Tiers for our trade

Oct. 1, 2002
A couple of months ago I wrote a column about a hygienist jailed for battery. The response to that column was amazing. People all around the country thought it was a real news story. It wasn't true ... yet.

A couple of months ago I wrote a column about a hygienist jailed for battery. The response to that column was amazing. People all around the country thought it was a real news story. It wasn't true ... yet.

The authentic essence of the piece is the fact that hygienists across this great land dance with catastrophe. Hygienists choose to diagnose and treat without the doctor's stamp of approval every day. For the majority of us, that's pretty risky.

Battery is a real charge. Some people just don't want to be treated, and that is their right. If they decline treatment, then we need to dismiss them from our practice, not treat them behind their backs. A dismissal letter will impact their oral health much more than tincture of steel. If the doctor doesn't diagnose periodontal disease when it's apparent, then a dismissal letter to the doctor from the hygienist also is in order. The permutations of the scenario in that column were getting busted for treating an unwilling patient, arraigned by the employer, litigated against by the insurance company for fraud, and more.

One concept comes to mind that should solve the whole thing — tiered hygiene.

Some people hate that idea. But in actuality, what they should hate is working next to another hygienist who has not seen the inside of a classroom since graduation 10 years ago. The kind who has not read a single research article, doesn't recognize periodontal disease, has forgotten how to take a blood pressure, and thinks a 6 is a PSR score. The hygienist whose patients — three years after she's been seeing them every six months — have black calculus in the 5mm sulcus on the upper anterior teeth. The concept of being a colleague of a hygienist who freely admits she's happy to have a job where she doesn't have to bring work home and earns a nice paycheck — the same income — should drive them nuts.

Every hygienist who brings home articles, production reports, volunteers time as a hygienist, spends time on the Internet researching topics and products, uses a computer for work-related activities, makes trips to medical and dental libraries, and participates on Internet lists should be following the rally cry, "Tiers for our trade!"

If a hygienist wants an "8-to-5" job, wants to polish teeth and never be challenged, then she (or he) should have one. Lots of patients don't need more than that. Invite that Class I patient to come in on Fridays. But on Monday morning around 9 a.m., some hygienists are ready for a week of challenges. Bring on the perio, the caries prone, the gaggers. Pile on the research; come with big new fresh ideas. Bring a conference, CE course, new instrument, new thought. There is more to dental hygiene than removing plaque and noticing tissue color changes. The Class I "prophy princess" cannot think she's a twin to that.

If I was Queen of the world, this is how I would do it.

• Tier One — The two-year degree would be an actual two-year degree. Twelve credits a semester for four semesters. No summers, no two-year waiting list where students take enough credits to whittle down the course requirements to be a manageable amount of hours for two years. The focus would be on prevention of disease: Class I prophies only and no sub calculus. She would study the chemistry of fluoride, enamel development and basic development courses of histology, embryology, chemistry, microbiology, oral anatomy, radiology, and preventive medicine as well as core courses of English, a foreign language, sociology, psychology and gym. She would graduate from an accredited school, maybe pass a state board exam.

In my world, these graduates could see only Class I prophies and take prescribed films. This hygienist would remove supra calculus, apply fluoride and be directly supervised by a dentist or executive hygienist. She could not work by prescription, do anesthetic, treat any disease (including periodontal disease), recommend products or be required to take continuing education. She would see people with "Friday teeth."

• Tier Two — Once the above hygienist gets bored, she can take the challenge and move forward in one of two ways. She can take formal courses in an accredited school to elevate her professional status. Or, she can take continuing education courses in treating periodontal disease offered by various groups throughout the year. After a certain amount of accumulated credits, actual chair time and passing a national exam, this hygienist could work her way up to treating periodontal disease. The orders, written by a dentist, periodontist, or executive hygienist would allow this level of hygienist a little leeway of free thought, within strict guidelines. This level would be called periodontal therapist.

• Tier Three — If the two-year degree hygienist wants more formal education, a third year could be added. Courses would include anesthetics, management skills, research reading, anatomy, physiology, corporate psychology, periodontology, pathology, communication, writing, atraumatic restorative therapy (ART, removing decay without a rotary instrument and restoring biologic dimensions with glass ionomer), tooth morphology, art of medicine, preventive medicine, and public health.

