A common voice: leaders from international dental hygiene organizations around the world share oral health practices from abroad.

If a talented translator gathered dental hygienists from around the world, the many represented languages would share one voice. For dental hygienists, the international language is not love, but improved oral health.

Regardless of the challenges faced within their borders, from payment coverage and access to care issues to shortages in the professional workforce, dental hygienists from around the world treat one patient at a time and join national organizations to find strength in numbers.

The International Federation of Dental Hygiene (IFDH) represents 26 member countries out of the 37 countries worldwide that recognize dental hygiene as a profession. Each member country provides two representatives to the IFDH House of Delegates. The non-governmental, nonprofit organization has the daunting task of uniting a body of professionals that speak 15 languages.

Communication issues frequently complicate the work of organizations such as IFDH, according to the organization's president, Marjolijn Hovius, RDH. Within the same country, she said, it is easy to call up a person and collect professional opinions and advice. It becomes more complex to share ideas with a border country that speaks a different language.

"What we would like to do as an organization is to help one country help another," said Hovius. "The focus has more been to look at dental hygiene in all those other countries and [determine] where do we have a consensus, what do we do mutually, and where can we help each other," she said.

Organizations in large countries face a different set of challenges in uniting members, even when they speak the same language. In Australia, approximately 1,000 registered dental hygienists serve the country's population of 22 million people, according to Terri Slough, RDH, acting national president of The Dental Hygienists' Association of Australia, Inc. (DHAA Inc.).

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"We have a significant workforce shortage, but will see this continually improve now that we have nine training facilities and more schools in the planning stages," noted Slough. DHAA Inc. consists of 600 dental hygiene members and 250 student members.

The Japan Dental Hygienists' Association (JDHA) represents 16,000 members who work in general dental offices, hospitals, public health centers, education institutions, dental industries, and health care facilities for the elderly, according to Noriko Kanazawa, RDH, president of the organization and director of the Japanese Foundation for Oral Health Promotion.

"Now, about 90,000 dental hygienists work in Japan," commented Kanazawa. "The goal is to increase membership in the national organization."

The Israeli Dental Hygiene Association (IDHA) has 450 members, representing a third of the country's dental hygiene population.

"All members are registered dental hygienists who have successfully passed the government exams," reported Yael Carlin, RDH, president of IDHA. "Our goals are to support our dental hygienists and to improve oral hygiene care for the population."

The Dutch Dental Hygienists' Association, referred to as the NVM, has 1,821 members and 223 student members. Approximately 620 members operate their own dental hygiene office.

"This can be alone, together with one or more dental hygienists, or with one or more dentists," explained Corina Julien, NVM president.

Approximately 700 members comprise the membership of the Italian dental hygienists' organization (known as AIDI). Similar to the Netherlands, dental hygienists in Italy work both as clinical practitioners and as employees in various oral health practices.

"Some teach [dental hygiene] in the university, some collaborate with the pharmaceutical firms," commented Marialice Boldi, president of AIDI, who added that dental hygienists perform typical preventive services while promoting and educating patients about good oral health.

Scope of Practice Around the Globe

The dental hygiene organizations that responded to Access inquiries shared that dental hygienists provide basically the same services as practitioners in the United States. The five countries interviewed offered a range of responsibilities based upon their governmental regulations.

In the Netherlands, hygienists have the ability to provide professional services to improve oral health based upon prevention, treatment of primary caries and providing local anesthesia as well as professional services to improve periodontal diseases such as gingivitis and periodontitis. In Israel, Italy and Japan, the limitations are a bit more restrictive, but the ultimate goal of the dental hygienist is to improve the overall oral health and welfare of their patients through oral health practices and services provided in their work environments.

From Slough's perspective, Australia ranks equal to the United States in many aspects of dentistry, and she rates the country somewhat higher in the fields of restorative dentistry and orthodontics. She has firsthand knowledge of oral health care in the United States, having primary citizenship here, and from having completed her dental hygiene degree and 10 years of clinical practice in the U.S. prior to immigrating to Australia.

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The majority of Australian dental hygienists are employed as clinicians with dentists in the private sector, working in single and group dental practices. Dental hygienists are also employed as educators (clinical tutors/demonstrators, lecturers and academics), researchers, editors, consultants and industry sales and marketing managers. In addition, Slough added that the entrepreneur dental hygienist is also emerging in Australia, working directly on dental hygiene practice management and recruiting. Dental hygienists offer a wide range of services from oral health assessments that include taking a health history, dental charting, oral cancer screening, salivary diagnostic testing and taking vital signs, to giving supraperiosteal or mandibular nerve block injections of local anesthetics not involving, in either case, any other regional, intra-osseous or intra-ligamental anesthesia.

