By Nancy LeBrun
Teamsmanship is an ideal deeply ingrained in many dental practices.
Dentists work closely with hygienists, dental assistants, office managers, case managers, laboratory technicians, accountants, insurance administrators, receptionists, and others to serve the needs of patients and ensure the financial viability of the office.
But what happens when one or more of the team members—in this case, hygienists—seek greater autonomy, and perhaps even full independence, to offer patients the kind of treatments that until now have been the exclusive purview of licensed dentists?
In short, team members can quickly become rivals.
Such scenarios are increasingly common, as what’s in the best interests of those in the dental hygiene profession diverges from what dentists view as being in their economic interest. Moreover, both hygienists and dentists each contend that their divergent positions are the best way to serve patients.
Dental hygienists can trace their origins back more than a century, to perhaps as early as the 1880s.
By one account, Dr. F.W. Low, a member of the Dental Society of New York, espoused the following view in 1902: “I advocate that we should establish a new profession—that of odontocure. A girl with an orange wood stick, some pumice-stone, and possibly a flannel rag shall go from house to house, and fashionable folk shall have that nasty condition in their mouths attended to as often as every two weeks.”
“Odontocure” never took off, but there are now approximately 185,000 dental hygienists in the United States—98% of them women. In the past several years, the role of the hygienist has begun to evolve.
“There’s a lot of excitement around what and where and how hygienists can be used more effectively. Momentum’s on our side, and we’re really excited about that,” Ann Battrell, MSDH, CEO of the American Dental Hygienists Association, told Incisor.
With a shortage of dentists forecasted by the U.S. Department of Health and Human Services by 2025—and a surplus of hygienists—the agency has suggested that “changes in oral health delivery and in health systems may somewhat ameliorate dentist shortages by maximizing the productivity of the existing dental health workforce.”
Translation: The scope of hygienists should be expanded to cover the shortfall in dentists.
There are variations on the theme, but they all share a model of allowing hygienists to handle a broader range of treatment with less supervision.
No Collaborating Dentist Required
Two states, Colorado and Maine, permit hygienists to set up their own businesses. Each state has its list of allowable procedures that can be performed by these independent hygienists without a “collaborating” dentist.
In 42 states, according to the ADHA, hygienists can offer direct access, which is defined as the ability of a hygienist “to initiate treatments based on assessment of his or her patient’s needs without the specific authorization of a dentist,” and, “to treat the patient without the presence of a dentist.” It also means that hygienists can bill Medicaid, which many dentists don’t accept because they find the reimbursement scale too low.
In many cases, these hygienists, whether as independents or utilizing direct access, are providing on-site services where it’s easier to go to the patient than for the patient to go to the dentist: to nursing homes, special needs facilities, or public schools, for example.
A third permutation is the dental therapist, a provider who is akin to a nurse practitioner, according to Battrell.
Currently, only Minnesota has practicing dental therapists—about 98 of them at last count, according to news accounts. Several other states have passed legislation permitting dental therapists, but have been unable to set up the training courses needed to qualify for a dental therapist license.
Maine is one such state.
Bonnie Vaughan, MEd, a dental hygienist and executive director of the non-profit Kennebec Valley Family Dentistry in Augusta, Maine, says, “We were the second in the nation behind Minnesota [to pass a law to allow dental therapists]. But we’ve been blocked by the dentists—we can’t get a school going.”
No One’s Talking
There’s not much discussion, productive or otherwise, between independent hygienist advocates and the dental profession on the role that hygienists should play in the 21st century.
However, in a 2010 survey cited on the RDH magazine website by hygienist Laura Milling, more than 37% of hygienists said the one thing they would change about their profession would be to offer patients better “access to care.” The survey’s second most desired change, noted by 25% of the respondents, was “improved autonomy, independence, and self-determination.”
In the years since that survey, hygienists have made progress toward those goals. How are the changes going over with dentists?
When hygienist Melissa Turner solicited comments from dentists on independent hygienists in May 2018, also on the RDH website:
The overwhelming number of those commenting quickly opposed even the suggestion of independent practice by questioning economic viability, citing public safety concerns, arguing that the in-office hygiene department is the sole source of patients for dentists, and highlighting fears about potential competition for patients.
Dentists who supported independent hygiene practice suggested that it may initiate a new dental model fostering improved oral health literacy and patient-provider relationships.
Sarah Summers, RDH, has one of the few independent hygienist practices in Colorado, a state that has permitted them since the mid-eighties. She was inspired to set up shop after she noticed poor dental hygiene in her own grandmother, who was living in senior housing. Summers also recognized the pending onslaught of Baby Boomers, many of whom stand to be left to fend for themselves when it comes to dental care. For Summers, who worked in private practice for seven years, that is what “fueled the fire for getting everything started.”
She set up Front Door Dental—a mobile company geared toward providing services to underserved areas of the community—while she continued to work for a private dental practice.
“He was my referring doctor,” Summers recalls of her boss at the time. “All of my new patients, anyone who needed care and did not have a dentist, I was referring to him. That was the plan.” Summers was ticking along, with appropriate callbacks set for almost all her dental office patients, until Jan 30, 2017. “I went to clock out and human resources was waiting for me with a termination paper. I was absolutely flabbergasted,” she recalls.
“I picked myself up and got out in the community and started pushing harder,” she told Incisor. “I panicked because I didn’t have a collaborating dentist. Nobody would take me.” She acknowledges the complexity of the situation. “It’s not just reluctance on the dentist’s part—there are insurance and liability issues, too.“
Still, Summers feels dentists may be short-sighted. “I would say that you’re looking at it from a narrow-minded point of view. You’re missing an opportunity for a referral base for patients—to be able to see them for restorative needs, root canals, fillings, and crowns.”
One independent hygienist Summers knows referred 120 patients to area dentists in a single year. Many, if not most, of these new patients likely would have avoided seeing any dentist if not for the hygienist’s examination and referral.
Given the patchwork of regulations, the shape of the new hygienist model varies according to where the providers are located.
“We have to go state by state by state, so every state association has its own advocacy plan,” says Battrell. “In some states out west—such as Washington, Oregon, and California—they have an expansive scope; hygienists allowed to see more people. Then you go to the Southeast—for example, Mississippi, Georgia, and Alabama—their practice acts are much more restrictive.”
Turning to Physicians
Even out west, there can be foot-dragging. As of July 2019, Summers has yet to find a dentist willing to collaborate with her. Without one, she says, “I cannot apply SDF (silver diamine fluoride), can’t do ITRs (interim therapeutic restorations), I can’t prescribe toothpaste or mouthwashes.”
To navigate around the recalcitrant Colorado dentists, Summers turns to the physicians who also serve her nursing home patients and asks them to write the necessary prescriptions. “Otherwise, I’m stuck,” she says.
A day of reckoning between hygienists and dentists is inevitable, although it’s impossible to predict when it will occur or what will trigger the two sides to seek common ground. It could be a lawsuit; it could be a vocal consumer health advocacy group; it might even be level-headed leaders on both sides who see to the benefit to all parties—hygienists, dentists, and patients—of finding a suitable resolution.
Until then, the friction between dentists and hygienists—often roiling just beneath the surface—will continue to challenge the notion of dental practice camaraderie.
Author: Contributing writer Nancy LeBrun is a veteran health and wellness writer, and an Emmy-winning video producer. A former editorial staff member at WebMD, she is based in Roswell, GA.
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