S. Department of Defense regarding a dental health provider’s compact for U.S. states and territories [1].   Yet, there needs to be a realization of the significance and priority for joining the Dentist and Dental Hygienist Compact, since it directly incorporates into health care security as a strategy component.  While there is a gross lack of research and information shared in this area, this article serves to offer such research, information, insight and clarification on the value and necessity of a dental compact agreement for all U.S. states and territories.

DENTAL COMPACT DESCRIPTION*

The Dentist and Dental Hygienist Compact is a contract among states that utilizes mutual recognition of licensure by privileging dentists and dental hygienists to practice in states where they do not currently hold a license. The compact privilege is equivalent to a license and grants the practitioner the full scope of practice authorized in states where such privilege is granted (FIGURE 1).  Regulators in compact states will access a secure database system which holds dentists’ and dental hygienists’ continuously updated licensure information, including any disciplinary actions or investigations.  It is from this database that privileges may be granted or denied.

The compact does not control or mandate the state’s licensure requirements or scope of practice. Any state belonging to the compact agrees to accept practitioners from other participating states as long as compact requirements are met. To be eligible for a compact privilege a licensee candidate must have:

• An unencumbered license in a state that has joined the compact.
• Graduated from a dental or dental hygiene education program accredited by the Commission on Dental Accreditation (CODA).
• Passed the National Board Examination.
• Completed a clinical assessment for licensure.
• Passed an FBI background check.
• Passed any jurisprudence requirements established by the participating state they wish to practice in.
• Pay all required fees.

RELEVANCE OF THE DENTAL COMPACT TO NATIONAL HEALTH CARE SECURITY

During a disaster, medical care is provided to U.S. Citizens in need by the Federal Emergency Management Agency (FEMA).  FEMA then activates the National Disaster Medical System (NDMS), which in turn sends the Disaster Medical Assistance Teams (DMAT) to the site of disaster. [6]

DMATs provide quality rapid-response medical care when public health and medical emergencies overwhelm state, local, tribal, or territorial resources. In the aftermath of natural and technological disasters, acts of terrorism, and during disease outbreaks, DMAT members are on location to protect health and save lives [7].

Each DMAT team consists of the following specialties:  Advanced clinicians (nurse practitioners/physician assistants), physicians, medical officers, registered nurses, respiratory therapists, paramedics (EMTs), pharmacists, safety specialists, logistical specialists, information technologists, communication and administrative specialists [7]. As one examines this medical provider list, it is evident that dentistry is absent.  Obviously, this is a dangerous omission that needs correction.

Sadly, injuries during disasters and in prolonged recoveries can include dental trauma and other acute oral conditions.  According to the Cleveland Medical Clinic, “A dental emergency is any injury to your mouth that causes uncontrolled bleeding, severe pain or broken facial bones. Left untreated, a dental emergency can lead to even further issues, including the spread of infection, tooth mobility and even tooth loss. Prompt, timely treatment is key” [8].

It is absolutely necessary that all dental providers have access to help with DMAT efforts.  Each state needs an agreement in place to ensure proper dental health of all residents during a disaster.  A comprehensive health model, such as that afforded within a dental compact agreement, may not only better serve citizens in need but also protects medical teams in the field should oral injuries or acute disease patterns arise.  Not acting on this oversight now will place risks on the overall health of citizens later during an emergency.

A dental compact, once established, would also become an integral part of a time-efficient and cost-effective strategy that prevents or mitigates national/regional disasters and emergencies.  The Dentist and Dental Hygienist Compact as such is consistent with the U.S. Department of Health and Human Services’ National Health Security Strategy (Strategic Goal 1) [2].   Dentists, dental hygienists and other dental auxiliaries are valuable contributors to medical surge events, and can offer a wide range of dental care expertise in a mass disaster response.  Regardless of a provider’s status in the dental compact as a volunteer dentist, private practitioner, employee or paid contractor, being privileged in multiple states under the compact implement’s mobility of care professionals from any one compact state to another member state for any desired length of time.   Thus, access to care in a compact state during an emergency can be maximized in that a uniform response of several dental professionals, having been pre-qualified, privileged through the compact, and organized into an extensive base of providers, may be mobilized relatively quickly in selected state if providers elect to participate there.    

Preparedness is the process of preparation to mitigate emergencies or disasters using training, planning and organization.  Readiness is a condition of having the confidence and motivation to carry out the actual mitigation tasks after appropriate preparation.  The dental compact provides both of these attributes to privileged professionals while building a large provider base established within uniform standards and requirements.

