Lynne Slim is an award-winning dental author who has published extensively in dental/dental hygiene journals including 

Journal of the Western Society of Periodontology

. She was the periodontal columnist for RDH magazine for about 17 years and is now a columnist for 

 and is a member of their advisory board. In 2003, Lynne founded Perio C Dent, a dental practice management company that specializes in the incorporation of non-surgical periodontal therapy into the hygiene department of the general dental practice.

As a key opinion leader in the dental industry, Lynne is frequently asked to review new products and write product reviews. She participates in product development and is consulted about consumer/RDH product awareness. Lynne received the Philips Oral Healthcare “Mentor of Distinction” award at the 2012 ADHA Annual Session.

Lynne H. Slim, RDH, MS

A Comparison of Nursing and Dental Hygiene: Part II. Image credit: © DC Studio – stock.adobe.com


In Part 1 of this article the authors provided a comparison of nursing and dental hygiene and how the profession of nursing has far surpassed that of dental hygiene. Advanced Practice Registered Nurses (APRN) are clinical nurse specialists, and nurse anesthetists and nurse midwives are often primary care providers who play a pivotal role in providing preventive care services to the public.

But what about dental hygiene? Can we really say that dental hygiene mirrors nursing with similar advancements? Are dental hygienists, like nurses, beginning to achieve the status of a full profession, and does our educational level make a difference in the practice of dental hygiene?

Dental hygiene education has advanced since its inception in the early 1900s. Back then, there were no bachelor’s or master of dental hygiene degree programs, and dental hygienists were restricted to practice under the direct supervision of a dentist. A master’s degree in dental hygiene is a terminal degree and there are no doctoral dental hygiene degree programs in the United States. Like nursing, as the needs of the public increased requirements of care, many states began expanding the dental hygiene scope of practice. This included administration of local anesthesia for pain management, restorative services, nonsurgical periodontal therapy, and direct access to the public.

“Direct access” refers to the ability of a dental hygienist to initiate treatment based on their assessment of a patient’s needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship.

 Currently, 42 states authorize dental hygienists’ direct access to the public to serve low income and underserved populations.

In 2000, Surgeon General Dr David Satcher published the first Surgeon General report addressing Oral Health in America which called for a national effort to improve oral health among Americans. As a follow up to the 2000 Surgeon General’s Report, in 2003 Surgeon General Dr Richard Carmona published “A National Call to Action to Promote Oral Health.” The report called for a national effort to change perceptions of oral health among the public, policy makers and healthcare providers, and to promote and increase underutilized oral disease prevention measures. At the time, only 19 state dental hygiene practice acts authorized dental hygienists to provide dental hygiene services directly to the public.

To address the 2003 Surgeon General Action Report, the American Dental Hygienists’ Association (ADHA) developed the concept of an Advanced Dental Hygiene Practitioner (ADHP). Duties of this midlevel dental therapist included diagnostic, preventative, and basic restorative care for underserved population groups.

 The model was based on training similar to the highly successful Forsyth Experiment which took place in 1972 and trained dental hygienists to administer local anesthesia and prepare and fill Class I through Class V restorations.

Although dental examiners for the Forsyth Experiment found the quality of the dental hygienists work to be equivalent to that of practicing dentists, a small group of dentists in Massachusetts urged the Board of Dental Examiners to close the project down. This action prevented the advanced trained dental hygienists from ever utilizing their skill set beyond that of the experiment.

Although both the Forsyth Experiment and the ADHA received push back from organized dentistry, the ADHP received support from many coalition groups and stakeholders. In 2009, the University of Minnesota passed legislation to grant a degree in Dental Therapy. By 2016, the program evolved into a Bachelor of Science in Dental Hygiene/Master of Dental Therapy dual degree program to better meet the needs of oral health care providers and patients in the state.

As of February 2024, 14 states have passed dental therapy legislation.

 However, opposition from the American Dental Association and their state affiliates have prevented many of these states from enacting the legislation. Although dental hygienists have provided direct access to oral hygiene care to the public for decades, the exact number of direct access dental hygiene providers in the US is unknown. Additional research is needed to accumulate qualitative and quantitative outcome data related to direct access care provided by dental hygienists and other mid-level dental providers of oral health services.

Dental hygiene has come a long way since its humble beginnings in the early 1900s. As of 2023, 70% of states authorize dental hygienists to perform some restorative functions, with 60% of them authorizing the placement of temporary restorations. 49 states authorize dental hygienists the administration of local anesthetic, 11 of which authorize administration under the general supervision of a dentist. During the height of the COVID public health crisis, 20 states authorized dental hygienists to administer the COVID vaccination. 40 states authorize dental hygienists to work in some form for the integration of preventive dental care in medical settings. 42 states authorize the public direct access to dental hygienists and 2 states authorize dental hygienists the administration of a neurotoxin for the treatment of bruxism and temporomandibular joint dysfunction.

But is this enough for dental hygiene to catch up with nursing? Are we being delusional by calling dental hygiene a “profession?" We weren’t a profession in the eyes of the United States government until 2018, when the United States Office of Management's Budget Standard Occupational Classification changed the classification of dental hygienists from “technicians” to Healthcare Diagnosing or Treating Practitioners, which is in the same broad grouping as dentists.

But does classification labeling qualify to make dental hygiene a profession? How is a true profession defined? Few academic pathways can match the depth and many contributions of a doctorate. Not only are there academic gains, but also analytical, critical thinking, and research skills rise to a level beyond the bachelor’s or master’s degree. A doctorate in one’s chosen profession is a research degree that expands knowledge in a field of study and dental hygiene has fallen short in obtaining a growing body of knowledge. The mark of a true profession is one that continually acquires new knowledge and skills that relate to one’s profession.

Around the world, there are about 250 nursing journals and nursing content includes: practice, education, policy, administration and/or specialty areas, nursing knowledge and processes.

 Dental hygiene, by contrast, has a handful of journals and the American Dental Hygienists’ Association only has one Journal that includes dental hygiene research. Science that promotes the application of emerging theories and research findings to the practice of dental hygiene is mostly missing and it’s possible that the placement of dental hygiene in entry level technical school programs versus four-year colleges and universities has contributed to the challenge of increasing dental hygiene research knowledge.

Is it possible to predict dental hygiene’s future by looking at nursing? There are approximately 327 entry level dental hygiene programs in the United States, 51 baccalaureate degree-completion programs, and 17 dental hygiene Master’s degree programs.

 In comparison, there are over 2600 nursing colleges or universities in the United States, 1631 of them offer certificate or associate degree programs for registered or practical nursing, 1033 offer a bachelor’s degree, 594 offer graduate nursing programs, and 135 offer PhD nursing programs.

 In addition, an RN with a BSN can complete a focused graduate master’s or doctoral nursing program and become a Nurse Practitioner (NP) who has greater autonomy, specialization, and leadership in the workplace.

Even though dental hygiene has advanced in many areas, it seems plausible that the profession of dental hygiene will struggle as a semi or quasi profession. Until the dental hygiene profession becomes self-regulated, and dental hygienists effectively advocate for their profession at the state and national levels, dental hygiene may never realize the autonomy, or respect earned by other professions like nursing.

Advanced Practice Registered Nurse (APRN). American Nurses Association. Accessed May 2, 2024. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/aprn/

Scope of Practice. American Dental Hygienists Association. Accessed May 2, 2024. https://www.adha.org/advocacy/scope-of-practice/

Direct Access – ADHA. American Dental Hygienists Association. Accessed May 2, 2024. https://www.adha.org/advocacy/scope-of-practice/direct-access/

The Advanced Dental Hygiene Practitioner. National Oral Health Conference. Accessed May 2, 2024. https://www.nationaloralhealthconference.com/docs/presentations/2006/0502/Wendy%20Kerschbaum%20NOHC%20Presentation.pdf

Lobene R, Berman K, Chaisson L, Karelas H, Nolan L. The Forsyth Experiment in Training of Advanced Skills Hygienists. American Dental Hygienists' Association. Jan 2013, 87 (suppl 1) 63-66;

Standard Occupational Classification. American Dental Hygienists Association. Accessed May 2, 2024. https://www.adha.org/hypac/self-regulation/standard-occupational-classification/

AACN Fact Sheet – DNP. American Association of Colleges of Nursing. Updated June 2023. Accessed May 2, 2024. https://www.aacnnursing.org/news-data/fact-sheets/dnp-fact-sheet#:~:text=The%20DNP%20is%20designed%20for,other%20research%2Dfocused%20nursing%20doctorates.

Dental Hygiene by the Numbers. American Dental Education Association. Accessed May 2, 2024. https://www.adea.org/GoDental/Future_Dental_Hygienists/Dental_hygiene_by_the_numbers.aspx

Data Reports 2022-2023. American Association of Colleges of Nursing. Accessed May 2, 2024. https://aacnnursing.org/news Data Reports 2022-2023.

Donley, R., Flaherty, M.J., (Sept. 30, 2008) "Promoting Professional Development: Three Phases of Articulation in Nursing Education and Practice" OJIN: The Online Journal of Issues in Nursing. Accessed May 2, 2024. https://ojin.nursingworld.org/table-of-contents/volume-13-2008/number-3-september-2008/phases-of-articulation-/

Articles

This part 2 of this series, the authors explore key differences between nursing and dental hygiene, and the importance of self-advocacy in the hygiene profession. 

A Comparison of Nursing and Dental Hygiene: Part II

A Comparison of Nursing and Dental Hygiene | Image Credit: © Valerii Honcharuk - stock.adobe.com

Regarding the history of the dental hygiene profession, it does seem that, in many ways, it paralleled the development of general nursing in the sense that both began with a general concept that took many years to mature and become established practice. And yet the profession of nursing has expanded far and away beyond that of dental hygiene.

Although modern registered nurses (RN) and registered dental hygienists (RDH) share almost identical general education prerequisites and core curricula specific to their field, RNs are licensed and regulated through their own professional board, have more autonomy, a broader scope of practice, and less restrictive practice acts than licensed dental hygienists. It is reasonable to question this discrepancy and ask, can dental hygiene ever catch up?

Most people think the nursing profession began with the work of Florence Nightingale. However, the concept of formalized nursing began as early as the late 1700s when some physicians initiated courses for women interested in caring for patients. It wasn’t until 1854, when Nightingale led a group of women to the Crimea to deliver nursing services to British soldiers, that she confirmed that a corps of educated women informed about health and the ways to promote it, could improve the care of patients based on a set of particular principles.

By 1873, there were 3 educational nursing programs established in the U.S.based on Nightingale’s ideas.The success of the schools led to a proliferation of similar nursing programs and by 1900 there were somewhere between 400 to 800 nursing programs operating in the country.

 However, there were no consistent training standards in place and many of the programs varied from 6-week to 3-year programs. Most of the programs were located in hospitals, schools, private residences, or through correspondence schools.

In comparison, the concept of dental hygiene as a profession didn’t emerge until 1902, when Dr. C.M. Wright published the article, "A Plea for a Sub-Specialty in Dentistry.” Dr Wright stated “the time has arrived when I believe we should make it possible for, and encourage, a specialty within a specialty devoted to the polishing of teeth and caring of the gums.” The article called for dental colleges to provide the education and training and grant a certificate of competence to graduates. Dr Wright went on to emphasize that graduates of the program could be employed by dentists, practice at offices of their own, or at the homes of patients. In addition, he urged dentists to use their influence to recommend the new specialists, 

“just as physicians and surgeons recommend and insist upon the services of the trained nurse.”

 Dr Wright’s article was the first of many to advocate not only for the profession of dental hygiene, but also for the recognition of this as a specialty within the wider frame of oral health, with its own experts established as independent practitioners.

In 1906, Irene Newman became the first dental hygienist and began providing prophylactic work for the patients of Dr. Alfred Fones. By 1916, dental hygiene education was formalized by its establishment in institutions of higher education.

 Although nursing organized 2 major professional associations in the late 1890s, it wasn’t until 1923 that dental hygiene organized on a national level by founding the American Dental Hygienists' Association (ADHA). It took another 34 years for dental hygienists to receive the title of Registered Dental Hygienist in 1940.

When nursing organized in the late 1890s, the primary objectives were to establish some control over the profession and stem the growth of substandard nursing schools. State licensure seemed to be a reasonable mechanism to achieve these goals as physicians were already registered in all states and the Union. The United States Supreme Court had ruled that occupational licensure was a legitimate function of the police powers of the states.Thus the model was available and the way cleared for nurses to seek licensure.

To facilitate the registration campaign, nurses organized to set up constituent state groups with local memberships lobbying for registration acts. By 1923, all 48 states had passed some form of nursing licensure legislation.

 Although medicine was in a monopoly position, each state eventually had a nursing board composed of both nurses and physicians.

 In 1978, the National Council of State Boards of Nursing (NCSBN) was created to manage the nurse-licensing examination which consisted of a representative from each state board, an executive director, and the staff. The purpose of the change was to relieve the American Nurses Association (ANA) from management of the licensing examination and give state boards ‘‘autonomous control over the entire licensure process.’’

 Thus the profession of nursing became self-regulated.

In comparison, it wasn’t until 1951 that all 50 states required licensure and regulation of dental hygienists. However, unlike nursing, dental hygienists were licensed and regulated 

by state dental boards comprised only of dentists

California is the only state to have its own dental hygiene board.

Although dental hygiene has advanced since its inception in the early 1900s, nursing has far surpassed dental hygiene in practice acts and autonomy. Advanced practice nurses have achieved general supervision for most of the specialties they provide and are widely recognized as delivering more efficient, less costly and safer health care services. How about dental hygiene? Can we really say that dental hygiene mirrors nursing with similar advancements? Are we, like nurses, beginning to achieve the status of a full profession and does our educational level make a difference in the practice of dental hygiene?

In Part 2 of this series of articles, we will evaluate how nursing and dental hygiene have undergone a progression of academic and career ladders along with advancement in new types of healthcare providers who specialize in different settings and how grassroots advocation for one’s profession makes a difference.

1. American Nursing: An Introduction to the Past https://www.nursing.upenn.edu/nhhc/american-nursing-an-introduction-to-the-past/ Accessed March 8, 2024.

2. The Story of Nurse Licensure https://downloads.lww.com/wolterskluwer_vitalstream_com/journal_library/nne_03633624_2011_36_1_16.pdf Accessed March 8, 2024.

3. The Origin and History of the Dental Hygienists https://jdh.adha.org/content/jdenthyg/87/suppl_1/58.full.pdf Accessed March 8, 2024.

4. A Plea for a Sub-Specialty in Dentistry https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10156230/pdf/intdentjphil142911-0008.pdf Accessed March 8, 2024.

5. The Law and the Expanding Nursing Rolehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1653228/pdf/amjph00490-0005.pd

6. The Evolution of Dental Hygiene Education https://dimensionsofdentalhygiene.com/article/the-evolution-of-dental-hygiene-education/ Accessed March 8, 2024.

In part 1 of this series the authors look at the early beginnings of dental hygiene and how the profession attempts to parallel the growth and autonomy of nursing.

A Comparison of Nursing and Dental Hygiene

Image Credit: © K KStock / stock.adobe.com

I don’t know about you, but I cringe when I hear the Ozempic (semaglutide) and other pharmaceutical jingles

When I’m watching cable TV, the commercial with the familiar Ozempic jingle pops up almost daily. I knew nothing about this medication until I decided to read about it. In my mind, I assumed it was another medication for type 2 diabetes, and I had no idea that is can also drive weight loss in some people.

In the first seven months of 2023, drug companies spent a whopping $500 million on advertisements for obesity and diabetes treatments. While widely used in treatment of type 2 diabetes, the weight loss potential of Novo Nordisk’s Ozempic is gaining traction, and publicity, with companies such as Optavia, Ro and WeightWatchers each launching a subscription program focused on health and nutrition needs of patients taking these or similar drugs called Glucagon-like peptide-1 receptor agonists (GLP-1RA).

What is a GLP-1RA and What are the Indications For Use?

GLP-1RA medications aren’t just a popular weight loss fad, but rather they are FDA-approved medications to treat obesity and other metabolic disorders like diabetes. Like other GLP-1Ras, Semaglutide—the specific medication in Novo Nordisk’s Ozempic, Wegovy and Rybelsus brands—mimics a hormone that helps the body control blood sugar levels, suppresses appetite, and slows the body’s stomach emptying. This combination of outcomes can lead to weight loss in some patients. Clinical trials have found that GLP-1RA is associated with significant weight loss of up to 10-15% and it has been approved for the treatment of both type 2 diabetes and obesity.

The discovery, description, and clinical development of GLP-1 medications spans 30 years with contributions from multiple investigators.

 Experimental findings on incretins—AKA gut hormones—were designed to establish the biology of GLP-1 as an insulin-stimulating hormone.

 In 2017, the Harrington Prize for Innovative Medicine was awarded for the discovery of GLP-1 and the translation of these findings into transformative therapies for major metabolic changes like diabetes. Incretin hormones are secreted after nutrient intake and stimulate insulin secretion together with hyperglycemia. In diabetes, incretion effect is diminished.

GLP-1RAs are available as a monotherapy in injectable or oral dosage forms. The FDA has approved GLP-1RAs as a second line treatment option for better glycemic control in type 2 diabetes and it is still under scrutiny for anti-obesity purposes.

 Multiple clinical trials have shown GLP-1RAs reduce cardiovascular risks in patients with diabetes and atherosclerotic cardiovascular disease (ASCVD), or high cardiovascular risk independent of HbA1C. All of the currently available GLP-1RA medications have effects on cardiovascular risk factors including hypertension.

 The American Diabetes Association guidelines recommend using GLP-1RA for patients with established ASCVD or indicators of high ASCVD risk independent of A1C levels.

Cost, however, is one major barrier to patients accessing GLP-1RA medications. Subcutaneous weekly injections can cost approximately $1,200.00 per month. Patients can use manufacturer coupons which can give pharmacists time to work with the provider in getting insurance coverage. In addition, providers sometimes can obtain off-label GLP-1RA which can lower cost by about a third.

Most often, GLP-1RAs are injected by pens or insulin syringes with minimal discomfort with different dose frequencies. This medication is titrated up with a starting dose and dose increases until the full dose is reached. Patient counseling is often combined with injections including advice on obtaining optimal health through a combination of strategies including eating smaller meals, eating more slowly, and staying hydrated.

Common side effects are gastrointestinal issues including nausea, vomiting, and diarrhea. The risk of hypoglycemia is minimal with these drugs unless they are used in combination with drugs that cause hypoglycemia.

 Patients using these medications may also report severe or persisting abdominal pain and constipation.

GLP-1RAs are contraindicated in pregnant or breastfeeding women, as well as for patients with severe gastrointestinal diseases including pancreatitis, multiple endocrine neoplasia, and medullary thyroid cancer.

Patients with type 2 diabetes who take concomitant glucose-lowering drugs benefit from GLP-1RA independent of Metforin which is commonly used as a first-line medication in the type 2 diabetes patient population.

The American Society of Anesthesiologists (ASA) have recently issued guidance which advises patients taking GLP-1RA to withhold taking these medications prior to elective surgical procedures. There are reported concerns about potential adverse effects and complications associated with these medications during surgery and patients on daily dosing are advised to consider withholding GLP-1RA the day of the procedure. Patients on weekly dosing are advised to withhold GLP-1RA on the week prior to the procedure.

Obtain the name and contact information of the prescribing healthcare team

Ask how long they have been taking the medication

Ask about their outcomes including how they are feeling on the medication

Also, ask the patient if any other medications have been altered due to adding a GLP-1RA to their medication regimen

Ask about their daily water consumption because it is recommended that they consume 64 ounces a day to aid digestion, minimize or prevent nausea, minimize headaches, and prevent constipation.

In summary, semaglutide is a class of medications known as glucagon-like peptide-1 receptor agonists that are given in the form of subcutaneous injections in patients with type 2 diabetes. It is also now being prescribed for obesity based on clinical trials that have shown semaglutide to be effective in promoting weight loss. These drugs are expensive and often not covered by the patient’s health plan but off-label GLP-1RAs can lower the cost.

The treatment of metabolic diseases like type 2 diabetes and obesity is changing based on the discovery of GLP-1RAs. For some patients to learn that obesity is a treatable medical condition is a life changer.

Listen to your patients as they navigate new ways to achieve successful health outcomes and cheer them on.

Loren Bonner. GLP-1 receptor agonists: Breaking down the hype and demand. Pharmacy Today. Published: March 2023. Accessed: February 13, 2024. 

https://www.pharmacist.com/Publications/Pharmacy-Today/Article/glp-1-receptor-agonists-breaking-down-the-hype-and-demand

Drucker DJ, Habener JF, Holst JJ. Discovery, characterization, and clinical development of the glucagon-like peptides. 

. 2017;127(12):4217-4227. doi:10.1172/JCI97233

Mahapatra MK, Karuppasamy M, Sahoo BM. Semaglutide, a glucagon like peptide-1 receptor agonist with cardiovascular benefits for management of type 2 diabetes. 

