The Professional Practice Environment of Dental Hygienists in the Fifty States and the District of Columbia, 2001

Chapter 2. Background and Context

This chapter provides a context for the subsequent discussion of the professional practice index for dental hygienists. It includes the following subsections:

• Historical Context
• History of the Dental Hygiene Profession

• “Oral health is much more than healthy teeth”.^[7] The mouth is a central organ and a “sentinel” of disease processes in the body. The mouth enables social interaction through speech and expression. It is the pathway for nutrition, and it provides key indicators of overall health status. Many systemic illnesses manifest in the oral cavity. Accurate and early diagnosis by medical and dental providers can alter the progression and treatment of more pervasive disease.^[8]
• Oral health status is determined by a number of individual factors including biology, behavior, socioeconomic status, and the environment.^[9]

• Prevention of oral disease requires both a public health perspective and an individual orientation. Healthy People 2010 asserts the need for “promotion of oral health requiring self care and professional care as well as population based initiatives.”^[10] Community water fluoridation, tobacco education programs, community screening programs, and school-based clinics are important to increasing the oral health status of the public.^[11] Increasing access to preventive, prophylactic and restorative services including oral health education and dental screening are substantive initiatives at an individual level.

The Problem

• Untreated dental conditions contribute significantly to documented loss of school days for children and workdays for adults.^[12] A 1989 survey indicated that 52 million hours of school and 164 million hours of work were missed because of oral health problems or for dental treatments to treat oral conditions.^[13] Oral health status is correlated to quality of life issues, to mortality and to morbidity.^[14]
• Although there have been significant reductions in the incidence of oral health disease over the last decade, there is still a striking incidence of oral cancers and dental caries. The annual mortality rate from oral cancer is about 8,000.^[15] It is estimated that 80 percent of tooth decay is found in 25 percent of children.^[16] The number one chronic illness in childhood is dental disease.^[17] Dental decay is five times more common in children than childhood asthma.^[18]

Access

• Access to oral health services is disproportionately available to certain racial, ethnic, and socioeconomic groups. The National Health and Nutrition Examination Survey found that Mexican Americans and non-Hispanic black populations were more likely to have untreated decay than non-Hispanic whites.^[19]
• The needs of the homeless, the elderly, children with disabilities or children with lower socioeconomic status, and migrant workers present challenges to the health system that are multi-dimensional.^[20]
• Access to care increases with the availability of dental insurance^[21]. In one study, half of the people identified as having no insurance had no dental visit in the year prior to the survey while only 28 percent of those with dental insurance had not seen a dental professional in the same time period.^[22] The 2001 National Health Interview Survey found that among those under 65, only 37.6 percent of those without dental insurance had seen a dental professional in the previous year. Of those under 65 with private dental insurance, 72.5 percent had seen a dental professional in the previous year. For those over 65 without dental insurance, 37.6 percent had seen a dental professional in the previous year while among those in the same age cohort with dental insurance, 62.2 percent had seen a dental professional within the previous year^[23]. A study of 1994 national survey data found that those with private dental insurance were twice as likely to receive oral health services as those with Medicaid and four times as likely to receive oral health services as those with no insurance.^[24]
•  In 1996, it was estimated that approximately 45 percent of the population had dental insurance.^[25] The National Health Interview survey of 1995 revealed that 44 percent of the US population had some form of private dental insurance, 9 percent had public insurance such as Medicaid or State Child Health Insurance Program, 2 percent had other forms of dental insurance with 45 percent reporting an uninsured status.^[26]  A study published in the Journal of the American Dental Association in May 2003 which reviewed data in the 1989 and 1999 National Health Interview Survey revealed that overall there had been a drop in the number of people with private dental insurance over the decade.  The study found that the overall percentage of people with private dental insurance dropped from 40.5 percent in 1989 to 35.2 percent in 1999.^[27]
• Access to insurance is not necessarily a predictor of utilization of services. Other factors may prevent those with insurance (and particularly public insurance) from seeking care including “structural”^[28] barriers related to workplace restraints or lack of transportation, and “non-structural” barriers such as cultural attitudes that affect perceptions about the need for oral health services.^[29]
• More than 40 million people live in areas designated as Dental Health Professions Shortage Areas.^[30] Rural areas present special challenges with fewer providers or public programs available for residents. It is estimated that 11 percent of those living in rural areas have never seen a dentist.^[31]

