The tenacious hygienists from Washington state

June 1, 1998
In your April 1998 issue, the letter from Nancy Randall of Clarkston, Wash., caught my eye. She discussed her opinion regarding the Washington state Initiative 678 for unsupervised dental hygiene practice sponsored by the SHOUT committee, which went to the voters last November. I, too, am a dental hygienist and wholeheartedly supported the initiative. I would like to respond to Ms. Randall`s comments and specific issues she brought forth in opposition to the bill.

Dear RDH:

In your April 1998 issue, the letter from Nancy Randall of Clarkston, Wash., caught my eye. She discussed her opinion regarding the Washington state Initiative 678 for unsupervised dental hygiene practice sponsored by the SHOUT committee, which went to the voters last November. I, too, am a dental hygienist and wholeheartedly supported the initiative. I would like to respond to Ms. Randall`s comments and specific issues she brought forth in opposition to the bill.

I have worked in the dental field for 35 years as an expanded duties assistant, a receptionist, and a lab technician. My last 10 years have been in dental hygiene after my eldest daughter and I graduated together as dental hygienists. My youngest daughter is currently an expanded duties assistant and attending college prerequisites for dental hygiene.

In my years in the dental profession, I have known many dedicated hygienists who are truly professionals. Their main concern was the welfare of their patients. As a hygienist, I have been a member of the Washington State Dental Hygienists` Association and, through the years, have attended various scientific sessions and houses of delegates. The hundreds of hygienists who helped organize these functions take their roles very seriously. As 1990 vice president of WSDHA, I worked with very talented and dedicated hygienists. They sacrificed much to provide quality continuing education courses for the annual scientific session. For three years, I was a temporary examiner for the Washington State Department of Health during the June and September dental hygiene boards. As an examiner, I had a great admiration for those hygienists who gave so much of their time to assure that the dental hygiene boards were not only fair but, above all, protected the health and welfare of the public.

It was those very same hygienists who supported the initiative and worked long, hard hours on the streets gathering signatures to put the bill on the ballot. One recently retired hygienist, Bertha Dasher, donated all of her savings to support the bill for the sake of the profession, even though it would not benefit her directly.

In Washington state, the dental hygiene profession has come a long way since its initial inception. Through the years, anesthesia, restorative, and general supervision have been added to the scope of practice along with the dental hygiene practice acts.

For five years, I had my own contract dental hygiene "business" while working part-time as an employee in another general practice office. As a contracting dental hygienist, I saw patients for periodontal hygiene care through a referral base provided by the dentist from whom I rented office space. The contract we both signed also provided a supervision clause for state law purposes.

I was able to provide high-quality periodontal initial therapy and follow-up maintenance at almost half the cost other offices were charging for the same procedures. Our "cure" rate for periodontal disease was over 95 percent. The rent I paid the dentist was substantial and included building and equipment. I paid all other overhead costs of supplies, instruments, clinic supplies, and handpieces, along with providing all necessary billing and clinical charts. The wage I made in my own business was equal to or higher than employee status, and I had the luxury of setting my own schedule with much longer appointments.

I also incorporated other valuable "no fee" procedures into my care for the patient. Because of scheduling constraints and more costly overhead expenses necessary to operate a general practice office, I could not add these procedures to my already busy schedule as an employee hygienist. During that time the "supervision" stigma was ever-present, and I finally chose employee status only. I now am enjoying my new grandchildren and don`t feel a need to operate my own business at this time.

The dental and dental hygiene professions are doing the public a great injustice when hygienists could provide quality dental hygiene care at a more reasonable cost, but are limited to where it can be provided under current state laws. Taking the contract hygiene concept one step further with unsupervised practice would only enhance patient care, not dilute it.

I don`t believe the majority of hygienists who supported the initiative claimed that unsupervised practice was more safe for a patient than in a dentist`s office. It was the dental profession that claimed it was unsafe for a hygienist to practice in her/his own office or another setting without a dentist. That claim is simply not true. I have worked in practices where the dentist did not keep up with current protocol and did not allow his staff to utilize appropriate disinfectant procedures. I have also witnessed a dentist unsure of proper procedures in an anaphylactic patient reaction which required the dental hygienist to perform the necessary procedures. I`ve witnessed child abuse by a dentist; overdosing of anesthetic by a dentist; sexual harassment by a dentist; and drug abuse by a dentist. Not to mention the many poorly done crowns, bridges, extractions, fillings and root canals performed by dentists. I refused to continue to work in such offices. In Washington state, dentists are not required to attend continuing education to perfect their skills or learn new techniques. Dental hygienists, on the other hand, are required to show proof of 15 continuing education credits which specifically qualify for dental hygiene, along with CPR, to renew their yearly license. The dental hygiene profession has a proven safety record, but the record doesn`t speak so well for the dental profession.

