The systematic stripping away of dental hygiene`s professionalism by organized dentistry took center stage in Topeka.
David Eggert
One state legislator in Kansas commented that he received more letters and phone calls about a bill titled HB 2724 than on abortion, capital punishment, firearms control, and taxes combined. HB 2724 was about dentistry, though, and more than 500 dental professionals squeezed into a jam-packed hearing room at the Topeka statehouse to observe the first two days of testimony in February. Countless letters and articles by dentists and dental hygienists filled newspapers` opinion pages. Kansas politicians cringed at settling the election-year dispute, expressing reservations about establishing policy for something they knew little about - a claim that a shortage of dental hygienists in rural Kansas could be solved by letting dental assistants perform a hygienist`s duties.
Governor Bill Graves signed HB 2724 into law on April 23. Kansas, as a result, became the first state to allow dental assistants to perform coronal scaling. In the end, the conflict rendered numerous questions, few of which have been answered.
The origins of HB 2724 can be traced back to 1995. During that year, the Kansas Dental Hygienists` Association (KDHA) asked the state`s attorney general to define who, under state law, could perform a prophylaxis. "Looking back, I think that`s when things started boiling," says Lori Holt, RDH, and KDHA public relations chairwoman. The attorney general unequivocally denied dental assistants the right to scale or polish above or below the gum line.
For years, the state`s dentists (mostly those who practice in rural areas) had delegated supragingival polishing and scaling to assistants, interpreting the 1943 dental practice act to mean unlicensed persons could not perform an entire prophylaxis, but they could perform component parts of one. "It`s been permissible," says Kevin Robertson, executive director of the Kansas Dental Association (KDA). "Maybe you could call it scaling or polishing in conjunction with a prophylaxis." He says that`s how the Kansas Dental Board understood the act as well. Yet, allowing assistants to scale and polish was illegal.
"The KDA members believed there was a critical shortage of hygienists throughout the state," Robertson says. Realizing it had no sympathy from the attorney general or KDHA, the KDA sought support in the statehouse.
"The practice act has always prohibited prophylaxis by assistants," said Patty Seery, RDH, and vice president of the Kansas Dental Board, "but the dental board`s enforcement of the practice act has varied with the makeup of the board. That has been the frustration of hygiene groups and consumers."
How `favors` undermined a compromise
Beginning in January 1998, HB 2725 (later changed to HB 2724) navigated its way through nearly four months of committees, subcommittees, compromises, and revisions. After continual discord between the KDHA and KDA (an ad hoc committee to address the shortage was disbanded in September 1997), the KDA introduced HB 2725 to allow assistants with board-approved training to scale and polish above the gum line.
The first stop was the House Health and Human Services Committee. After two days of testimony from backers and critics, an appointed subcommittee made revisions requiring assistants to wear name tags so patients could identify who would do the work. Also, offices would post staff members and their titles. The House committee liked the "compromise" bill and combined it with HB 2724, a pro-hygiene measure seeking general supervision. Supported by the KDA, the measure was approved by the full House and sent to the Senate.
After overseeing failed negotiations between the feuding sides, a three-member Senate subcommittee gave hygienists a short-lived victory. Assistants could polish but not scale - as in 27 other states.
The amended HB 2724 passed the Senate easily and a conference committee of three senators and three representatives attempted to draft a compromise both sides could live with. KDA sent out a letter saying it was OK with the changes. Yet, a few members were not satisfied, persuading a representative to call in "favors."
"It was political blackmail," says Seery. A representative on the conference committee liked the House version of HB 2724. Coincidentally, this representative was from the same district as the president of the Kansas Dental Board and the president of the KDA. He did not concur - refusing to pass a senator`s other unrelated bill. The Senate side wouldn`t budge either.
Eventually, the representative won out because the senator owed "favors." The senator had to agree to the House version of the bill if she wanted to pass an unrelated bill he was pushing through. For good measure, the conference committee tacked on a provision expanding the numbers of the dental board.
"The legislature told the conference committee they were tired of hearings and to get unified," Seery says.
Holt calls it "political maneuvering at its best." The final bill allowed assistants with specialized training to polish and scale above the gum line. The dental board would write and review implementing rules. Dentists called the bill a compromise: The law would expire in July 2001.
The bill requires the Kansas Board of Regents, the State Board of Education, and the dental board to present a plan in 1999 on how to train more hygienists. Also, three dentists and a hygienist were added to the five-person dental board. Hygienists came away with favorable provisions, including general supervision in dental offices.