The Providers

• The supply of professional providers is affected by a number of factors. The rate of dentists per population is decreasing,  raising concerns over the availability of providers to meet the oral health needs of an expanding population.^[32]
• The refusal of some dentists to participate in Medicaid due to low reimbursement rates further affects the availability of services to publicly insured populations.^[33]
• There is a need for culturally competent and/or minority dental professionals to work with populations that are underserved.^[34]
• The lack of supply of dental providers affects care in certain geographic locations where medical and dental services are not widely available.^[35]
• Public health providers cannot meet the need for oral health services.^[36] The safety net is deficient. Only about one third of community health centers offer comprehensive dental services.^[37]

Possible Solutions

• Achieving nationally established goals (Healthy People 2010) to improve the oral health status of all Americans will require the participation of both medical and dental primary care providers.^[38] Dental hygienists may contribute to increased access through their competencies in cleaning, instruction, nutrition, and behavior education.^[39]
• The Surgeon General’s Report states that “safe and effective measures” already exist to prevent or treat decay and gum disease.^[40] However, disparities in the delivery of those services to certain populations are notable and must be addressed.
• Encouraging community partnerships in oral health promotion is seen as a necessary strategy to provide multiple points of entry to the oral health system and to reach populations with marginal or no access.^[41] The Surgeon General’s Report calls upon “the collective and complementary talents” of an array of community, health, and citizens groups to achieve better oral health in their communities.^[42]
•  The interplay of a number of factors contributes to the oral health of a community. Creative solutions will require differing strategies and a variety of approaches depending on the needs and the characteristics of the public being served. The needs of the elderly living in a nursing home will differ from those of children in a Head Start Program. The Surgeon General suggests that a customized approach that addresses the distinctive needs of a group will best achieve optimal oral health outcomes.^[43]

As suggested by this brief overview of the current status of oral health in America, improvements in oral health status will only be achieved through creative collaboration and rational allocation of existing and emerging resources. This study addresses the professional workforce component, dental hygienists, that are trained to provide preventive and prophylactic oral health services and patient education about lifestyle and social behavior that affect oral health. Dental hygienists are uniquely educated in these competencies. Presently, however, they are not being effectively utilized within the delivery system in a manner that maximizes their potential contributions to oral health. Positioning the profession to enable it to contribute to increased access will require change at the local, State, and National levels in several areas including professional regulation, supervision, professional practice, and reimbursement for the profession.

History of the Profession

Dental hygiene has a history that dates to the early part of the twentieth century. A Connecticut dentist, Dr. Alfred Civilion Fones, who was himself a legacy to dentistry, is considered the founder of the profession.  Dr. Fones’ father was a dentist and a dental commissioner in the State of Connecticut.^[44] In the early part of the 1900s when the young Dr. Fones began practice, the contemporary solution to dental problems was tooth extraction. However, it was Dr. Fones’ belief that such extreme action would become increasingly unnecessary for patients who received proper preventive oral health care.

Another dentist, Dr. Levi Spear Parmly, had championed the concept of preventive oral health services as early as a century before.^[45] Although his ideas generated some interest in the dental community in the 1800s, no change in dental practice or procedure had occurred to implement Dr. Parmly’s theories.

Young Dr. Fones adopted the idea that preventive dental services and patient education about oral health would contribute to a reduction in dental disease, particularly among children. It was his theory that prophylactic services could be provided by a dental aide. He trained his cousin, Irene Newman, to be his first assistant by teaching her to remove calculus and plaque from patient’s teeth, to “clean” teeth. With this training, the “hygienist” profession was born.

Dr. Fones and Ms. Newman practiced in an old carriage house in Bridgeport, Connecticut in which Dr. Fones eventually established the first school of dental hygiene. He established an educational model for the profession that included courses in anatomy and other clinical subjects and taught sterilization techniques.^[46] Dr. Fones also invited both local and international lecturers to teach his students.   The first graduating class from the Fones program completed their education in 1915. Dr. Fones subsequently traveled widely to lecture and share his ideas with others.^[47] The profession that began with 16 assistants in 1915 has swelled to a licensed profession of more than 120,000 hygienists in the year 2002.^[48] These professionals are trained in more than 260 accredited education programs in 50 States and the District of Columbia, which graduate approximately 5,000 new hygienists each year.^[49]

The profession is presently licensed in every State and the District of Columbia. Professional hygienists practice in a variety of settings providing preventive oral health education and oral health services including prophylaxis (scaling and polishing teeth), dental hygiene assessment, fluoride varnishes, sealant applications, etc.  In some States they are legally enabled to perform more extended functions such as placing and polishing amalgam restorations and administration and monitoring of local anesthetics and nitrous oxide.