Liberating your skills

Sept. 1, 1997
`I would never stay in dental hygiene without variety,` one reader wrote in response to our survey about expanded functions. She sums up the sentiment of many hygienists who believe they are under-utilized when it comes to patient care.

`I would never stay in dental hygiene without variety,` one reader wrote in response to our survey about expanded functions. She sums up the sentiment of many hygienists who believe they are under-utilized when it comes to patient care.

Heidi Emmerling, RDH, MA

In your practice as a dental hygienist, do you perform expanded functions? If so, how do they affect your overall patient care, as well as your feelings about your profession? RDH asked readers last December about their thoughts on expanded functions. More than 320 readers responded to questions about:

- Specific expanded functions that are allowed in various states.

- Which expanded duties they would like to see implemented.

- What types of supervision requirements are preferred.

- The appeal of restorative procedures.

- How they feel about the expansion of dental assistants` functions into hygienists` scope of practice.

The overwhelming majority felt positive about expanded functions. Most of the comments were in the genre of saying the duties are timely and efficient, saving the dentist and the patient time. Expanded functions, according to readers, also decrease boredom and make hygienists more valuable employees.

Kathleen Lachance, a hygienist for 21 years, wrote, "I think that all functions that can be performed by hygienists should be. Hygienists are highly skilled and capable to perform all of these procedures. Hygienists like myself who have been in practice many years enjoy the variety of these various duties. Patients are very accepting of treatment by hygienists whom they know and trust."

Maryjean Penaranda, a Washington State hygienist, echoes this concept of trust: "Expanded functions maximize the use of my chair time and help build trust relationships with my patients. Also, expanded functions help me from experiencing burnout. My boss primarily does crown and bridge. His chair time is billed at prime rates. Doing amalgams and composites in my chair, in addition to prophys and root planings keeps patient costs down. Some patients specifically ask for me to do their restorations. They claim my injections are painless, and I`m gentler than the dentist."

Although most survey respondents embrace the concept of expanded functions, a few have reservations - mainly that expanded functions without expanded compensation is a problem. Kathryn Nathan Marcus, a hygienist with 32 years experience, writes, "Expanded functions let the dentist make more money and give me less time."

Joyce Maxwell Warren, another hygienist who has been practicing for 32 years, shares these sentiments: "Adding functions but no extra time compromises quality. Hygiene is exhausting and often grueling with little respect from dentists, staff, and, therefore, patients."

If you could, would you?

RDH posed the question, "Are there expanded duties that are allowed which you do not perform?" The answers were split fairly evenly with slightly more reporting they perform all delegatable duties. One hygienist writes, "My employer allows me to do all I can (plus some - I may be walking on the line here)."

Those who do not perform all allowable expanded functions had varying reasons. Many do not perform the functions aimed at restorative procedures, citing that it is more economical to use the dental assistant for restorative functions. The reason most frequently cited was that the hygienist stays busy doing preventive functions and does not have time to perform restorative duties.

One hygienist wrote, "I am restricted to mostly routine duties. The dentist`s uncertified dental assistant takes impressions, seats crowns, excavates decay, adjusts dentures, and more." Another writes, "The dentist feels he is the only one who can do these procedures properly."

One survey question specifically asked about performing restorative procedures. The question yielded an almost even split between those who would welcome it and those who were not interested. Many reflected the fact that hygienists are knowledgeable about the importance of properly shaped restorations, and we see the effect on gingival health of less-than-ideal restorations. Therefore, it follows that we should be the ones shaping the restorations.

Others felt that the increased scope of practice would hopefully increase our earning potential.

Still others find the variety appealing. Anne Wells, a hygienist with 22 years of experience from Washington State where this procedure is legal, writes, "I would never stay in dental hygiene without variety."

A hygienist from Nova Scotia in Canada said that restorative procedures allow for creativity and are personally satisfying. She adds that the variety helps prevent burnout. A 14-year veteran hygienist from Michigan writes, "I enjoy variety and do not want to be a `cleaning machine.`"

Some readers differed with the idea of hygienists performing restorative procedures. The reasons varied. Some don`t even like doing sealants, let alone amalgams. Some feel they are too old to learn restorative procedures. Some are concerned about it being too much like "assembly-line" work. Some don`t like amalgam, period. Some feel restorative procedures undermine our expertise in preventive dentistry.

One hygienist wrote, "Hygienists are soft tissue experts. What good does it do to follow the dentist around and do his work?"

Florance Thomas, a New York hygienist wrote, "I don`t feel that packing or carving amalgams will make a difference in the role of a hygienist, because you still need the dentist to prepare the tooth. What will make the difference is to be allowed to open up an oral hygiene office where oral hygiene techniques and education are provided."

Donna Gingsterblum added, "I have a master`s degree in dental hygiene. If I wanted to do restorative work, I would have gone to dental school instead."

Another expanded duty that is legal for some - yet often voluntarily not performed - is the use of nitrous oxide sedation. A California hygienist with 25 years of experience observed, "I refuse to do nitrous oxide for which I am licensed to administer because, one, it is a danger to me and, two, using it decreases my ability to communicate with or teach my patient."

