Pioneers in independent practice

March 1, 2000
These contented hygienists have found their own special niche as pioneers in the independent-practice movement.

These contented hygienists have found their own special niche as pioneers in the independent-practice movement.

Cat Schmidt, RDH

When Wendi Harmon* visits her hygienist in California, she gratefully leaves her fear of the dentist at home. Home for Wendi is 2,000 miles away in Columbia, Mo. Though busy studying for her business degree, Wendi doesn`t hesitate to make time for her two yearly recalls during the school year. In fact, she enjoys these visits!

Wendi saves her dental jitters for the rare filling, which is done by her family dentist in the Midwest, and breezes into her biannual prophys as if treating herself to a manicure or facial. Having her teeth cleaned in a highly professional, relaxed atmosphere without the daunting presence of a dentist is the main reason Wendi stays regular with her appointments.

Wendi`s hygienist is an independent practitioner who is among the handful of hygienists who practice independently in California. These professionals deliver dental care in a manner befitting our occupation: as competent women and men who do not need a dentist to provide a paycheck and employee benefits, as well as the office rules and regulations that accompany the status of "employee." Whether or not we deem the solo flight as right for us, a great many of us support the right of others to spread their wings.

"I act as the taskmaster. I draw the team together," says Laurelyn Borst, RDHAP (alternative practice), BS, owner of the The Elegant Tooth in San Francisco. She sits on the edge of a plastic couch in a nursing home waiting room scented with the fragrance of flowers and urine. Her expressive eyes come alive with excitement as she explains her business.

Borst describes her definitive job - the role of project manager - guiding her patients` care for their maximum benefit. From insurance submissions to referral to a dentist, she directs each and every aspect of the dental-delivery system. Working as an independent practitioner gives her the freedom to make her own decisions and offer her patients a wider range of choices. They aren`t locked in to the policies and procedures of one dentist. In the end, her patients have greater control over their own treatment plans.

Borst rents an operatory from a dentist who practices part time. He`s never in the office when Borst sees her private patients. This is the best benefit of working solo, as many hygienists in states that allow independent practice have discovered. Patients are more relaxed without the dentist present, claims Borst. She says they are much more willing to share information and ask questions in the informal - yet strictly professional - atmosphere created by the absent authority figure. The intimate interaction provides increased awareness and communication for both practitioner and patient.

Borst was attracted to owning her own business because she wanted to run her own practice, dictate her own philosophy for care, and serve people who otherwise wouldn`t seek treatment. She sees her business as broadening the accessibility of available preventive care. Her patients blanket the spectrum. She sees those who have just moved to the area, but have not yet found a dentist, and those who are waiting for their insurance benefits to kick in, but are due for prophys. She accepts overflow patients from other practices where the hygiene schedules are tightly booked, as well as vacationers from overseas and those who just need an extra cleaning - like the bride who wants "pearly whites" for her wedding photos.

Not content to simply run a private office, Borst practices in alternative settings other days of the week. You are just as likely to find her practicing in a nursing home as in a private home, helping the homebound and elderly achieve dental success with the aid of their caregivers. She believes our nation`s seniors are a decidedly underserved population. We are touching the tip of the iceberg as far as oral care for the elderly is concerned, she explains. Our profession needs to assertively address the interim period in a person`s life between full function and death. Borst is doing just that, undertaking various venues of practice. The variety in her schedule offers fufillment and pleasure. There`s rarely a boring moment.

"I put my own spin on health care," she says with a contented smile that indicates she`s found her niche. Having her own practice allows her that ability. "The very best health care is the care that educates people so well that they need less professional and preventive service."

Judy Boothby, RDHAP, BS, is another hygienist with her own practice in California. She spends the workday immersed in alternative-practice sites assisting the elderly with their dental needs. Boothby holds a bachelor`s degree in gerontology, and enjoys working primarily with the senior population. Her voice is articulate and warm as she speaks of the joys and trials of working with her graying patients.

In December 1999, Delta Dental approved direct payment reimbursement to hygienists, and Boothby is ecstatic with this development. Delta Dental did not bestow membership status to the hygienists, but extended them certain courtesies, providing them with a direct contact person and a helpful public relations staff. The ease in insurance payments will allow hygiene practices to run more seamlessly. Medi-Cal, the state insurance benefit program for the indigent, has been reimbursing hygienists for some time. Negotiations currently are underway to streamline the billing process with the Medi-Cal Dental Program, which will ultimately result in better access to care for patients. The road to increased independence is paved with direct payments to hygienists. RDHAPs in California stand on the brink of a new era of health-care delivery.

Boothby also is part of the bandwagon now pushing for the state to pay for more dental services per year for patients with disabilities. This directly affects the amount of care she can offer her patients, most of whom are institutionalized and rely on government assistance. She laments that her patients - many of whom need multiple cleanings a year - must cope with merely one visit. Those needing more intensive treatment cannot receive it. Nationwide, this probably is the most serious problem facing hygienists who treat the disabled and indigent. Publicly funded programs simply do not place enough emphasis on oral health.

