The long and winding road

California's path to self-regulation was full of twists and turns

by Heidi Emmerling, RDH, PhD, and Ellen Standley, RDH, BS, MA

California dental hygienists did it! In 2009, the Dental Hygiene Committee of California (DHCC) distinguished California as the first state to achieve their own regulatory agency. The self-regulation process has not been a fast track. Thanks to many progressive California dental hygienists who have paved the way, certain key milestones stand out. The following events are considered part of the long history in the formation of the DHCC professional self regulating agency:

• Early independent practice
• Increasing the dental hygiene scope of practice and licensure categories
• Joining northern and southern California for stronger advocacy
• Acquiring dental hygiene representation on the Board of Dental Examiners
• RDHAP licensure including pilot projects.

March Fong Eu was one of California's true gems. In the early 1940s, Fong, who later became California's Secretary of State and member of the State Assembly, began her career as a dental hygienist. Susan McLearan writes that Fong's position on self-accreditation and self-regulation has never wavered. Thus, the vision, discussion, and hard work that goes into becoming professionally autonomous started many years ago. Fong also served as ADHA president in the 1950s. During her presidential address she stated, "Dental hygiene is controlled by the dental profession. Dental hygiene is the only profession I know that is controlled entirely by another profession. It is not a simple process to divorce oneself from a dependency which has become part of our professional thinking; yet we must make this first step if we hope to be free."

Early independent practice

California dental hygienist Linda Krohl became the first in the nation to own and manage a dental hygiene practice in 1976. McLearan, who has done extensive research on the history of organized dental hygiene, noted that Krohl opened her own practice with the support of her employers, and the practice was legally confirmed by the dental board. However, three weeks after she opened her practice, the approval was withdrawn. Krohl eventually had to put the names of her referring dentists on the front door of her practice to disguise her ownership.

After attending a presentation by Krohl, Anne Wells Hunnicutt was inspired to open her own practice in Santa Barbara. An author of three self-published books on independent practice, she saw her first patient in 1977. Hunnicutt practiced for 15 years as an independent dental hygienist. During that time, she treated 3,000 patients. She recently celebrated her 80th birthday. Hunnicutt said, "Even though I am retired, I remain active in the community, and I still love dental hygiene."

Expanded duties and regulatory representation

The 1970s was an exciting decade for California dental hygienists. Under the regulatory umbrella of the Dental Board of Examiners (DBE), the legislature created the Committee on Dental Auxiliaries (COMDA) in 1974, allowing the licensees to have a voice in their profession.

At the same time, a number of states, including California, pursued expanded duties and broadened the scope of practice to meet an increased demand for dental services. Another license category was created, RDH in Extended Functions (RDHEF), providing for such duties as packing retraction cord, taking final impressions, and fitting endo filing points.

In 1976 a landmark bill was passed allowing California dental hygienists to perform soft tissue curettage, and administer local anesthesia and nitrous oxide under direct supervision. California was among the first states to allow this scope of practice. Now, in order to get a license to practice in California, competency in these duties is a required part of the RDH credential. Maureen Titus explains, "Expanded duties gave us the momentum and framework to move forward with self-regulation."

North and South join forces and hire a lobbyist

The California Dental Hygienists' Association (CDHA) is the largest state constituent of ADHA. Historically, CDHA was one association. For a number of reasons, in 1942 northern and southern California separated into two state associations. This worked for a number of years. As time passed and legislative advocacy goals were emerging, the two reunited in 1985. CDHA, now as one single association, possessed a more unified voice and the strength of a larger membership.

In 1985, CDHA retained Aaron Read and Associates to enhance the profession's political agenda. Read's group still represents CDHA members as a lobbyist. California also has the Cal-Hy-PAC, a political action committee. This is a separate financial entity supporting CDHA's goals via contributions to legislators and political candidates. Thus, having a single association, a strong lobbyist, and PAC has proven essential to CDHA's pursuit of self regulation, as well as many access-to-care issues.

About the same time the California associations reunited, CDHA achieved another significant milestone. In 1984, the first dental hygienist, Evelyn Pangborn, was appointed to the DBE. As with CDHA's other accomplishments, this was also some time in the making. Prior to Pangborn's appointment, the DBE, which oversaw dental hygiene licensure and practice, was composed of eight dentists and four consumers.