Shortage or distribution problem?
"That`s been the question of the year," says Barbara Burkindine, RDH, and KDHA president. According to the dental board, 38 of the state`s 105 counties have no practicing registered dental hygienist. Thirteen of these counties also have no dentist.
Dentists like to cite "full-time equivalency" (FTE). FTE is compiled by dividing the number of part-time workers by two and adding the result to the number of full-time workers. As of August, there were 975 hygienists working in Kansas; 382 work part-time. This indicates a FTE of 784. About 1,300 dentists were practicing in the state (roughly 100 part time for a FTE of 1250). After specialists (who do not hire hygienists) and other variables are considered, there are approximately two full-time dental hygienists to three full-time dentists in Kansas. According to the ADA, 40 percent of dentists nationwide employed two or more hygienists in 1995.
Robertson also refers to a 1994 needs-assessment survey for hygiene education in Kansas, completed by Renee Arnett, RDH, a dental-hygiene instructor at Johnson County Community College in Overland Park, Kan. The Bi-State Task Force on distance education (made up of representatives from dental and dental hygiene organizations and institutions) wanted to gauge the need for hygiene personnel and determine the feasibility of using hygiene distance education. Arnett received responses from 592 dentists.
- More than 50 percent indicated difficulty in finding a registered dental hygienist.
- Respondents indicated 209 potential full-time and 265 potential part-time openings for hygienists over the next four years.
- Respondents indicated 46 full-time (32-plus hours a week) and 132 part-time (less than 32 hours a week) positions currently open.
The KDHA counters with a 1997 Practices and Procedures Survey, compiled and analyzed by the ADHA Division of Professional Development. The report states there is no hygiene shortage: "While the distribution of hygienists is largely urban, that distribution is consistent with the workforce distribution of employers who are likewise concentrated in the urban areas of Kansas." The dental board reports approximately 41 percent of dentists have primary offices in Douglas, Johnson, Shawnee, and Wyandotte counties. Yet, these four counties make up only 31 percent of the population.
According to the ADA Survey of Dental Practice Employment of Practice Personnel (1995), the normal hiring ratio is two dentists to one hygienist. In 1997, the ratio of dentists to hygienists in Kansas was 1228:913, or 1.3:1. The survey stipulates Kansas actually had a surplus of 299 hygienists.
Kelly Chrouser, PhD, and ADHA manager of research, analyzed the survey and wrote up the findings. "There just aren`t employers (dentists) in rural areas," Chrouser says. "Many hygienists work part time and may have two positions. The benefits in rural areas have to make up for what`s lost coming from urban areas." In other words, hygienists should be guaranteed full-time jobs and benefits because other employment opportunities would not be available. Hygienists claim dentists like part-time employees and want to save money by delegating expanded functions to cheaper assistants.
But Robertson believes there also is a problem in urban areas. He notes that even some dentists in the heavily populated Kansas City area cannot keep up with consumer demand. "If one hygienist leaves and goes somewhere else, it produces a domino effect," Robertson says.
A century-long phenomenon may support both sides: urbanization. Rural populations will continue to decrease while urban populations will increase. According to population forecasts conducted by the Institute for Public Policy and Business Research at the University of Kansas and the state`s Budget Division (1994), 75 counties are predicted to decrease in population by the year 2030, while 35 will increase. The two areas with the largest number of dentists and hygienists (Kansas City and Wichita) can expect booming numbers. Johnson County`s population is projected to increase 85 percent by 2030 - 355,059 residents (1990 U.S. Census) to a projected 655,447 in 2030. Wichita`s Sedgwick County is projected to increase 21 percent - 403,662 to 488,891.
During the same period, 17 counties are predicted to lose more than 30 percent of their populations. Six of these counties (Clay, Cloud, Norton, Pawnee, Russell, and Jewell) have a combined 18 dentists and 6 hygienists (three counties have no hygienists).
Finney County in rural southwest Kansas is projected to increase 183 percent - from 33,070 to 93,517. At the time of the forecasts, Finney had 11 dentists and five hygienists.
While dentists and hygienists disagree on whether there is a shortage or distribution problem, most hygienists accept that rural areas are lacking hygienists. "I get calls from dentists out in rural Kansas looking for hygienists all the time," Burkindine says. "I think there is a shortage; but the ratios are within the recommended ratios. It`s not just a dental problem. There`s a lack of assistants, dentists, everybody ... because unemployment is very low."