She would pass a national board exam that would allow her to work in any state. This hygienist could develop treatment plans and work under general supervision. She could not deliver anesthetic without the doctor present, or make decisions without contact with the dentist or executive hygienist. This degree would mirror the inflated two-year degree that is available now in many states. The employment of these hygienists would tax the dentist in a way to which they are already accustomed. The doctor is ultimately responsible.

• Tier Four — The next level of hygienist would be a baccalaureate degreed hygienist, or executive hygienist. Education core would be the same as the three-year degree mentioned above. This advanced dental hygiene degree would allow the hygienist to oversee the first two levels of hygiene. This hygienist could determine the level of treatment each patient would need, relieving the burden from the dentist. She could place ART, treatment plan perio cases, contribute to research projects, and deliver anesthetic with the dentist on the premises.

This hygienist could specialize by formal education in perio, pedo, public health, preventive medicine, cariology and systemic disease links. This level of hygienist could also teach, if so inclined. In the private office, this hygienist would take on the leadership role in prevention; she would oversee the hygiene staff, relieving the burden of a doctor willing to relinquish those duties. She would publish regularly as part of her licensure requirement. This would eliminate the need for required continuing education. She could not open her own practice.

• Tier Five — A hygienist with a master's degree probably would not work in private practice — we'll call her an administrative hygienist. This level hygienist would work in public health, or in other institutions under physicians' or dentists' orders. The orders would be vague, like oral care. This hygienist would work independently in the access problem areas, such as hospitals, pediatric offices, long-term care facilities, and inner city clinics. Education would be focused on grant writing, advanced prevention techniques, bureaucracy, red tape, nursing core classes, and some level of diagnosis. This hygienist would be able to develop and oversee research projects, as well as nursing staff in the institutions. She would also have a requirement to publish original research on some schedule to retain licensure.

• Tier Six — A hygienist with a doctorate would be like a 400-pound gorilla — she could do whatever the heck she wanted except for fancy restorative procedures.

The model of nursing

I really see our profession so very different from dentistry. Our goal is to maintain health; we don't need active disease to provide care. The dentist's focus is on filling holes, whether it's a hole in a tooth or arch. Education does not make a good hygienist. Anyone with money can further their education and not know that fluoride works on the smooth surfaces of the tooth better than the pits and fissures. Tiered dental hygiene will help identify those with a passion for their career and charlatans will become exposed.

Classification is not going to divide the ranks. It will bring us together. It will allow for professional growth. More than that, it will allow for better patient care. Imagine if a certified nursing assistant's payscale was the only compensation available for all nurses. Or imagine if their level of autonomy was the only type available. Why would anyone be a BSN, nurse practitioner, physician's assistant, or even an associate degree nurse? How could physicians stand the pressure? Glory is one thing, but it doesn't pay the rent, and people with a single year of education cannot be expected to provide all of the advanced care procedures that the different level of nurses render to their patients.

Nursing is a good model, if not perfect. Using what they have learned, we can build a ranking that is supportive and facilitates harmony. Educators would be charged with making sure spitefulness was dealt with harshly. Nurses often talk about "eating their young," about not helping them, not respecting them and treating them as if they were totally uneducated. If done right, we would have none of that.

Tiering hygiene would allow hygienists to deliver care at the level of their interest. Those hygienists who demand an hour per patient, yet spend 20 minutes of each hour on the phone or chatting with co-workers, would be held to task. A hygienist only willing to be available for patient care from the time she clocks-in in the morning until Miller Time shouldn't have the same level of pay, respect or responsibility that another hygienist might have.

Tiered hygiene's time has come. The more we fight it, and lump all hygienists together as interchangeable pieces, the longer we give marginal care to patients who deserve better. The longer we put it off, the closer the story of Patti Doe and her litigation with the Big Bad Insurance Company comes to reality. Will tiered hygiene protect the public? Maybe. Will it protect hygienists? Sure thing.

Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected].