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Dental hygiene: reflecting on our past, preparing for our future.

Introduction

As we reflect on the past, it is apparent that the Advanced Dental Hygiene Practitioner (ADHP) and the American Dental Hygienists' Association's (ADHA) new branding campaign have the potential to elevate the profession and ultimately improve access to care as Alfred C. Fones, DDS, imagined a century ago (Figure 1). To understand our achievements, let us review where we have been.

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Historic Overview

In the mid 1800s, dental pioneers recognized the benefit of a clean oral cavity. Prevention was a frequent topic of discussion. By 1900, the value of periodic removal of plaque from teeth was documented by Dr. David Smith, who told dentists that recall appointments had improved his patients' health--not just their oral health, but also their overall health. Dr. L. S. Parmly had been recommending the regular use of waxed silk floss, and M. L. Rhein, MD, DDS, was vocal in promoting dental home care education for his patients. (1)

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At this time, dental print advertising appeared for toothpaste and animal hair toothbrushes (Figures 2 and 3). Although silk dental floss was available, it was not readily used by the masses. Most patients had not embraced the concept of preventive oral health and visited the dentist only when they were in pain. (2)

In 1902, Dr. Cyrus Wright published an article reflecting his predecessors' ideas while defining his concept of a new specialist to help patients maintain optimum health (Figure 4). (3)

"With this training and the dental college certificate, these ladies may be employed by dentists for this special work, or may practice at parlors of their own, or at the homes of patients, the dentists using their influence and recommending the new specialists, just as physicians and surgeons recommend and insist upon the services of the trained nurse...." (3)

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Fones later credited Wright as the visionary who saw the future of dental hygiene. (1) Rhein initially proposed calling this new professional a dental nurse, who would be the graduate of a special new training school, an offshoot of nursing programs. Rhein recommended state board examinations to insure competence and wrote:

"The cleansing of the mouths of properly selected patients in the dispensaries, combined with the proper education for preserving oral hygienic conditions would be of greater value in the uplifting of the masses than any other means at present employed." (4)

Fones taught his dental assistant, Irene Newman, to treat his patients in 1906. It is believed that other dentists also used this system of apprenticeship. (5) Fones didn't like the term "dental nurse" since it indicated disease rather than prevention and health. "These women are not to perform any service that resembles the work of the medical nurse," he wrote. (6) It was Fones who originated the name dental hygienist.

Around the same time (1910) in Ohio, Dr. William G. Ebersole conducted the "Marion School Experiment." The goals of prevention of dental disease for children, overall health and affiliation with the schools were paramount in the creation of the profession.

"Public welfare was not the only goal of the dental hygiene campaign. The program also gave dentists the opportunity to prove "scientifically" that their efforts were vitally important to the overall well being of the children's health." (7)

Ebersol opened a school to educate dental hygienist-like auxiliaries. It was one year before organized dentistry in Ohio closed the program. This was in fact the first program for dental hygiene-like auxiliaries.

After documenting the success of using a dental hygienist to improve the health of his private patients in Connecticut, Fones wanted the children in Bridgeport to be able to "secure similar prophylactic service ... in contradiction to relief and repair dental clinics." (1) To establish a program for women to work in school clinics, Fortes invited his colleagues to lecture the new students, and all enthusiastically volunteered their services. Rhein was one of the lecturers; another was Cordelia O'Neil, a teacher who had been involved with the now defunct Marion School Project Ohio. The original school was located in his carriage house. Students were recruited in the local newspaper in 1913. For $20, they could attend a lecture series and six weeks of practical training. This program lasted three years, and, as expected, all graduates worked initially in the Bridgeport Connecticut public school system (Figures 5 and 6). (1)

Fones' original plan had been to improve students' general health by improving their dental health through preventive services. The Bridgeport Board of Education initially approved this project for five years. The grant money, the volunteer services of the dental faculty, and the donations from SS White Company all occurred with the belief that the program was not meant to be permanent. The original program was a success. (8)