Holt agrees: "There is a shortage in certain areas, but that happens everywhere." With the U.S. economy the strongest it`s been in two decades, there is not a large base of workers to pull from - especially unlicensed workers like dental assistants.
In documentation presented before the House Health and Human Services Committee, the KDHA reported the number of classified ads for hygienists and assistants in the Kansas City Star Sunday edition from July 1997 to February 1998 - 519 ads for assistants and 314 for hygienists. Although findings from one newspaper should be taken with a grain of salt, dentists are looking for personnel, whether it be hygienists or assistants.
Cindy Scott, RDH, and immediate past-president of the Johnson County Dental Hygienists` Association, also acknowledges there could be a distribution problem. "They (KDA) argued that there are 25 counties with dentists but without hygienists," she says. "But who knows? There might be more cows and pigs than people in those counties. Maybe dentists don`t want to work out there."
The solution is to open up more hygiene schools, not HB 2724, hygienists say. Denise Maus, RDH, and KDHA legislative chairperson, says future solutions might include independent/unsupervised practice. More hygienists could move to rural areas and more students would be drawn to dental hygiene.
Meanwhile, here comes the PDA...
The most important single argument against HB 2724 is public safety, hygienists say. They fear lower standards. "Allowing a person with minimal training/experience to perform these functions is not in the best interest of the public," Holt says. "It`s detrimental."
Robertson disagrees: "The educational programs set up (for assistants) ensure that they can perform the small portion of what hygienists are trained to do."
The dental board has written the rules and regulations to enpower dental assistants to coronal scale and polish above the gum line - once a board-approved instruction course is completed. Any nonlicensed person can polish above the gum line, as long as he/she is under direct supervision and has received "appropriate training" in polishing techniques from the dentist.
To be eligible for the board-approved instruction course, nonlicensed personnel first must meet certain prerequisites:
- Have six months` experience as a chairside assistant and have completed an ADA-accredited dental assisting program and dental assisting certification test, or have two years as a chairside assistant and have successfully completed a dental assisting certification test.
Assistants completing the course will obtain 90 hours of classroom and laboratory instruction, and they then must demonstrate clinical competency.
Shelly Douglas, CDA, and immediate past-president of the Kansas Dental Assistants` Association (KDAA), supports the bill and the board`s regulations. "I`m not concerned at all about any health risks by allowing assistants to scale," she says. "The training will be extensive. It`s not for just any assistant." Throughout the year, the KDAA worked together extensively with the KDA.
However, board vice president Seery disagrees. "I don`t think the current rules and regulations meet legislative intent. They are supposed to educate the assistants according to ADA Accreditation standards. There are no rules/regulations in the ADA`s standards to perform scaling. But I think taking a look at applicable guidelines from the Accreditation standards was not done."
HB 2724 requires that the unlicensed person have successfully completed training to coronal scale teeth "in a course of study approved by the board, which ... is consistent with American Dental Association accreditation standards..."
Seery also claims the rewording leaves ambiguity. In a few years, with turnover on the board rather high, new members might not understand how the current members interpreted the standards.
Scott says the advantages of hygiene training far surpass those of the regulations set forth for assistants. "Just go to a hygiene clinic and walk around and observe its setup," she says. "Everything is so professional. Each student receives individual attention from the teacher, who can observe his/her questions. In a busy dental office, is the dentist going to stop everything and help an assistant who`s having trouble with a certain procedure?"
To become licensed, potential hygienists must complete approximately 2,000 hours of education in a college-level program recognized by the Commission on Dental Accreditation, including about 600 hours of supervised, clinical instruction.
Hygienists point out that scaling above the gum line is purely cosmetic. Scott compares supragingival scaling to a glacier in the ocean. "You are told to break up the glacier by only scraping above the water. But you can`t do it unless you go under water as well. Or it`s like buying a new car. You take it in for its first six-month checkup and the shop washes and waxes but never looks under the hood.
"How in the world is the dental board going to monitor assistants using razor-sharp instruments in consumers` mouths? There`s no way - unless they`re physically standing over them. If there are 800 practicing dentists in Kansas, they will teach 800 different ways to perform these additional duties. There`s no consistency."
Yet, as a group, the dental board supported the bill. Its president, Dr. Estel Landreth, testified that he believed the quality of care would increase because assistants would be required to undergo training. During the 40 years the law wasn`t enforced, many assistants had no formal training to clean teeth, he argued.
Some hygienists argued dentists might not come in behind assistants and finish the cleaning below the gums. Dentists replied, nonsense, they cannot bill for only half a cleaning.