A dental professional, when licensed by the compact and having mobility that the compact allows, may decide without obligation to participate in this national strategy when privileged in other states.  A few of the many compact benefits, examples and rationale relevant to health care security, preparedness and readiness include:

Quickly staffing a surge event for mitigation of public health emergencies.

Licensees from other compact states may electively decide to travel to and from other compact states to practice in public dental health surge events (FIGURE 2), help mitigate public health emergencies, or offer relief from provider shortages for any desired length of time.   Access to potential staffing is readily available since the compact provides an immediate source of certified providers serving over a range of member states to help in a qualified emergency response.

Decompressing state licensure review boards in an emergency.

The compact decompresses dental review boards of member states since information on applicants and licensees is collected and maintained within the compact’s secure database for reference, versus dependence entirely upon an internal state database system.   In an emergency or surge, when an influx of additional care professionals is necessary, valuable time, expense and effort is saved by a compact state since there is no need to modify an internal, independent, and separate administrative computer infrastructure to review applications or licensees.  Furthermore, the compact, already having been established by all member states, is a redundant and central authoritative database that can be referenced in the event a state government’s computer infrastructure is incapacitated by a cyberattack, and especially concurrent to the emergency.

Providing pre-qualified professionals speeds care mobilization and reduces risks to the public during emergencies.

As implied above and despite any non-compact state’s process for efficiently licensing of out-of-state applicants (even for temporary licenses), there will be delays and a critical time loss interim to authorizing a professional’s direct care to patients.   This especially impacts residents in underserved areas with acute or long-term shortages of care professionals.  Also, leaving areas unattended with widespread acute and urgent needs creates multiple complications that may challenge or limit emergency management effectiveness.  The compact already provides a base number of professionals with privileges in a subject state.  This supplement planning for quick and effective action for mitigation and control of emergencies and/or surge events.

Compact privileges are already compatible with current dental professional training programs.

With few differences, certified dentist and dental hygienist training programs throughout the U.S.A. are largely considered to be mostly equivalent in the level, standards and scope of education for eligibility of licensure anywhere in the U.S. including within a dental compact.   Thus, it is understandable that the Dentist and Dental Hygienist Compact has the official endorsement of the American Dental Association (ADA), American Dental Hygienists’ Association, American Dental Education Association (ADEA), American Student Dental Association and other authoritative oral health organizations nationwide [3].

Serving the national interest in a declared military action

It may easily be construed that in the case of a large-scale surge requirement for extensive dental prevention, treatment and stabilization of service members at military facilities and clinics, the compact can be an immediate source for mobilizing pre-qualified licensees privileged across member states to help clear dental conditions of personnel and maximize their readiness before deployment [5].

CONCLUDING INFORMATION AND COMMENTS

As of the date of this article, only 9 U.S. states have agreed to participate in the Dentist and Dental Hygienist Compact [1].  It is noteworthy that currently, there is a U.S. medical licensure compact and a nurse’s licensure compact, each with 42 members consisting of 40 U.S. states, the territory of Guam and the District of Columbia [4].  Physicians and nurses in these compacts are ready to serve within practice formats that are similar to that of the dental compact.   Similarly, any state that joins the dental compact not only brings the potential improvement of health care for its residents as well as those of any other member states, that state also advances participation for national health care security, preparedness, and readiness.  Finally, it is implicit from the COVID 19 pandemic that we should not wait for the next crisis to begin joining a large partnership of cooperating states to mitigate emergencies.  Now is the time for all states to join this compact for the collective good of the country.

*Dental Compact Description provided by the National Center for Interstate Compacts- Council

  of State Governments, Lexington, KY

 REFERENCES

1. Dentist and Dental Hygienist Compact www.ddhcompact.org (last accessed 7/15/24).
2. U.S. Department of Health and Human Services – Administration for Strategic Preparedness and Response, National Health Security Strategy, Strategic Goal 1 https://aspr.hhs.gov/NHSS/Pages/default.aspx (last accessed 7/15/24)
3. Dentist and Dental Hygienist Compact https://ddhcompact.org/letters-of-support/ (last accessed 7/15/24).
4. https://www.imlcc.org/, https://www.imlcc.org/participating-states/ https://www.nursecompact.com/ (last accessed 7/15/24).
5. https://media.defense.gov/2022/Oct/27/2003103845/-1/-1/1/2022-NATIONAL-DEFENSE-STRATEGY-NPR-MDR.PDF (page 18, VII-Force Planning), (last accessed 7/15/24).
6. Federal Emergency Management Agency: National Disaster Medical System (NDMS): Disaster Medical Assistance Teams (DMAT) & Definitive Care. https://www.fema.gov/emergency-managers/practitioners/recovery-resilience-resource-library/national-disaster-medical (Last Accessed 7/15/24).
7. U.S. Department of Health and Human Services: Disaster Medical Assistance Teams. https://aspr.hhs.gov/SNS/Pages/Disaster-Medical-Assistance-Teams.aspx (Last Accessed 7/15/24).
8. Cleveland Medical Clinic:  https://my.clevelandclinic.org/health/articles/11368–dental-emergencies-what-to-do (Last Accessed 7/15/24).