According to Kanazawa, Japanese dental hygienists can provide preventive dental care and assist in dental treatments, including scaling and root planing and root debridement to maintain and improve oral health. While not able to monitor nitrous oxide levels or give local anesthesia, dental hygienists in Japan offer oral health instruction to pregnant women, mothers for themselves and their babies, children, students, adults and elderly people in the community, schools and hospitals.

Kanazawa shared that one perceived difference between Japan and the U.S. is that American patients are more aware of the importance of oral health than people in her country.

"Recently, Japanese people have [become] interested in oral health care, but many over-thirties have chronic periodontitis," she observed. "They have the perception of the importance of oral health care, because they have been given information and instruction about oral health care since when they were children, but it's difficult to change their lifestyle."

Differences between The Netherlands and the U.S., according to Julien, amount to differences in insurance.

"In our country, there is some social insurance, that [is] a general difference in care and the way it will be paid," Julien commented.

Hovius agreed. "In Holland, you have free entrance to care," she explained, adding that in The Netherlands, approximately 6 in 20 dental hygienists have their own practice. Another 20 per 100 work with dentists, hospitals or in universities.

"For most things, you don't need a referral from a dentist to be treated--in theory at least. For some things, you do need a referral." Taking radiographs, for example. Due to European law, dental hygienists are not allowed to have their own radiographic equipment.

The dental hygienist has become an important player in the dental team and works with dentists and prophylaxe-assistants, according to Julien who explained that in May 2006, dental hygienists in The Netherlands achieved direct access to patients. "A challenge within the profession is how to deal with the different players on the field and their experience and skills. The prophylaxe assistant takes over more of the [responsibilities] of the dental hygienist [so that] the dental hygienist [can assume more responsibilities] from the dentist."

Dental hygienists in The Netherlands provide preventive care to address oral diseases, including the prophylaxis and intervention for gingivitis, periodontitis, dental caries, root caries, dental erosion and bad breath.

In 2007, The Netherlands organization wrote new rules of professional conduct that identify the key responsibilities of the dental hygienist to their patients, clients, the public and the professional colleagues. The dental hygienist is still considered a teammate even when located in an independent office.

In Israel, Carlin reported that the dental hygienist is also a respected member of the dental team, performing prophylaxis, scaling and root-planing procedures.

"We can apply topical anesthetic and subgingival, slow-release devices," Carlin continued, adding that dental hygienists also take study models and X-rays, apply fissure sealants, polish fillings, remove sutures, and apply desensitizing agents and topical fluoride. Like other countries, Israeli dental hygienists also teach and advise on oral health care in dental clinics, educational institutions and hospitals.

Since 2006, dental hygiene in The Netherlands is offered as a four-year education in four of the country's higher-education institutions. According to Julien, one of the NVM's goals is to strengthen the position of the dental hygienist by allowing those professionals with a two- or three-year education to have an opportunity to upgrade to a bachelor's degree.

DHAA Inc. members, according to Slough, have qualifications ranging from an Advanced Diploma of Dental Hygiene to a Master of Science degree. In Australia, the highest academic qualification specifically in dental hygiene, is the bachelor of oral health. The DHAA Inc. foresees that tertiary qualifications of the dental hygienist will expand to include graduate certificates, graduate diplomas and masters' and PhD degrees in dental hygiene in the future. Admission to advanced degree programs is currently available to dental hygienists in public health, research and dentistry.

Slough stated that uniformity in education will improve as Australia's new graduates eventually will emerge in dental hygiene research as a continuance of their university studies and begin to foster more dental hygienist academics.

According to Kanazawa, new postgraduate education programs in Japan (including an approval system for dental hygienists) start this year.

Issues Impacting Dental Hygiene Around the World

As it is with oral health care in the United States, a number of issues impact dental hygienists' work in other countries. Access to care topped most lists as the greatest challenge, primarily due to patients' ability to pay, as well as their ability to access care due to physical and intellectual challenges.

Insurance coverage for dental care ranges from government-funded oral health plans for children and young people to countries where all dental visits are the patient's responsibility.

The Netherlands offers free dental care, except for orthodontic treatment, to anyone under 22 years of age. For the NVM, focusing on preventive measures in their country instead of treatment is an issue on which the organization is sharply focused, said Julien, who commented that many Dutch patients are experiencing dental erosion caused by new eating habits. Diabetes, heart diseases and obesity are main problems in general health care in The Netherlands.

