The Forsyth Experiment proved hygienists were good at restorative work - too good

Trisha E. O`Hehir, RDH, BS

As you know, I enjoy reading research - a slight character defect, I`m told. The research discussed here is not about periodontics. But it is a study that every dental hygienist should be familiar with, because it`s about us! A book titled, "The Forsyth Experiment," by Dr. Ralph Lobene was published in 1979. I have looked in many dental school libraries for this book, but was unable to find it until I browsed the list of dental books available through Amazon.com on the Internet. It`s definitely an interesting read!

The experiment took place at the Forsyth Dental Research Facility in Boston. In a nutshell, in less time than it took dental students and to the same level of quality as practicing dentists, dental hygienists were taught to give anesthesia, drill, and fill Class I through Class V restorations.

The study was so successful that the dental association and state board closed it down and made sure the program graduates never worked in their advanced training capacity. They even attempted to prevent any further research of this kind.

This all took place between 1965 and 1977. In fact, this study was a second attempt; the first took place in the late 1940s. Almost as soon as that proposed five-year study began in 1947, the American Dental Association passed a disapproving resolution that triggered a raging battle in the Massachusetts press. Supporters believed the idea was justified, considering the high rate of decay among the state`s children. Dentists condemned the project as "socialistic and dangerous."

The original goal was to take this question out of the public arena of debate and place it into a scientific research setting where the facts would be the deciding factor. The project was halted, but not before the young women demonstrated considerable proficiency in cavity preparation and restoration.

In 1965, Forsyth trustees again approved a proposed study of expanded functions for dental hygienists. Based on past experience, the dentists involved - Dr. John W. Hein, dean of Forsyth Dental School and driving force behind the project, and Dr. Ralph Lobene, project director - spent the next five years informing the profession of its plans and gaining support for the study. In 1970, the Massachusetts Dental Society approved the experimental studies of expanded functions for dental hygienists.

Between 1970 and 1972, funding was sought, faculty and trainees were selected, and a circular clinic facility with 10 operatories and all the support areas was constructed. The circular facility resembled the spokes of a wheel, and each operatory opened onto the center sterilization area. The rotunda design prompted the code name of "Project Rotunda." Money for the facility was raised through a last- minute appeal to the alumni of the dental hygiene school. Their generous support was achieved in just three weeks. Throughout the years of the project, several research grants were received.

Project participants paid tuition for this special, advanced education. Ten dental hygienists who had graduated in June 1971 from three New England schools - Bristol Community College, Fones School for Dental Hygienists, and the Forsyth School for Dental Hygienists - were selected. Due to construction delays, the project actually began in March 1972. The hygienists gained private practice experience during the nine-month delay.

Basic dental school curriculum was adapted for the project on a "need to know," as opposed to a "nice to know" basis. Only critical information was included. The detailed curriculum was developed by Dr. Lloyd B. Chaisson, an outstanding restorative dentist and very effective team leader within the project. Existing restorative programs similar to Project Rotunda were visited and studied for their expertise. The four curriculum models studied were the United Kingdom`s New Cross School, the New Zealand Dental Nurse Program, the Royal Canadian Dental Corps, and a program at the University of Alabama. Since the Forsyth Experiment involved licensed dental hygienists, they already had much of the basic science didactic material as well as clinical experience prior to entering the program.

Generous estimates were made about how long it would take the hygienists to master each level of the program. To ensure skill development by the dental hygienists, a variety of teaching methods were used.

In every case, they accomplished the tasks to the desired level of expertise much faster than anticipated. The preclinic training period was estimated to require 47 weeks at 30 hours per week. But it actually took 25 weeks at 30 hours per week. Since the time was shortened, sophisticated restorative procedures were included which the instructing dentists had not expected to be able to present. After 25 weeks, the hygienists began working with certified dental assistants to learn four-handed dentistry. Six weeks later, they began the internship phase of the training under the direct supervision of the staff dentists.

