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Hot topics in dental hygiene.

In the operatory, laboratory, classroom and staff meetings, oral health professionals discussed the latest trends in 2008 and how they will impact treatment in 2009.

In 2008, oral health hit the mainstream headlines. The articles filled major publications such as The New York Times, the Washington Post, Business Week and Forbes, and the topics reflected those typically featured in dental profession publications.

The overall issues on everyone's mind ranged from access to care and the oral-systemic disease link to the increase of oral cancer awareness and new techniques and technology. Recently, Access Editorial Advisory Board members shared their thoughts on how these issues might change the dental profession and the dental hygienist's role.

What topic has had the most impact? In all likelihood, the expanding economic crisis will touch all areas of the profession. This situation, according to Louis G. DePaola, DDS, MS, is one of the most significant problems that the profession will face in the coming year.

"How do we maintain high levels of oral health in a declining economy?" he asked. "Oral health is always at the bottom of the funding pile, and with all the red ink everywhere, it is certain that many oral health initiatives will be slashed or even eliminated."

Patricia J. Nunn, RDH, MS, agreed, adding education to the list of funding reductions. She also said that practitioners face economic problems as they decide how to survive in a down-turned economy and still meet patient needs.

James B. Fine, DMD, observed that the federal budget crisis most likely will lead to a tightening of research funding from the National Institutes of Health (NIH).

"This, unless offset by industry funding, will delay needed research in [several] areas," Fine continued. He also expressed concern that fewer dental professionals are pursuing academic careers at a time when there is a knowledge and information explosion. Fine added that the practicing dental hygienist can take a leadership role in providing for access to care and lobbying for more research funding.

On the upside, Laura Mueller-Joseph, RDH, BSDH, MS, EdD, stated that she believes that oral health care delivery will ultimately improve in the U.S.

"Professional groups, along with state and federal agencies, are working to provide better access to oral health care for communities in need," Joseph commented. "As we continue to address this issue, many decisions will have to be made, especially with regard to levels of education needed to ensure consumer safety."

Hot Topics, Part One: What Shapes Daily Practice?

Access to Care Issues

An expanded scope of practice for the dental hygienist, paired with the challenges patients face in accessing care, have led many to assert that the dental hygienist needs to take a leadership role by moving oral health care into the community. An at-risk population that would benefit greatly from this approach is the elderly, stated Rene Stephenson, RDH, BSDH. This group of people is living longer, retaining dentition and needing personal assistance in maintaining good oral health.

"This will require more dental hygienists in facilities for the aging," stated Stephenson. "We can no longer depend on the medical health industry to provide the needed oral health care instructions."

Another group that could benefit from an expanded scope of dental hygiene is special needs patients, said Mae Chin, RDH, MEd. "I think many clinical dental hygienists are stepping up to the plate and providing care for special needs patients," she said. "I would like to see more dental hygienists take time to provide oral care seminars to residents and care staff in long-term care, assisted living facilities and group homes."

More than ever before, dental hygiene has the opportunity to break down the barriers to affordable oral health care, commented Cynthia C. Gadbury-Amyot, BSDH, EdD.

Amyot explained that programs such as Kansas' Extended Care Permit designation for dental hygiene allow clinicians to practice without direct supervision in a variety of settings. However, she has found that dental hygienists are not flocking to this model of care "because they lack the background and network to consider this career option."

"As educators, we need to raise the students' consciousness of this while they are in school, and we need to work with students to give them the background and experience to go out into the working world and be part of the solution," stated Amyot.

The Oral Health/Systemic Disease Link

Pancreatic cancer, lupus, depression, Rheumatoid arthritis, Crohn's disease, psoriasis, respiratory disease, osteoporosis what do these diseases have in common? According to Marilyn Cortell, RDH, MS, FAADH, these systemic diseases possess an inflammatory component that connects them to oral disease. Ongoing research, she continued, is seeking the causal ways the inflammatory component can be treated. Making the issue even more complex for dental professionals is the expansion of the pharmacologic agents used in prevention and treatment, along with the oral implications of these drugs, said Cortell.

The increasing evidence of the connection between dental health and systemic conditions has always been a significant hot topic with clinical consequences, stated Su-yan L. Barrow, RDH, MA, MPH. The research findings strengthen the case for dental hygienists to act as prevention specialists in the management of preventable oral diseases, especially dental caries and periodontal disease, Barrow said.

"The medical-dental connection is additional evidence to be used to increase public awareness of the importance of oral health," said Barrow. "As dental hygienists, it is our professional duty to engage in health promotion at every opportunity."

Denise Bowen, RDH, MS, noted that the explosion of information about the oral-systemic health link in consumer media has piqued patient interest. "Our patients either are asking questions about the relationship of their periodontal disease to their heart disease, diabetes, COPD and pregnancy or are very interested in information we share with them."

Holistic dentistry, which views oral health, the systemic link, the mouth and the body as an integrated whole, is adding perspective to this issue. For Fred Pockrass, DDS, prophylaxis is no longer "just a cleaning," but rather preventive health care.