"Although dental care is free [to those under 22], still not all children go to the dental office regularly," she commented. "The whole structure of the pricing of the preventive intervention has to change. [After] the age of 22 you can obtain an additional insurance for dental care."

Gingival diseases and caries top the list of oral health issues in Italy, according to Boldi, who noted, "Treating caries is very expensive, and there are not many dental hygienists."

Dental hygiene in Australia, like many countries with a developed system of dental hygiene education, is on the cusp of expansion, owing to a range of elements: a new government and leadership, the initiation of new registration and accreditation plans and the need to increase access to dental care in the midst of a workforce shortage. Australia additionally has experienced a shortage of faculty members within educational institutions who are qualified dental hygienists, and the curriculum content for dental hygiene education is not universal.

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As a result of the shortage in the public sector, Australia has more than 600,000 people on a waiting list for public dental services. It is, according to Slough, the natural effect of an ageing population and the economy.

"The regulatory limitations on dental hygienists imposed by strict supervision and scope of practice impede the provision of essential preventive dental services for those unable to physically attend or afford to attend the traditional private dental practice," she commented.

In addition, the consequences of introducing the western culture have directly impacted the general health of Australia's Aboriginal people, with higher incidences of dental caries, periodontal disease, diabetes, heart disease, obesity and reduced life expectancy.

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Further complicating matters, dental benefits from Health Funds (Insurance) in Australia are minimal compared to the U.S., Slough shared.

"Most dental services incur 'out of pocket' payment by the patient," she explained, and patients take responsibility for reimbursement of their Health Fund benefits at convenient retail locations within their communities.

Like many other respondents, Carlin shared that a lack of dental coverage in the public insurance plans makes access to dental care in her country quite expensive. "Reaching all sectors of the public is a challenge," she commented.

Serving elderly populations was a particular challenge for many respondents to Access' informal survey of international associations. The Netherlands has experienced a sharp increase in elderly patients with their own teeth and who have complicated dental needs.

"For them, dental treatment isn't free and is only partially paid by insurances," Julien shared.

The age distribution of the world's population is changing, according to information from the World Health Organization (WHO). With advances in medicine and prolonged life expectancy, WHO estimates that the proportion of older people will continue to rise worldwide. For example, there were 390 million people aged over 65 years recorded in the 1998 World Health Report, and this figure is estimated to double in 2025. The postwar baby boom generation will reach 65 years of age in 2011, significantly augmenting the number of older people. In many developing countries, particularly in Latin America and Asia, increases of up to 300 percent of the elderly population are expected by 2025. By 2050, there will be 2 billion people over the age of 60, 80 percent of those will be living in developing countries. (1)

Australia's aging population also is on the increase. In the 1970s, according to Slough, nine percent of the population was over 65 years old; that figure rose to 12 percent in 1996, and is projected to reach 16 percent by 2016.

"With our residential care facilities at capacity and a growing number of residents having their own natural teeth, more preventive care services are needed to assist in maintaining both their oral health and systemic health," commented Slough. The DHAA Inc. is seeking an expanded scope of practice to allow dental hygienists to deliver their full range of clinical skills to patients outside the traditional dental practice. The majority of jurisdictional regulations on the services delivered by a dental hygienist require that a dentist first examine the patient to prescribe the required treatment, Slough shared, adding that the inability of dentists to extend their professional time beyond their private practice is a disadvantage to this patient demographic in her country.

Similarly in Japan, Kanazawa shared that a government regulation stipulates that dental hygienists must receive instructions from the dentist or physician in charge by case. The primary dental hygiene issue in Japan is educating caregivers of patients who are elderly or have special needs, such as those with a variety of ailments that range from chronic diseases such as dementia, Parkinson's disease, rheumatoid arthritis, apoplexy, cerebral infarction, cerebrovascular disease to diabetes among others. Preparing dental hygienists to provide such education is a goal of the programs that will start this year.

In Australia, the access to care issue pivots on jurisdictional regulations in the practice of preventive dentistry by dental hygienists and is a major issue on the health minister's agenda, Slough shared. The Council of Australian Governments (COAG) began a national restructuring of the nine primary health professions for the purpose of ensuring greater safety and quality in the delivery of health care services to the public. Its initiation was in 2006, with a projected launch on July 1, 2008. A national election occurred in the middle of this process (November 2007) resulting in a major change of leadership.