During this time, extensive evaluations were made of the hygienists` skills in providing anesthesia, cutting preps, final restorations, patients` acceptance, and team productivity. Patient care was provided free of charge, but estimates of productivity based on fees at the time were calculated.

Anesthesia evaluations revealed that 92 percent of all injections given were successful on the first try. Of the 20,000 injections administered by the dental hygienists, no serious consequences resulted, demonstrating the high degree of safety. Not a single hematoma was observed or reported. Only three minor cases of short-term (12 hours) paresthesia were reported. Clearly, dental hygienists who provided local anesthesia did so safely and effectively. It is interesting to note that no information of this nature is available for dental students or practicing dentists.

After the four-month internship, the Massachusetts Dental Society Liaison Committee was invited to evaluate the quality of procedures performed by the hygienists and dentists in the clinic. Without knowing who had placed which fillings, the examiners found the quality of the dental hygienists` work to be equivalent to that of the practicing dentists. Two more evaluations were conducted between 1973 and 1974 - one by the Liaison Committee again, and another by restorative faculty from Boston dental schools. Each time, the dental hygienists` work was found to be equivalent to that of the dentists.

Simulated experiments in private practice began after the internship period. Productivity was measured in a variety of configurations involving a supervising dentist and one to 10 restorative teams. Given the time to do other procedures, the dentists` yearly net income was estimated to increase 47 percent when working with two advanced skills dental hygiene teams.

It was the hope of those who designed the Forsyth Experiment that such earnings would be shared with the patients and not go entirely into the pocket of the dentist. They estimated that a reduction in basic restorative fees of 10 to 25 percent was possible, while still showing a respectable profit for the dentists.

In the 1950s and 1960s when the high-speed handpiece was introduced and production rose by a factor of two to three, no savings were passed on to the patients. Another failure to pass on savings to the patients would have been viewed as price-fixing and monopolistic. Unfortunately, this problem was never faced.

The success of the Forsyth Experiment was never transferred to private practice. In October 1973, a small group of dentists urged the Board of Dental Examiners to close down the project. Favorable testimony was presented to the board by officers of the Massachusetts Dental Society as well as representatives from Forsyth. The Board was this, but, a short time later, the members reversed their ruling and voted unanimously that drilling of teeth by dental hygienists was a direct violation of the state law.

In March 1974, a ruling from an assistant attorney general confirmed the board`s decision, and the project was shut down in June of that year.

Attempts were made to change the practice act to allow the study as well as practice of expanded functions by dental hygienists. The recession of 1974, however, increased resistance on the part of organized dentistry, resulting in a "hardening of attitudes" against expanded functions. Repeated invitations by the Forsyth faculty to ADA and the state`s dental association officers and members to visit the facility and view the process had been ignored. Many foreign visitors viewed the advanced skills hygienists at work, but only three Massachusetts dentists and no one from the ADA visited the project before it was closed.

A survey in 1974 showed that 62 percent of Massachusetts dentists were not as busy as they wanted to be. That finding was included in a report of the Massachusetts Dental Society opposing expanded functions for dental hygienists. Dentists at that time didn`t want to change their ways and didn`t want the possibility of other dentists employing expanded function dental hygienists and making more money than they did. Opposition was based entirely on economics.

Instead of fighting for expanded functions, the supporters of dental hygiene had to fight to retain academic freedom. The Board of Dental Examiners submitted legislation that would allow them veto power over any research through administrative rules and regulations. In 1977, a bill was finally passed that contained no provision for expanded functions, but did protect research. Had this bill been in place when the Forsyth Experiment was taking place, the Board could not have shut it down.

Dental hygiene has had many supporters over the years. Unfortunately, many show the scars of standing up for our profession. Be sure to thank any dentist you know who has stuck his or her neck out for us. It is often a thankless job!

Trisha E. O`Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics. The Web site for Perio Reports is www.perioreports.com. Her e-mail address is trisha @perioreports.com.