I agree that the drug application portion of the bill was not clearly defined and probably wasn`t necessary. It is my understanding that those drugs we currently use to provide dental hygiene care were the drugs intended. That would include fluoride, chlorhexidine, and amoxicillin for premedication purposes. Dental office concentrations of fluoride can now be found in over-the-counter toothpastes; over-the-counter chlorhexidine can be mixed with mouthrinse at the same concentrations used in the dental office; and amoxicillin can readily be bought legally without a prescription in Mexico and Canada at the same dosages necessary for dental procedures. Even anesthesia necessary to perform dental hygiene procedures can be accomplished using the new anesthetic patches.

I don`t believe working with a dentist in a dental office has increased my dental hygiene skills as they pertain to preventive care, but my continuing education courses have. Dentists do not generally focus their attention on dental hygiene procedures.

On the contrary, one dentist asked me how I was able to get profound anesthesia with one cartridge when he always had to use two. Another asked me what I did to take vertical bitewings. I told him I just turned the bite tab around. As an employee, I currently do restorative procedures, and I most certainly have learned a great deal about dental restorative materials and their application from the dentist. But that is his expertise, and dental hygiene is mine.

Dental hygiene training is not dental training and vice versa. Initiative 678 was not about dental restorative procedures. It was about dental hygiene procedures and access to care. A true professional dental hygienist will perform his or her duties well in any setting, whether it be in a dental office, in a nursing home, in a school, or in the jungles of Africa.

The reason more hygienists do not work in health care facilities allowed by existing law is because the law is still too restrictive in its scope to be practical. Portable equipment must often times be used, and dental supervision continues to be an issue. I believe Ms. Randall would have to admit that it doesn`t make much sense to provide dental hygiene care to unhealthy people in certain settings and not be able to provide the same type of care to unhealthy people in other settings.

I`m very familiar with Clarkston, Washington, where Ms. Randall lives. My great-grandparents, grandparents and parents were raised in that area, and I have visited the city often. Clarkston has a high Indian and migrant worker population because of the local Indian reservations and commercial farming. The people of that small city, along with its bordering city of Lewiston, Idaho, would benefit a great deal from having dental hygiene clinics available. Surely, she is aware that very few dental offices take dental welfare coupons, and folks in farming communities seldom have dental insurance.

I have attended legislative day for dental hygienists at the Washington state legislature for many years now and fully understand the political games that are played between the dentists and certain members of legislative health care committees. The majority of legislators, the Washington State Board of Health, and the Washington State Department of Health support the dental hygiene bill. It takes only one man in a health care committee to stop a bill from going forward.

Initiative 678 actually did quite well at the voter booths even though it did not pass. Virtually all of my patients voted for the bill. The dentist I am employed with supports the bill because he sees a great advantage for his practice and all dental practices with the passage of such legislation.

It is my sincere hope that I have helped Ms. Randall open her mind and heart to other dental hygienists in Washington state who have given so much to their profession. Some have even put their jobs on the line in support of a bill that would benefit us all. These hygienists are very concerned about the welfare of the public and the profession of dental hygiene. With the ADA pushing for preceptorship dental hygiene and HMOs coming to the forefront, unsupervised practice may be the only way to save our profession in Washington state in the future.

It is also my sincere hope that those who worked so hard for Initiative 678 will continue to perfect the bill, so that no matter what scare tactics the dentists may use, the public will be well informed and well prepared to vote "yes" the next time around.

I look forward to reading RDH and the excellent educational articles you provide for the benefit and enhancement of the dental hygiene profession. I also want to thank you for the press coverage you gave Initiative 678 in order to inform dental hygienists across the nation of the challenge and heartbreak experienced by the SHOUT committee and those who supported the bill.

A word we use often in dental hygiene circles is "tenacious." I believe that word best describes Washington state hygienists who continue to work so hard and give so much for the preservation of their profession and the public health and welfare of our great state. Thanks for all!

Carol Levanen, RDH

Vancouver, Washington