"Although we are back to a starting point, the progress is expected to pick up momentum in the very near future," Slough commented. The DHAA Inc. is seeking a national scope of practice modeled from a jurisdiction with the least restrictions so that all states/territories support a comprehensive utilization of dental hygienists.

"The dental professions are divided on expanding the role of the dental hygienist that would enable us to utilize our full range of skills and to have direct primary access to special needs patients in settings outside of the traditional dental practice," Slough stated. "Making national changes through the COAG initiatives will require a consensus involving the Australian Dental Association Inc. (ADA) and all of the allied dental health professions to bring this objective to fruition. It is by request of the government that a united stance be presented from the dental professions rather than the represented views of each of the dental professions."

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Changes for the Future

How will these issues change over the next 5-10 years?

Julien predicted that issues in The Netherlands will get worse, and that the NVM won't hesitate to take a stand.

"A government report warns the dental profession to pay more attention to the treatment of children. The dental hygienist could play a bigger role, but with a lack of money, nothing will change!" she shared, adding, "We also must be prepared to work [in a] more interdisciplinary [fashion]."

What will have the greatest impact on changing this situation, according to Julien, is to inform the public about direct access to care offered by independent dental hygienists.

"Only 10 percent of the Dutch population is treated by a dental hygienist," she commented. "National media like magazines, journals, Internet, radio and television must [educate] the public on the role of the dental hygienist."

Boldi applauds the education in schools, which she credits for the improvement in spreading the word about good oral health practices.

"The information and the education of the population and the introduction of the dental hygienist in the public structures," she said has made the greatest impact on improving the situation. As for the shortage in Italy's oral health workforce, she said a yearly upsurge of 500 dental hygiene professionals should help.

One of the goals of the dental hygienists' association in Israel is to update dental health educational programs and to broaden their implementation in schools.

In addition, Carlin commented that the greatest impact in changing the challenges faced in Israel will come if dental hygienists can receive enough reimbursement to allow them to teach and work in schools and public clinics.

This will only come to pass "if dental hygienists will be able to achieve a university degree in dental hygiene or at least be able to consolidate their dental hygiene studies with other degree programs in order to achieve a degree in public health or the like," Carlin added.

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For the challenges Australia faces, including the health of its Aboriginal population, change in government regulations suggest that hope is on the horizon. Expansion in the rural and remote provision of health care through networks of professionals will assist the Aboriginal population. The DHAA Inc. is the first oral health component within the Services for Rural and Remote Allied Health (SARRAH) network.

"Our participation will provide an increased delivery of oral health care through efforts concentrated on dietary counseling, homecare and preventive maintenance," commented Slough.

The government, especially the Department of Ageing, have approached the allied dental professions to explore resolutions that have neither been presented nor endorsed by the Australian Dental Association (ADA Inc.) The new alliance has invited the ADA Inc. to become a member for the purpose of creating resolutions that are harmonious to all of the dental professions and that serve to increase the access to quality dental services to the population.

As for the challenges of government regulations in Australia, Slough mentioned that the new national registration and accreditation plans will be in effect. "We are hopeful for a national scope of practice defined by a statement of practice rather than a prescriptive list of duties," she commented, describing this as a less restrictive delivery of clinical skills across all jurisdictions.

Practicing Abroad

Many of the countries queried for this article mentioned that foreign dental hygienists are welcome to practice in their countries, providing they have the proper accreditation to meet the particular country's requirements. Sometimes a limited scope of practice is imposed on foreign dental hygienists.

Foreign dental hygienists may study in Japan; however, to practice or work there, they must obtain Japanese hygienist's license. Kanazawa recommends that those interested in such an arrangement should make a call first to a Japanese consulate for more details.

Even among European Union countries there are challenges to working across borders. Rules change per country. "[Many countries] will not acknowledge diplomas, licenses or exams that people have," Hovius explained. So when an Italian dental hygienist comes [to The Netherlands], he or she cannot practice because the tasks of the Dutch hygienist have changed, and these changes are not taught in Italy. In principle, however, with the European community, there are no boundaries.

Hovius continued that the Netherlands is an extremely difficult country to get into for the purpose of practicing dental hygiene, adding that only the United Kingdom has the same practice rules and is even more complicated with the addition of dental therapists to its hierarchy of oral health care providers.

Israel welcomes foreign dental hygienists who must first pass a government exam. The initial step for interested professionals would be to contact the Ministry of Health or the IDHA, whose board members would be happy to advise on the process.