. 2022;23(3):521-539. doi:10.1007/s11154-021-09699-1

Marx N, Husain M, Lehrke M, Verma S, Sattar N. GLP-1 receptor agonists for the reduction of atherosclerotic cardiovascular risk in patients with type 2 diabetes. 

January 2024: AAOMS News and Announcements. Journal of Oral and Maxillofacial Surgery. January 2024;82(1):134-136. doi.org/10.1016/j.joms.2023.10.001

Ozempic, and other glucagon-like peptide-1 receptor agonists are mainly used for managing type 2 diabetes, but the medications are also gaining popularity as a weight loss option.

Understanding Ozempic and Wegovy, the Drugs at the Center of the Latest Weight Loss Craze

Future of the Scaling Assistant – Part II. Image credit: © rh2010 - stock.adobe.com

, the authors discussed the 1998 Kansas House Bill (HB) 2724 authorizing dental assistants to scale teeth supragingivally. The HB was written to address a shortage of dental hygienists in the state and outcomes from the 2007 performance audit report of the Kansas Dental Practice Act. The report indicated dental scaling assistants are only subject to minimal oversight by the Kansas Dental Board and unlike dentists and dental hygienists, they are not required to be licensed.

In 2015, Illinois became the second state in the United States to authorize dental assistants to scale teeth supragingivally on children 12 years of age and younger after attending a weekend course.

Although both the Kansas and Illinois scaling assistant bills require a dentist or dental hygienist to complete the prophylaxis after the supragingival work has been completed by the assistant, most of us know that time constraints of the dentist and dental hygienist prevent this from occurring as it is not an effective use of time. This suggests offices utilizing scaling dental assistants typically end up billing the supragingival scaling procedure as a complete prophylaxis. However, there is no CDT procedure code for supragingival scaling because the American Dental Association does not recognize it as a separate therapeutic procedure.

In 2021 approximately 333,942 healthcare providers, including members of the dental field, left their jobs due to the COVID-19 public health crisis. The American Dental Association Health Policy Institute Report on Dental Workforce Shortages identified enrollment in dental assisting programs had been trending downward since 2015, and the pandemic had a negative impact on dental hygiene program enrollment. While there has been some recovery of enrollment in dental hygiene programs, data suggest that dental assisting program enrollment will not rebound in the near future. As a result, workforce shortages are likely to remain an issue for years to come.

Hence, some states have again begun looking for “solutions” to the dental hygiene workforce shortage by initiating legislation via a scaling dental assistant. In 2021, the Wisconsin Dental Association initiated legislation for an expanded duty dental assistant which included scaling. However, after strenuous opposition and advocacy by the Wisconsin Dental Hygienists’ Association, this section of the bill was removed. In 2022, the Illinois Dental Society passed legislation authorizing dental assistants with 32 hours of instruction to provide coronal scaling on Medicaid children 17 years of age and younger. And in 2023, a House representative and dentist from the Bozeman area introduced HB411 under the premise of the “workforce shortage of dental hygienists that would have authorized dental assistants to provide an “oral prophylaxis” on children aged 12 and under.

 Although Kansas and Illinois allow “coronal scaling” by dental assistants, this bill would have been the first to allow dental auxiliaries to provide a complete prophylaxis.

The bill did not include any language requiring a preprocedural evaluation, a post-procedural check, nor did it contain language that parents be informed that an unlicensed person other than a licensed dental hygienist would be cleaning their children’s teeth.

Meanwhile, the Colorado Dental Association (CDA) has created a Resolution “to direct the CDA to submit a Sunrise Review application to the Colorado Department of Regulatory Agencies to address the expansion of dental assistants’ scope of care to include scaling dental assistants.

In researching data for this article, nothing can be found in any common dental database, research articles or abstracts to indicate supragingival scaling alone (without a complete prophylaxis) increases access to dental care or provides a health benefit to the public. As such, one might suggest that delegation of dental hygiene duties to dental assistants is motivated not by a sincere interest in patient health, but rather to maximize profits

Dental hygiene is the only licensed health care profession regulated by another profession to depreciate the rigors of one’s education, training, and licensure to that of a weekend course.

Although dental hygienists know the value of the oral health services they provide, local state legislators do not. Their job is to provide legislation that benefits the public at large. Without understanding the scope of practice of dental hygienists or their education, state legislators will continue to pass legislation for scaling dental assistants. As licensed oral healthcare professionals, it is our job to inform them of the possibility of incomplete care with little or no health benefit. This takes the form of a grassroots effort which begins with getting to know your local state senator and representative.

The Montana Dental Hygienists Association was able to defeat the scaling dental assistant legislation using 3 “A” pillars to their lobbying efforts: advocacy, accuracy, and all together.

This begins by introducing yourself to your local state legislator and scheduling an appointment to meet them in person to discuss concerns impacting your profession. Provide your legislator with accurate information and data to support your concerns. This should be done now regardless if your state is looking at implementing scaling dental assistant legislation. Become a member of your professional Association as legislators want to know that information and it provides a greater voice to make an impact at the state legislature.