Good ol` politics
For the most part, the public and even some dentists were against HB 2724. With the letters and calls flooding in, some legislators still chose to ignore their constituents, Holt says. The KDA had more money, power, and resources in its corner. It spent about $30,000 for contract lobbyists and $15,500 for meals and other lobbying expenses. The KDHA spent about $10,000 on its attempt to oppose the legislation.
Hygienists believe the election-year aspect was influential as well. "Everybody is campaigning," Burkindine says. "Many legislators were led to believe these dental offices would close down. The measure is just sunsetting the issue."
Robertson calls the bill a "stopgap measure" to help alleviate the shortage of hygienists. "We said all along that hygienists would continue to play a critical role in dentistry," he says. "If they come up with a way to increase numbers by July 2001, the KDA members may be content to let the bill expire. But I can`t speak for them."
The public was surprised to see the legislation pass, hygienists say. "Of all my friends, colleagues, and patients, not one person has told me he would allow an assistant to clean his teeth," Maus says. "They want hygienists, not just anybody."
Perhaps not coincidentally, the president of the dental board happened to be the KDA legislative chair, causing a significant conflict of interest. With the bill supported by the state`s dental governing board, legislators were less likely to question the bill`s merits.
"I look at it as David vs. Goliath," Holt says. Dentists had already given hefty campaign contributions and had the support of legislators before the game started.
Burkindine adds, "We definitely were out-financed and out-powered. But that`s the same on the national level. The ADA has always had more power and money than the ADHA."
In the end, relations between the sides have been strained. Not so much on a one-to-one basis, but on an organizational level.
"Politically, there`s been a strain on relations," Burkindine says. "But we shouldn`t burn our bridges. They (dentists) are our employers."
"If we can put our heads together we can rise above the tension," Holt says. "I would like to think that as dental professionals we`re all concerned about the best interests of the public."
Some hygienists fear they`ll lose work to assistants. Others are concerned that students will be reluctant to pursue hygiene careers.
Holt, a hygiene educator at the University of Missouri at Kansas City, says there have been many questions about the bill from students. "Some are considering dropping out of the program," she says. "It could have a direct impact. It won`t help recruiting."
Perhaps a dentist`s comment in Arnett`s study four years ago told the story all too well. When asked to comment on distance education programs in rural Kansas, the dentist wrote: "Good luck with this. I don`t know if the political climate in Kansas dentistry will allow any more steps forward."
"Ad astra per aspera," Latin for, "To the stars through difficulties," is the Kansas motto. HB 2724 classifies as a "difficulty" for the field of dentistry in Kansas. Your state could be next.
David Eggert, a journalism student at Northwestern University, worked as an intern for RDH and Dental Economics magazines during the 1998 summer break.
Patty Seery, vice president of the Kansas Dental Board, poses in front of the state flag.
Classes on the wide-open prairie
All parties involved praise the opening of a hygiene school at Colby Community College in western Kansas. The Kansas Dental Association has given $15,000 to fund the new program, which is a distance-learning operation with North Central Technical College in Wisconsin.
North Central will downlink by video all its classes to Colby, where there will be an educator for the training and clinical part, says Kevin Robertson, KDA`s executive director.
Six students started fall classes in the two-year program. Once the program gets on its feet, the school hopes to graduate 12 students a year. The KDA also donated chairs and lab equipment.
"I`m hoping such a program could be started in the other community colleges throughout the state," Barbara Burkindine, president of the Kansas Dental Hygienists` Association, says. "It`s definitely a step in the right direction." Denise Maus, KDHA legislative chairperson, says Colby will help supply hygienists to that part of the state.
The problem is money. Where will funds come from in order to expand existing programs at Wichita State University and Johnson County Community College, or add more distance-learning programs like Colby`s?
Skeptical in the `Show-Me` state
Kansas dentists aren`t the only ones complaining about a lack of hygienists. Jake Lippert, DDS, executive director of the Missouri Dental Association (MDA), says there "absolutely" is a shortage of hygienists in Missouri. The MDA sent 135 surveys to dentists in north central Missouri. Of the 60 percent who responded, Lippert says all but two said they could not find a hygienist - 20 to 25 percent had been looking more than five years.
"Many [dentists] had just given up," he says.
"We want to increase the numbers through the community college system," Lippert adds. Missouri has three hygiene schools in Kansas City, Joplin, and St. Louis.
