When push comes to shove

June 1, 2003
Ethics in dental hygiene come under fire every moment of every single day. Employers across the country ask hygienists to break the law, and most hygienists do it for a number of different reasons.

By Shirley Gutkowski

Ethics in dental hygiene come under fire every moment of every single day. Employers across the country ask hygienists to break the law, and most hygienists do it for a number of different reasons. Maybe it's job security or not wanting to be labeled a prima donna. Maybe they don't really know the law and are trusting souls who would never dream their employer would lead them astray. A certain type of person is attracted to dental hygiene as a career — that someone isn't necessarily confrontational and is often eager to please. More importantly, hygienists are sensible, and the laws they are asked to break on a daily basis are senseless; so they do it.

The question of who should see a new patient first is a great example. In most offices, new patients are scheduled with the hygienist. It's sensible to do it that way, right? Good production for the hygienist vs. poor time utilization for the doctor. The hygienist evaluates the health history, takes the blood pressure, and then takes the films, usually under the general guidelines of the office set up by the doctor. The hygienist does the perio probing, and cleans the patient up for presentation to the doctor for diagnosis and treatment planning. It's a sensible routine.

In most states, however, this routine goes against the letter and intent of the law. The hygienist who provides any service to a patient without a treatment plan telling him/her what to do is practicing dentistry without a license — a felony. Here's why. The doctor cannot make a diagnosis if the oral environment has been altered, right? Hygienists work much like pharmacists; without a prescription, we cannot provide our service. The pharmacist cannot see a man in the pharmacy and decide to give him an antibiotic, simply because he looks like he has a bacterial infection. The pharmacist cannot then send the fellow to the doctor for diagnosis and treatment plan. Diagnosis cannot be made that way.

OK, so now you're rolling your eyes. Your argument is that the dentist in some cases cannot see the oral environment until we clean it up. Or your argument is that our cleaning won't change one single thing in a Class I patient. Where's the harm? What's the big deal? I agree with that argument — nearly 100 percent. We're smart, intuitive people; we're formally educated, and we learn some invaluable lessons through the school of hard knocks. If the dentist is in the building, or available the next day or so to see this patient, hygienists can certainly clean the teeth of someone without "The Dentist" overseeing their every move. That's true, too, I believe.

Here is the reality. These are the rules of organized dentistry, not dental hygiene. If more dentists strictly followed the rules, they would be on a fast track to get the laws changed.

Some hygienists reading this will be getting on the phone right now to talk to their dental examining board or other significant legislative branch to see if this is all true. Those hygienists who do call may get an erroneous answer. The person on the other end of the line will undoubtedly say that it's perfectly proper for a hygienist to see a patient before the dentist does. If you get this type of answer, I challenge you to ask that person if you can quit your job and start your own practice, or start seeing patients in long-term care facilities. Because, if it's true that we can see patients without a prescription or treatment plan, then we've been lied to long enough and should immediately start addressing this access to care atrocity.

Hygienists cannot clean teeth, provide periodontal therapy, fluoride therapy, or any of the other things we do on a regular basis in a dental office without a diagnosis or treatment plan by the doctor. Liberties are taken because of the close physical proximity between diagnosticians and therapists. It's understood that the doctor will do the exam, and retro-prescribe the prophy or whatever. I'd like to see that kind of slipshod behavior in a medical practice. What would happen if a woman goes in for a depo provera birth control shot on a new patient visit and the doctor is busy? The nurse gives the women her shot to save time? This is not any different. We are not just cleaning teeth; we are affecting the whole body with our instruments and therapies.

The state statutes of Wisconsin, a general supervision state, states:

447.06(2)(c) A dental hygienist may practice dental hygiene or perform remediable procedure under par. (a) 1., 4., 6., 7., or 8. only as authorized by a dentist who is licensed to practice dentistry under this chapter is not present in the facility in which those practices or procedures are performed only if all the following conditions are met:

1. The dental hygiene practices or remediable procedures are performed under a written or oral prescription.

2. The dentist who made the written or oral prescription has examined the patient at least once during the 12-month period immediately preceding:

a. The date in which the oral prescription was made; and

"b. The date on which the dental hygiene practices or remediable procedures are performed.

"3. The written or oral prescription specifies the practices and procedures that the dental hygienist may perform with the informed consent of the patient or, if applicable, the patient's parent or legal guardian.