"The systemic link of periodontal disease is now being recognized as directly related to a whole host of health-related issues," said Pockrass, who added that periodontal disease affects approximately 70 percent to 80 percent of the U.S. population and is frequently misdiagnosed. "This requires that as a profession we recognize the signs and symptoms of periodontal disease and that our treatment plans are both preventive and proactive."

Joseph believed that the connection would bring the medical and dental professions together when treating the whole patient. "Obstetrics and gynecology offices are more open to discussion about oral health care for their pregnant patients and are beginning to recognize the risks associated with poor oral health conditions," she explained.

Fine observed that the oral-systemic disease link has found its way into medical literature as well. This included a recent study that identified a potential association between poor oral health and systemic cancer. (1)

"Next would be the relationship between IV bisphosphonates used by oncologists to treat certain cancers and osteonecrosis of the jaw," Fine continued. "These two topics continue to show the close relationship between oral and systemic health." He also noted the close relationship between the effects of oral inflammation and the management of diseases such as diabetes and obesity, problems that are on the rise in the population.

"Just providing medical care and neglecting adequate oral health will no longer be the standard of care," Fine continued. "In the future, evaluating the patient for hyperinflammatory states and the function of their immune system will be required. At the present time, many physicians are testing patients for levels of C-reactive protein, a marker of inflammation. This leads to a better understanding of certain patients' susceptibility."

Fine added that genetics will eventually find a bigger role in developing risk profiles in dental patients.

"These risk profiles are another developing area in oral health," he observed. "All patients are not genetically predisposed to oral diseases to the same degree. We all encounter patients with poor oral hygiene, but no periodontal disease or caries."

Cortell expressed that crucial documentation is missing in many patient health histories and treatment notes.

"Dentists do not realize that omissions in recording sufficient patient detail may lead to overlooking a relevant component of both oral and systemic health," she commented. Cortell added that there is an apparent lack of involvement within the medical community in that physicians are not eager to embrace their role in supporting the oral-disease systemic-disease connection.

Cortell identified the American Dental Hygienists' Association's adoption of Standards for Clinical Dental Hygiene Practice as one of the hot topics in 2008; in particular the standards' addition of documentation as the sixth component of the dental hygiene process of care. She noted that many attendees at her lectures report that dentists say dental hygienists write too much during a 45-minute patient visit. She believed that having standards to support the necessity of thorough documentation will justify the time dental hygienists spend performing it.

Increase in Specific Oral Diseases

Another piece of the oral-systemic puzzle is the increase of certain oral diseases. Fine and Cortell both mentioned the Bisphosphonate-Induced Osteonecrosis of the jaw (BIONJ), and Cortell also referred to methicillin-resistant staphylococcus aureus (MRSA).

Stephenson added that sleep apnea is a rising problem in the U.S., possibly due to the increased weight of many adults. "There are many dentists in the U.S. who are treating sleep apnea with dental appliances. It is no longer a procedure for the medical profession only," she commented.

These are all issues dental hygienists need to continually update in their ongoing education and research.

Oral cancer, in particular, is a red-hot topic, partially because of an increased awareness in oral cancer detection devices. A growing number of dental hygienists are using these devices and educating their patients about oral cancers.

An oral cancer that is linked to the human papilloma virus (HPV) has gained even more attention as the year drew to a close. It is one well worth the dental hygienist's extra hours of study, according to Mark Varvares, MD.

High-risk, HPV-associated head and neck cancers occur most often in the oropharnyx--not the oral cavity, he stressed.

"The difference is the oral cavity is the part of the mouth you can see easily when people open their mouth and stick out their tongues," Varvares stated. "The oropharynx is the part in the back where the tonsils and the base of the tongue are located."

It's an important distinction, he explained, because although there has been some increase in the detection of HPV in the oral cavity of patients with oral cancer above and beyond the general population, "it's the oropharnyx where now we're seeing a 50 percent to 75 percent incidence of cancers that have evidence of high-risk HPV infection," Varvares commented.

"I've seen many patients through the years with tonsil cancers that were picked up by dental hygienists. Very often, there will be a lesion the dental hygienist can see," Varvares said, stressing that most of these cancers of the tonsils can be seen.

Instead of relying only on a visual exam, Varvares advised dental hygienists to be aware of symptoms. Be alert to patients who may have a head and neck cancer with any of the following: a lump in neck that doesn't go away; unilateral ear pain; pain or ear pain upon swallowing; unexplained difficulty in swallowing; any bleeding in the oral cavity; or unexplained appearance to tonsils or the back of the tongue, and a change in one's voice.

Varvares also noted that patients with HPV-associated oropharyngeal cancer are not the typical head and neck cancer patients. They tend be young, non-smoking males.

"We all have a heightened sense of awareness when we are examining the mouth and throat of a patient with a heavy smoking history who is older and has a history of heavy alcohol use. That is not the case with this group," explained Varvares. He added that women with cervical cancer tend to have a higher incidence of HPV-related head and neck cancer than the general population. Varvares said that in taking a patient's history, the dental hygienist needs to be even more attentive to a patient's oral examination upon learning that the patient has cervical cancer in her past.

New Technology and Techniques

According to DePaola, the new technologies that are being introduced into the profession are hot and will be hotter. Included are some of the oral cancer screening devices.

Harold A. Henson, RDH, MEd, agreed that emerging oral diagnostics are the next step in preventive care.

"Oral diagnostic systems used for conditions such as oral cancer detection and Caries Management by Risk Assessment (CAMBRA) have all made impacts in oral health delivery. Developing oral diagnostics will assist in detecting diseases at an early stage, thus providing quicker intervention," Henson commented.

Pockrass was interested in the high-tech approach to periodontal disease and the use of micro-ultrasonics and laser therapy. "These new solutions for periodontal disease are effective, reduce patient treatment time, are cost effective and relatively painless. This is a positive use of high tech dental care," he observed.

"So many disease processes appear to be affected by the same group of bacteria that are involved in periodontal infections," said Nora Raffetto, RDH, whose area of expertise is laser periodontal therapy.

"The role of the laser in treatment of periodontal disease is becoming more important and widely used in general practice. The photo-thermal effect of the laser on bacteria is profound destruction," continued Raffetto.

With any new technology comes concern in the realm of infection control, DePaola stated. Dental teams need to evaluate the design of new equipment as it comes into the operatory.

"Another new element [of practice] is infection control in the digital age. Many of the new devices are very unfriendly as far as infection control is concerned," said DePaola, who added that the fundamentals of disease prevention must be constantly reinforced, and that dental teams should be flexible because new threats emerge constantly.

Changing Profile of Clinical Practice

As technology and science shape how the patient is treated, the role of the dental hygienist evolves, too. The members of Access' editorial board encouraged dental hygienists to step into the leadership role and direct how change will occur.

The dental professional will play a greater role in managing the patient's overall health in the future, according to Fine. He predicted that the dental hygienist will now be responsible for referring the patient with chronic poor dental health to the physician to be evaluated for the potential medical/systemic effects of oral inflammation.

Aiding this move to treating a patient's whole health picture was the approval of the Advanced Dental Hygiene Practitioner (ADHP) competencies in March 2008 and the continuing plans for the first ADHP master's program in 2009. Barrow applauded the lobbying efforts put forth by ADHA and other stakeholders in this endeavor.

"I am extremely optimistic [that] with a cadre of ADHPs entering the workforce, the barrier to oral health care will begin to [lift]; by this means, all members of our society will eventually receive the oral health care they have long deserved," Barrow commented. She added that with the increase in globalization, it is important to have a strategic plan that includes the education of competent oral health care providers to ensure that all community residents receive culturally sensitive and appropriate dental care.

Joseph agreed, commenting that the future of oral health care delivery in the U.S. revolves around the proposed workforce models.

"In dental hygiene education, the ADHP has gained some ground with the development of two programs at the master's level," Joseph commented. "Additional changes in state practice acts to allow dental hygienists more autonomy over their practice roles in the community have had positive effects on the delivery of oral health care."

For the dental hygiene profession, Bowen observed, the collaborative practice model and ADHP model have provided alternatives to the challenges created by legal requirements for dental supervision for many years.

"When I spoke about collaborative practice to the Western Conference of Dental Deans and Examiners in July 2008, the notion of a different health care delivery model for dentists and dental hygienists to address access to care issues was well-received," Bowen commented.

For Meg Atwood, RDH, MPS, the ADHP model is a great start. "I do not accept or would not promote any of the ADA models that are out at this time that expand the role of the dental assistant in providing preventive services," she commented, adding that the dental assistant education is not in that realm. It is better, she said, to utilize dental hygienist or dental hygiene models to serve that need. She mentioned that the models used in the nursing profession are viable and accepted by the public and professionals in health care.

"I think that would work very well in our profession, and I see that the ADHP is working towards that direction," Atwood continued.

According to Nunn, restorative procedures also are shaping the scope of practice for clinicians in the western states.

"This responsibility requires that dental hygiene programs change focus somewhat and include restorative in the curriculum, which could be a huge stumbling block for non-baccalaureate degree programs--it's hard enough for Bachelor of Science Dental Hygiene (BSDH) programs!" Nunn explained.

Winnie Furnari, RDH, MS, FAADH, cited evidence-based practice as the most overlooked area in the profession. She encouraged "recruiting dental hygienists into research to expand our body of evidence and educating hygienists as to the evidence behind what they do in practice."

"I think that we need to really push the envelope as [much] as we can to better advocate for the dental hygiene side of the practice and expand it," Atwood said. "We need to include as many services as we've been educated to do."

How to Share Hot Topics with the Patient Population

Dental hygiene is fortunate as a profession because practitioners are able to foster patient relationships if they take the time, Amyot observed. With consumer news articles sharing information about the oral-systemic link so readily available, it is easy for the dental hygienist to have an ice-breaker topic for visiting patients.

The oral-systemic message has become a great education tool in the hands of the dental hygienist, said Atwood. The clinic in which she teaches frequently employs existing consumer information regarding the oral-systemic link to motivate patients who are resistant to change.

"Since we started utilizing information on the oral-systemic link and tied it in with their health issues, I have seen dramatic change," reported Atwood. "If a dental hygienist is not using that information, they must. It is just an amazing tool in motivating patients to change. We have had patients not only take control of their oral health but take much better control over managing their diabetes, for example."