Carolyn Young, a licensed hygienist since 1968 who also holds a Ph.D. in toxicology agrees. "Most patients can undergo most procedures without nitrous oxide. A soothing voice, good communication with patients, and excellent clinical skills are always better than nitrous oxide."

Ironically, when RDH asked which expanded duty would readers like to see implemented, nitrous oxide kept surfacing. More than 30 specifically mentioned they would like to see administration of nitrous oxide legal in their states. This duty was second only to administration of local anesthesia, which was on the wish list of a whopping 160 readers. Other duties mentioned include the ability to diagnose and plan treatment for periodontal procedures, the placement of tetracycline-imbedded fibers, the ability to lay flaps and place sutures, laser use, prescription of antibiotics and fluoride, placing, packing and carving restorations, pedo extractions, and curettage.

Penaranda, the Washington hygienist, wrote, "My fantasy is a one-year course in drilling amalgam and composite preps, not so much for my current setting but for my missionary and volunteer work. I understand hygienists in New Zealand can prep primary teeth."

Self-regulation still tops many wish lists

Although we may have these inspiring fantasies and wish lists, a New York hygienist with 19 years of experience wrote, "Unless hygienists are self-regulated it does not matter. It would be nice if all hygienists had the same practice laws and expanded duties. Reciprocity would be nice too. If hygienists would all be equal maybe employers would see us as a united force and would treat us more professionally. The patients would too. Hygiene to me is not only scaling but patient education as well. Root planing and curettage should be expanded functions for all hygienists. If we were allowed to practice in the manner we felt was needed for our patients, the care would be high quality."

Merry Johnson, a Nebraska hygienist with five years of experience writes that she would like to see self-regulation also. "The dentist is not a hygienist. Dental hygiene is a separate and distinct discipline. Therefore, hygienists should set our own highest standards."

Speaking of self-regulation, on July 1, Washington State hygienists delivered 272,764 signatures to the secretary of state for Initiative 678. The initiative will allow the voters to vote on self-regulation and independent practice on November 4. The significance of the SHOUT initiative (which is an acronym for Support Hygienists & Oppose Unequal Treatment) is that it demonstrates public support and sets a national precedent by placing these issues before the public. There are four components to this initiative:

- The creation of a dental hygiene board that will give the profession full self-regulation.

- Unsupervised practice of dental hygiene in all settings for the full scope of practice.

- Removal of the restriction on the number of hygienists that can be employed by one dentist.

- Require that dental hygiene services such as prophylaxis be performed only by licensed dental hygienists and dentists.

The initiative`s chairperson, Anita Munson, asserts, "We are closer now than at any time in the history of professional dental hygiene in Washington State to independent practice options and self-regulation." To contact the I-678 Committee, with much needed contributions or questions, write: The SHOUT Committee, 603 Stewart Street, Suite 604, Seattle, WA 98101 or call (206) 344-4130.

Independent practice is still desired

"Independent practice and dental hygiene state boards are what are needed to preserve quality dental hygiene," wrote Joyce Maxwell Warren of Michigan who has 32 years of experience.

Others agree. In fact, only about 15 respondents specifically stated they did not want independent practice. Those who are not interested in independent practice voiced the standard comments such as liking the "team" approach to dentistry and being concerned about the cost and liability of running a business.

More than half of the respondents reported that they would be comfortable with or welcome independent practice. Sandra Golay, an Idaho hygienist who has been in practice for 33 years writes, "I would be interested in independent practice. I hope to see it allowed in more states before I retire."

Most of the comments reflected the fact that hygienists are well-educated, licensed professionals with expertise in preventive care. Many feel they could deliver better patient care without feeling as if they have to compromise their standards. One hygienist added, "With independent practice I could deliver better patient care - no more 30 minute prophys."

The argument that it is necessary to have a dentist on the premises to handle medical emergencies just doesn`t wash for some readers.

Sandra McCoy, a Florida hygienist, wrote, "I have a BSDH, MS, MBA and 18 years experience so I would feel comfortable working unsupervised."

Marcus, who also is an RN with a master`s degree, concurs. "I am much better prepared for an emergency than some dentists."

Many readers also are offended at having to have their work "supervised." Theresa Graveen, a Michigan hygienist, wrote, "I don`t need a baby-sitter just because I am in a `woman`s` profession. If there is more I need to know, teach me. Even dentists started with no background, and they learned."

Another concern about supervision requirements is the message it sends to the public. "Hygienists are very intelligent and highly skilled people," wrote Carolyn Young. "To have to work under supervision of dentists (who actually depend on our patient evaluation and expertise) leads patients to think otherwise."

The role of the dental assistant

A year ago, at their annual session in Orlando, the American Dental Association passed several resolutions aimed at increasing the scope of practice for dental assistants. This should be a huge concern for hygienists who would like to see their profession remain intact since these resolutions, if passed at state levels, would make the dental hygiene profession virtually extinct.