4. If the practices or procedures are performed in a dental office, the patient has been the dentist's patient of record for not less than six months.

(d) A dental hygienist may not diagnose a dental disease or ailment, determine any treatment or any regimen of any treatment outside of the scope of dental hygiene, prescribe or order medication or perform any procedure that involves the intentional cutting of soft or hard tissue of the mouth by any means.

A new patient does not fit the requirements outlined in the statements with a bold font above. If the dentist isn't doing the exam first, it's the same as if he or she wasn't in the building. Looking into each state with general supervision's practice acts should reveal the same type of language. It will never change if hygienists in general clinical practice keep going with the flow and allowing their employers to ask them to commit a crime.

That's a pretty big example of how oral health care providers are asked to bend the laws that are maintained by organized dentistry. Most dentists seem to think they are poor laws too, as evidenced by the enormous amount of practitioners who ask oral health care providers to break them. If dental hygienists continue to play along, there is no incentive for the laws to change.

Illinois is a direct supervision state, as are many states. That means that every procedure done by anyone other than the dentist should be evaluated by the dentist at completion of the procedure. I would be willing to bet that the majority of dentists in that state don't do exams on three-month recall patients, or check all sealants done by hygienists.

I would also wager that most hygienists don't insist that their doctor/employer check all patients after completion of a procedure. That's not practical or sensible. Hygienists are capable, conscientious professionals who take pride in their work. They don't need overseers for the most part. But the law is the law. If the law isn't working or doesn't reflect reality, it should be changed, not ignored.

So your next argument is going to be valid too and I'll accept it also. You're going to say that one single hygienist in a single corporate office (Dr. Donut SC) with one dentist isn't going to bring about change. All I can say is, "Rosa Parks."

What about all the other laws dentists ask hygienists to break? Personally, I've been asked to give injections before our state allowed hygienists to give injections, or treat patients without the doctor present and without the mandatory prescription. How about the one where the dentist asks hygienists to charge for an exam when the doctor didn't come in to see the patient, or maybe wasn't even physically in the building or even the state?

These things are also covered in the state statutes. The Wisconsin book lists the following under Chapter DE 5 Standards of Conduct:

DE 5.02 Unprofessional conduct. Unprofessional conduct by a dentist or dental hygienist includes:

(20) Violating, or aiding or abetting the violation of any law substantially related to the practice of dentistry or dental hygiene

(21) Aiding or abetting or permitting unlicensed persons in the practice of dentistry, as defined in 447.01 (8) Stats.

(22) Aiding or abetting or permitting unlicensed persons in the practice of dental hygiene, as defined in 447.01 (3), Stats.

For further edification: "447.01 (3) Dental hygiene means the performance of educational preventive or therapeutic dental services. Dental hygiene includes any of the following:

(d) Conducting a substantive medical or dental history interview or preliminary examination of the dental patients' oral cavity or surrounding structures, including the preparation of a case history or recording of clinical findings.

(e) Conducting an oral screening without the written prescription of a dentist

(f) Participating in the development of a dental patient's dental hygiene treatment plan.

This allows the hygienist to see the new patient, take the films, ask questions about the health history, and maybe even perform a periodontal health screening. However, that's where the line is drawn. No scalers, fluoride, sealants — nothing else until the dentist has an opportunity, read obligation, to evaluate the patient and make a treatment plan for oral hygiene services. Most states have these same restrictions.

So, what to do if the doctor insists on the hygienist breaking these laws? Leaving the practice is the easiest answer. However, these "rule bending" practices are widespread throughout dentistry. Another job usually means another set of rules to bend. The mindset of examining boards is that the dentist will have to change his or her ways, if enough employees leave a practice. But the dentist may start wailing about a shortage of good help, get the ear of a legislator on the golf course, and dumb down hygiene education to increase the work force.

The slickest answer is to change the laws to reflect reality. No, one hygienist can't do it alone. Join the American Dental Hygienists' Association. Even if you can't be active, numbers count. Read the laws of your state. Don't count on the lady who answers the phone. There's no incentive for anyone to tell her the right answer to give us. In one phone call that I heard about, the lady stated that hygienists just want to read the rules to suit themselves. I submit it's the other way around.

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].