The importance of the student dental hygienist's exposure to underserved populations.

At Northern Arizona University (NAU), every NAU dental hygiene graduate is required to complete a three-week internship at a community health facility (e.g., Veteran Affairs, Indian Health Service/Tribal or other public health facility) and there are also several external rotations throughout the third- and fourth-years of the program.

Prior to entering dental hygiene school, I worked as a dental assistant for three-and-a-half years in Tucson, Ariz. During that time, I saw a variety of patients who had insurance or were able to afford fee-for-service treatment. My first exposure to public health was when I was in the junior class at NAU and went to an orientation at the Hopi Health Care Center, a traditional clinic on the Hopi Reservation. I went through Health Insurance Portability and Accountability Act training and one of the faculty, Maxine Janis, RDH, MPH, facilitated the deeper understanding of the student dental hygienist's role in public health.

Diabetes mellitus (type 2) is the most widespread epidemic affecting the Native American population at the Hopi Health Care Center. Scientific evidence shows a synergistic negative effect of having diabetes mellitus and periodontal disease. (1) Janis stressed the importance of providing education about prevention and the disease process to the patients who were traveling hundreds of miles from rural areas to receive therapeutic services. She helped me understand that the long-term commitment to oral self-care is the most effective way to treat the overall health of the individual.

The Hopi Health Care Center is part of the Indian Health Service (IHS). The center receives federal monies every fiscal quarter and is responsible for treating every member of the tribe. This sounds reasonable until the numbers are considered. According to Janis, "Many Indian Health Service and Tribal dental programs have user populations of 40,000 (plus) patients. Oftentimes [there is] only one dental hygienist providing care or no dental hygienist at all, hence accessing dental hygiene/prevention service becomes a real health care problem in these rural areas." (1) With the underserved population receiving less frequent recare than the general population and often requiring multiple quadrants of scaling and root planing, the task of providing complete patient care is monumental. A dental hygienist can see about 2,000 patients per year. As a student dental hygienist and former private practice dental assistant, I find it outrageous hat access to oral health care could be so dismal for any community, and it was eye-opening to learn that this level of need exists.

In 2005, Janis ran the Hopi Project with support from the Ottens Foundation. The Hopi Project aims "to provide dental hygiene services to American Indians, by rotating NAU dental hygiene students to the Hopi Indian Health Dental Clinic." (1) During the 2005 spring and fall semesters, there were 425 patient encounters (374 diagnosed as Type II diabetics) that included 1,460 quadrants of scaling and root planing, 165 sealant applications and 425 fluoride varnish treatments. (1) As mentioned before, the shortage of providers at IHS facilities means any additional help is welcomed. At the present time, Janis continues to direct this amazing program.

In April, I decided to spend my internship at the Winslow Indian Health Care Center, Inc. (WIHCC), another NAU external rotation site. Having been increasingly drawn to the field of public health over the past year and wanting to gain the maximum amount of experience as a student, I contracted for a three-month stay instead of the three-week requirement. WIHCC serves the Navajo Nation, the largest tribe and reservation in the United States. This was a fantastic opportunity to closely observe the major health needs of a population.

Lieutenant Junior Grade Sarah Wheeler, BSDH, for the United States Public Health Service (USPHS), was my supervisor during my time at WIHCC. In addition to the main dental clinic located in Winslow, Ariz., I assumed responsibilities at two satellite clinics, Leupp and Dilkon, in rural areas of the Navajo Nation. Wheeler created the perfect learning environment. I was never pressured to work outside my comfort zone, yet I tackled the schedule of a full-time dental hygienist. Frequent alternation between clinics required flexibility and willingness to adapt to each clinic's expectation.

I saw patients from the age of 2 years to 85 years old. Nothing could have prepared me for the challenging patients whom I would be treating each day. Over half of the patients 16-years-old and younger in my chair had black subgingival calculus, heavy biofilm accumulation and moderate-to-severe inflammation. On a few occasions, young patients had calculus bridges present on the lingual of their mandibular anterior teeth. The typical child also had multiple stainless steel crowns on primary teeth. Early periodontal disease and rampant caries indicated a very poor outlook for the future of these children's oral health.

On back-to-back days, two pregnant patients in their early 20s visited my chair. Sadly, the only reason they had scheduled appointments was due to the Maternal and Child Health department requiring their treatment. Neither woman had ever visited a dental clinic. Their encounters exemplify the critical need for basic oral health education and preventive and therapeutic services throughout the entire Navajo Nation.

The Winslow Service Unit of the Indian Health Service encompasses 1,600 square miles and serves over 14,000 people in the Navajo Area. (2) There are one full-time and two part-time dental hygienists. Not only is it impossible to treat 14,000 people with essentially two full-time dental hygienists, patient recare and revisits were not afforded much thought. As a result, until nearly two years ago, the patients were going years between cleanings and did not understand the importance of regular dental visits. Wheeler has been the force in remodeling the dental hygiene protocol at WIHCC. Through her strong will and persistence, the WIHCC dental hygienists still provide needed therapeutic services, but now have a system to schedule more frequent maintenance and recall appointments. Therefore, the patients who can and want to be seen will have a reminder "recare" card sent to their residence, much like a private practice. Wheeler's restructuring is a positive inspiration to all those desiring to make changes to the public health system.

My participation at Hopi Health Care Center and WIHCC was priceless. My confidence grew as a professional and my instrumentation technique has improved. I gave beneficial dental hygiene services, including scaling and root planing and local anesthesia, to over 200 Native American patients at WIHCC. The opportunity for full-fledged involvement in a grossly underserved area was the single greatest growing period of my student tenure and life. The ability to realize a daily impact on a people's oral and overall health and creating new ways to educate and motivate patients constitutes the fundamental dynamic of a student dental hygienist's education. Meeting these challenges head-on, through rotations and externships, thoroughly balances the student's knowledge and understanding of our profession and our commitment to public health. As long as these opportunities are available, there remains hope that future dental hygienists will choose the path of public health and that every person will receive equal access to care.

References

(1.) Janis, Maxine L.; HOPI Project grant report/proposal. December 30, 2005.

(2.) Winslow Indian Health Care Center, Inc. Available at http://wihcc.com/index.htm. Accessed Aug. 26, 2007.

James Duncan is a 27-year-old dental hygiene student at Northern Arizona University (NAU). James recently attended ADHA's 2007 Annual Session in New Orleans and presented at the National Indian Health Board Conference in Portland, Oregon as NAU's student representative.