Imagine taking your child to a dental practice with certain expectations from a licensed, primary oral health care professional only to discover that care was provided by a technician who may have completed a weekend course. What happens when this so-called technician or “scaling assistant” uses sharp and/or powered instruments in a child’s mouth with no knowledge of fulcruming and instrument safety? Dental hygienists are educated to solve oral health problems of patients and residents based on a process of care that is well defined by the United States and Canadian Dental Hygienists’ Associations. The dental hygiene process of care serves as a foundation for the dental hygienists’ role as professionals who are primary healthcare providers.

 Even in the early 1900s, Dr Alfred C. Fones, educated the first dental hygienist, Irene Newman, for an entire year before she began treating patients in his dental practice.

Do we really want to stand still and go backwards by promoting oral health care interventions by unlicensed scaling assistants? What happens if we do nothing? The Scaling Dental Assistant may be coming to a state near you!

PERFORMANCE AUDIT REPORT, Kansas Dental Practices Act: Determining the Impact of the 1998 Changes to the Act https://www.kslpa.org/wp-content/uploads/2019/08/r-07-23.pdf

ADA HPI Dental Workforce Shortages: Data to Navigate Today’s Labor Market. American Dental Association. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/dental_workforce_shortages_labor_market.pdf?rev=e6025d77df184e6c95dc7cefde4adee3&hash=225FCBBCCB67174AAFC760FE2287322D#:~:text=Vacant%20positions%20in%20dental%20assisting,positions%20is%20a%20contributing%20factor

Montana HB 411. LegiScan. https://legiscan.com/MT/text/HB411/id/2683516

The Montana experience: Fighting House Bill 411 to protect children. RDH Magazine. https://www.rdhmag.com/career-profession/article/14291305/the-montana-experience-fighting-house-bill-411-to-protect-children

Kwak SH, Bae SM, Shin SJ, Shin BM. Definition and Classification of Dental Hygiene Interventions Based on the Dental Hygiene Process of Care: A Delphi Study. 

. 2023;20(17):6704. Published 2023 Sep 2. doi:10.3390/ijerph20176704

The 100 Year of Evolution of the Science and Practice of Dental Hygiene. DentistryIQ. https://www.dentistryiq.com/dental-hygiene/clinical-hygiene/article/16363590/the-100year-evolution-of-the-science-and-practice-of-dental-hygiene

In this follow up piece to “The Scaling Assistant,” we take a look at the complicated laws behind scaling assistants, and how to ensure your patients receive the best care possible. 

Future of the Scaling Assistant – Part II

The Scaling Assistant. Image credit: © Kawee - stock.adobe.com

Back in the late 1970s, Lynne and I can remember our first days in a clinical laboratory setting, learning how to scale teeth, mostly with manual instruments. We were both accepted into academically competitive accredited United States dental hygiene educational programs, and we were excited to be there. Dental hygiene education was a highly respected major for young women at the time and we were motivated to excel. There was so much to pack into the curriculum including general science prerequisites. Entry level programs were either associate or baccalaureate level educational programs.

We practiced on typodonts before working in the mouth because we had no idea how to hold an instrument, how to fulcrum, what a working stroke was, etc. Instrumentation guidance came from instructors and the Esther Wilkins essential book, 

Clinical Practice of the Dental Hygienist.

 Besides practicing on typodonts before working on each other, we also took detailed competency exams. Back then, manual instrumentation was the preferred scaling instrumentation method and powered instrumentation consisted of a large Cavitron box with 1 insert. The insert was mostly used for supragingival scaling due to the thickness of the tip, which was called a P-9 and not much was taught in the way of powered instrumentation. Our curriculum required us to master anterior and posterior sickle instrumentation and gracey instrumentation, which included about 9 types of instruments with each one being practiced to competency.

At the time, it seemed that all our dental hygiene student compatriots, including us, were constantly filled with apprehension and fear. Our fear consisted of not being “enough,” or being unable to find a patient for clinic, or passing an upcoming competency, etc. But the worst fear we faced was something called “preceptorship.” Although most of us had heard about it, we knew little about it other than what our instructors told us. After having completed 2 to 4 years of rigorous study, passing an 8-hour written National Board Examination and a regional or state clinical board examination, it was impossible to understand how a dental assistant in the State of Alabama could become “a dental hygienist” after spending approximately 200 hours in a classroom 1 weekend per month for 10 months, while working full-time as a dental assistant (hygienist trainee) for their sponsoring dentist. In comparison, a 2-year or 4-year CODA Accredited dental hygiene program requires at least 1000 hours of classroom instruction and 700 hours of clinical instruction.

In 1998, the Kansas legislature knocked the dental hygiene world on its heels by passing HB 2724 to address a shortage of dental hygienists in the state. The bill changed the dental practice act to authorize “a specially trained dental assistant” to polish and scale supragingivally, but specified a licensed dentist or dental hygienist was required to complete the rest of the routine cleaning.

 With the passage of the bill, Kansas became the first state to allow dental assistants to perform coronal scaling, and thus began the systematic dismantling of dental hygiene's professionalism by organized dentistry.

In 2007, the Kansas legislature requested a performance audit report from the Kansas Dental Practices Act. The objective of the audit report was to determine the impact of the 1998 practice act changes that authorized dental assistants to perform supragingival scaling. Key points from the Executive Summary of the Performance Audit Report found dental scaling assistants are subject to only minimal oversight by the Kansas Dental Board and unlike dentists and dental hygienists, they are not required to be licensed.

Although the Kansas Dental Board requires scaling assistants to submit a copy of the course completion certificate and report changes in work address, the Board has no power to enforce the requirements. In addition, the Kansas legislature asked how many dental scaling assistants are working in Kansas and if they had affected the availability of dental care in underserved areas.

The Report found that although 400 dental assistants reported completing the course since 1999, the Board had incomplete and dated information on their status because they were unable to determine if everyone submitted their certificate. The Board had no way of knowing if scaling assistants were notifying the Board when they changed jobs or left the profession altogether.

Furthermore, the Dental Board lacks a reliable method for obtaining updated information, as the database on dental scaling assistants is at best an inventory of people who completed the course and where they worked at that time. Of the 400 dental assistants who submitted information to the Board did so within 3 years after the Act was changed 22 years ago. Although 70% of dental scaling assistants initially reported working in underserved areas, it’s impossible to know whether they currently are working in those areas because there is no complete information on their current employment status.

The 2007 Performance Audit Report survey indicated only 158 scaling dental assistants were still working but spent most of their time assisting the dentist instead of scaling and polishing teeth. The survey also indicated that of the responding dentists who regularly used the 158 scaling assistants, only 60% of the dentists stated they worked in shortage areas, and 66% said although they felt they increased the number of patients seen, most described the increase as slight to moderate.

Kansas law requires dentists employing a supragingival scaling assistant who has received a certificate from an educational entity to file a report with the Dental Board within 30 days of employment, or change in employment of the names and business addresses of all dentists who are employing or supervising the non-licensed person. However, as of 2023, when asked how many scaling dental assistants were currently working, the Kansas Dental Board stated “they are a non-licensed person in Kansas, and we do not have a list nor know where they are working.”

In Part 2 of this series, we will examine perceptions from Kansas dental hygienists and scaling assistants on Kansas HB 2724. Specifically, we will address access to care and workforce issues and the “new” and very real threat from scaling assistants to the dental hygiene profession.

Minutes of the House Committee on Health and Human Services. 2001. http://www.kslegislature.org/li/s/historical/committees/minutes/01_02/house/HsHHS3-7-01.pdf

PERFORMANCE AUDIT REPORT. Kansas Dental Practices Act: Determining the Impact of the 1998 Changes to the Act https://www.kslpa.org/wp-content/uploads/2019/08/r-07-23.pdf

The first part in a 2 part series. The authors take a look at the history of “scaling assistants” and rules that impact what they can and can not do in dental practice.

The Scaling Assistant 

In recent years, evidence-based research such as systematic reviews, meta-analyses, and randomized controlled trials has increased and replaced anecdotal or successful personal experience by practitioners. As you’ll see in the research I’m going to discuss about peri-implant diseases, scientific evidence has become an important aspect of care compared with expert opinion and clinical experience. We now talk about “best practice” instead of “the art of medicine/dentistry.”

 presents an evaluation of the quality of the relevant scientific literature and benefit/potential harms of treatment. For example, the American Dental Association has published several clinical practice guidelines on a variety of topics, such as 

recommendations by the American Heart Association

 on the use of antibiotics to prevent infective endocarditis or fluoride toothpaste recommendations for children younger than 6 years. Guidelines assist clinicians in the decision-making process for best outcome and consider systematic appraisal of published evidence as well as clinical experience. These guidelines can also help clinicians defend themselves in a court of law.

When a reversible inflammatory lesion affects the soft tissues surrounding a dental implant in the absence of radiographic bone loss (with bleeding on probing [BOP] as a key tool to distinguish an unhealthy peri-implant mucosa), a clinician will diagnose peri-implant 

Other factors associated with peri-implant mucositis onset include biofilm accumulation, smoking, and radiation therapy.

When a clinician observes an irreversible pathological condition affecting hard and soft tissues around a dental implant, the resulting bone loss is referred to as 

 Peri-implantitis sites exhibit BOP and/or suppuration besides inflammation and are also associated with increased probing depths and recession of the mucosal margin.

 Etiology includes peri-implant plaque biofilm, history of severe periodontitis, poor oral hygiene, and irregular or no supportive peri-implant care following surgery. Less conclusive evidence for peri-implantitis consists of the following factors: smoking, diabetes, submucosal cement following prosthetic restoration of the dental implant, and positioning of the implant in such a manner that limits access to oral hygiene including professional maintenance.

General Framework Used in Clinical Practice Guideline Development

The clinical practice guideline (2023) for peri-implant diseases was developed by the European Federation of Periodontology and overseen by an expert workshop committee. The overall effort included 13 systematic reviews conducted in support of the guideline development process. After the 13 reviews were conducted on specific, focused questions (eg, the efficacy of adjunctive measures to treat peri-implant mucositis), evidence-based recommendations were debated, and a consensus was reached and voted on.

The quality of evidence for each of 13 areas (focused questions pertaining to peri-implant disease) was included, which reflected the degree of certainty/uncertainty of the evidence and the robustness of study results. In addition, the recommendation was graded, which reflected the criteria used to form a judgment and strength of consensus. Risk of bias was also included in group discussions and clinical practice guidelines.

The clinical practice guideline for peri-implant diseases (prevention and treatment) includes the following components:

Prevention, diagnosis, and treatment sequence

Recommendations for the prevention of peri-implant diseases

Recommendations for the management of peri-implant mucositis

Recommendations for nonsurgical management of peri-implantitis

Recommendations for the surgical management of peri-implantitis

In highlighting some of the clinical practice guideline recommendations below, keep in mind that recommendations by the workshop committee were based on strength of available evidence and/or expert consensus and was graded according to quality and certainty. The clinical practice guideline is considered valid until 2028 and is free to read in its entirety.

