Dentist, hygienist team up to provide access on remote Maine island
by Regina Dreyer Thomas, RDH, BS, MPA
It's not every Maine dental hygienist who takes a ferry to work, but RDH Laurie Thompson likes the challenge of driving an hour from her home on the mainland to the ferry slip in Rockland to catch the 7:00 a.m. nonstop ferry ride to Vinalhaven, Maine's largest offshore island community. Here's where she and her mainland employer, Dr. Catherine Bunin-Stevenson, work different days in the island's medical/dental center as Maine law allows unsupervised dental hygiene practice.
Dr. Catherine (as her patients and staff call her) was the state's first public health dental hygienist in 1998, but relinquished that role at the FQHC (federally qualified health center) in Vinalhaven once she became a dentist. Now Laurie serves as the public health dental hygienist in Vinalhaven. There are 18 FQHCs in Maine, and more than 1,000 nationwide, the main purpose of which is to enhance the provision of primary care services in underserved urban and rural communities. This means that the Vinalhaven FQHC -- as all others -- accepts people who are uninsured, underinsured, those who have insurance, must serve all income levels, and must offer a sliding fee scale.
How it all came about
When Dr. Catherine was a hygienist, she saw a need for dental care on the island, and joined forces with two other Maine hygienists to initiate legislation to reopen the long-dormant clinic for prevention purposes as a service to the community. Their efforts paid off, legislation was passed, and the then Catherine Bunin became the state's first public health hygienist. The problem was there was no continuity of care since dentists did not come to the island on a regular basis to treat the people Catherine saw.
"I had a bunch of X-rays and met regularly with several dentists, but their involvement soon petered off," she says. To counter this, she became a dentist, a formidable task given the four-hour daily commute to Boston for four years, having a new baby, and a husband who was less than thrilled by this turn of events. Fortunately, with support from the established dental community and federal resources, the dental part of the clinic was reopened to join with the medical portion to become the Islands Community Medical Services/Islands Community Dental Services, Inc.
Laurie became involved in the dental clinic while waiting for Dr. Catherine's private practice to open on the mainland. "I was temping," she says, "and the hygienist at the medical/dental center was leaving. Dr. Catherine brought me out there to be interviewed by the administrative director of the medical center, and they hired me. I like being a public health hygienist and practicing with indirect supervision," she says. "I feel very trusted."
In addition to her dental hygiene license, Laurie is also certified as an EFDA -- an expanded function dental auxiliary. This designation allows her to perform certain procedures under the direct supervision of a dentist. For example, an EFDA can place and remove rubber dams and matrices; place and contour amalgam, composite, and other restorative materials; apply cavity liners and bases; cement provisional/temporary crowns and bridges and remove excess cement, in addition to many of the traditional procedures performed by a registered dental hygienist. The EFDA designation is assigned to both registered dental hygienists and certified dental assistants who have completed training in a school or program approved by the Maine Board of Dental Examiners. The course consists of one weekend a month for an entire year along with on-the-job training with a supervising dentist and testing by the Board.
A little known fact is that Maine has more designations, or categories, of dental auxiliaries than any other state. There are dental assistants, expanded function dental assistants, noncertified dental assistants, certified dental assistants, regular dental hygienists, public health dental hygienists, hygienists who are practicing independently, and even dental laboratory technicians and denturists, each with their own set of defined procedures.
Laurie points out that she can do more for patients as a hygienist than an EFDA because the dentist does not have to be in the building, although she admits to preferring the restorative aspect over the perio.
"When I see pockets more than 5 mm, I refer them to a periodontist. When Dr. Catherine is around, whether on the mainland or the island, I do an equivalent amount of restorative."
A recent patient review on the private practice Wiscasset Dental website attests glowingly to Laurie's interest and talent: "Laurie always greets me with a smile and asks me how ‘it's going' before she even begins to prepare me for treatment. She was exceptionally careful to shape my new lower front filling for a comfortable fit against the overbite of my top teeth, an artistic feat!"
A typical day on the island
In her one day a week working on the island, Laurie sees between 10 to 14 patients. Her daily schedule is filled up to at least 10 patients of all ages, taking about half an hour for a child and 45 minutes for an adult unless they need X-rays. "I usually go in the day before Dr. Catherine. Then when she comes in the next day, she reviews the X-rays and charts, unless it's an emergency, in which case I email the X-rays to her." (Dr. Catherine believes that many dental emergencies can be handled by antibiotics and pain medication until she can get to the island to treat the patient.)
When asked if she goes into the one K-12 school on the island, Laurie says, "I have but it's easier for the kids to come to the clinic as there's not a good setup at the school. We usually get a grant for sealant placement, and we give sealants to all second-grade children on their six-year molars after their prophies." In addition, the Center's dental assistant goes to the school to lead a fluoride mouth rinse program.
Laurie says she wouldn't work in a public health setting where there wasn't a dentist. "People don't always understand that I can't diagnose X-rays or do certain procedures. If I say to a patient, ‘This tooth doesn't look right to me. You need to have the dentist look at it,' I get ‘Okay,' but then they don't keep their appointment with the doctor and show up six months later for a prophy. I tell them, ‘I will clean your teeth today, but not anymore until you see Dr. Catherine.' Then I get, ‘I just want to get my teeth cleaned; I don't want to see the dentist,' whereupon I say, ‘This isn't a beauty parlor; you can't just get your teeth cleaned and move on!' Total dental care is still a hard sell for some people on the island," she says with a slight edge of impatience.
