The ADA continues to define dental hygiene; Do their actions match your definitions?

The American Dental Association met in Washington, D.C., last October for its annual meeting. Though it may not come as a surprise to many of us familiar with ADA goals, organized dentistry has officially come out in support of the establishment of non-accredited dental hygiene programs, as noted with the adoption of Resolutions 42, 97, and 99.

Heidi Emmerling, RDH, MA

The American Dental Association met in Washington, D.C., last October for its annual meeting. Though it may not come as a surprise to many of us familiar with ADA goals, organized dentistry has officially come out in support of the establishment of non-accredited dental hygiene programs, as noted with the adoption of Resolutions 42, 97, and 99.

Resolution 42 rewords the ADA Comprehensive Policy Statement on Dental Auxiliary Personnel (italics are changes):

"Dental hygiene education programs are designed to prepare a dental hygienist to provide preventive dental services under the direction and supervision of a dentist. Two years of study, or its equivalent in an education program accredited by the Commission on Dental Accreditation, typically prepares the dental hygienists to perform clinical dental hygiene services. However, other programs, accredited or otherwise, which utilize such methods as institutionally based didactic course work, in office clinical training or electronic distance education can be an acceptable means to train dental hygienists.Boards of dentistry are urged to review such innovative programs for acceptance."

Several things come to mind here. First, should hygiene programs be merely designed for the sole purpose of "training" hygienists to "provide preventive services under the direction and supervision of a dentist?" This clearly spells out their intent to not educate hygienists in areas of unsupervised or independent practice. It also indicates their intent to discourage hygienists from working independently in nursing homes, for example.

Secondly, note the emphasis on "innovative means," which bypass accreditation.They cite "in-office training" as an acceptable means for entry into the dental hygiene profession.

Resolution 99 builds on this (italics for emphasis):

"Resolved that the American Dental Association House of Delegates urges the Commission on Dental Accredi-tation to review existing standards for dental hygiene educational programs, with a view toward establishing additional standards, specifically directed toward the development and recognition of nontraditional programs which satisfy curricular/outcome standards, but utilizing such methods as institutionally-based course work, in-office clinical training, and/or electronic distance education."

Again, note the emphasis on "non-traditional programs" and "in-office training."

Resolution 97 states:

"Resolved that the appropriate agency of the ADA develop an easy-to-follow, step-by-step guide on how to become an accredited hygiene program which includes, but is not limited to, basic curriculum and clinical training guidelines, and operations models and be it further resolved that this workbook be made available to constituent and component dental societies, educational institutions, and others to provide the appropriate mechanisms for meeting the personnel needs of the dental care delivery system."

This might not sound alarming until you realize that this resolution (as well as the other two) was made regardless of establishing the need for more hygienists. They already have increased the number of hygienists by endorsing for-profit institutions with policy and cash. They stood by while academically founded four-year degree dental hygiene programs have folded.

Again, there are several effects here. First, with more institutions, more hygienists are produced. If they are produced via an "accelerated" or "innovative" program, it would seem there would be less focus on education and almost a complete focus on mechanical skill (and it is definitely arguable whether the "training" for these "skills" is adequate). Hygienists can graduate quicker and in larger numbers. The ADA feels it is critical to produce more hygienists and this "critical need" is justified on the shoddy assumption that there is a shortage of hygienists.

For some reason, the ADA feels that there should be 1.5 hygienists for every dentist, since this is what the Alabama preceptorship model yields. However, when you consider the number of oral surgeons, endodontists, and other dentists who for some reason or another do not employ dental hygienists, the numbers show that only 68 to 69 percent of licensed dentists hire dental hygienists. Most of those that employ hygienists do so part time since most practices cannot support a full-time hygienist. Therefore, the effect of these resolutions will result in downward pressure on the labor market and wages of dental hygienists.

The other effect of these resolutions is increasing proprietary control over dental hygiene education. It is much easier to have control when hygienists are "trained" in a proprietary institution or an in-office institution than in a community college or university. Thus, these resolutions were based on greed and control, not need or quality of care.

Now is the time to take a critical look at how we see ourselves. Is dental hygiene just about technical skills like scaling and polishing or can it evolve into a more professional, perhaps more academic discipline? It has been common practice to view dental hygiene as mechanical, focusing on the physical, clinical skill of scaling and polishing.

When we were in school, we were graded on how much calculus we could remove in a set amount of time, how smooth we could get the roots, and how much stain we could remove. We were graded by focusing on errors, which made clinical hygiene measurable. The trouble with this paradigm is that it is built on a set of questionable assumptions:

- That a hygienist has a fixed repository of clinical blunders that can be pinpointed through repetitive clinical exercise.

- That repetitive exercises will result in the mastery of dental hygiene.

- That clinical skills, apart from an academic context, can make for a great hygienist.

- That correctness has to do with the ability to choose between a Gracey and a universal curette.

When hygienists are viewed in this pseudo-scientific way, hygiene gets defined in very limited terms that one performs merely to make a living. This perception has yielded ADA Resolutions 42, 97, and 99. Preceptorship is a base skill that is stripped of its art and complexity - a skill that, in fact, looks and feels basic and fundamental. It`s a skill that doesn`t belong to a professional or academic. There is a lot to question in this definition of a hygienist.

Do we possess more than second-class skills?

Let`s look at the distinction between a skill and a body of knowledge. If we discuss hygienists as mere possessors of clinical skills, then we will remain technicians. In current, research-based university settings, this is the kiss of death. Last June, our professional organization, the ADHA, adopted "research-based practice." Therefore, it seems we do not see ourselves as mere technicians but, indeed, possessors of knowledge.

It is true that we commonly use the word "skill" in ways that suggest a complex activity and rich knowledge. We praise the interpretive skills of a literary critic, the diagnostic skills of a physician, and the interpersonal skills of a clinical psychologist. We imply a competence that is more in line with obsolete definitions that equate skill with reason and understanding than with the more common definition of the American Heritage Dictionary (an art, trade, or technique, particularly one requiring use of the hands or body).

By current definitions, then, a skill is absolutely necessary, yet "second-class." It is not an integrated body of knowledge but a technique, something acquired differently from the way one acquires knowledge - from drill, practice, procedures that conjure up the hand and the eye, but not the mind. To view dental hygiene as a skill reduces the possibility of perceiving it as a complex ability that is continually developing as one engages in new tasks with new materials (which means we can go beyond the "supervising dentist").

Another paradigm is the myth that if we can just do x or y (managed care, preceptorship), then our problem will be solved. Down the road, dentistry, along with dental hygiene, will be able to return to its "real" work. Like any golden age or utopian myth, this myth assures its believers that the past was better or that the future will be. The turmoil we are currently in will pass. The source of the problem is elsewhere, someone else`s fault. As a result, it can be ignored or temporarily dealt with until the leaders of organized dentistry or politicians make the changes they must make.

The myth then serves to keep certain fundamental changes at bay. It is ultimately a conservative gesture, a way of preserving the status quo. The presence of this myth does not allow hygienists to be thought of in terms of the whole health care system. Thus, the myth allows the final exclusionary gesture: The problem is not ours in any fundamental way; we can embrace it if we must but with surgical gloves on.

Basic modifications in our educational philosophy, institutional purpose, and professional training need to be more fully considered. Let`s peel these gloves off.

Heidi Emmerling, RDH, MA, is a consulting editor for RDH, a writer, speaker, and clinician from Sparks, Nevada. Her e-mail address is heidi@unr.edu.

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