The RDH survey asked readers whether dental assistants should perform expanded functions that are currently done by hygienists, such as coronal polishing, sealants, supragingival scaling, and using ultrasonics. Although an overwhelming percentage of readers emphatically stated their opposition to such an expansion, it was not unanimous.

One hygienist wrote, "I believe competence of the individual is paramount in any profession. I believe a dental assistant is a necessary partner in delivering care and some functions get them involved in treating patients which elevates their commitment and feel important."

Another hygienist noted that, although she doesn`t like the idea of assistants increasing their scope of practice into hygiene duties, she doesn`t blame assistants for pushing forward. After all, she wrote, that is exactly what we are doing when we look at expanded functions for ourselves.

Again, there were very few readers who felt expanding assistants` scope was a good idea. And of these, virtually all were adamant that expanded functions be allowed only after formal training and certification.

An Oklahoma hygienist wrote, "I have seen most assistants polish teeth incorrectly, leaving the rubber cup in contact with the teeth for too long and creating too much heat and irritation to the pulp. They do not know which grit to use. They most often use coarse which causes damage to the enamel. I have found that dentists ignore formal training for the expanded-functions dental assistant, and unskilled assistants are causing harm to patients. Even assistants who took a coronal polishing course are not polishing safely. They clearly do not understand the damage that can be done. I`ve already seen in many offices where dental assistants illegally clean children`s teeth."

A Wisconsin hygienist agrees. "After teaching a class on coronal polish to dental assistants, I`m against delegating any of the functions to dental assistants without proper education. Through the class that I taught, it was evident that dental assistants lack the dexterity or technique to perform even coronal polishing. It definitely takes the time and practice allowed in a two-year dental hygiene program."

In a 1996 publication by the American Dental Hygienists` Association titled, "Position on Polishing Procedures," ADHA took the position that only a licensed dental hygienist or dentist is qualified to determine the need for polishing procedures. Polishing should be performed only as needed and not considered a routine procedure. In the paper, ADHA points out that only about half of the states allowing coronal polishing by dental assistants require education or examination. Another concern is the potential for fraud by billing for a prophylaxis when only a polishing is performed.

Other reader comments in opposition to expanding assistants` duties were strong:

- "They are not even to work intraorally."

- "The day an assistant scales is the day I retire."

- "No! I am so sick of seeing dental assistants do sealants because they are so `easy!` Boundaries must be set and followed. So many duties are broken now in dentistry. My blinders on my eyes are only so big. Ethics were taught in our school. But when I got out in the private practice I see a breakdown everywhere. I`ve worked in different offices and it`s everywhere. I`d love to see OSHA show up or the dental society checking the dental assistants to make sure they are staying within their duties. I`m tired of being looked down on because I follow the rules."

- "When working with humans, one must have an established background such as dental hygiene or dentistry to include communications, anatomy, psychology, English, and the like."

Linda and Joe Cravens, a married couple who are both veteran hygienists, put it quite simply: "It is an insult to our profession and a danger to the public."

Heidi Emmerling, RDH, MA, is a consulting editor for RDH. She also is a writer, speaker, and clinician from Sparks, Nevada.

Under what type of supervision would you like to practice?

`I feel we should be under general supervision but trusted to use our education as a dental partner, not competitor.`

- Sally Eatherly, California RDH with 30 years experience

`New Jersey has a dentist on every corner. They try to hold us back because of greed. Money is the bottom line. We need autonomy.`

- Diane Katz, New Jersey hygienist with 61/2 years experience

`Independent practice is not for me but I believe in practicing in alternative settings without direct supervision.

- Jean Rice, California RDH with 161/2 years experience

`I would like independent practice. Hygienists are over educated to have a dentist-babysitter. RNs are allowed to have people`s lives in their care and they have the same education level we do.`

- Ellen Fein, NJ hygienist with 12 years experience

How do you feel about expanded functions for dental assistants?

`They don`t understand the medicine behind the mechanics and that disturbs me.`

- Sally Eatherly, RDH, California hygienist with 30 years experience

`Assistants are already overwhelmed and underpaid.`

- Nancy Nigro, MS, RDH, Massachusetts hygienist with 5 years experience

`They are already performing functions that I would not allow them to do on my family.`

- 14-year veteran of Michigan

`I did not go to college for fun! I was a CDA for eight years prior to hygiene school and don`t think assistants should be performing hygiene functions.`

- T.C. Funkhouser, Los Angeles hygienist with 16 years experience

`Let them go to hygiene school and get paid what they`re worth.`

- Florence Thomas, a NewYork hygienist with 31/2 years experience

`If we allow more, our needs become less and our worth is lesser and the 24 years it has taken me to get a good paycheck will be out the door.`

- Jean Tilley, North Carolina hygienist with 24 years experience

`Out of the question. Doctors already allow too many illegal procedures to be performed by auxilliary staff. This would open the door for further abuse. I am also a CDA and have been in the dental field for 17 years. I know what I`ve seen.`

- Marie Yuliano, New York hygienist with 51/2 years experience