The first step for those interested in practicing in The Netherlands is to report to the government department of health, which then checks the validity of the foreign dental hygienist's diploma or degree.

"This is checked by a special commission from the government department of health. Our dental hygiene organization participates in this committee," reported Julien.

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For dental hygienists interested in practicing in Italy, Boldi pointed them to the Ministero Della Salute to have all credentials reviewed. Additionally, when applying, applicants must submit all documents in Italian, she advised.

Australia has experienced a lack of uniformity in its educational system for dental hygienists, Slough noted. While the current system does not require a national theory and clinical competency examination for the country's own graduates to qualify for registration, all overseas-trained dental hygienists wanting to gain an Australian registration must take this exam to demonstrate competency.

"The profession of dental hygiene is relatively young in Australia with many of the initial dental hygienists coming from overseas," commented Slough. "In some states/territories the foreign-trained dental hygienists have outnumbered the Australian dental hygienists. This proportion is changing rapidly with the increased number of training schools."

Overseas-trained dental hygienists can enter Australia individually through an immigration points system or through a sponsor (employing dentist), according to Slough. "This latter option is getting much tougher now that Australia has increased the number of dental hygienist graduates," she commented, adding that this increase in the workforce will ultimately influence the Department of Immigration in its willingness to allocate work visas to foreigners. Slough added that Australia has a reciprocal agreement with New Zealand, which allows dental professionals to gain registration without undergoing an examination.

A dental hygienist interested in working in Australia should first ascertain their eligibility for a Work Visa through the Department of Immigration (www.immi.gov.au/skilled/index.htm).

Conclusion

"The global role of the dental hygienist is increasing," observed Hovius. "It's getting more important." She pointed out, in particular, the growth in importance of dental hygienists in countries such as Pakistan, Saudi Arabia and the Philippines, which are not yet members of IFDH. "There is also a dental hygienists' association in Nepal," she added.

Slough echoed the one voice of dental hygienists from various countries, saying that patients respond to the encouragement to improve both oral and overall health.

"One of the more rewarding experiences in pioneering preventive dentistry in Australia has been the patients' receptiveness in learning about their oral health and the proper use of the homecare products," Slough concluded. "Patients treated by dental hygienists are amazed with and take pride in the resulting health benefits."

Note

(1.) World Health Organization (WHO), 2008. Available at www.who.int/oral_health/action/groups/en/indexl.html. Accessed Feb 15, 2008.

Uniting Professionals

Dental Hygiene Organizations Share Their Mission and Successes

Access contacted 12 dental hygiene organizations from around the world, five of which shared information about their members, the work of their organizations, collaborations the organizations have shared with other health care bodies and their greatest achievements during the past two years. The following highlights the accomplishments of the organizations that replied to our questionnaire.

The International Federation of Dental Hygienists (IFDH) was officially formed on June 28, 1986, in Oslo, Norway. The forerunner of IFDH, the International Liaison Committee on Dental Hygiene, was established in 1973, by European countries that included the Netherlands, Norway, Sweden, the UK, the U.S., Canada and Japan.

The federation represents and advances the profession of dental hygiene and promotes professional alliances with its association members as well as with other associations, federations and organizations whose objectives are similar. IFDH also promotes and coordinates the exchange of

knowledge and information about the profession, its education and its practices, as well as promoting access to quality preventive oral health care services. The organization has increased public awareness that oral disease can be prevented through proven regimens and provides a forum for the understanding and discussion of issues pertaining to dental hygiene.

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IFDH recently created an oral health pamphlet soon to be posted on their Web site for members to copy and use in their own countries. In addition, the organization offers a twice-a-year newsletter for members, to which they may contribute information.

"The biggest achievement is the fact that we have grown, the fact that the people in the house of delegates (HOD) are a very motivated and an enthusiastic group who want to accomplish things," said Marjolijn Hovius, president of IFDH. "The countries see it is more and more important to send good people to the HOD."

The Israel Dental Hygienists Association (IDHA) was set up in 1981 by several dental hygienists who felt the time was right to organize a professional association to represent the interests of their profession. More than 25 years later, the IDHA is a nationally and internationally recognized body that represents more than 1,2 dental hygienists throughout Israel.

Yael Carlin, RDH, president of the IDHA, reported that the organization has succeeded in amending the law, now allowing dental hygienists to work without a dentist on site.

"We are continuously working together with our members of parliament and other prominent figures to improve the working conditions of the dental hygienists, and we are in discussions with various groups about degree programs in dental hygiene," she commented.