FIGURE 1

license holder in a compact state (Wisconsin) can apply for equivalent practice privileges in any other state(s) participating in the compact.  In this example, the Wisconsin license holder can obtain privileges in any number of other states that are compact members, such as Iowa, Colorado, Kansas and Tennessee.

FIGURE 2

Public dental health surge events are presently being offered at various times and locations throughout the country.  These events often involve volunteer personnel providing care to the underserved with portable equipment inside large buildings as temporary field clinics.  Such clinical settings would appear much like those expected in a declared emergency.  Photo courtesy of Wisconsin Dental Association.

AUTHORS

Gregory S. Jacob, BS, MS, BS, DDS Glenview, IL

Karin Buchanan, PhD, RN, APN, NHDP-BC, CCRN, CEN Trauma Services Manager Ascension St. Alexius Medical Center Barrington, IL

Jamie Johnson, PhD. Professor Assistant Director of the School of Law Enforcement and Justice Administration Western Illinois University Stipes Hall 404 Macomb, IL

DDH Compact Implementation Timeline

On April 22, 2024, the Dentist and Dental Hygienist Compact (DDH Compact) was enacted in its seventh state. The compact legislation specifies that it will come into effect upon enactment of its seventh state. See the DDH Compact Map for an updated list of participating states. Although the compact has been enacted by seven states, applications for compact privileges are not yet available. Below is a timeline of implementation activities that must take place before the compact can be used by dentists and dental hygienists. The compact will not be fully operational for an estimated 18-24 months.    

April 22, 2024 – DDH Compact enacted in 7^th state.

The DDH Compact legislation specifies it is effective upon the enactment of the 7^th state.

Summer 2024 – Formation of Compact Commission

Each member state must appoint a one representative to serve on the compact commission. The commissioner is selected by the state’s dental licensing board. The compact specifies that the commissioner must be a representative of the state licensing board.

Fall 2024 – Inaugural Commission Meeting

The state commissioners will convene for the inaugural meeting of the DDH Compact Commission where they will elect an executive committee, vote on initial rules and bylaws, and take other steps for the compact to move towards being fully operational. Commission meetings will be open to the public.

2025 Ongoing – Creation of Compact Data System

The compact commission will continue to work on operationalizing the compact by acquiring a data system. The data system is a foundational piece of compact operations. Compact member states communicate licensure and compact privilege information via the data system. It is expected that the data system process will take 10-12 months. Once the data system is available, states will be tasked with onboarding to the system. States will have varying timelines to onboard.

2025 Ongoing – Additional Commission Meetings

The compact commission will hold commission meetings throughout 2025 for additional rulemaking. The commission will also hire staff, develop a budget, approve a fee structure, select a secretariat organization and take additional steps for the compact to be fully operational.

Privilege Applications Open

Once the data system is up and running and an application process is established, the compact commission will open applications for compact privileges to dentists and dental hygienists.

The application process will involve verifying the dental professional has a qualifying license and is eligible for compact participation. Once the application has been reviewed, the applicant will receive confirmation that they have been issued compact privileges in the member state(s) they selected. After a privilege is issued, the dentist or dental hygienist can practice in those member states in which they hold a privilege.

Download a PDF version of this resource below.

This memo was drafted to describe critical issues that have been identified in the AADB Dental and Dental Hygiene Compact as proposed by the American Association of Dental Boards (hereinafter, the “AADB Compact”). This Compact is styled as proposed legislation and was reviewed in light of the legal principles governing the creation and operation of interstate compacts and their commissions, and the standards historically applied during judicial review of interstate compact statutes.

This review revealed significant legal concerns, ranging from state constitutionality concerns to possible violations of federal antitrust laws. Moreover, the language, style, and overall drafting of the compact fails to enact many best practices in compact drafting that have been identified over the years, yielding a structure that will likely have significant administrative challenges even if adopted.

In short, this Compact, if enacted in its current state, would be materially insufficient to establish an effective interstate compact commission, and it would almost certainly give rise to potentially fatal legal challenges.

It is imperative to ensure that a compact is legally and mechanically sound before it is circulated to potential member states. The AADB Compact simply does not meet this standard.

Download the entire memo below.