1. Prevention, Diagnosis, and Treatment Sequence

Patients who receive a dental implant should be considered at risk for some type of peri-implant disease.3 During the 2014 European Workshop in Periodontology, 2 systematic reviews demonstrated a patient-level prevalence estimate for peri-implant mucositis and peri-implant implantitis. In one systematic review, meta-analyses from 11 studies demonstrated a patient-level prevalence estimate of 43% (95% CI, 32%-54%) for peri-implant mucositis and 22% (95% CI, 14%-30%) for peri-implantitis. Another systematic review included 47 studies and reported a prevalence of 46.83% (95% CI, 38.30%-55.36%) for peri-implant mucositis and of 19.83% (95% CI, 15.38%-24.27%) for peri-implantitis.

Interventions to prevent peri-implant disease should begin at the treatment planning stage and continue throughout the life of the dental implant in the oral cavity. Known risk factors associated with peri-implant diseases should be controlled, such as poor oral hygiene, smoking, diabetes, and untreated periodontitis.

Perioperative interventions for the prevention of peri-implant diseases must include placing the dental implant(s) in an optimal position while considering local factors that prevent ideal placement and designing/installing prostheses that allow access for oral hygiene. Avoid submucosal cement and select screw-retained restorations instead.

Peri-implantitis is an irreversible condition. Even after successful peri-implantitis therapy, a diagnosis of “stable” is made.

 Upon diagnosis, refer to an appropriate specialist and decide whether the affected tooth can be treated. The following key aspects in the management of peri-implant diseases are important to remember

Arresting the inflammatory processes and controlling local/systemic factors within the peri-implant tissues are key. Disruption of locally accumulating biofilms must be a priority.

Treatment of peri-implant mucositis is a key strategy in preventing early onset of peri-implantitis.

Treatment of peri-implantitis is performed sequentially: nonsurgically and then surgically, depending on the outcome of nonsurgical treatment. Supportive periodontal care must be an important component of treatment management and long-term success.

2. Recommendations for Prevention of Peri-Implant Diseases

Risk assessment and controlling risk factors are necessary in preventing peri-implant diseases in individuals who are candidates for dental implants, who have received dental implants, and who currently have healthy peri-implant tissues. Workshop participants created prevention categories of 

primordial primary, secondary, and tertiary 

to interpret evidence and expert-based consensus.

Primordial prevention refers to the concept of optimal oral and general health prior to implant placement, but there is no current definition of optimal health and no studies directly addressing primordial prevention of peri-implant diseases. Instead, recommendations are based on indirect evidence and expert opinion. Primary prevention refers to the prevention of disease onset following dental implant placement and loading. No studies existed to provide direct evidence for primary prevention.

Clinical guidelines should be based on a thorough evaluation of the evidence and generally include a rating of the quality of evidence and an assigned strength to recommendations. Grading of Recommendations Assessment, Development, and Evaluations guidance warns against making strong recommendations when the certainty of the evidence is low or very low.

In this section, recommendations are mostly expert-consensus based due to low certainty of available evidence, and I would strongly recommend reading each pico question addressed online. [

Pico questions are a way to construct a well built question in research. More information on this is available in the clinical practice guideline document referenced below.

] Clinical practice guidelines should be based on a thorough evaluation of the evidence and assigned a strength of recommendation. When the certainty of evidence is low or very low, strong statements are not usually made.

Please read the entire clinical practice guideline document in the 

 for components not covered in this article. What follows is a synopsis of the recommendations for the prevention component:

Assessment of patient’s risk profile should be completed to identify and manage modifiable risk factors for peri-implant diseases.

Treatment of gingivitis and periodontitis should achieve a stable end point, and adherence to regular supportive care should be considered prior to implant placement.

Adequate buccal/lingual bone thickness will allow the implant to be placed in a guided position with good primary stability and surrounded circumferentially by bone.

Adequate mesio-distal distance between an implant and adjacent tooth/implant must allow adequate space for prosthetic components and access for oral hygiene aids.

Good access for oral hygiene aids by the patient to remove plaque is recommended (moderate evidence in addition to expert opinion).

Good access for professional monitoring (peri-implant probing) and professional plaque removal is recommended (moderate evidence in addition to expert opinion).

A prosthesis contour with a favorable emergence angle and profile to facilitate optimal plaque removal is recommended (moderate evidence in addition to expert opinion).

Experts recommend peri-implant probing to assess presence of BOP and to monitor changes in probing depths and in mucosal margin level. Baseline probing should be done within 3 months of prosthesis delivery and at every clinical exam. Width of keratinized attached peri-implant mucosa should be assessed and recorded. BOP and probing depths should be recorded at 6 sites circumferentially. 

A baseline intra-oral radiograph should be obtained at the completion of the physiological remodeling to document marginal bone levels. If there is an increase in probing depths at future visits in conjunction with BOP/suppuration, oral radiograph is recommended to evaluate marginal bone levels.

In patients with diabetes who have healthy peri-implant tissues, experts recommend glycemic control to maintain peri-implant health.

Scientific evidence is a critical piece of care, but be aware that guidelines are only as good as the existing evidence and the judgment of the experts writing them.