The dental hygienists' organization in Italy (AIDI) represents some 700 members. AIDI President Marialice Boldi cited the organization's participation in a project defining preventive guidelines for oral health as their greatest achievement of the past two years. AIDI collaborates with the principal associations of dentists in Italy and is a member of the IFDH.

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The Japan Dental Hygienist's Association's (JDHA) 16,000 members take the lifelong learning programs seriously thanks to a record-keeping system established by the organization. JDHA maintains a record of each member's attendance of lectures and training administered by the association. Those dental hygienists who earn a certain amount of points can take an approval program. The purpose of this system is to educate dental hygienists so that their knowledge level and skills are appropriate to meet social needs. JDHA collaborates with Japan Dentist Association (JDA), and has a relationship with Korea Dental Hygienists Association.

The Dental Hygienists' Association of Australia, Inc. (DHAA Inc.) consists of the national branch, initiated in 1991, and seven state/territory branches. All states/territories of Australia are represented with exception of the Northern Territory due to its high proportion of rural and remote areas in which there are low numbers of dental hygienists.

The DHAA Inc. is working toward initiating community health service affiliations with the Breast Cancer Foundation, The Heart Foundation and Diabetes Australia. They are also working collaboratively to establish educational standards, clinical excellence and practitioner accreditation.

"Our biggest achievement has been the understanding of and the development of an interdependent business model from which the association now functions," commented Terri Slough, RDH, acting national president of the DHAA Inc. "We are expanding in our membership numbers and in our approach to representing dental hygienists and the profession of dental hygiene as a Peak Body. The business model has been instrumental in raising dental hygienists' professional profile in the dental community and will serve as well to broaden the profession's public profile.

DHAA Inc. is currently involved in an alliance of the dental professions to assist in attaining fair and equitable resolutions in the national registration and accreditation plan currently in development, according to Slough. This is known as the Australian Oral Care Alliance (AOCA) and is composed of dental hygienists, dental therapists, dental prosthetists, dental technicians, dental laboratories and the dental industry.

The Dutch Dental Hygienists Association in the Netherlands (NVM), founded in 1967, has several goals and

projects on its list. Before 2010, NVM is seeking to motivate young people to see dental hygienists for preventive care. The organization also hopes to reach pregnant women with information about their oral health and that of their babies. These goals require new collaborations with different disciplines, commented Corina Julien, NVM president. NVM currently collaborates with the two dentist organizations in the Netherlands.

"This year we also have our second symposium together with a dentist organization that provides a program for the whole dental team," commented Julien. "Still a lot of older dentists have problems with the change of role of the dental hygienist and her/his independence. They have to learn how to let go. They see us everywhere!"

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Marialice Boldi, a native of Milan, Italy, holds a degree in biology and in dental hygiene. She works as an independent professional in the dental study of her husband and in other two additional dental studies. She teaches in the dental hygiene program at University of the Insubria to Varese, and has been president of the AIDI since 2006 after having been vice-president of the organization for three years.

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Yael Carlin has been president of the Israeli Dental Hygiene Association (IDHA) since 2005. In addition, she has served as the organization's treasurer (2000-2005) and held the post of secretary of the International Federation of Dental Hygienists (2004-2007). Carlin has been a practicing dental hygienist since 1981, with a primary interest in dental hygiene for people with special needs.

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Marjolijn Hovius is president International Federation of Dental Hygiene (IFDH) and the previous director of the School of Dental Hygiene at INHOLLAND University. She is now a project manager within the INHOLLAND University School of Health. She is editor-in-chief of the International Journal of Dental Hygiene, an honorary member of the Dutch Dental Hygienists' Association and received a prize from the Dutch Society of Periodontology.

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Corina Julien is president of the Dutch Dental Hygienists' Association, referred to as the NVM, and owns her own dental hygiene practice where she employs dental hygienists.

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Noriko Kanazawa, RDH, graduated from Fukushima Prefectural Dental Hygienists Training School in 1964. She served as president of the Japan Dental Hygienists' Association (JDHA) from 1984 to 1993, and has been serving her current term as president since 2003.

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Terri Slough, RDH, is a reflexologist and the Acting National President of the The Dental Hygienists' Association of Australia, Inc. (DHAA Inc.). Originally from Ohio, she earned her dental hygiene degree from Mankato State University (Minnesota) in 1983 and moved to Australia in 1993. She holds a dual citizenship for the United States and Australia and works as a professional freelance writer with an emphasis on educational dental literature.

By Christine A. Hovliaras-Delozier, RDH, BS, MBA