Dentists Hygienists—Creating Models of Collaboration
Allison M. DiMatteo, BA, MPS
Whether you call them tensions, controversies, or battles of will, something heatedly argumentative has been simmering atop the surface of relations among organized, political, and state dentist and dental hygienist groups. In some instances, those tensions may involve the scope of hygienists’ duties or functions. They may focus on a hygienist’s ability to perform his or her trained or licensed duties outside of a practice setting under the general supervision of a dentist. Or, they may pertain to which organized group or legislative body is going to have the last word in effecting real and meaningful changes in how educated and trained hygienists deliver the care they are licensed to provide to those who need it most.
"With any profession, change is hard, and in oral healthcare, changes have to be made, and that has been recognized. We are all working toward the common goal of doing what is best for the patient," notes Jean Connor, RDH, president of the American Dental Hygienists’ Association (ADHA). "Typically when changes have to be made, everybody who’s involved feels they should be the first to make the change because they need to own it."
The changes that are needed involve workforce issues, Connor explains. All segments of oral healthcare have acknowledged that there is an access to care problem, and what needs to change is the manner in which professionals in the oral healthcare workforce are utilized to the fullest of their capacity, she emphasizes.
"To be successful in improving outcomes for patients, dentistry—of which hygiene is a part—will need to step outside of the practice models we have now and expand them," Connor believes.
Mark J. Feldman, DMD, president of the American Dental Association (ADA), notes that the professions of dentistry and hygiene have much in common when talking about the provision of prevention and oral care. Dentistry supports a team approach where the hygienist is providing delivery of dental care under the direction of a qualified dentist in the office, he says.
"This is the way that traditional dental hygiene has been practiced for a long time," Feldman says. "However, both dentists and hygienists understand the need to provide more care, especially in underserved areas. That’s where the ADA is working very hard to develop models that will improve the efficiency of the dental team so that more care can be given as efficiently as possible, especially prevention, which is key to getting rid of oral health disease."
At the present time, most professionals in oral healthcare—whether dentist or hygienist—would agree that the pressing issue facing the profession is access to care. "Dental disease is a preventable disease," Feldman says. "What we [hygiene and dentistry] really are looking to do is take the workforce that we have now and figure out ways of working more collaboratively."
Compounding the issues is the fact that what hygienists are and are not allowed to do—despite their education, training, and skills—varies from state to state. According to Rebecca S. Wilder, RDH, BS, MS, associate professor and director of graduate dental hygiene education at the University of North Carolina, the way to meet the oral healthcare needs of someone in one area of the country or state may be very different from how those needs should be met elsewhere. What’s more, the abundant oral care needs of the population have been realized in the last several years—really brought to national attention by the 2000 Surgeon General’s Report on Oral Health in America. Oral healthcare professionals are witnessing an insufficient number of dentists to meet the access to care crisis, Wilder observes. Innovative models need to be established to utilize dental hygienists’ knowledge and skills in more effective ways, she says.
"On a national level, most people are saying that the relationship between organized dental hygiene and organized dentistry is the best it’s been in decades," observes Mercedes Franklin, DMD, MPH, president of the Harvard University School of Dental Medicine Alumni Association. "Both groups are working together to develop a solution to the access to care problem, which is not only a problem for the underserved population, but which will become a growing problem for the general population, also, as the number of dentists in certain areas becomes increasingly inadequate."
The various professional guidelines governing the delivery of dental care have been established based on the training and ability of the professional—whether it’s a dental hygienist, dental assistant, dentist, or specialist, explains Connie L. Drisko, DDS, dean and Merritt Professor of the Medical College of Georgia School of Dentistry. They are established to protect the public and limit the scope of practice to not allow the person to go beyond what their capabilities, their competencies, and their training is, she says.
"I have always been a strong supporter of hygienists or dental assistants being able to do those procedures that they have been trained to do, and that varies so much from state to state that I think it contributes to individual state controversy," Drisko suggests. "That’s why it’s so hard to do something at a national level because each state has different laws and different practices that they allow hygienists to perform."
As noted earlier, therein may lay the root of the tensions between the organized factions of oral healthcare. Dentists and their dental hygienists always have been working very well together as part of an allied oral healthcare team, emphasizes Feldman. Hygienists are a very important part of the practice of dentistry, he acknowledges, with the thousands of dedicated dental hygienists playing a very im-portant role in providing care to patients in dental offices all over the country.
