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The audacity of hope

Jan. 1, 2007
Some of the most carefully planned vacations can be idyllic in unexpected ways, and our recent trip to Cape Cod was just that and more.

Some of the most carefully planned vacations can be idyllic in unexpected ways, and our recent trip to Cape Cod was just that and more. A dear friend of mine, who died recently of uterine cancer, traveled the world and always told me to be sure to visit Nantucket. When I couldn’t decide on a birthday present for my husband of 27 years, I remembered my lifelong friend planning a surprise birthday trip for her husband, and I borrowed the idea.

The Nantucket harbor, a scene of rebellious and independent thinking during America’s history.
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Off we flew to Providence, R.I., and from there we drove to Hyannis to catch a ferry to Nantucket Island, where we spent four wonderful days touring, eating, and resting. Originally a booming whaling port, Nantucket was awash in rich colors, sparkling waters, clean, salty air, and lush hydrangeas and roses. In addition, seaside cottages have changed very little since the 17th century, with cobblestone streets and old-fashioned street lamps.

I’ve never been a big history buff, but I do know that the first settlers in Nantucket in the late 1600s were Quakers anxious to escape the repressive conditions being imposed by the Puritans of the Massachusetts Bay Colony. The Quakers were a bit like the hippies of the ‘60s; they were Christians but also rebellious and independent thinkers. Puritans were conservative Christians who opposed individualism and any other religious movements that threatened the social order of the day. Quakers were not welcome when they landed in Massachusetts, and Quakerism was suppressed by Colonial officials. Suppression included fines and hangings, similar to the atrocities that occurred during the Salem, Mass., witch trials.

Are we considered a threat to the authority of dentists who govern us? Will the dental profession continue to control our destiny as we have threatened the social order of the dental establishment? Is our radical thinking a departure from the dental practice management thinking of the day?

As we are entering a new year, it’s important to revisit some of the changes occurring within the oral health-care delivery system that may affect the political, clinical, and economic autonomy of dental hygienists. Through my periotherapist yahoo group, I learn a lot about the thoughts, dreams, and fears that dentists, periodontists, and hygienists have regarding their careers.

The debate over AAP guidelines

In Oct. 2006, the American Academy of Periodontology (AAP) posted new referral guidelines for the co-management of periodontal diseases by dentists and periodontists on the AAP Web site. I knew beforehand that these guidelines were in the works, and I prepared myself for the firestorm that would ensue when they were published. Sure enough, the Academy of General Dentistry responded with its concerns, as did others who oppose the new guidelines. (If you haven’t read the new guidelines, go to the AAP Web site at

Periotherapist yahoo group members debated the new guidelines online, and many hygienists are worried about their implementation. They worry that they will no longer feel comfortable treating periodontal patients nonsurgically, and that periodontists issued the guidelines to discourage hygienists and dentists from treating early and moderate periodontal diseases in general dental practices. The Academy of General Dentistry (AGD) disliked the guidelines because general dental practices sometimes treat periodontal diseases themselves. In addition, general dentists want to continue to be, as they see it, the primary providers of periodontal services, or “gatekeepers,” before referring patients to an appropriate specialist.1 The AGD also expressed its displeasure at the “strong tone used and the portrayal of some inconsideration for the role, education, and ability of the general dentist to treat his or her patients.”1 The AGD also expressed its concern about the AAP reference to the registered dental hygienist in the document. Here is what the AGD says about us:

“The AGD is concerned that dental hygienists are mentioned above, as anyone reading this document could

make a reasonable inference that dental hygienists are qualified to make referrals to periodontists. This would be an incorrect assumption because very few hygienists are able to make referrals. Colorado may be the only state in which this is a reality, but in other states to do so is illegal. Adhering to the concept of a unified dental team, it is important that it is the dentist who shoulders the responsibility of diagnosing and making referrals.”1

A sense of feeling violated

After reading these two documents, I felt violated. I also wanted to give anyone who got in my way a good tongue-lashing. Like most of you who are reading my column, I felt my beloved profession had been harmed. I have poured over thousands of bureaucratic documents in the past (such as infection-control guidelines), and I’m used to reading the term “dental or oral health-care professional.” The authors of these documents usually address dental team members collectively to avoid any distinction between the dental assistant, registered dental hygienist, and dentist.

