Autonomously where the need is: Dental hygiene earns more self-control with care in areas of need

By Jamie Collins, RDH, CDA

The profession of dental hygiene has changed and adapted throughout the years, including adjustments with the laws and regulations overseeing the profession. We now focus on whole body health, disease management, and prevention. Most states now allow hygienists to practice autonomously with limited supervision.

Many states alter laws to allow hygienists to practice at least somewhat independently in many scenarios. In turn, portions of a state's population receive care that may otherwise be difficult to obtain. This can apply to senior citizens, long-term care facilities, prison systems, school and Head Start programs, free clinics, and residences of homebound patients. In a few states, hygienists are allowed to practice with limited reporting or referrals to a dentist.

Focus on the elderly

One of the most important services is the ability to provide care to patients in nursing facilities. These patients are often unable to come to the dental office without coordination of services for transport, and mobility can be very difficult. Frequently, these patients are the most critical to see in practice due to concerns such as xerostomia and diabetes, among other health problems that play a large role in oral and systemic health. Being able to provide even basic care to these patients can often prevent future pain and infections.

My grandmother was in a nursing care facility for a few years. My visits with her made me realize how desperately professional oral care was needed in the facility. Many residents had limited chewing ability due to broken teeth or ill-fitting dentures, often with discomfort present.

Within many long-term care facilities, the employees have many duties and, in my experience, most don't have the time to ensure the residents are getting oral care in addition to overall medical care. When certified nursing assistants and nurses are overworked while caring for multiple residents, daily oral care is a task pushed to the back burner.

Most nurses are not trained for oral care practices. For residents with dementia, systemic diseases, or physical limitations, dental problems ranging from decay to infections or advanced periodontal disease are common. When you add in systemic effects such as diabetes and periodontal disease, it creates a vicious circle, making both the oral and systemic diseases harder to control and maintain, and both are likely to worsen in relation to each other. It makes me wonder, if we can control the periodontal disease, would it help prolong the life of a patient, or at least ease the pain?

According to the American Dental Hygienists' Association, many states now allow for hygienists with a certain level of training and experience to gain the endorsement to provide care for the elderly and disabled in their residences or care facilities-without direct supervision of a dentist. It may be a small thing for a hygienist to be the first line of oral care and then refer to the dentist for an exam and treatment, but diminishing the progression of disease can bring tremendous relief for the patient. The elderly are often a forgotten population in dental care but can be in the most need of frequent care and treatment due to multiple risk factors.

Other areas expanding with autonomous options are:

Pediatric preventive care-Schools and states are now employing dental hygienists to provide preventive care, sealants, and fluoride applications for children in free or school-based clinics. I have a friend in Washington State whose job requires travel from school to school to provide prophylaxis, sealants, and fluoride to children who may not otherwise be screened. She provides an initial screening as well as a referral if additional care is needed. This often bridges the gap for those children who don't qualify for state funded insurance but don't have private dental insurance. As we know, sealants don't prevent all areas of decay but can greatly diminish caries risk in the pits and fissures of the teeth.

For some hygienists, this type of practice is appealing because the usual workdays are those when children are in school; in other words, the hygienist is off on all the days the kids are off and able to spend time with their families.

Prison care-Another option for hygienists to work independently is within the state corrections system. Hygienists are often employed by government agencies with funding budgets to oversee and provide care to prison and juvenile facilities, where residents are not able to go outside of the facility for treatment. Usually there is a dentist on staff as well; however, the dentist and hygienist may practice on separate days providing treatment to best utilize the available dental chair space.

Rural care-One of the most relevant areas for hygienists to practice with limited supervision is in rural areas of the country. In many cases, these areas have lower median incomes, and residents often will forego preventive dental care due to cost or lack of dental office availability. Most states have limited availability for Medicaid services for adults, thus putting access to care out of financial reach.

The ability for hygienists to provide care in alternative settings opens the possibility for access to this group of patients. With alternative practices, the cost of preventative care and therapy is often less than in a traditional dental office. In some areas, the benefits of oral care (not to mention whole body health) have not been taught. There may be very limited access to a dentist; whereas hygienists may be available to provide treatment as needed based on evaluations. Certain states allow hygienists to be directly reimbursed from dental or Medicaid insurance programs.

I live in an area of the country where we have a large population of refugees from other countries as well as a significant migrant population, most of whom don't have dental insurance and live below the poverty levels. It gives me great satisfaction to volunteer my time to provide care at reduced or free clinics to give back a little to some of these patients who may have sacrificed greatly in their lives. I have seen oral conditions that I will probably never see in private practice, and I gain experience with difficult periodontal cases.

Finding a dentist to be present at each of these clinic days is a difficult task; the ability to work under general supervision guidelines has made it much easier to allow appointment times for basic services, especially when multiple hygienists are able to volunteer.

Each state determines its own scope of practice in relation to allowed duties and levels of supervision related to direct access. Most states have varying degrees of allowable sites or facilities in which a hygienist may practice with limited supervision, along with the requirement of reporting to a supervising dentist. Being allowed to provide direct care based on assessments of the patient without the prior authorization of the dentist allows for care that may be provided to a broader range of patients. Colorado and Maine allow hygienists to have independent practices without the oversight of a dentist. The hygienist may provide basic hygiene services such as prophylaxis, x-rays, periodontal therapy, and sealants among other delegated duties depending on each state. With this model of practice, hygienists have freedom to set schedules and own their own businesses.

California and Massachusetts also provide models to allow freedom of autonomy for dental hygienists in a broad spectrum of practice opportunities with limited supervision of the dentist. According to the ADHA, 41 states currently have some regulation that allows direct access policies, allowing the hygienist to provide care "based on their assessment of a patient's needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship."

With the ability to practice hygiene autonomously comes the added responsibility to carefully screen medical histories, as you should anyway. Always be sure to update and complete a thorough intra- and extraoral examination with each and every patient. Whether you are in a state that requires no supervision or in a contract with a dentist requiring a referral for an exam every one to two years, it is imperative to refer patients when concerns arise.

After years of experience as a hygienist, like many others, I am able to identify the risk factors and anomalies prior to the dentist appearing for an exam. When he or she arrives, I already have a list of things to check and bring to the dentist's attention. We are experts in dentistry, and having the ability to practice in alternative settings to provide care is imperative to the wellness of all citizens. We have the ability to identify risk factors and disease that may prove to be serious if left untreated. Maybe the screening and treatment in an alternative form of practice will be enough to save a life.

The ability to provide care to patients who often would go without, whether it is the young, the elderly, migrants, or those in underserved rural areas, is an important service that many states are now allowing hygienists to provide with little to no supervision. Dentistry and dental hygiene are ever-evolving professions, and the ability to provide care to all walks of life and citizens is gradually following along.

Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four children. She currently works as a full-time hygienist as well as an educator at the College of Western Idaho. In addition, she acts as a content expert and contributor in multiple upcoming textbooks. She can be contacted at [email protected]. RDH