"There is a tremendous amount of respect between hygienists and dentists. On an individual, practice-by-practice, group-by-group level, that respect has always been there," Drisko says. "I think where the controversies come, where the harsh words sometimes are exchanged, and where the difference of opinion exists is the scope of practice and how to approach access to care issues at the political and organizational level; that’s where they [dentists and hygienists] don’t always agree."
This month, Inside Dentistry highlights the ongoing diligent efforts taking place between organized dentistry and organized hygiene to address the key issue both sides face: access to care. The emphasis is on demonstrating the collaboration and communication taking place within the greater oral healthcare profession, with mutual respect as a basis for continued discussion about how to work together to increase access to quality oral care for all people who need it. The results of those diligent efforts include workforce models, greater leadership and policymaker collaboration, and recommendations for oral health literacy.
New Workforce Models in Progress
On a national level, Connor says discussions are talking place in such a way that everybody feels a part of the change and that they’re working toward the same goal. Hygienists are not looking to work independently from dentists, she says, but as a part of the "dental home," as one aspect of all of oral healthcare.
According to Drisko, new categories of dental auxiliaries approved by the ADA this past year—although not yet adopted by all states—represent a move in the right direction toward utilizing dental support staff in a more efficient manner. She notes that national trends suggest that dentists are working more efficiently, adding that she believes some of that efficiency is because they have adopted better use of expanded duty hygienists and dental assistants, as well as the state laws to allow their support staff to be able to do more.
The current practice scenario or whole dental team includes dentists, hygienists, assistants, laboratory technicians, and front office receptionists, Connor explains. However, this model is not satisfying the population’s needs.
Connor parallels what’s needed in dentistry to different medical health models in which there are doctors, nurses, nurse practitioners, physical therapists, and others taking care of a patient. "We need different kinds of practitioners inside of dentistry in order to be able to take care of the population’s needs," Connor explains.
She suggests that a provider such as the ADHA’s proposed Advanced Dental Hygiene Practitioner would be someone who would be working in between a dentist and a hygienist. This Advanced Dental Hygiene Practitioner would be educated at a Master’s level and hold a higher education degree than the traditional dental hygienist who’s working clinically. He or she would have more skills and be able—with proper state approval—to go out into the field and provide care inside of what they are licensed and capable of for prevention, therapy, and impact on clinical outcomes, Connor explains. This professional would provide more of the simple types of restorations, leaving the complex care for the dentist, but still working as a member of the dental team. According to Connor, the ADHA Board of Trustees recently approved the competencies for the Advanced Dental Hygiene Practitioner.a
The ADA has been working on a model called the Community Dental Health Coordinator, Feldman says, that will be similar to a Community Health Worker with some dental skills. This provider will be a person trained in oral care prevention, community outreach, and certain therapeutic techniques such as fluoride applications, placement of sealants, glass ionomer temporaries, and possibly some minor scaling procedures that can help people in underserved areas who have not been able to get to a dentist, he says. This provider would also arrange for patients to get to a dentist for more complex care when a dentist is available so that visits are more efficient.
The ADA is currently piloting the Community Dental Health Coordinator concept, Feldman says. There is a written cur-riculum, and some pilot sites have already been funded and are about to get started in some underserved areas (eg, tribal communities, urban inner-city areas, rural areas).
Feldman states that there will always be a place for the current practice model of dentistry. Many communities have high standards of dental care, with many dentists and hygienists available to meet the respective local population’s needs. This includes needs for cosmetic and specialty care, he says.
Leadership and Policymaker Collaboration
From the perspective of the ADHA’s strategic plan, attending to patient care is the first and foremost priority, and a major goal of the organization and its members is partnering with dentists to promote oral healthcare for all patients, Connor says. For this reason, the ADHA has been working closely with the ADA. On a national level, the leaderships of both organizations are emphasizing mutual respect, cooperation, and an examination of the population’s oral care needs as they move forward with collaborative efforts.
"There is always room for improvement at all levels of organizational interactions," explains Drisko. "Dental hygiene and dentistry both have the public’s health in mind; sometimes their approaches to how to deliver the best care to the public are not always in line with each other’s thinking."