Predictably, the appointment of a dental hygienist was not popular with the dentists serving on the board. Although it was only one vote and did not promise to sway any decisions, it was the beginning steps to having a dental hygiene voice at the regulatory table.

Pangborn served for nine years. Other dental hygienists who followed were Genevieve Klugman, Katie Dawson, Tricia Osuna, and Joyce Yale. The dental hygiene position on the DBE (now termed the Dental Board of California) has been vacant for several years. The vacancy is still awaiting the gubernatorial appointment. Having a dental hygienist on the DBC set the precedence for dental hygienists to have a voice in their own licensure and regulatory issues.

HMPP #139 and HMPP #155: The pathway to RDHAP

Michelle Hurlbutt and Kristy Menage Bernie clarified the following sequence of events in their RDHAP PowerPoint presentation: The Health Manpower Pilot Projects (HMPP) Act (1972) was created by the California legislature as a vehicle to demonstrate and evaluate new or expanded roles/delivery alternatives for health-care professionals. These eventually lead to the RDHAP (Registered Dental Hygienist in Alternative Practice).

HMPP addressed more than dental hygienists; it also included such professions as nurses, physician's assistants, and emergency medical technicians. HMPPs are administered by the Office of Statewide Health Planning and Development (OSHPD).

There were actually two HMPP studies for the purposes of increasing access, demonstrating the ability of a dental hygienist to manage a practice, developing curricula to prepare practitioners in their new role, and producing data supporting the efficacy and safety of unsupervised dental hygiene practice.

While CDHA was initiating independent practice concepts, Dental Hygiene Associates Incorporated (DHAI) was created to serve as the administrative body and vehicle to collect funds to finance HMPP #139 in 1981. It was necessary to create this not-for-profit foundation for fiduciary purposes. According to Glenda Flora, Toby Segal spearheaded the formation of DHAI. Flora states, "We showed perseverance despite roadblocks and kept pushing because it was the right thing to do. This new category will bring more people into the dental health care delivery system."

Despite legal challenges by organized dentistry to halt the pilot project, 15 participants were certified (but not licensed since a license category had not been created) to practice independently in 1986. Judy Boothby, Toby Segal, Laurelyn Borst, and Nicki Smith, were among the hygienists in the first class.

In 1990, legal challenges terminated HMPP #139. Another HMPP was submitted and approved the same year: HMPP #155. Under #155, two more classes were completed. Several bills for the RDHAP license were sponsored in the California legislature, one failing by merely one vote. Ultimately a bill was signed, and in 1998 the RDHAP license became a reality.

In addition to the challenge of getting the bills passed for the new license category, the next step was to get programs approved and implemented. CDHA was proactive in supporting and financing curriculum development of the RDHAP programs. West Los Angeles College was the first on-site program with the first class graduating in August 2003. University of the Pacific was the first online program, graduating their initial class in December 2004. There are currently over 300 licensed RDHAPs in California.

Diane Azevedo, who was in the second HMPP class, writes of her journey, "It is not completely over. Just remember, don't be discouraged. Take the first step."

The formation of the DHCC

All of the previous advancements bring us to where we are today: with the newly formed Dental Hygiene Committee, the first of its kind. The DHCC did not sail through the first time it was introduced. Katie Dawson reports that for a period of six years, CDHA sponsored three similar bills. The first two were vetoed by Governor Schwarzenegger, and the final one was signed into law on Friday, June 13, 2008.

Although that Friday the 13th was indeed a lucky day, luck is not what accomplished this milestone. Dawson reminds us that the formation of the DHCC is a culmination of more than a decade of work by CDHA, spearheaded by JoAnn Galliano. Others instrumental in the success of the formation of the DHCC are Senator Don Perata and legislative advocates Terry McHale and Aaron Read.

The DHCC, instead of being a subcommittee of a dental board, reports to the Department of Consumer Affairs. According to Dawson, "Although there are a number of dental hygiene committees throughout the nation, California's committee will be the first that is not a subcommittee of a dental board. In other words, like nurses and other professions, we won't be regulated by our employers."