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Fones felt that dental hygiene programs should be continued as a standardized course, two years in length. (6) When the original program closed, he went "on the road" to continue to advocate the creation of legislation for the new profession and to propose the new curriculum at a variety of sites throughout the country. As a result of the efforts of Fortes and his colleagues, legislation in New York, Connecticut and Massachusetts allowed the first collegiate schools of dental hygiene to open. Many of the original graduates of the Fortes School were teachers and directors of these and other new programs. The first three schools to open, around 1916, were The New York School of Dental Hygiene (affiliated with Columbia University); The Rochester Dental Dispensary in Rochester, N.Y.; and the Forsyth Dental Infirmary for Children in Boston, Mass. (1)

Data on the success of Fones graduates in the elementary schools of Bridgeport was documented over five years. This laid the groundwork for the future of school dental health programs. Data is available in a 1939 Journal of the American Dental Hygienists' Association article by Mabel McCarthy, RDH, an original Fortes graduate. (2)

The 1920s and 1930s

In a 1926 article, Fones acknowledged the following schools in addition to the original three (Figures 9 and 10): (1)

University of California-San Francisco, California Marquette University-Milwaukee, Wisconsin University of Michigan-Ann Arbor, Michigan University of Minnesota-Minneapolis, Minnesota Northwestern University-Chicago, Illinois University of Pennsylvania-Philadelphia, Pennsylvania Temple University-Philadelphia, Pennsylvania

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With new schools opening throughout the country and legislative changes needed, hygienists organized the American Dental Hygienists' Association (ADHA). The following quote from 1927 is a membership appeal to practicing dental hygienists, expressing feelings similar to those of today.

"What you get out of it [membership] will depend ... on what you put in. If you stay on the outside edge, lost in the dimness of inconspicuousness, your returns on the investment will be slim, but if you come forward where you may be seen, then will you be amply repaid in more efficiency, alertness, and contentment." (10)

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At the same time hygienists were organizing, the public was beginning to practice home care more regularly than before. This was in part due to the use of nylon in the late 1930s, which made toothbrushes and floss more affordable (Figure 11). Charles Bass, MD, medical dean at Tulane University, was a prevention advocate who taught innovative tooth-brushing and flossing techniques to his patients. He published numerous articles and lectured on what became the "Bass technique." (11))

[FIGURE 11 OMITTED]

By 1938, there were only 19 dental hygiene schools opened throughout the United States. During this period, many of the existing schools offered certificates after one year of education and others gave associate degrees. Baccalaureate degrees were available in Hawaii in 1938 and at University of Michigan in 1939. (12)

The 1940s - 1950s

Meetings were set by the American Dental Association (ADA) Council on Dental Education to establish curriculum and standards for all dental hygiene programs. There were schools that wanted a four-year minimum requirement. The committee, which was chaired by Frances Stoll, RDH, EdD, decided that, after 1947, all accredited dental hygiene programs would be a minimum of two years in length. (6) Interestingly, Dr. Wilkins was a member of the committee. (6,8)

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The Fones School of Dental Hygiene re-opened in 1947 (Figures 12 and 13). One of the original faculty members, and co-author of the first Fones textbook, Robert Strang, MD, DDS, became the new director at the Junior College of Connecticut (University of Bridgeport). The first master's program in dental hygiene was offered at Columbia University in 1953 to prepare future teachers and administrators. Sigma Phi Alpha, the national dental hygiene honor society, was founded in 1959.

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During the mid 1940s, a pilot study of fluoridation in paired cities evaluated the effect of adding sodium fluoride to the public water supply and found it to be beneficial. By the mid 1950s, fluoride treatments were routine in dental offices.

Also of note, in 1951, Texas became the last state to established licensure for dental hygiene (Figure 14).