Since as far back as 10 years ago when such reports as Dentistry at the Crossroads pointed to the need for enhanced policymaking decisions, most oral healthcare groups have been working toward more collaborative efforts to provide better patient care, Drisko believes. She notes that much of those endeavors depends on the leadership and the ability of the leadership to communicate.
"We are all part of dentistry, whether you’re the dentist, the hygienist, the assistant, those who work at the front desk, or the laboratory technicians who also support the clinical aspect," explains Connor. "We need to communicate among all aspects of dentistry to work out the issues, so there won’t be tension between anybody."
Unfortunately, that sometimes is not the case, and divisions may become ingrained as early as the dental school or dental hygiene school years. For example, Wilder recalls a freshman dental student asking her recently why dental hygienists would want to give injections and perform restorations. The student was frustrated with the idea, having just attended a lunch and learn presentation about practice acts and the current practice models proposed by the ADA and the ADHA. However, after Wilder explained access to care, Medicaid reimbursement problems, the actual education level of dental hygienists, and a workforce model that would resemble a medical model (eg, nurse practitioner with a Master’s degree), he felt he had a better understanding of the issues and the challenges, she believes.
According to Connor, the ADHA’s most recent branding campaign emphasizes collaboration, teamwork, and communication—working with dentists toward a com-mon goal of improved public oral health. "We looked at the fact that people have viewed hygienists as possibly being adversarial, so it is our goal and part of our strategic plan to work with dentists to find out what the issues are and try to reach a consensus and a better, equitable solution," she says.
Interestingly, Feldman notes that government entities will also have to "step up to the plate" in order to make care more readily affordable. "The ADA has been actively advocating legislation that would provide dental healthcare for children who basically don’t qualify, but it’s repeatedly vetoed," he says. "The ADHA has also been working with us to advocate this State Children’s Health Insurance Program model to help improve access to care."
Some have suggested that among the policymakers should be representatives of those who actually need the care—members of the community and the public. A precedent for community involvement in dental-related processes has been set in the past 5 to 10 years with the advent of community-based participatory research, suggests Dushanka Kleinman, DDS, MScD, the associate dean for research and academic affairs at the School of Public Health at the University of Maryland. Community-based, participatory research has until recently been an endeavor new to the profession, but dentists and researchers alike are learning how to implement this approach to research.
"The bottom line is that this approach requires active community involvement from the genesis of the project, where the partnership between the academic and the community works in tandem to address and bring the best scientific evidence forward through a collaboration," Kleinman explains. "I think this is the same issue we’re facing in oral healthcare, and we now are experiencing the need to have the community and the patients speak at the table with us and co-lead solutions to the problems that they perceive in their community."
Simply stated, Kleinman emphasizes that true solutions are all local, as is politics. Therefore, the profession will be best served as a helping profession by having the community public join the profession, whether at the national, state or local level, when designing and testing workforce models.
"It’s not going to be easy. It’s not going to be the same," Kleinman says. "But by working together, principles and values that everyone can agree upon in terms of issues related to the quality of care and priorities for prevention will emerge and serve as the foundation for demonstration research."
Oral Health Literacy and Community-Based Programs
Kleinman notes that among access to care programs that make treatments available to the underserved, there is a backlog and a major need in care delivery for dental caries prevention, health promotion, and health equity. Focusing on these areas will provide the oral healthcare profession "with two amazing doors to walk through," she says. "One is the legacy of the dental profession for prevention and health promotion, with the major support for community-wide efforts such as water fluoridation. The other door it opens involves the dental profession as a leader in changing behaviors and policies."
However, changing policies and public behaviors requires more than efforts from oral healthcare professionals; and dentists and hygienists cannot be the only implementers of solutions, Kleinman says. Rather, prevention requires work that everybody needs to do—self-care practices at home; health promotion programs within the context of schools, workplaces, and the community; and clearly through legislative actions—so that the tiers of involvement include the whole health professions and beyond, she explains.
Effecting changes in the overall oral health literacy of the population may therefore need to include reinforcing positive messages, in addition to the early recognition/prevention of caries or disease and appropriate referrals for care by other health professionals. Kleinman suggests that this should incorporate the totality of social support systems, such as Women Infant and Children (WIC) programs, the providers and program directors within that program, as well as in programs such as Head Start, schools, and nursing homes.b Additionally, it’s important to identify that oral healthcare includes self-care as well as professional care; both are needed.
"Such a public health approach requires a population-based focus and an incredible leadership requirement for the profession to not only reassess how we configure our own internal models, but concurrently look at models that go beyond the family of dentistry," Kleinman says. "This will be very important as dentistry, the profession and the dental team, integrates those efforts within a broader blueprint for improving oral health."
Both the ADA Committee on Health Literacy and the preceding Academy of General Dentistry taskforce have helped dentistry move forward in addressing and exploring all of the potential for what oral health literacy could mean, Kleinman says. Oral health literacy involves enhancing not only the ability of patients to perform the tasks required of them to ensure good oral health, but also the ability of dentists and hygienists to communicate clearly to patients what those tasks and expec-tations are, she explains. It also involves education and healthcare delivery systems and, clearly, the cultural background of the populations and communities.b
Franklin comments that the ADA’s proposed model is one that takes into consideration the need for oral health literacy and continuity of care. "This is a patient navigation system; the Community Dental Health Coordinator can work with patients, help them get in, help them with follow-up, and conduct education," she says. "This model will be working with the attitudes of the patients, trying to change their views toward their oral health so that it is as important to them as their general health."
There is a great deal of good that can be accomplished in oral healthcare when the groups within the profession work together toward their common goals, believes Drisko. Through good leadership and good communication, different segments of the oral healthcare profession could maximize the potential for enhanced patient care by enabling hygienists and dentists to work together better, she says
"I would encourage the leadership of dentistry and dental hygiene to continue to communicate and collaborate, because I think a lot of progress has been made in the last few years," Drisko observes. "We have a long way to go, but the future is bright, and oral healthcare—both dentistry and hygiene—is a profession that really cares about its patients."
To keep things moving forward, open communication among all organized entities will remain significantly important, Connor suggests. "Once you start communicating, you stop assuming what other people are thinking or what’s going on. You’re actually having the dialogue that’s needed to share commonalities," she explains.
The ADA’s message is that the dental profession is looking to absolutely improve access to oral healthcare. Dental disease is a preventable disease, and everyone needs to work together, Feldman emphasizes. That includes the government, the public policymakers, the community, and the dental profession. Everybody has to kick in, he says, and he believes that everyone has been willing to do their share.
Similarly, our interviewees agree that progress has been made at the national level with communication. Wilder’s hope is that the communication will continue, despite the fact that the problem(s) they’re collectively facing will not be solved soon. "Patients will still have problems accessing care; those who need care the most will not receive it unless we explore alternatives," she says. "So much can be gained if we are all open with each other and talk honestly about the people who matter most—the patients."
b Institute ofMedicine. Health Literacy: A Prescription to End Confusion. April 8, 2004.
Hygienists: Partners in Disease Prevention and Profitability
One such diagnostic tool that has been well-researched is a software tool (PreViser, www.previser.com) that provides dental hygienists or dentists with a predictive diagnosis for periodontal disease, a 4-color printout that patients find educational and motivational, and a correlation to what treatments should occur, ex-plains Roger Levin, DDS, founder and chief executive officer of Levin Group, Inc.1,2 Any dentist or hygienist can use it, and no special certification or licensing is required, he says.
"Production in hygiene jumps dramatically the minute it’s implemented," observes Levin. "Patients see the report and immediately understand what the problems are and what they need to do. It’s very motivating, which allows the hygienist to increase his or her diagnostic capability and then enhance patient case acceptance for periodontal treatments."
Dental hygiene is the second largest revenue center in the practice, and it is usually the only other revenue center in the practice besides the doctor, Levin explains. Based on that, models can be implemented to enhance the success of the practice by enabling the hygiene department to reach much higher levels of productivity and growth.
"The hygienist represents tremendous potential for growth, development, patient education, and efficiency in terms of freeing up the doctor to do other things," Levin says. "He or she has the ability to identify necessary and potential elective treatments for the doctor to perform and communicate those possibilities to the patient, as well as to educate and motivate the patient to accept treatment."
Additionally, Levin notes that hygienists themselves are profit centers when they perform services beyond the basic prophy. These may include periodontal treatment and other ancillary services, such as whitening, fluoride treatments, recommending homecare products, and performing oral cancer examinations using products like the brush biopsy (Oral CDx), he says.
"As technologies for oral cancer screenings are developed and scientifically evaluated for accuracy, that’s certainly some-thing that I would like to see every dental hygienist being able to perform," notes Rebecca S. Wilder, RDH, BS, MS. "Oral cancer screening should be done routinely in dental practices, and that is something that a dental hygienist could do in terms of collecting the data that would be evaluated to screen for oral cancer."
"Yes, performing an oral cancer screening using the brush biopsy is a profit center, but more importantly, we could do incredible things for people if we catch it earlier," Levin stresses. "Hygienists can screen to rule out oral cancer and to prevent cancer, rather than find cancer."
Levin Group conducted a survey that was co-published last year based on 1,200 practice responses.3 They found that the medium gross practice production of a practice with $800,000 in revenue in 2007, and with its hygiene staff wages only accounting for about 10% of the total overhead, had a gross hygiene production of only $125,000, Levin said. He added that this is very low compared to the potential that is available.
To change this, Levin suggests that the first thing to do is change the way hygiene appointments are scheduled. Don’t just have eight straight hygiene appointments a day without thinking about whether or not some appointments should be longer, some shorter, or what type of services are being provided. Additionally, hygienists could have specific goals that are identified at the beginning of the year based on Power Cell Scheduling™ and what services the practice and hygienist want to add.
Without question, hygienists have traditionally done well providing oral homecare education, but Levin suggests that some professionals could do more in terms of educating patients about other potential services offered in the dental practice. The majority of general dental procedures are single-tooth treatments, and there are some patients who only need one tooth treated, he admits. However, there are many patients who need and might accept more treatment that they are not hearing about, whether it’s comprehensive care, quadrant care, cosmetic dentistry, implant dentistry, occlusal dentistry, etc. Hygienists who educate patients about ancillary hygiene services can also be mindful and/or advise patients of the need for doctor production oriented services. Finally, when hygienists are in communication with the rest of the team, the most efficient and effective systems can help the department reach the daily hygiene goal.
1 Page RC,Martin J, Krall EA, et al.Validity and accuracy of a risk calculator in predicting periodontal disease. J Am Dent Assoc. 2002 May;133(5):569-76.
Nursing Homes—A Question of Direct vs Indirect Supervision
One of the areas often discussed in the context of the debate of "dentistry vs hygiene" is the nursing home setting and the need patients in those facilities have for preventive oral healthcare. Dental hygienists have been willing to go to nursing homes to provide the care that their education, training, and licensure allow, as well as press for changes to the dental practice acts in many states to allow them to go to nursing homes and treat elderly patients who need care, explains Connie L. Drisko, DDS.
"After having a parent who lived in a nursing home for a while, I really saw the need for dental care to be provided there," recalls Rebecca S. Wilder, RDH, BS, MS. "There are many dental hygienists who want to be able to have the flexibility to provide care for those patients and educate the care providers in the facilities. We are seeing more states witness the advantages of allowing general supervision so that dental hygienists can go into these settings and provide much needed treatment."
"I think where the controversy comes into play is that some states’ statutes—but not all—indicate that a hygienist must work under the direct supervision of a dentist, and it is direct supervision in the scope of practice that causes part of the controversies for nursing home care," Drisko explains. "Some states have changed their scope of practice to allow hygienists to work under the prescription of the dentist, so that once the dentist has seen the patient, then they can prescribe to the hygienist certain parts of the treatment plan that the hygienist is trained and legally able to do. In those cases, I would say that is a win/win for the patient and the community."
In other scenarios, such as the public health sector, some of those particular state government institutions have granted permission for hygienists to perform some work within their scope of practice under the general supervision of public health dentists, Drisko elaborates. However, she says that some states limit dental hygienists’ scope of practice to direct supervision.
While some oral healthcare professionals might be apprehensive at the prospect of general supervision of dental hygienists leading to a desire for independent dental hygiene practice—which is allowed in Colorado—Wilder has observed that relatively few hygienists have gone in that direction. Rather, hygienists seek the flexibility and ability to use their education and knowledge to assess, diagnose, and treat patients—such as in nursing homes and other settings—but not necessarily in their own practice, she says.
Jean Connor, RDH