Bowen agreed. "Talk to your patients about the relationship between oral and systemic health, and print consumer information from credible Web-based resources directly related to their prehypertension/hypertension, heart disease or other conditions related to their periodontal disease," she said. Bowen mentioned the cover feature in the August 2008 issue of Access entitled, "Breaking News in Inflammation," which she felt provided informative and practical suggestions for incorporating this information in daily practice.

As for sharing the link between environmental issues and patient health with clients, Pockrass urged dental hygienists to incorporate earth-saving tips into patient education, such as encouraging patients and colleagues to join the "Save 90 A Day" campaign of the Eco-Dentistry Association (, which advocates turning off the tap while brushing the teeth.

Pockrass further stressed the importance of stimulating conversations around personal and planetary healthy choices and collaborating with other health professionals--dentists, medical doctors, nurse practitioners, nutritionists and naturopaths--to find new ways to motivate patients and professional communities to participate in the global conversations that are relevant to this time.

Ultimately, Nunn stated that practitioners, educators, and students need to realize that every patient is unique and should be taught for his or her particular circumstances, taking into consideration where that person happens to be educationally. The goal, she explained, is always to impact health for the better.

Hot Topics, Part Two: What Will Shape the Profession for the Future?

Today's issues impact the whole spectrum of dental hygiene, from redefining education in the U.S. and abroad for the student population to shaping legislative initiatives that outline the work life of practitioners. Another concern that will shape the profession is how dental practice affects the environment.

Redefining Dental Hygiene Education

As the profession turns to the future, it must redefine the education a dental hygienist needs for entry-level practice, Joseph asserted.

"If we are to grow as a profession and take our place in the health care community as the expert in preventive oral health care, the educational arena is where we need to begin," she concluded. "With the average curriculum credit load at 80 credits for an associate degree, we are providing a disservice to our profession."

While she understands the issues faced by programs housed in two-year colleges where a bachelor's degree is unattainable, Joseph suggested that there are creative ways to partner with institutions so that students can complete their bachelor's degree via distance learning venues. Nunn, who previously spent 19 years in a community college setting, understood the threat these institutions may feel.

"Everyone needs to really understand that elevating the entry-level degree is not going to denigrate their personal credentials, but could help give each person the respect for their RDH that they deserve," she stated. "The biggest hurdle, however, is to help the non-BSDH programs move toward being able, through articulations or new innovations, to move their programs up to the BSDH level."

Joseph added that limited practice permits can also be considered for students who have completed an associate degree and are in the process of completing their bachelor's degree requirements.

Atwood considered that it might take an educational effort aimed at other health care professions and the public to help them understand dental hygiene education and preparation for licensure.

"I think ... we are underutilized because dentists don't understand how well dental hygienists are prepared," she observed. "We help our students really broaden their view of a dental hygienist as a health care provider. I think that the students come into the program ... with a very limited vision of the [profession] as people [who] clean teeth in a dental office. Many of them leave here with a much broader vision than that."

In another step to prepare dental hygiene students for the rapidly changing profession, Chin mentioned that the Commission on Dental Accreditation (CODA) adopted a new standard that directs dental and dental hygiene programs to prepare students for the care of persons with special health care needs. This includes people with developmental and acquired disabilities whose medical, physical, psychological and/or social situations may make it necessary to modify normal dental routines in order to provide dental services.

"Schools are making changes in curriculum to include clinical experiences along with didactic instruction in the management of patients with special needs," Chin explained. "Graduates of dental and dental hygiene schools should be better prepared to care for these patients and more dental professionals may be willing to treat these people who live in their community." Chin added that even if these professionals see only a few patients in their private practices, it will help the access to care issue for this population.

"Responses to these hot topics should be for increased scope of practice as our knowledge increases to more than just cleaning teeth," concluded Stephenson. "We are highly educated and need expanded duties. Many of these topics have afforded us the ability to increase our scope of practice without having to battle our states' legislatures."

Oral Health Legislation

From legislation that improves access to care to expanding the dental hygienist's role, 2008 revealed a few changes that may improve how oral health care is delivered in the U.S.

Brohawn commented on the introduction of H.R. 5549, the Deamonte Driver Dental Care Access Improvement Act of 2008. This bill amends the Public Health Service Act to require the Secretary of Health and Human Services to make grants to schools of dentistry and hospitals with accredited training programs in pediatric dentistry. It was developed in response to the 2007 case of 12-year-old Deamonte Driver, whose family lost their Medicaid benefits, delaying the extraction of an abscessed tooth that had bothered the boy for some time. Bacteria from the infection reached the child's brain and, after two brain surgeries and more than six weeks in the hospital, he died.

This sad story, Brohawn said, has brought access to oral health care to the forefront to be considered along with access to health care in general. She hopes that the resulting action "will include adoption of the ADHP nationwide; the negative would be the creation of a two-tiered system using individuals without credentialed education."

Amyot pointed to the legislative activity in Minnesota related to the Oral Health Practitioner, aka, Advanced Dental Hygiene Practitioner (see box). "This has all educators interested in what this will mean to dental hygiene education. Those of us who teach in a university setting, and especially those of us who have a long track record in graduate education, are most excited about what opportunities lie ahead," Amyot stated.

Nunn said that implementation legislatively of a true mid-level dental hygiene provider is a hot issue in the profession. She urged those in oral health care to become advocates for this critical change and for partners outside of dentistry to facilitate it.

"Another hot topic is the ADA House of Delegates pushing a request of the Commission on Dental Accreditation to remove 'dental hygiene diagnosis' from the accreditation standards," Nunn said. "This change could give carte blanche for states to disallow dental hygienists to use DH diagnosis and move the profession backwards."

Globalized Oral Health Education and Awareness

The impact of globalization on the education of oral health care providers is another hot topic, particularly in countries such as India, China and the United Arab Emirates, Amyot commented.

"The shift in the U.K. from separate dental hygiene and dental health therapist educational programs to a blending of the two is of particular interest as we follow outcomes from this model of oral health care delivery," she said.

Bowen observed that in some countries, collaborative practice has always existed.

"The challenge we face in the U.S. will be to learn to collaborate with allied health and medical professions rather than primarily within the oral health professions," she commented.

Raffetto noted that laser soft tissue therapy is an accepted treatment used widely in Japan, Europe, Israel and Canada, to name a few countries, and is something the U.S. needs to adapt more readily. Through education, she said, laser use is becoming more widely accepted and used in a general practice setting.

"There are two areas that need to be addressed so that laser soft tissue therapy can be readily available to the general public," Raffetto continued. "First, dental hygiene programs need to have laser education as part of their curriculum. Second, our dental hygiene professional organization should be active in lobbying for all states to allow the dental hygienist to deliver laser treatment."

Eco-Friendly Dentistry

Due to greater awareness of the urgency and devastating impact of global climate change, all dental professionals are being asked to re-think, reduce, re-use, recycle and refine the way they practice dentistry, commented Pockrass, who operates a sustainable dental practice.

"Imagine saving the planet and your teeth while reducing medical and dental waste by the ton and using all-natural, chemical-free products wherever possible," he continued. "Dental professionals and patients now have more choices in the delivery systems of oral health care from an ecologically sustainable viewpoint."

Stephenson also supported green products and procedures and indicated that these practices are slowly affecting the U.S.

"We will need to become more aware of the effects many of the products used daily in the average office are having on our environment," she said. "People in the dental professions need to be given alternatives that are better for our environment."

Pockrass recommended that all dentists do their part, beginning with such actions as installing an amalgam separator on the vacuum suction system to prevent toxic mercury waste from entering drinking water tables that are otherwise at risk when dentists replace old amalgam fillings. He also urged the use of digital X-ray systems to decrease the patient's exposure to ionizing radiation, elimination of the use of toxic photo-developing chemicals and elimination of the lead foils from the landfills. Pockrass encouraged dental hygienists to seek training in eco-friendly practices and join the Eco-Dentistry Association to stay abreast of the trend-making developments.

"Everyone can make a difference, no matter how small their contribution to their patients' health and the well-being of the planet," Pockrass concluded.

Conclusion: Every Dental Hygienist Can Make a Difference

Whether it's the environment, access to care or preventive education, dental hygienists can make a difference. The key is remaining current on the hot topics in the profession. Dental hygienists, said Cortell, must pursue dialogue with patients, the general public and other health care providers, while continuing to emphasize our expanded knowledge of up-to-date and relevant health care issues.

According to Furnari, a dental hygienist must educate him- or herself, as well as other dental hygienists, assistants, dentists and other health care professionals. She urged dental hygienists to become role models who stimulate interest and participation.

"It is all about lifelong learning," said Amyot. "If we stick our necks out there and say that we can be part of the solution, then we need to be willing to do what it takes to make that happen." Executing change in the profession means being involved in local, state and national organizations, or being politically active, Amyot said, adding that it will require building relationships and coalitions.

"For too long, we have been willing to sit back and allow ourselves to be 'taken care of' by the dentist," Amyot continued.

Bowen urged dental hygienists to provide leadership within the practices or local/state associations in which they function to change the way health history is collected and used, to treat periodontal disease with attention to all risk factors, and to branch out in collaboration with medical and allied health professionals.

For Fine, the dental hygienist's response to hot topics in the profession is to continually update their knowledge in the systemic disease and oral health relationship. Dental hygienists need to conduct risk assessment for both oral and systemic disease, especially diabetes and cardiovascular disease in active and re-care patients.

Fine stressed that the dental population must be constantly made aware of the importance of oral health for good systemic health. "Thus the leadership role of the hygienist in not just dentistry, but dental medicine," he concluded.

Nunn cautioned the profession against complacency. "It's when we become robotic in our daily provision of care that we lose the true connection with people that allows change to occur," she concluded. "However, let's never forget that most dental hygienists do care and perhaps simply need information and suggestions for how they could help facilitate positive change!"

Although national and state elections seem barely behind us, preliminary activity has already started in some state legislatures for the 2009 session. Bills of interest to the dental hygiene community have been prefiled in at least two states--Montana and Texas. Prefiling, allowed in the vast majority of states, means the sponsor of the legislation has authorized printed copies of a proposed bill to be made available for public review before the legislature officially convenes. Typically, this means the bill may be heard in committee and discussed early in the session.

The Texas measure (Senate Bill 97) amends the access to care provision that currently allows dental hygienists to provide one-time delegated services to some patients who have not been examined by a dentist. Currently, these patients must be seen in nursing homes or school-based clinics. The proposed law would add Head Start programs and community health centers to the approved settings. It would also allow dental hygienists to continue to provide services for up to one year before a dentist would need to examine the patient to authorize any additional procedures.

According to the Texas Dental Hygienists' Association, these minor changes would have a big impact on improving access to care for the underserved. Currently there are 82 counties in Texas that are designated as Dental Health Professional Shortage Areas by the Department of State Health Services. In 2007, only 50% of Medicaid eligible children received dental treatment services.

A separate measure (House Bill 168) would allow a dentist to delegate the administration of block and infiltration local anesthesia to a dental hygienist. The dental hygienist would need to complete a board-approved course and administer under direct supervision.

The Montana proposal (Legislative Concept 302) would transfer the regulation of denturists from the board of dentistry to the existing board of hearing aid dispensers. The combined board of hearing aid dispensers and denturists would have seven members, three of whom would be denturists.

The independent practice of denturitry is allowed in Arizona, Colorado, Idaho, Maine, Montana, Oregon and Washington. In four of these, the dental board oversees the regulation of denturists. However, in Idaho, Oregon and Washington, denturists are self-regulating under a denturitry board.

Stateline is prepared by the ADHA Division of Governmental Affairs.

Hot Products

A focus on improving oral health made these products a hot topic in 2008

Eco-Friendly Products

For Fred Pockrass, DDS, who operates an eco-friendly dental practice, all-natural oral health care products are a must. He recommended a careful inspection of labels to "avoid oral care products containing SLS which can irritate the oral mucosa or harsh chemicals like titanium dioxide, a substance used in wall paints."

Digital Radiographs

Rebecca Lockyer, RDH, endorsed digital X-rays interfaced with Patterson EagleSoft software with a flat screen monitor chairside. Lockyer said the 17-inch screen has a lot more impact on patients. "I have been holding up those four little bitewings for years to dazed stares." She reported that patients are better able to comprehend issues such as restoration size, decay, bone loss and abscesses. Lockyer concludes, "The old adage, 'A picture is worth a thousand words' is so true with this technology."

Unit-Dose Packaging for Fluoride Varnish

For Kerri L. Cook-Descheene, BSDH, CDHC, the product that has most changed her professional practice is fluoride varnish--specifically the unit-dose packaging. "Working in public health certainly has its challenges, with one of the greatest being able to deliver preventive services in a large community setting," she commented. "The single-dose packaging has allowed us to expand the delivery of fluoride varnish to our young schoolchildren on a regular basis," said Cook-Descheene, who is the dental program prevention coordinator for the Seminole Tribe of Florida Dental Program.

Better Oral Health for Babies

Dental caries is finally being recognized as the health care crisis that it is, noted Annie Gibbs, RDH, BS, who explained that the caries rate in preschool children, as compared with that for older children, has increased significantly in the past decade.

"Treating young children and pregnant morns is quickly becoming a priority for many states, and even the federal government," said Gibbs, who sees approximately 30 child-patients between the ages of birth and five years each month. She also works with pregnant moms to eliminate their caries.

The primary product she uses in the fight to reduce early childhood caries is fluoride varnish, which is applied as the child's baby teeth emerge. She also uses caries risk assessment, which includes interviewing the child's caregiver.

Finally, she uses a knee-to-knee technique to help her young patients get more comfortable for examinations. After a good examination and some varnish to dab on newly emerged teeth, Gibbs educates the caregiver on brushing techniques. She also sends home with the child a bag that includes an infant toothbrush, child-friendly toothpaste and a pamphlet entitled "Cavity-Free at Three" (available at

Oraqix and Profound

Jennifer Bryant, LDH, who has practiced in Indiana for 16 years, feels that "the use of Oraqix has been such a great asset to my patients, myself and the dentist I work for. Although none of the patients like the taste, they love needle-free anesthetic!" Pockrass revealed information about new topical anesthetics such as Oraqix and Profound. Profound is a topical anesthetic gel made from a combination of tetracaine, lidocaine and prilocaine. It allows for pain-free laser periodontal therapy, deep cleaning and other soft tissue procedures with little or no need for local anesthesia.

Remineralization Products

For Rene Stephenson, RDH, the hot products in 2008 included Recaldent, a calcium phosphate product that aids remineralization. "I feel like calcium phosphates are impacting the future of oral health care in the United States because they allow for more minimally invasive procedures," she commented.

Winnie Furnari, RDH, MS, FAADH, supported this, adding that the profession should be making a greater effort to educate more dental team members on the latest research for remineralization.

Saliva Check Kits

Stephenson also recommended saliva check kits that allow clinicians to determine the amount of saliva as well as the patient's buffering ability.

"The lack of saliva provides a susceptible environment for increased caries. By increasing saliva and providing an environment for less decay, we will be able to provide once again minimally invasive procedures," Stephenson said.

Enlightened Dental Hygiene

Tammie Wanless, RDH, recently purchased her first set of loupes and "cannot believe I practiced without them!" Wanless, who endured a poorly lit operatory, tired of the dentist with whom she is in practice seeing what she was missing. She purchased the 2.5 version of Sheervision flip-up loupes with the Firefly LED light. "Now, I want to send them back to get the 3.0 vision instead. I love it," Wanless reported.


In 2008, Minnesota became the first state in the country to consider legislation to establish the Advanced Dental Hygiene Practitioner (ADHP) in state statute. After a series of hearings and negotiations with all stakeholders engaged in the issue, a legislative compromise was reached--establish an Oral Health Practitioner (OHP) in statute and convene a workgroup, comprised of issue stakeholders, to make recommendations for education, licensure and supervision requirements for this new provider.

The legislation, which passed in May, lays out a basic scope of practice for the OHP, nearly mirroring the scope of practice articulated in the ADHP competencies. The workgroup is currently working on its recommendations, which will likely be used in drafting legislation to be introduced during the 2009 legislation session to further establish the new provider. The OHP workgroup is considering a number of provider models, including the ADHP.


(1.) Michaud DS, Liu Y, Meyer Met al. Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort study. Lancet Oncol 2008; 9(6): 550-8.

* Access magazine recently polled its editorial advisory board in regard to the hot topics in dental hygiene that were important and discussed in 2008. The following board members contributed to this article: Cynthia C. Gadbury-Amyot, BSDH, EdD; Meg Atwood, RDH, MPS; Su-Yan L. Barrow, RDH, MA, MPH; Denise Bowen, RDH, MS; Nancy T. Brohawn, RDH, BSDH; Mae Chin, RDH, MEd; Marilyn Cortell, RDH, MS; Louis G. DePaola, DDS, MS; James B. Fine, DMD; Winnie Furnari, RDH, MS; Harold A. Henson, RDH, MEd; Laura Mueller-Joseph, RDH, BSDH, MS, EdD; Patricia J. Nunn, RDH, MS; Fred Pockrass, DDS; Nora M. Raffetto, RDH; Rene Stephenson RDH, BSDH; and Mark Varvares, MD, FACS.

Cynthia C. Amyot, BSDH, EdD, is professor and director of Distance Education and Faculty Development, University of Missouri-Kansas City (UMKC) School of Dentistry. She has been a fulltime faculty member at UMKC since 1993, serving three years as director of Graduate and Degree Completion Studies and five years as director of the Division of Dental Hygiene. Amyot has received numerous teaching awards and has been published in several peer-reviewed journals. She served as chair of the Council on Research for the American Dental Hygienists' Association for several years, as well as other committees.

Meg D. Atwood, RDH, MPS, is an associate professor of Dental Hygiene at Orange County Community College in Middletown, N.Y. and has taught there for 23 years. Her interests in public health have led to involvement in a number of public health initiatives including community water fluoridation, consulting with Head Start and migrant health programs, and participating in development of the New York State Oral Health Plan. She has been involved in ADHA at the component and national level and has received numerous awards including the ADHA Student Advisor Award.

Su-Yan L. Barrow, RDH, MA, MPH, is baccalaureate program coordinator and coordinator, International Exchange Program, Dental Hygiene Programs at New York University College of Dentistry.

Denise M. Bowen, RDH, MS is a professor in dental hygiene at Idaho State University. She also serves as a consultant, advisory board member, and editorial board member for many entities including other dental hygiene educational programs, dental product companies, funding agencies, the National Center for Dental Hygiene Research, Contemporary Dental Hygiene, Compendium of Oral Hygiene, and various professional associations. Additionally, Bowen co-authored an oral health research text and regularly contributes chapters on preventive oral hygiene and periodontics to popular dental hygiene texts.

Nancy T. Brohawn, RDH, BSDH, has worked as a clinical dental hygienist at Newark Dental Associates in Newark, Delaware since graduating from West Virginia University with a BSDH in 1972. She is currently serving as secretary of the New Castle County Component of the Delaware Dental Hygienists' Association and has served many positions at the component and constituent level. She is on various boards and committees, including the Oral Health Care Liaison of DDHA and the executive board of the Delaware Oral Health Coalition, and she has been honored as the DDHA Hygienist of the Year, in addition to numerous honors and awards.

Mae M. Chin, RDH, MEd, clinical associate professor with the DECOD Program, (Dental Education in Care of Persons with Disabilities), Department of Oral Medicine and the dental hygiene program, Department of Dental Public Health Sciences, has many years of varied experience in working with the disabled population in the DECOD Clinic, nursing homes, state institution for autistic residents, and community outreach clinics. She provides direct patient care as well as instructing dental students, dental assistants, dental hygienists and dentists on the care of the disabled. She has lectured nationally and internationally, sharing her knowledge and skills in dental care for special populations.

Marilyn Cortell, RDH, MS, FAADH is a full-time associate professor at New York City College of Technology. She is a fellow in the American Academy of Dental Hygiene, Consultant Member Examiner to the North East Regional Board of Dental Examiners, member of the Editorial Advisory Board of Access magazine, and has earned professional membership status in The National Speakers Association. Her recent service to the Editorial Board of RDH magazine, contribution to three prominent dental hygiene textbooks, and recognition as an international lecturer make her a sought-out speaker and author on relevant dental topics.

Louis G. DePaola, DDS, MS is a professor, Department of Oncology & Diagnostic Sciences, Dental School, University of Maryland, Baltimore. He received his DDS in 1975, completed a Master's Degree in Oral Biology, is a Diplomat of the American Board of Oral Medicine and the American College of Dentists and has a Certificate in Prosthodontics. DePaola serves as the executive director of Biosafety and Continuous Quality Improvement at the Dental School, and the director for dental training for the PA-Mid-Atlantic AIDS Education and Training Center. He has authored and co-authored of over 130 journal articles, book chapters, and abstracts and serves as a consultant to the American Dental Association and numerous other professional groups and private industry.

James Burke Fine, DMD, is presently assistant dean for Postdoctoral Education, associate professor of Clinical Dentistry and postdoctoral director of the Division of Periodontics at the School of Dental and Oral Surgery of Columbia University and associate attending dental surgeon on the Presbyterian Hospital Dental Service. A graduate of The Johns Hopkins University, he received his DMD degree from Tufts School of Dental Medicine in 1982. He has served on the American Academy of Periodontology committees, in addition to various other committees, and has been the recipient of several teaching awards and fellowships. Fine has also authored or coauthored numerous texts and presented at invited lectures and seminars. He maintains a practice limited to Periodontics in Hoboken, New Jersey and in the faculty practice at Columbia University.

Winnie Furnari, RDH, MS, FAADH, is an assistant clinical professor at New York University College of Dentistry and teaches the only Forensic Dentistry/Bioterrorism Preparedness course for dental hygienists in a Baccalaureate program in the country. She was awarded the Pfizer/ADHA Award of Excellence and has received both national and international recognitions for her forensic work. She is immediate past president of the New Jersey Dental Hygienists' Association and has held numerous positions on the state and local levels. She serves on the ADHA Committee on Ethics and numerous other boards and committees. She has been published in national and international journals.

Harold A. Henson, RDH, MEd, is currently an associate professor in the Department of Periodontics, School of Dental Hygiene at The University of Texas Dental Branch at Houston. He has held numerous leadership positions at the national, constituent and component levels. He is currently a PhD candidate in the College of Education at Texas A&M University.

Laura Mueller-Joseph, RDH, BSDH, MS, EdD received her Associate of Science degree in dental hygiene from the State University of New York at Farmingdale. She earned a baccalaureate and master's degree in dental hygiene from Old Dominion University and a doctoral degree in College Teaching and Academic Leadership from Columbia University. Presently, she is a professor and program director at the State University of New York at Farmingdale where she has taught in the Dental Hygiene Department since 1987. Laura has coauthored the book Dental Hygiene Process: Diagnosis and Care Planning and has contributed chapters to numerous dental hygiene texts.

Trisha Nunn, RDH, MS, is the dean and director of dental hygiene at the Utah College of Dental Hygiene. Nunn has been involved in dental hygiene education for over 35 years, 23 of those years as a dental hygiene program administrator and prior to that as professor and chair of the Department of Dental Hygiene at the Oklahoma University College of Dentistry. She has been active nationally and locally on dental hygiene and dental hygiene educational matters, serving on numerous committees, advisory boards and elected offices. Nunn has published over 30 articles on dental hygiene topics, been appointed to editorial review boards of two professional publications, and has presented numerous continuing education courses.

Fred Pockrass, DDS, has been a restorative and general dentist since 1981. He graduated from McGill University, Montreal, Canada, and is a graduate of the acclaimed PAC-Live program in Aesthetic Dentistry at University of the Pacific in San Francisco, CA. Pockrass also holds a PhD in meditation, is a certified Tai Chi instructor, and has taught these arts for 20 years. Pockrass is a member of the American Dental Association, the International Academy of Oral Medicine & Toxicology and Teleosis Institute, Green Health Care, in addition to numerous other organizations. He also co-founded Transcendentist, Inc., the leading eco-friendly dental products and services company.

Nora Raffetto, RDH, is a dental hygienist with Prima Dental Group, a general dentistry practice, in Redwood City, Calif.

Rene Stephenson, RDH, BSDH, has been a clinical dental hygienist for 22 years. She is the Texas Dental Hygienists' Association Corporate Relations Chair and an ADHA Delegate. Her current employer is Dr. R.W. Ingram in Diboll, Texas.

Mark Varvares, MD, FACS is a native of St. Louis, Missouri, and graduated from Saint Louis University in 1986. He joined the faculty at the Massachusetts Eye and Ear Infirmary and was appointed Instructor of Otology and Laryngology at the Harvard School of Medicine. He then accepted a position at the Saint Louis University School of Medicine in the Department of Otolaryngology-Head and Neck Surgery. In 2003, he was offered the position as Chairman of the Department of Otolaryngology-Head and Neck Surgery at Saint Louis University, and in January 2006, he was named Director of the Saint Louis University Cancer Center. Varvares has won four awards for outstanding residency training.
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Title Annotation:lead story
Author:Gadbury-Amyot, Cynthia C.; Atwood, Meg; Barrow, Su-Yan L.; Bowen, Denise; Brohawn, Nancy T.; Chin, M
Geographic Code:1USA
Date:Dec 1, 2008
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