The 1960s - 1970s

Issues of diversity and the woman's liberation movement were important in the '60s. The National Dental Hygienists' Association (NDHA) re-organized as a result of difficult issues with segregation within some local dental societies. This was the time of the civil rights movement, and NDHA addressed the needs of the minority community. NDHA remains active today and works cooperatively with ADHA. (15) There were a few practicing male hygienists who had been trained in the military, but it was not until 1965 that ADHA by-laws were changed to allow equality for male dental hygienists. (15) The first male dental hygienist graduated from the University of New Mexico in that year. (6) A few other firsts during the 1960s:

* the new Dental Hygiene National Board Exam (1962--see box on this page)

* the first electric toothbrush in America (1962)

* the first insurance policies issued for professional liability (1963)

* continuing education recommended by ADHA for the first time (1967).

* Sealants became accepted preventive treatment for children.

Another major issue of the 1960s was the promotion of Expanded Function Dental Auxiliaries (EFDA--see box on page 17).

In the 1970s, new auxiliaries were created in all aspects of medicine. The movement for holistic health care and prevention, along with increased government funding resulted in tremendous growth of allied health programs within community colleges throughout the United States. The number of dental hygiene schools dramatically increased (Figure 18). In 1974, the first dental hygienist was appointed to a state dental board in Maryland. (25) A dental hygienist independently owned and managed a practice in the mid-seventies. This experimentation with ownership led the ADHA House of Delegates to issue an official statement in 1980 indicating that dental hygienists may own their own dental hygiene practice. (5)

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The buzzword among health care practitioners in the 1970s was "behavior modification." Dr. Robert Barkley lectured on patient motivation for prevention. (26) Plaque control strategies changed when Dr. Paul H. Keyes adapted a number of old techniques to decrease the amount of bacteria in periodontal pockets. Dental practices throughout the country purchased microscopes and utilized his technique for "anti-infective non-surgical periodontal treatment." (27) Ultrasonic scaler use spread rapidly, and dental sealants became more popular.

The 1980s Until Today

With sit-down dentistry, pants became necessary for modesty (Figure 19). Caps were phased out. Capping ceremonies were replaced by pinninq ceremonies. Uniforms became available in colors.

[FIGURE 19 OMITTED]

A new magazine, RDH, began and was followed by the introduction of ADHA's Access in 1987. By that time, HIV/AIDS was being covered regularly in the dental literature, having been identified in 1981. OSHA recommendations arrived in 1985, followed by mandated changes in 1988. Sterilization and personal protection radically changed.

The first home tooth-bleaching system became available in 1989 and the esthetic dentistry movement (28) increased the demand for veneers and implants.

Demographic changes within the United States population led to the creation of the Hispanic Dental Association in 1990, which included dental hygienists. To meet the need for access to care, additional responsibilities for dental hygienists were legalized in many parts of the country.

Use of computers in dentistry increased, and along with it new software became available. The popular Web site AmyRDH began in 1999. Within the dental office, comfort with new technology led to greater acceptance of digital radiography. Plaque was renamed biofilm, and varnish became an accepted treatment for tooth sensitivity and preventive dentistry.

Today

It is interesting to see how some of the unresolved issues from 1975 are being resolved today: (29)

* The difficulty in achieving fluoridation.

Many cities in the United States are still resistant to fluoridation. In some cases, this is due to anti-fluoridationists with misinformation. Elsewhere, the challenge is that treatment of water supplies occurs at the municipal or county level, so changes in the law and development of funding for fluoridation needs to occur in many local areas rather than one state level. Nevertheless, according to the Centers for Disease Control and Prevention, nearly 70% of the population does have access to a fluoridated water supply. (30) Dental sealants, fluoride therapies, varnish programs and other new preventive treatments are frequently utilized for the prevention of dental caries and strengthening enamel.

* Portability of licensure between states. "Dentistry and dental hygiene are among the few remaining professions without one uniform national clinical licensure exam." (22) Almost every state currently provides a system for dental hygienists to obtain a license upon relocation, either by endorsement or credentials. Typically, additional requirements exist that may include a clinical examination. There is movement to put in place a nationally accepted clinical exam, such as the recently developed American Dental Hygiene Licensing Examination (ADHEX). Although state boards will continue to have the ultimate authority on licensure in their states for the foreseeable future, uniformity of the clinical exam should facilitate whatever portability process a state has in place. ADHA has recently announced a page of its Web site devoted exclusively to assisting dental hygienists in acquiring a license in another state.

