DOJ, 2004; Nolan et al., 2003). Variations in permissible practice among the states are broad, especially for dental hygienists and dental assistants (ADAA/DANB Alliance, 2005; HRSA, 2004). As in medicine where physicians are given significant latitude to delegate to other health professions, in dentistry, dentists are provided with autonomy to delegate at their professional discretion. While part of the purpose of restricting scope of practice is to protect consumers from unsafe or untrained providers, some data suggest that overly restrictive licensure laws in oral health are not tied to better health outcomes; in fact, stringent laws have been tied to increased consumer costs, (IOM, 1989; Kleiner and Kudrle, 2000; Shepard, 1978).

The Role of the Private Sector

Certification is a process by which a private organization imposes a certain level of standards, either through testing or some other method, in order to become “certified.” Certification is often used as a measure of competence, especially in professions which do not have a formal licensure. The Dental Assisting National Board estimates that almost 12 percent of dental assistants in the United States are certified dental assistants (CDAs) by the Dental Assisting National Board (ADAA/DANB Alliance, 2005). As of 2011, 29 states recognize or require CDA certification to perform expanded duties, and a total of 38 states plus the District of Columbia recognize or require one or more of the components of the full CDA exam for particular expanded functions (e.g., Radiation Health and Safety Exam, Infection Control Exam) (DANB, 2011).

Dental technicians can voluntarily become certified dental technicians (CDTs) by the National Board for Certification in Dental Laboratory Technology, an independent board established by the National Association of Dental Laboratories (BLS, 2010g). Certification can occur in crowns and bridges, ceramics, partial dentures, complete dentures, and orthodontic appliances. Three states (Kentucky, South Carolina, and Texas) require dental laboratories to employ at least one CDT, and in Florida dental laboratories must register with the state, and at least one technician must meet requirements for continuing education (18 hours every 2 years) (BLS, 2010g).

ORAL HEALTH AND QUALITY MEASUREMENT

Despite the current interest in the quality of health care, little is known about the quality of oral health care provided in this country. Measurement and assessment of the quality of oral health care lag far behind similar work in the rest of health care (Stanton and Rutherford, 2003). For decades, significant research, resources, and expert opinion has focused on the quality and safety problems in health care, but oral health has largely been left



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