A different approach to setting up an independent practice is the formation of the hygiene station, proposed by Sandra Senzon, RDH. She outlines the setup and marketing strategy for starting your own hygiene center within a dentist`s office in her new book, The Hygiene Professional: A Partner in Dentistry (PennWell Corporation, 1999). Her innovative idea can be implemented by anyone in any state, as long as federal, state, and local laws are followed. Seeking legal counsel for this type of arrangement is a must.

Senzon describes a contractual, simpatico arrangement between hygienist and dentist. Senzon owns and operates her own business, while attracting and creating patient flow for the dentist. In turn, the dentist provides oral exams and oversees other lawful aspects of the hygienist`s company as required by the state dental board. Having a hygiene center is a wonderful marketing tool for the dentist, and the hygienist benefits from the freedom of self-employment. In Senzon`s model, both parties are equal partners in the practice. They are associates joined in a binding contract. For those of us wishing more autonomy, implementing this idea would be a wonderful step toward personal accountability and self-governorship.

"If we wish to keep dentistry growing through free enterprise, we must be aware that it takes change and adjustment to make the new system work," Senzon writes. "In medicine today, there are physician assistants and private-duty nurses. We must create new paths for growth in dentistry."

Developing your own hygiene business is part of that growth, and one that is sure to be paramount to the continuation and proliferation of preventive dentistry. For those of us living in states where independent practice seems light years away, creating our own contractual business within a dental office is a wonderful expression of independence.

Our profession is poised to set forth some awesome changes in this new century. As preventive health care emerges to overtake the general public`s perception of health care as a whole, we must ready ourselves for the shift.

Patients are becoming increasingly proactive in the assessment and treatment phases of their own health, including their oral health. We must acknowledge this trend, and respect the fact that it will not only continue, but also flourish. Patients are the central part of any dental team, and the other players ? hygienists, and dentists most notably ? can work together or individually, but no one works without the patient. However hard it is for the dentist and us to hear, the patient is the true captain of the team. We offer advice and service, but the patient must make all final decisions regarding treatment. Ever more importantly, this captain assumes greater responsibility, calling the plays, and dictating the lineup.

As patients who seek dental care in this new century desire more varied options, those in our ranks willing to set up individual practices should not encounter stumbling blocks. Dentistry is changing because our patients are changing. Our patients are intelligent, motivated, and accustomed to participating in their own health-care treatment. We must anticipate the shifting nature of health care and put forth a grand effort now, changing our state laws to coincide with the future of hygiene. Hygienists need to push for independent practice in every state, no exceptions. Even if you won?t use it yourself, you must fight for this vital agenda for the public?s benefit, and the progress of our profession.

As a profession, we do not promote ourselves as competent, autonomous caregivers, yet the reasons to do so are abundant. We know that more patients are served and more hygienists are practicing. We know that people who wouldn?t normally see a dentist will see a hygienist. We know that residents of nursing homes or long-term-care facilities will receive much needed care. We know that those without insurance, or those with a lapse in coverage, can keep cost-effective, regular cleaning appointments. We know these facts and a multitude of others, but we still find that most of us buy the rhetoric that independent practice is bad for dentistry. Patients deserve the right to have choices in their health care. Since patients are the number one interest in dentistry, we should offer them any alternative that will increase their willingness to seek treatment.

Not everyone embodies the entrepreneurial spirit necessary to set up his or her own practice, just as not everyone practices hygiene identically. We all possess our strong suits. Some are better with the challenges that children bring to dentistry, others shine with perio recalls, and some of us tackle nursing homes and the elderly with ease. There is not onecorrect way in which to practice. We have all discovered our own special forte. Independent practice simply allows some of us another venue in which to deliver services in a way that makes dental care available to more of the population for the public good ... period. Contact your state dental hygiene association and join the fight for independent practice.

* Patient name is fictitious.

Cat Schmidt, RDH, holds a bachelor of arts degree in communications from Southern Methodist University and a dental hygiene degree from New Hampshire Technical Institute. She is a freelance writer living in San Francisco. Her book, Not Just the Cleaning Lady: A Hygienist?s Guide to Survival, is available from PennWell Corporation for $29.95. To purchase the book, call (800) 752-9764 or fax to (918) 831-9555. She can be contacted at 88 Howard. St. #815, San Francisco, CA 94105; by phone at (415) 543-5212; or by e-mail at [email protected].


Y Senzon, Sandra, RDH, The Hygiene Professional: A Partner in Dentistry, PennWell Corporation, Tulsa, OK, 1999. [Available for $29.95 by calling (800) 752-9764.]

Y California Dental Hygienists? Association: 660 J St., Ste. 480, Sacramento, CA, 95814; Web site: