Legislative changes in Ontario: self-initiation has finally arrived.

ON SEPTEMBER 1, 2007, THE ONTARIO DENTAL Hygiene Act, 1991 was amended to permit dental hygienists to self-initiate their authorized act of "scaling teeth and root planing, including curetting surrounding tissue." This amendment to the Act was neither all that was desired by the profession nor all that was promised by the government. However, it will enable the public of Ontario to choose when, where and from whom they wish to receive preventive oral-health-care services, and it will provide dental hygienists the freedom to choose where to practice their profession. The amendment is of benefit to both the public and the profession.

HISTORY

When dental hygiene achieved self-regulation in Ontario in 1994, forces external to the profession convinced the government of the day to include the provision in the Dental Hygiene Act, 1991 (DHA) that an "order" from a member of the Royal College of Dental Surgeons of Ontario (RCDSO) had to be given before a registrant of the College of Dental Hygienists of Ontario (CDHO) could perform their authorized acts. When this order provision was included in the DHA, there was no complementary requirement for the order to be given in the Dental Act, 1991, which put many dental hygienists in a situation where they could have been in contravention of their Act because there was no mechanism for giving an order. Consequently, the CDHO and the RCDSO agreed on the concept of "standing orders" for those dental hygienists who work in dental offices and protocols for those in public health. Unfortunately, many dentists were reluctant to provide orders for clients who were unable physically to attend the dental office and, thus, the intent of the DHA to facilitate access to preventive oral-health care was never fully realized. The CDHO Transitional Council immediately saw the flaw in the legislation and requested an amendment.

In 1994, the Ministry of Health indicated to the CDHO that orders were to be flexible and not unreasonably withheld by the issuing dentists. Unfortunately, as time progressed, organized dentistry tightened its stance on when, where and to whom orders could be given and the issuing of orders became a mechanism for controlling the practice of dental hygiene. While this scenario unfolded in Ontario, it also played out elsewhere in North America, most notably in jurisdictions that were seeking self-regulation for the dental-hygiene profession. Where self-regulation was achieved, it often came with an "apron string" to dentistry that ostensibly tied the practice of dental hygiene to the dental office in most cases. Where dental hygienists did take the initiative to institute mobile clinics to visit clients who were unable to visit a traditional dental office, they found significant resistance from local dentists and, in many cases, were unable to secure the orders necessary to complete the preventive service.

True, there are many forward-thinking dentists who have been supportive of the dental-hygiene profession's desire to take oral-health services to clients who are unable to come to a dental office, but they work silently in the background for fear of reprisal by their colleagues who are not as progressive. (In recent years, a greater effort has been made by organized dentistry to reach out to residents in long-term care and residential homes.)

As the CDHO grew and matured as a regulatory college under the Regulated Health Professions Act, 1991 (RHPA), it became increasingly evident that the order requirement in the DHA not only hampered access to important preventive oral-health services, but also indirectly regulated the dental-hygiene profession by giving control to another regulated health profession. Many thought this to be paternalistic and economically driven. The more organized dentistry tried to control the practice of dental hygiene, the more the dental-hygiene profession, their public supporters and the regulators realized that the Act had to be amended for the good of the people of Ontario. No public good was achieved by maintaining the order. In fact, a 1996 report by an independent advisory body to the Minister of Health recommended that the Act be amended, but politics intervened and it took another 11 years before that recommendation, albeit in an incomplete form, was finally enacted.

For almost 14 years, the college requested and challenged successive provincial governments to listen to the profession and heed the needs of the Ontario public. It seemed to many of the supporters of the amendment that the government instead was listening to health-care professionals who were against change and an alternative delivery system they could not control. In the meantime, nursing moved to the nurse-practitioner model and registered practical nurses were permitted to self-initiate. But both are part of provincial health-care funding and the result of a cost-conscious government's incentive to find alternatives. Oral health, by and large, is not included in the provincial health-care funding system and therefore did not appear to be a priority issue for legislative change. And a powerful, well-funded lobby was adamantly opposed to any legislative initiative that reduced the dentistry monopoly on oral-health care.

WHAT HAPPENED TO MOVE THE ISSUE ALONG?

During the 2003 provincial election campaign, a dental hygienist who felt passionately about making the DHA amendment a reality used her personal connections to secure a promise, in writing, from the future provincial premier that, if elected, he would amend the Act. Dental hygienists constantly reminded the premier of his promise and expected him to keep it! An agreement that the Act should be amended was reached between the provincial dental and dental hygiene associations and the two related regulatory organizations after many delays--partially caused by ill-advised closed-dialogue sessions between the two associations. Those sessions resulted in a very strict Contraindications Regulation for Self-Initiation. The catch was that the dental organizations insisted that dental hygienists currently are not qualified to self-initiate, while the dental-hygiene organizations insisted that no further formal education is required. Another long dialogue ensued, during which it became obvious that the dental representatives were unaware of the stringent and comprehensive requirements of the Commission on Dental Accreditation of Canada for the accreditation of dental-hygiene programs. The CDHO maintained all along that dental hygienists in Ontario are capable of self-initiation based on a set of standards developed by the CDHO.

In the spring of 2007, the two dental organizations submitted a curriculum to the government for a two-year, post-diploma dental-hygiene program--which would not lead to a baccalaureate degree--recommending that all dental hygienists complete the program before being eligible for self-initiation. The submission was carried out without consultation with the CDHO, the governing body for dental hygiene in Ontario. The CDHO was not impressed and told the government that the dental organizations had definitely overstepped their bounds. Subsequently, CDHO representatives met with the Minister of Health and Long-term Care and proposed that the college establish standards under which dental hygienists can self-initiate. The minister agreed and outlined the elements to be included in the CDHO proposal. A tight deadline was given, but the college more than met the time frame requested.

PROCESS CONSIDERATIONS

One of the requirements made by the minister was that there had to be a visible identifier on registrants' wall certificates indicating they had been approved by the college to self-initiate. Other requirements included identifiers on the CDHO website, an application process accompanied by a fee and a directive that the CDHO post the business addresses of independent practicing dental hygienists on the website for public accessibility. The CDHO agreed to comply with the minister's requests.

The college then posted the proposed Standard of Practice for Self-Initiation on the CDHO website for a brief consultation period. The standard includes three streams by which a registrant could be approved to self-initiate. Streams two and three include taking an online course developed through the CDHO but administered by the Canadian Dental Hygienists Association. While the time frame imposed by the minister was short, the college received a significant number of submissions with many helpful suggestions regarding the standard. Both dental organizations stressed the need for a regulation instead of a standard. The CDHO decided to continue with the standard-development process and ultimately approved a streamlined version based on the comments received during the consultation period. The revised standard was submitted to the government and the college waited.

PROCLAMATION 

On September 1, 2007, after 14 years of hard work by the many supporters of increased access to preventive oral-health care, the amendment to the DHA was finally proclaimed with little fanfare. But the really hard work has only just begun!

Having seen hopes dashed and promises broken in the past, the CDHO was reluctant to develop the infrastructure required for the approval process for self-initiation until the amendment was actually proclaimed. Of course, the college had all the components in draft form but nothing had gone to the printers. It has been decided not to spend additional money until the amendment was a reality.

WHERE ARE WE TODAY?

CDHO registrants are already applying for approval to self-initiate. The information and application forms are available on the CDHO website (www.cdho.org) under What's New. Information packages have been sent to all CDHO registrants and members of the CDHO administrative staff are travelling around the province to discuss the implications of the new legislation with dental hygienists.

One of the key pieces of information to be conveyed is that self-initiation is not dependent on practice setting or employment relationship. A dental hygienist can as equally self-initiate in a dental office as set up a mobile practice to visit nursing homes or residential facilities. As self-regulating health-care practitioners, it is the dental hygienists who will determine whether they can self-initiate or require an order from a dentist; it is the dental hygienist who will review the client's medical history and determine whether consultation is required; it is the dental hygienist who makes the decision to proceed with treatment; and it is the dental hygienist who is responsible for the interventions she or he decides to provide. Nothing has changed in that regard.

HOW WILL THIS AFFECT THE PUBLIC?

Ontarians who regularly attend a dental office for their dental-hygiene care will not see any difference. Dental hygienists will continue to work in dental offices and many will be employed by dentists. But change will occur outside the dental office in the community, in residential homes and in public health. Some dental hygienists will choose to open stand-alone clinics in strip malls or in multidisciplinary health clinics. The public will be able to choose where to obtain preventive oral-health services. Some people will choose to have a house call.

HOW WILL THIS AFFECT THE DENTAL HYGIENIST?

Dental hygienists in Ontario will now have the opportunity to choose how they wish to practice their profession. Along with that choice will come challenges, but that is the price of progress. For the entrepreneur, there are numerous possibilities. For the person who wants to make a difference in the quality of life of housebound people, there will be endless possibilities.

WHAT IS SELF-INITIATION?

Self-initiation is the decision by a dental hygienist to proceed with the authorized act of "scaling teeth and root planing, including curetting surrounding tissue" without an order from a dentist, based on the principles inherent in the Dental Hygiene Process of Care. Makes sense!

Fran Richardson is the Registrar at the College of Dental Hygienists of Ontario (CDHO) and a Past President of CDHA.