The AAP authors, unfortunately, departed from this drift, and focused on addressing only two providers: the dentist and the periodontist. Even when they tried to include hygienists toward the end of the guidelines, the AGD commented on its inappropriateness. Throughout the AAP guidelines, the co-management of periodontal diseases by the general dentist and periodontist is emphasized to the point where it is obvious we are excluded for political reasons. As I pondered the document, I concluded that we should have been included as co-managers of periodontal diseases early in the written guidelines. Instead, the periodontists decided to pander to general dentists in the hopes that their document would be more widely accepted.

Like nurses, registered dental hygienists are educated to assess a patient’s oral diseases, determine risk for diseases, and deliver the appropriate intervention(s). Like dentists, we are licensed providers who are part of patient care teams. We are clinical providers of care and we, with clinical assistants and dentists, work to provide direct delivery of quality care. Do we manage our patients’ gingival and periodontal diseases? Absolutely. We complement the care delivered by the entire patient care team by managing our patients’ diseases through teaching self-management of diseases and providing nonsurgical therapy and periodontal maintenance.

Don’t get me wrong: I have tremendous respect for periodontists and the AAP, and the content of the new guidelines is reasonable. It makes sense to develop guidelines for referral because not all periodontal diseases can be managed by the RDH and dentist. I’ve said many times that periodontal surgery can complement nonsurgical periodontal therapy, and our profession understands the importance of referring aggressive, severe, and refractory periodontal diseases. We also understand the additional criteria for referral and we respect the periodontists’ expertise.

Conscientious oral health-care professionals understand that we have the ability to clean, disinfect, and maintain many more pockets without resorting to Widman flap surgery. Patients are thrilled to have a variety of therapy choices. If and when periodontal endoscopy becomes less expensive and more user-friendly, oral health-care professionals will be able to gain access to more pockets, including those in difficult-to-access furcations.

Can general dentists be nudged out of a comfort zone?

What about this growing divide between dentists and RDHs as we mature as a profession and insist on recognition as oral health-care professionals? The general dentists I know and respect are disturbed by the language the AGD and ADA sometimes use, which is inflammatory to registered dental hygienists and professional dental assistants. Can general dentists be nudged out of their comfort zone in a delivery system that no longer meets the needs of the underserved?

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The excitement I feel at the progress we have made in California, where the Registered Dental Hygienists in Alternative Practice (RDHAP) expand access to care to those who need it most makes me want to shout from the rooftops our message of hope. It’s a message of hope regarding the epidemic of oral diseases among seniors, poor children, minorities, and other underserved populations. I am reminded of the new book by U.S. Senator Barack Obama, who has a deep sense of optimism and a strong commitment to civil rights, the poor, and the working class. He refers to the “audacity of hope” in his title, which signifies the sense of fearlessness and daring of U.S. citizens to reclaim inalienable rights which sometimes seem so unattainable for so many.

Like Senator Obama, we, too, can work to reclaim many of the oral public health programs that have disappeared, like the dental hygienists of yesteryear who provided preventive oral hygiene services to indigent children in the public schools. We now have mobile dental clinics throughout the United States that can deliver care to needy patients, including institutionalized geriatric patients who so desperately need our attention. Who better to deliver care to people who otherwise would not be treated than the RDHAP?

The Quakers of New England and today’s political leaders like Senator Obama were rebels who resisted authority and control just like we do. Perhaps we need to align ourselves with the medical/nursing profession instead of the dental profession as we advance our knowledge as providers of preventive care. History will tell how we fare, but in the meantime we need to follow our dreams with boldness and conviction, including the audacity of hope.

Lynne H. Slim, RDH, BSDH, MSDH, is a practicing hygienist/periodontal therapist who has more than 20 years’ experience in both clinical and educational settings. She is also president of Perio C Dent Inc. (Perio-Centered Dentistry), a practice management consulting firm that specializes in creating outstanding dental hygiene teams. Lynne is a member of the Speaking and Consulting Network (SCN) that was founded by Linda Miles, and has won two first place journalism awards from ADHA. Lynne is also owner/moderator of a periodontal therapist yahoo group: She can be contacted at [email protected].


1 Academy of General Dentistry. Letter to the American Academy of Periodontology. July 7, 2005. Accessed: Oct. 2006.