* "The need to convince the dental profession of the value of the dental hygiene profession, their expanded capabilities, and the loss to the dentists when these auxiliaries are not fully utilized ..." (29)

ADA's Web site acknowledges that dental hygienists are considered valued members of the dental team. (32) In fact, the value of the screening and prevention services provided by dental hygienists has become more evident in recent years, as research reveals the connection between preventable oral diseases and systemic disease.

A current goal for ADHA is to work in partnership with dentists to advance the oral health of our patients. (22) ADHA is working more collaboratively with the dental community today than in past years. "By augmenting productivity of the dental team, we will extend the accessibility of oral health care. That includes the importance of dental hygienists to recognize and treat periodontal disease." (33)

ADHA representatives in Washington now work collaboratively with other health professional groups on coalition-building to reduce unmet dental needs throughout the country. This involves working with legislators who can support increased funding for all issues relating to preventive dentistry. "As prevention specialists, dental hygienists understand that recognizing the connection between oral health and total health can prevent disease, treat problems while they are still manageable, conserve critical health care dollars and save lives." (22)

The ADHA branding initiative will improve public understanding and acceptance of dental hygienists. (22) Ann Battrell, RDH, BS, MS, executive director of ADHA, states, "Steps have been taken to ensure that ADHA is relevant to today's dental hygienist and creates an environment where every dental hygienist feels welcomed." (34)

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This brings us to the development of the ADHP. According to ADHA Immediate Past President Margaret Lappan Green, RDH, MS, "The ADHP would deliver diagnostic, preventive, therapeutic and minimally invasive restorative services directly to underserved Americans." (22)

Conclusion

Dr. Fones and his colleagues envisioned dental hygienists as auxiliaries who would improve the overall health of children; today, dental hygienists are true prevention specialists. They equally educate and treat a multitude of patients, providing professional advice and care for optimal oral health, which we know impacts total health.

Current technology offers treatment of adults and children in ways the dental pioneers could not have imagined at the turn of the century. New diagnostic tools are available for detection of oral cancer, dental caries and periodontal disease. Over the last few decades, increased numbers of dental hygienists have received advanced degrees and many practice in non-traditional settings, such as industry, corporations, research facilities and on forensic teams.

Legislative changes allow local anesthesia and general supervision in most parts of the country. Dental hygienists serve on many state boards of dentistry and participate in regulation of their practice. In many states, dental hygienists have direct reimbursement from Medicaid. The use of evidence-based practice will help us to properly use each new technology and opportunity as it unfolds (35) and the ADHP and the new branding campaign will improve access to care and respect for our profession.

Moving forward, it becomes evident that we should reflect on past unresolved issues as they continue to be resolved and take pleasure in the heightened respect for dental hygiene which will result in better health care for everyone. Dr. Fones would be pleased to see the path his vision has taken.

* The Early Textbooks in Dental Hygiene

The first textbook for dental hygiene was "Mouth Hygiene" published in 1916, compiled by Dr. Alfred C. Fones with 19 contributors (Figure 7). Four editions of the text were published between 1916 and 1934. Following the death of Fones in 1935, Dr. Russell Bunting, former dean at University of Michigan, became editor, and the title changed to "Oral Hygiene." The format of the text remained the same.

[FIGURE 7 OMITTED]

A new version of the textbook was re-issued in the 1960s, with Pauline Steele, RDH, MS as editor. Renamed "Dimensions of Dental Hygiene,' (8) the text continued through four editions until the 1980s.

In 1959, when Esther Wilkins, RDH, DMD, was director of the dental hygiene program at the University of Washington, Lea & Febiger Publishing

Company invited her to reformat the student clinical instruction manual from her program as an updated dental hygiene textbook. It became "Clinical Practice of the Dental Hygienist." The objectives as stated in the preface of the first edition would continue to appear through the 10th edition currently in production (Figure 8):

[FIGURE 8 OMITTED]

"It is expected that the book will be useful as a textbook for preclinical and clinical theory and practice courses for students, as a reference and guide for practicing dental hygienists, and as a source of review material for temporarily retired dental hygienists with plans for returning to practice." (9)

The first edition contained many concepts that are still correct today. Other chapters describing the ergonomics of standing correctly, since practicing in a seated position was rare at the time, and how to disinfect instruments with boiling water seem funny to us now.

* About Product Advertising

At the end of the 1940s, television was becoming common in American households, so families saw the first black and white commercials for toothpaste. This was a big departure from advertising that regularly appeared in family magazines since the turn of the century.

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Colgate advertising promised "dating success" with fresh breath and the protection of teeth with a "Gardol shield" (Figure 15). Pepsodent was known for its jingle, "You'll wonder where the yellow went when you brush your teeth with Pepsodent." Advertising for Ipana toothpaste was directed at children, with Bucky Beaver and the slogan, "Brusha, Brusha, Brusha ..." (Figure 16).

[FIGURE 17 OMITTED]

In 1956, Crest began the advertising campaign, "Look Mom, No Cavities," featuring Norman Rockwell illustrations (Figure 17). It was the first toothpaste with stannous fluoride added, taking toothpaste from being cosmetic to being therapeutic. (13)

Pepsodent lost its place as a top-selling brand since it did not offer a fluoridecontaining product. The leading brands in 1958 were Colgate, Gleem, Pepsodent, Crest and Stripe. (13) Crest got an endorsement from ADA in 1960 for fluoride effectiveness, and Colgate received the endorsement in 1969. That changed their promotion from the use of "Gardol" to sodium monofluorophosphate (MFP). (14)

* About the Dental Hygiene National Boards

The first Dental Hygiene National Board Examination (DHNBE) was offered in 1962 as a four-part subject examination. In 1973, it was changed to "a function oriented" exam. In 1998, a case-based section was added.

Shailer Peterson, PhD, authored the first review book for Mosby following the creation of the new DHNBE in 1962. "Comprehensive Review for Dental Hygienists" was published in four editions until 1980.

Michele Darby, BSDH, MS, and Dr. Eleanor Bushee were contributors to the Peterson review book and were invited to continue the series after Peterson's death. The first edition, re-named "Mosby's Comprehensive Review of Dental Hygiene" was published in 1986, and there have been six editions to date with Darby as primary editor.

There have been other review book authors and publishers; however, the Mosby series is the longest consecutively running board review text.

* The United States' Experience with the New Zealand Dental Nurse Model and Expanded Functions

In the 1920s, dental nurses were successfully utilized in New Zealand to treat children's dental neglect. New Zealand dental nurses focused on restorative work rather than the preventive curriculum advocated by Fones for dental hygienists in America.

As early as 1944, Dr. John O. McCall advocated that the New Zealand type dental nurse be utilized to improve access to care for children. Since not all states had passed dental hygiene licensure acts, ADHA did not agree to the concept. (6,16)

The issue of delegation of expanded functions was explored at the Forsyth Dental Center starting in the 1950s with a program that was scheduled to last five years, but was discontinued after one year by organized dentistry. (17)

The United States Public Health Service funded a large study of Expanded Function Dental Auxiliaries (EFDAs) in the 1960s with programs at the University of Alabama, Indian Health Service, University of the Pacific, University of North Carolina and Louisville Kentucky, which was also home to the study of Dental Auxiliary Utilization (DAU). DAU was the use of fourhanded sit-down dentistry with patients in a supine position to increase dental productivity. (18)

Training in Expanded Auxiliary Management (TEAM) was studied in dental schools throughout the country. The program included auxiliaries who administered local anesthesia, cut hard and soft tissues and placed restorative material. These studies, as others previously, showed positive results; however, the programs were discontinued. (19)

In 1972, graduate dental hygienists at Forsyth received advanced training in the areas of local anesthesia and preparation/restoration of dental caries, in a project known as The Forsyth Experiment. The project was not continued, even though it, too, showed positive results as an alternative system for dental care. (17)

In 2004, the first Alaska Dental Health Aide Therapists graduated from a program in New Zealand to address the oral health needs of Alaska natives in rural settings under the supervision of licensed dentists. The state approved the program in 2005; however, ADA started proceedings to have the program terminated. Fortunately, in July 2007, ADA agreed to settle the dispute and work cooperatively with the Alaska program toward improving the oral health of Alaska Natives. (20,21)

Currently, ADHA is developing the ADHP to improve access to care for underserved American populations (see box on this page). (22)

* About the ADHP

Mission Statement

TO improve the underserved public's health, the advanced dental hygiene practitioner provides access to early interventions, quality preventive oral healthcare and referrals to dentists and other healthcare providers. (23)

The ADHP (Advanced Dental Hygiene Practitioner) will be a licensed dental hygienist educated at the Master's Degree level who will provide primary oral healthcare services (preventive, therapeutic, and restorative). This will be a midlevel provider similar to the nurse practitioner who will improve access to oral health care similar to the way the nurse practitioner has provided an additional entry point to medical care. Oral healthcare services will be made available to underserved and un-served populations, including patients with special needs, as part of a multi-disciplinary healthcare team. The ADHP will serve as a new practice option for today's dental hygienists. (24)

References

(1.) Fones AC. The origin and history of the dental hygienist movement. J Am Dent Assoc 1926; 1809-21.

(2.) McCarthy MG. Dr, Alfred C, Fones--the father of dental hygiene. J Am Dent Hyg Assoc 1939; 16: 16-31,

(3.) Wright CM. A plea for a sub-specialty in dentistry, Int Dent J 1902; 23: 235-38.

(4.) Rhein ML The trained dental nurse. Dent Cosmos 1903; 45: 628-31.

(5.) Motley W. History of the American Dental Hygienists' Association 19231982. Chicago: American Dental Hygienists' Association; 1983: 23.

(6.) Fones AC, Kirk EC, Strang RHW. Mouth hygiene: a course of instruction for dental hygienists; a text-book containing the fundamentals for prophylactic operators. Philadelphia and New York: Lea & Febiger; 1916: vi.

(7.) Dittrick Medical History. Photography of dental care campaigns 19091919. Available at: www.case.edu/artsci/dittrick/site2/pics/dental.htm.

(8.) Steele PF. Dental hygiene profession. In: Dimensions of dental hygiene. 2nd ed. Philadelphia: Lea & Febiger; 1975: 392.

(9.) Witkins E, McCullough P. Clinical practice of the dental hygienist. 1st ed. Philadelphia: Lea & Febiger; 1959: 3.

(10.) American Dental Hygienists' Association. October 1927 Journal of the American Dental Hygienists' Association Reprint. Dent Hyg 1983; 57 (7): 32.

(11.) Bass CC. Collected papers relative to dental health. Chicago: Butler Co.; 1941.

(12.) Sisty-LePeau N N. Dental hygiene's heritage: 1927-1970. J Dent Hyg 1989; 63: 371-3.

(13.) Miskell P. How Crest made business history. Available at: http://hbswk.hbs.edu/archive/4574.html.

(14.) Mccoy M. What's that stuff? fluoride. Available at www.pubs.acs.org/cen/whatstuff/print/7916sci4.html. Accessed Jul. 10, 2007.

(15.) Motley W. Ethics, jurisprudence and history for the dental hygienist. 3rd ed. Philadelphia: Lea & Febiger; 1983: 158.

(16.) Hamilton P. The dental hygienist: The first half-century 1913 to 1963, Ann Arbor, MI: University of Nebraska-Lincoln; 1981: 241.

(17.) Lobene R. The Forsyth experiment, an alternative system for dental care. President and Fellows of Harvard College 1979: svii.

(18.) Sisty N, Henderson W, Paule C. Review of training and evaluation studies in expanded functions for dental auxiliaries. J Am Dent Assoc 1979; 98: 233.

(19.) Cvar J, Den Boer J. DAU/TEAM conference proceedings: innovations in team dentistry. 1972.

