Hygienists who achieve greatness (HWAG)

June 1, 2011
I love to exercise. It's how I clear my foggy mind when I wake up. While jogging past the nearby high school with my dog, I noticed a promotional sign ...

by Lynne H. Slim, RDH, BSDH, MSDH
[email protected]

I love to exercise. It's how I clear my foggy mind when I wake up. While jogging past the nearby high school with my dog, I noticed a promotional sign that read "SWAG: Students Who Achieve Greatness." I saw this as I prepared to interview a hygienist who's on his way to greatness. Let's meet him and find out what makes him tick.

Howard Notgarnie, RDH, EdD, isn't afraid to talk about his frustration with preventive oral health care in the U.S. He's practiced dental hygiene in Florida and now in Colorado, where he recently completed a doctorate in education. Howard spent three years in dental school before he realized that drilling and filling was not for him. He dropped out of dental school and pursued a dental hygiene education in Florida. After making the switch, he realized that the two professions are markedly different, and he believes we should highlight those differences when we market the benefits of our work to the public.

After graduating from Palm Beach State College in 1992, Howard practiced in a dozen dental offices in Florida. The restrictive state regulations prevent dental hygienists from offering the preventive care that is the hallmark of the profession. Howard found an office where his coworkers recognized his professionalism, but he was still unable to offer the highest quality of dental hygiene care. The delivery of care was limited due to clients' expectations, as well as the intrusive legal requirement to defer to the diagnosis of an employer who barely recognizes the conditions amenable to dental hygiene care, and who profits by not intervening early in the disease process.

Howard currently practices in a multidental practice corporation in Colorado that supports employee professional development. His office is a true team effort, where all members respect one another's professionalism. This respect is widely recognized by clients. Howard likes the fact that the company is publicly owned, so all employees have an opportunity to own a piece of it. His office has the highest percentage of periodontal care in the company, so I asked him about that.

The dentist is not the boss where Howard works. Instead, she is a coworker who consults with Howard to determine if the restorative treatment plan is consistent with the dental hygiene diagnosis he has made for his patient. Howard understands the restorative needs that he sells to patients along with their dental hygiene needs. He was educated before the saturation of associate level dental hygiene programs. He studied in an atmosphere that promoted professionalism, and he didn't have to worry about competing for jobs with low salary requirements.

In a free market economy, eliminating restrictive legislation would solve the serious unemployment problem many talented RDHs now face. Hygienists could then compete for consumers rather than dentist employers.

Howard doesn't sell himself short. He believes his skills are too valuable to be squandered on housekeeping duties (I say amen to that), and he is fortunate that the office manager and administrative professional keep him busy with the work he does best. His clients know they're getting quality service rather than some standard, one-size-fits-all service that ignores individual periodontal conditions.

When seeing a new adult patient, Howard's assistant takes a full-mouth series of radiographs. Then Howard performs a full periodontal exam while getting to know the patient's needs and expectations. He then makes a dental hygiene diagnosis that is not just a distinction between healthy/gingivitis/periodontitis, but includes the patient's knowledge deficits, systemic concerns, dental restorative concerns, facial image, and other needs that can be addressed by education, mechanical treatment, and consultation with other health-care professionals.

A professional "cleaning" is not performed at the initial visit, and administrative personnel explain to patients that a "cleaning" cannot be scheduled until the hygienist determines what type is needed. Howard is happy when he hears his patient coordinator substitute the term "hygiene appointment" for "cleaning." After the diagnosis, Howard explains it to the patient or the patient's parents. He explains the mechanical and medicinal treatments that are appropriate on a case-by-case basis, and if he has time he may begin the dental hygiene care he's recommended. He often has to address why the patient's previous dental hygienist did not provide periodontal therapy.

The legislative restrictions on dental hygienists in most states require them to work by dentists' approval rather than by a contractual arrangement between the dental hygienist and patient. Furthermore, the culturalization of dental hygiene students assumes that they should depend on dentists for decisions and authority to work.1 As a result, the majority of patients walk out of dental practices with bloody prophylaxes that should have received nonsurgical periodontal therapy based on an appropriate dental hygiene diagnosis. This lack of appropriate care is accompanied by a lack of appropriate revenue for dental hygiene, and the belief that dental hygiene appointments are loss leaders.

Dental hygiene leaders and educators are consistently improving the state of the profession. They have been creating a body of knowledge through research. They have been making laws less restrictive and increasing the profession's regulatory authority over itself. They have bachelor and master's degree programs, and are working on developing a doctoral program in dental hygiene, all of which are improving the career opportunities for educators and researchers. Bloody, superficial prophylaxes are worse than no treatment at all, and Howard pointed out how tragic it is that these bloody prophylaxes are so prevalent.2

General dentists such as Dr. E.J. Neiburger (see his letter in the March 2011 issue of RDH magazine) are recklessly determined to control the practice of dental hygiene and sabotage our advancement. These attitudes prevent dental hygienists from applying our knowledge and intellectual skills appropriately.3

According to Howard, dental hygienists can solve the hard times they are facing by working with consumers and colleagues who recognize the value of our work, and by dismissing those who fail to recognize our worth. We must continue to explain to legislators that we are the primary experts of our own work, and we need the rights of autonomy that other professions enjoy.

We also need to accept the responsibility that comes with the authority we're demanding. We need to make diagnoses accurately, based on sound science, even when that contradicts the dentists, and we need to record data accurately in order to diagnose periodontitis and other conditions so we can back up the diagnoses we make. Knowing when to refer to a specialist is imperative, and dental hygienists are capable of making these decisions chairside. It is inappropriate for us to hide behind the authority of another profession to defend our actions.

We're still pecking away at that stubborn glass ceiling, and dental hygienists like Howard are leading the way.

Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.


  1. Adams TL, Bourgeault IL. (2003). Feminism and women's health professions in Ontario. Women & Health, 38(4), 73-90.
  2. Matsuda S. (2010). Ultrasonics for periodontal therapy: evidence, Eras and formulas for success. Access, 1(2), 18-20.
  3. Cheng BSS (2009). Problem-based learning and the workplace: Do dental hygienists in Hong Kong continue to use the skills acquired in their studies? Journal of Dental Education, 73(8), 991-1000.
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