The MDA House of Delegates already has taken the directive of having lobbyists ask legislators for more money to increase class sizes. Resolution 98H-24 resolves that any efforts to address the shortage "must have the continued high quality standard of patient care as its first and foremost goal."
The MDA also appointed two councils to investigate and develop a five-year plan for alleviating the hygiene personnel shortage. The resolution calls for an outline to be reported back to the House of Delegates in November 1998.
Yet, as in Kansas, the 1997 Missouri Dental Hygienists` Association (MDHA) Practice and Procedures Survey, reports the state has a surplus of 289.5 hygienists. The ratio of dentists to hygienists is 2709:1644, or 1.65:1. This is within the recommended 2:1 ratio.
The survey analysis, also done by the ADHA Division of Professional Development, uses population to dental provider ratios from the U.S. Department of Health and Human Services, Division of Professional Shortages. It indicates an adequate population to dental provider ratio is 5000:1. Missouri`s 5,190,719 residents would minimally need 1038 dental providers, says the MDHA survey. Yet, 2,709 licensed dentists are listed with the Missouri State Board of Dental Examiners.
The survey`s explanation for why the state has "pockets of dentally underserved area":
- 10.6 percent of dental offices with at least one employed RDH accept Medicaid clients.
- There is an inadequate supply of dentists practicing in rural communities.
Kelly Chrouser, ADHA`s manager of research, who also put together this report, points to numbers similar to Kansas. Sixty-eight percent of Missouri`s population is in six metro counties (Boone, Buchanan, Greene, Jackson, Jasper, and the independent city of St. Louis) and 16 adjacent counties; 78 percent of Missouri`s dentists or dental employers are in the same areas. The report concludes hygienists "must work where there are adequate employment opportunities."
"The numbers were most beneficial to the dentists," Chrouser says. "They`re constantly in flux. I gave them the benefit of the doubt."
One question that arises is the ADA`s 2:1 ratio. Is it adequate? Lippert says it is. "What the MDHA doesn`t mention is how many of the licensed hygienists are working," he says. "The FTE is important. The MDHA is not being factual with their numbers. Quite a few of them work part-time as well."
Diann Bomkamp, RDH, ADHA district VIII trustee and legislative chairwoman for the MDHA, says the MDA resolutions sound good on the surface and the organization hopes they stay that way.
"We`re looking for ADA-accredited programs," Lippert insists. To ensure this measure, Bomkamp and the MDHA fought a few years ago for a provision in the dental practices act that hygienists must complete two years of training. The MDHA wants to ensure that sound hygiene education in Missouri means no preceptorship-type training (Alabama).
Lippert denies wholeheartedly that his organization is attempting to go the Kansas route. He says he doesn`t want what happened there to happen in Missouri. "But, if we meet resistance," he says, "it may come to that. I sure hope not. It doesn`t help for the hygienists to say there is no shortage."
Bomkamp looks at the number of dentists graduating from the one dental school for Kansas and Missouri - the University of Missouri-Kansas City. She says the school graduates about 75 dentists a year. The three hygiene schools in Missouri have roughly 80 graduates, she says. Of the dentists, about 15 become specialists, 20 to 25 leave the state, leaving about 45 who practice in Kansas and Missouri. "Are there enough dentists to go around?" Bomkamp asks. "We can`t go places without the dentists."
Bomkamp says it`s difficult to prove there are enough hygienists. "How many hygienists does each dental office need?" she asks. "Some need four, others need one."
Lessons learned in Kansas
Dentists, hygienists, and assistants all agree: If this can happen in Kansas, it can happen anywhere. "Give your legislators a name and face," Holt advises. "Personally make contact with them. Get your ducks in a row. Be prepared."
"Public support is important," Barbara Burkindine, president of the Kansas Dental Hygienists` Association, says. "Educate the public so they know the difference between hygienists and assistants. Develop a strong presence in the legislator before these problems arise. It`s tougher to gain support in the heat of the battle."
Cindy Scott, a Johnson County hygienist, said to be wary of ad hoc committees. Many promises were broken in Kansas the summer before legislation was introduced, she points out. "If you want to work together with dentists and dental boards, don`t go to meetings without expert advice," she says.
Holt says KDHA learned from its mistakes. She said the group, as a whole, had not been legislatively active before. "I think legislators wondered, `Who are these hysterical women coming out of the woodwork?` I don`t know them," she says. "Instead of being reactive, be proactive."
Denise Maus says KDHA has a lot of work to do in fall House campaigns. Governor Graves is up for re-election as well, she pointed out. "This will create an excellent opportunity to reach the public," she says.