(20.) United States Public Health Service. AK dental health aide--Alaska Native tribal health consortium. Available at www.phsdental.org/depac/newfile50.html. Accessed Jul. 9, 2007.

(21.) American Dental Association. Alaska Native dental health initiative. Available at: www.ada.org/prof/advocacy/legal/alaska/dhat.asp. Accessed Jul. 9, 2007.

(22.) Green ML. 2007 president's report: creating community through collaboration. Access 2007; 21 (5): 55-9.

(23.) American Dental Hygienists' Association. Draft competencies for the advanced dental hygiene practitioner Chicago: ADHA, June 2007.

(24.) American Dental Hygienists' Association. The ADHP and You! 2006; Available at: http://www.adha.org/downloads/ADHP Fact Sheet.pdf. Accessed Jul. 15, 2007.

(25.) Schwab C. The future of our profession. Dent Hyg 1983; 57 (40): 42.

(26.) Symons B. Dr. Robert Barkley. Oral Health. 1977; 67 (October): 18.

(27.) Keyes PH. Dr. Paul H. Keyes. Available at www.drpaulhkeyes.com. Accessed Jul. 2, 2007.

(28.) ADA Library/Archives staff. Innovations in techniques and technology the 20th century. Available at: www.ada.org/public/resources/history/timeline_20cent.asp. Accessed Jul. 6, 2007.

(29.) Fales M. History of dental hygiene education in the United States, 1913 to 1975. Ann Arbor, MI: University of Michigan; 1975: 265.

(30.) Centers for Disease Control and Prevention. Fluoridation statistics 2002. Available at: www.cdc.gov/fluoridation/fact sheets/us_stats2002.htm. Accessed Jul. 10, 2007.

(31.) Cobb K, Ray L. The ADEX examination--access to professional mobility. Access 2005; 19 (10): 6-15.

(32.) American Dental Association. Dental team careers: Dental hygienist. Available at www.ada.org/public/careers/team/hygienist.asp. Accessed Jul. 10, 2007.

(33.) ADEA Institute for Public and Advocacy. Dental education at-a-glance. Available at www.adea.org/DEPR/2004 Dental_Ed_At_A_Glance.pdf. Accessed Jul. 15, 2007.

(34.) Battrell A. 2007 executive director's report. Access 2007; 21 (5): 60-64.

(35.) Forrest JL, Miller S. Evidence-based decision making in dental hygiene education, practice, and research. J Dent Hyg 2001; 75 (1): 50.

Rhoda Gladstone, RDH, MS is currently a clinical professor at New York University Dental School and taught at Union County College in New Jersey. She is a graduate of the Fortes School of Dental Hygiene, Boston University and Columbia University. As an active member of the New Jersey Dental Hygienists' Association she has been an ADHA delegate and SADHA advisor. In addition, she co-edited the original on-line instructor's guide for Dr. Esther Wilkins' text, "Clinical Practice of the Dental Hygienist," and has been presenting a PowerPoint program on the history of dental hygiene to many dental groups.

Acknowledgments by Gladstone: My experience at the Fones School of Dental Hygiene in the 1960s with two of the original pioneers, Mabel McCarthy and Dr. Robert Strang, influenced my interest in researching the history of dental hygiene. I wish to thank my colleagues Marilyn Cortell and Winnie Fumad who suggested that I move this article forward and Dr. Esther Wilkins, the ultimate mentor, for her advice and fact checking.

Wendy M. Garcia, RDH, MSEd, is assistant professor at the Fones School of Dental Hygiene, University of Bridgeport, Bridgeport, Conn., and coordinator of public health. She teaches head and neck anatomy, pharmacology, public health, internship for the BS degree, and dental hygiene leadership in the MS in dental hygiene program that starts fall 2007. She earned her AS and MSEd at the University of Bridgeport, her BS in dental hygiene from the University of New Haven, Conn., and is currently working toward her EdD at the University of Bridgeport. She is a past president of the Connecticut Dental Hygienists' Association.
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