Section 1: Title and Purpose

The purposes of this Compact are to facilitate the interstate practice of dentistry and dental hygiene and improve public access to dentistry and dental hygiene services by providing dentists and dental hygienists licensed in a participating state the ability to practice in participating states in which they are not licensed.

This Compact is designed to achieve the following objectives:

• Enhance states’ abilities to protect the public’s health and safety
• Facilitate the exchange of licensure, investigative and disciplinary information among member states
• Requires practitioners to practice within the scope of practice authorized by the state in which they are practicing
• Support active-duty military personnel and their spouses
• Encourage the cooperation of member states in regulating multistate practice for licensed dentists and dental hygienists
• Create a streamlined pathway for licensees to practice in participating states increasing the mobility of duly licensed dentists and dental hygienists
• Increase public access to dentistry services

Section 2: Definitions

This section establishes the definitions of key terms and concepts as used throughout the compact. Defined terms are capitalized throughout the document. The Dentist and Dental Hygienist Compact uses the term “Compact Privilege” to describe a licensee’s permission to work in a remote state.

Section 3: State Participation in the Compact

This section establishes the requirements for states to be eligible to participate in the compact, and what is required of participating states to continue to maintain eligibility.

To be eligible to participate in the compact a participating state must:

• Accept the National Board Examinations of the Joint Commission on National Dental Examinations
• Accept for licensure that applicants for a dentist license graduate from a predoctoral dental education program accredited by the Commission on Dental Accreditation and that applicants for a dental hygienist license graduate from a dental hygiene education program accredited by the Commission on Dental Accreditation
• Require for licensure that applicants successfully complete a clinical assessment
• Have continuing professional development requirements

• Have a mechanism to receive and investigate complaints about Licensees practicing in that state
• Enact a compact that is not materially different from the model compact
• Participate fully in the compact data system
• Notify the compact commission of any adverse action or the availability of significant investigative information regarding a licensee or applicant
• Implement procedures for requiring the background check of applicants for a privilege to practice
• Comply with the rules of the commission, the governing body of the compact
• Accept licensees from other participating states as established by the compact

Section 4: Compact Privilege

This section describes the requirements for a dentist or dental hygienist to obtain a compact privilege to practice in remote states.

To obtain and exercise a compact privilege under the compact a licensed dentist or dental hygienist must:

• Hold a qualifying license1 in a participating state
• Have passed a National Board Examination of the Joint Commission on National Dental Examinations
• Have graduated from a predoctoral dental education program accredited by CODA, leading to a D.D.S. or D.M.D. degree (for dentists)
• Have graduated from a dental hygiene education program accredited by CODA (for dental hygienists)
• Have successfully completed a clinical assessment
• Have not been convicted or found guilty, or have entered into an agreed disposition, of a felony offense under applicable state or federal criminal law, within five (5) years prior to the date of their application;
• Apply to the commission through the participating state where the licensee holds a qualifying license
• Pay any applicable fees
• Meet any jurisprudence requirements established by the remote state in which the licensee is seeking a compact privilege
• Report to the commission any adverse action taken by any non-participating state
• Report to the commission the licensee’s primary address and any change in address

CODA and Clinical Assessment additional information.

The compact states that a dentist or dental hygienist must graduate from a CODA accredited program or “another accrediting agency recognized by the United States Department of Education for the accreditation of dentistry and dental hygiene education programs.” This is intentional. If, in the future, the U.S. Department of Education approves another accrediting agency, the compact will not be obsolete. It can continue to exist long into the future without states having to go back and amend the compact through their legislative process in every state. CODA accredited programs are the only programs that qualify under this definition.

The compact states that a dentist or dental hygienist must take a clinical assessment. This is defined as an “examination or process, required for licensure as a Dentist or Dental Hygienist as applicable, that provides evidence of clinical competence in dentistry or dental hygiene.” States retain the power to choose which clinical assessment they use for licensure.

Section 5: Active Military Member or their Spouse

This section specifies that active-duty military members and their spouse shall not be required to pay the commission fee for a compact privilege. If a remote state chooses to charge a fee for a compact privilege, it may choose to charge a reduced fee or no fee to active-duty military and their spouses.

Section 6: Adverse Actions

This section establishes a disciplinary framework between the compact participating states. Remote states may take adverse action against a licensee’s compact privilege in that state and may issue enforceable subpoenas for witnesses and evidence from other participating states.

Participating states must report any adverse action and the existence of significant investigative information to the compact data system, which then promptly alerts the other participating states of this information. Any participating state may take adverse action based on the factual findings of a remote state. This section also directs the compact participating states to work together on joint investigative activities related to licensees using the compact.