Currently, the president and vice president of DHCC are dental hygienists: Rhona Lee and Michelle Hurlbutt, respectively. The other two dental hygiene members are Miriam DeLaRoi and Cathy DiFrancesco. In addition to the four dental hygiene members, three members of the public hold seats. Two open positions remain - one dentist and one additional consumer who have yet to be appointed by the governor.

Because the DHCC has a more equitable representation of RDHs, and they are not reporting to dentists, California dental hygienists possess more control of the profession. For this reason, as extensive hearings suggest, dental hygienists are able to advocate for the profession and better serve the consumers.

Noel Kelsch writes, "Dental hygiene in California will not be free from external review and regulation. The profession is responsible for formulating standards for independent practice, for the definition of the appropriate scope of its professional practices, and for the development of individual and institutional standards for the delivery of services to the public."

Megan Fitzpatrick, ADHA's director of governmental affairs, writes, "In the last year, New Hampshire, New York, and Vermont each pursued legislation for a dental hygiene board or committee. A number of other states considered legislation related to board composition/duties." In the next legislative session there may be other states joining the ranks. Furthermore, there are currently more than 30 states that allow dental hygienists to practice via direct access (i.e., can initiate patient care without the presence or prior exam of a dentist).

This has been the road to California's self-regulation. Minnesota's workforce models are another professional achievement. In celebrating each state's success and learning about the process of those successes, we are able to continually raise the bar of professionalism and autonomy.

Authors' note: The authors wish to acknowledge California's many progressive dental hygienists, including Susan McLearan for her research and generosity in providing us with information necessary to produce this article.

Heidi Emmerling, RDH, PhD, is interim director and assistant professor of dental hygiene at Sacramento City College and a CODA site consultant. She is owner of Writing Cures, a writing and editing service, and co-author, of The Purple Guide: Paper Persona, a guide to preparing professional development and job search materials. Dr. Emmerling can be reached at [email protected].

Ellen Standley, RDH, BS, MA, is president of CDHA and a long-time active member of ADHA, CDHA, and the Sacramento Valley Dental Hygienists' Association. She is a professor of Dental Hygiene at Sacramento City College and holds memberships in the California Dental Hygiene Educators' Association and the American Academy of Dental Hygiene. Ms. Standley can be reached at [email protected].

References

• ADHA
• Azevedo, Diane. Telephone interview. 9/4/10.
• Azevedo, Diane. "Health Manpower Pilot Project #155." Self published pamphlet, Sacramento, 1990.
• COMDA. Handbook of Laws and Regulations. 1998.
• Dawson, Katie. "California Gains Autonomy." Journal of the California Dental Hygienists' Association. Vol 24, No 1. 2008. pp10-11.
• DHCC, www.dhcc.ca.gov. Accessed 8/4/2010.
• Flora, Glenda. Telephone interview. 8/18/10.
• Hunnicutt, Ann Wells. Telephone interview. 8/12/10.
• Hunnicutt, Ann Wells. Be Your Own Boss. Santa Barbara: A New Direction, 1979.
• Hurlbutt, Michelle and Menage Bernie, Kristy. "RDHAP: Past Present, Future." Powerpoint, UOP RDHAP Program, August 22, 2008.
• Kelsch, Noel. "With the stroke of a pen." RDH Magazine Oct. 2008. 34-38.
• McLearan, Susan. "The Evolution of a Profession, Part I." Journal of the California Dental Hygienists' Association. Vol 18 No 3. 2003. pp 22-28.
• McLearan, Susan. "The Evolution of a Profession, Part II." Journal of the California Dental Hygienists' Association. Vol 19 No 1. 2004. pp 16-20.
• McLearan, Susan. "The Evolution of a Profession, Part III." Journal of the California Dental Hygienists' Association. Vol 19 No 2. 2005. Pp 20-27.
• McLearan, Susan. "The Evolution of a Profession, Part IV." Journal of the California Dental Hygienists' Association. Vol 19 No 3. 2005. pp 20-27.
• Titus, Maureen. Telephone interview. 9/5/10.

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