She says that when she's in the car to get to the ferry, people will stop her and say things like, "I have a tooth that's bothering me." She yells back, "Make an appointment with Dr. Catherine!" One fisherman wanted her to pull a diseased tooth of his. "I can't pull teeth," Laurie tells him, and he responds, "I'll never tell a soul, I swear!" Others will wait until they're in excruciating pain or with an abscess, whereupon Dr. Catherine -- if she's not on the island that day -- will work by phone with the nurse practitioner and/or the physician's assistant who can do incision and drainage and prescribe antibiotics and pain medication. The prevailing ethos of the island is to pitch in to do whatever needs to be done. Such stories seem to be typical of the nature of these hard-working islanders.
Weather can be a blip in the Center's productivity but not a serious one. Laurie explains that once she arrives in Vinalhaven via the ferryboat, an employee from the Center who lives on the island picks her up at the ferry slip in time for her first patient at 8:30. The run is reversed in time for her to catch the 4:00 back to the mainland. But if a snowstorm is brewing on the island and the ferry isn't running, what does she do then? "I put my spare pair of undies in my pocket," she laughingly says, "and come to visit Mama Sherry [Dr. Catherine's mother who lives on the island] for the night!"
Apparently such an event doesn't happen frequently, as the islanders know intuitively whether the boat will go or not. "They'll say, ‘A storm is coming; we'd better get you on the 1:00 ferry.' And they'll always be right. The reverse also happens. By the time I see the ferry terminal shut down, I'm already in Rockland after an hour's drive. So, I just turn around and drive back home."
On the mainland
Laurie usually works three, occasionally four days a week in Dr. Catherine's private practice in Wiscasset. "I'm not as excited about perio as I am about restorative. When I assist Dr. Catherine during extractions, you'd think I was doing the job. Fortunately," she says, "there are other hygienists in the practice who enjoy doing perio, but all pockets over 5 mm are referred to the periodontist." One wonders if there's any chance of Laurie's going to dental school as her employer did? "No," Laurie says, "I already made one career change. I really don't want to make another as I'm happy doing what I'm doing here and on the island."
Laurie contends that hygienists currently have difficulty finding employment in Maine because of the economics of the time, a common refrain heard virtually nationwide. Dentists are seeing fewer patients, which means they end up doing the work of hygienists. "They can't work without their assistants," she says, "but they can work without their hygienists -- unless they're EFDAs," she quickly adds. "If my book starts to slip a little, I can usually fill it up with EFDA. It's a win-win situation for both Dr. Catherine and me."
A unique school service program
A dental care project initiated by the Wiscasset practice in the Brunswick, Maine, school system will be repeated again as the pilot program was so successful. "We're the Dental Explorers," Laurie says. "We go into schools with all our portable equipment. That means a light, chair, unit, handpieces, compressor, a digital X-ray unit, intraoral cameras, preventive and restorative materials, the laptop for entering data -- the works! We clean teeth, take X-rays, assess the children, and conduct oral health education. Then Dr. Catherine comes in to do the exams and restorative work."
Which children are eligible for this unique program and who pays for it? The answers are quick and easy: all ages for those who don't have a primary care dentist are eligible for care, and the profit made from the insured groups covers the cost of those children uninsured. In this way the program pays for itself, a necessary fact since there are no grant or federal monies supporting this undertaking. In itself, this is most unusual. Dr. Catherine sums it up by saying, "We cover everybody regardless of ability to pay. My personal belief and commitment is that no child should lack dental care because of lack of funding."
An interesting note about this program that one would not expect comes from some school nurses who "don't get it." Of dental care, they'll say, "Oh, that's not important," and reject the program outright, or school administrators who say, "We don't want children to associate school with pain" (needles), to which Laurie mutters under her breath, "and what about the kids who have caries as big as my fist? You mean they don't have pain?"
To sum up, this dynamic duo would go to the ends of Maine's earth to bring dental care to those who need it. They cite some interesting forays into remote Maine islands, accessible only by air.
But that's another story. RDH
Vinalhaven is a working island 12 miles off the coast of Maine with a year-round population of 1,200 that can swell to several thousand visitors during the summer months. Its harbor is home to one of the world's largest lobster fishing fleets. Since there is no bridge to the island, it is only accessible from Rockland via a ferry ride across West Penobscot Bay, or by air taxi from Knox County Regional Airport.
There are ten major fishing grounds around Vinalhaven that the island's fishermen have used for centuries to capture such groundfish as cod, haddock, pollock, hake, scallops, and halibut. Shrimp, dogfish, mackerel, and herring are also abundant in the waters around Vinalhaven, but it's primarily lobster that most people associate with the island.
High-quality granite was discovered in 1826, and the island became one of Maine's largest quarrying centers for the next century. The pinkish-gray Vinalhaven granite can be seen in the State Department Building in Washington, New York City's Brooklyn Bridge, the foundation of the Cathedral of Saint John the Divine (also in New York City), and the Union Mutual Life Insurance Building in Boston among many others.
REGINA DREYER THOMAS, RDH, BS, MPA, is a retired dental hygienist who writes and presents programs on love and aging for health-care professionals. Her book, "Love & Successful Aging When You're 70+ and Single," is available in both print and as an e-book. To contact her, visit her website at www.loveat70.com for direct links to amazon.com and barnesandnoble.com, or email her at [email protected]
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