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Dental Hygienists Can Now Treat Patients Without Dentists

Following is an article noting a legislative victory from the last General Assembly Session: the Public Justice Center, working with a coalition of advocates, led the passage of a new law that allows dental hygienists to treat children without direct supervision of a dentist. Many more poor children will now receive preventive care.

Brushed Off No Longer
Citing Gaps in Care, Hygienists Are Beginning to Treat Patients Without Direct Supervision by Dentists

By Mary Otto

Washington Post Staff Writer

Tuesday, April 22, 2008; HE01

Call it the revolt of the dental hygienists. After years of working under dentists' strict oversight, some are eager to get out from under those supervisory thumbs.

"We want to work with dentists, but we have our own role," stresses Susan W. Polydoroff, a hygienist with 46 years of experience who coordinates public health dental programs for seniors in Montgomery County. "We just want to do what we've been educated to do."

Dentists have long served as the gatekeepers of dental care. But if they eased up on their control, Polydoroff and others say, hygienists' skills could help alleviate the acute shortage of oral health services in poor urban neighborhoods, isolated rural communities, nursing homes and schools.

Lawmakers and public-policy experts across the country are starting to agree. A bill passed early this month in Maryland promises a little of the autonomy Polydoroff craves.

The measure, which should take effect Oct. 1, will allow hygienists to provide preventive care such as cleanings, sealants and fluoride treatments in public health settings such as clinics, schools and Head Start programs without prior authorization or direct supervision of a dentist.

"The hygienist can be the point of entry, the case manager," explained Rockville hygienist Pamela Quinones, a board member for the American Dental Hygienists' Association, which supported the bill.

The Maryland bill doesn't apply to hygienists in private facilities, whose services still must be authorized by dentists. Virginia and the District both require a dentist's supervision of hygienists in both public and private settings, according to Megan Fitzpatrick, director of governmental affairs for the ADHA.

Last year Virginia passed a bill authorizing hygienists and nurses to administer fluoride treatments to young children under a doctor's orders.

In 2000, then-Surgeon General David Satcher called tooth decay the most common chronic childhood disease in America, and experts say that's still true. Five times more common than asthma, it is estimated to affect more than half of all children before second grade. And decay hits poor children the hardest. Beth McKinney, a dental hygienist in Montgomery County's public health dental clinic, calls the tooth decay she sees "rampant."

Last year's death of a 12-year-old Prince George's County boy from an untreated dental infection called attention to the difficulty of finding care in poor neighborhoods. The boy's mother did not have dental insurance, and the child's Medicaid coverage had temporarily lapsed.

Medicaid, the nation's health insurance program for the poor, entitles children to dental care. But many dentists refuse to accept Medicaid patients, citing low reimbursement rates, bureaucratic hurdles and the difficulties of working with poor families. Fewer than a third of Maryland's nearly 500,000 children on Medicaid were seen by a dentist in 2005, typical of the problem nationwide, according to data submitted by states to the Centers for Medicare and Medicaid Services.

Hygienists argue that they have the skills to fill some of these gaps by reaching patients who might not otherwise be seen. To obtain state licenses, hygienists must hold at least a two-year associate degree from an accredited school; some hygienists hold bachelor's or master's degrees. Besides providing cleanings, fluoride treatments, sealants, gum treatments and X-rays, hygienists screen for oral infections and cancers. Changing laws in some states are even enabling hygienists to build practices of their own.

Under Maryland's new law, hygienists visiting schools and other facilities will coordinate care with dentists based at local public health facilities, said Harry Goodman, director of the Maryland health department's Office on Oral Health.

When they see patients with further needs, such as restorative treatments for tooth decay, "they can refer them to the dentist they work for," Goodman said. "That's what makes this really neat. It's not just providing prevention and education. It links [patients] to a recognizable source of care."

But the expanding role of hygienists is not without controversy.

In South Carolina, for instance, the state board of dentistry fought back after the legislature eliminated a requirement that a dentist examine each child before a hygienist could perform preventive care in schools. But in a settlement issued last year, the Federal Trade Commission supported the hygienists' right to see the children first.

In Maryland's case, the state dental society endorsed a wider role for public health hygienists as a sensible division of labor.

The state's new legislation will "allow the dentists to take care of more-acute issues and the hygienist to take care of more preventive" treatments, said Maryland State Dental Association spokesman Frank McLaughlin.

By doing so, hygienists say they can stop many difficult and expensive problems from developing in the first place.

"The bottom line is this," said hygienist Katharine Lyter, who directs public health dental programs and oversees six clinics for Montgomery County: "The hygienist is going to prevent cavities. The better job she does, the more cavities are reduced over time. If you get an ideal patient, the hygienist does 100 percent of the care."


© 2008 The Washington Post Company

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