Section 7: Establishment and Operation of the Commission

This section outlines the composition and powers of the compact commission.

• Each participating state is entitled to one delegate
• The Commissioner will be a member or designee of the State Licensing Authority
• Each delegate has one vote on commission rules and bylaws
• The commission may establish a term of office, code of ethics, bylaws, rules, a budget and financial records in order to carry out the compact
• The commission cannot take action against a practitioner. It can not dictate policy to the member states. States retain control of the scope of practice and their licensure process.

Section 8: Data System

This section establishes the commission’s shared information system. Participating states are required to share licensing information on practitioners with compact privileges. Participating states will submit a uniform dataset to the data system on all practitioners to whom this compact is applicable as required by the rules of the commission. This database will allow for the expedited sharing of disciplinary and investigative information.
Adverse action information pertaining to a licensee in any participating state will only be available to other participating states. A participating state may designate information submitted to the data system that may not be shared with the public without the express permission of that participating state.

Section 9: Rulemaking

This section establishes the rulemaking authority of the commission to carry out the provisions of the compact.

• Rules carry the force of law in all participating states.
• A simple majority of participating state legislatures may veto a rule of the commission.
• Changes to rules require a 30-day notice of proposed rulemaking, with an opportunity for a public hearing.
• If the commission takes an action that is beyond the scope of the compact, the action is invalid and has no force and effect.

Section 10: Oversight, Dispute Resolution and Enforcement

This section ensures compliance with the compact by member states and details the procedures to be followed in the event a participating state fails to comply with the compact.

• A period of technical assistance in remedying the situation.
• Dispute resolution, including mediation and binding processes.
• Termination from the compact if no other means of compliance is successful.
• The commission shall attempt to resolve any compact-related disputes that may arise between states.

Section 11: Effective Date, Withdrawal and Amendment

This section establishes the effective date of the compact and includes provisions for states withdrawing from the compact and the member states collectively amending the compact.

• The compact takes effect on the date of enactment by the seventh state.
• States that join after this date are subject to the rules of the commission as they exist on the date when the compact becomes law in that state.
• Participating states may enact a law to repeal their membership in the compact. A state’s withdrawal takes effect 180 days after enactment of such law.

Section 12: Construction and Severability

The compact is to be liberally construed to effectuate its purposes.
The compact’s provisions are severable, meaning that:

• If a provision is declared to conflict with the United States Constitution, all other provisions remain valid for all participating states.
• If a provision is held contrary to a participating state’s constitution, the compact retains its full force in all other states, and all other provisions remain valid in the affected state.

Section 13: Consistent Effect and Conflict with Other State Laws

Participating states retain sovereignty over all laws, and nothing shall inhibit or prohibit enforcement of laws that are not in conflict with the compact. Any laws, statutes, regulations or other legal requirements in a member state that conflict with the compact are superseded to the extent of the conflict.

Download the Section by Section PDF below.

What is the DDH Compact?

The Dentist and Dental Hygienist Compact is an interstate occupational licensure compact. Interstate compacts are constitutionally authorized, legally binding, legislatively enacted contracts among states. This compact enables licensed dentists and dental hygienists to practice in all states participating in the compact, as opposed to them obtaining an individual license in every state they want to practice.

Who can use the DDH Compact?

A dentist or dental hygienist is eligible to participate in the compact if they have:

• An active, unencumbered license in any state participating in the compact.
• Passed the National Board Examination or other exam accepted by the compact commission.
• Completed a clinical assessment.
• Graduated from an education program accredited by the Commission on Dental Accreditation.
• No disqualifying criminal history.

What’s next?

The Council of State Governments (CSG) has facilitated the development of the Dentist and Dental Hygienist Compact model legislation. This legislation has been finalized for introduction during 2023 legislative sessions. Each state must enact the model legislation to join the compact. Supporters of the compact can contact the state chapter or national office of their professional membership association and state legislature to advocate for the interstate compact.

Download this information as a PDF below.

CSG and a diverse group of stakeholders including ADA, ADHA, state regulators, and others wrote the Dentist and Dental Hygienist Compact model legislation over the course of two years. After an extensive public review process it was finalized in January 2023.

To introduce the legislation in your state, please use the model legislation linked below.

This project is funded by the Department of Defense.
The following language must be enacted into law by a state to officially join the Dentist and Dental Hygienist Compact.
No substantive changes should be made to the model language. Any substantive changes may jeopardize the enacting state’s participation in the Compact.

The Council of State Governments National Center for Interstate Compacts reviews state compact legislation to ensure consistency with the model language. Please direct inquiries to Jessica Thomas at JThomas@csg.org.