Ms. Newkirk received her dental hygiene degree from the University of Alaska, Anchorage, in 1981. A recognized key opinion leader in periodontal endoscopy, Suzanne has published numerous articles and co-authored several dental textbook chapters on minimally invasive non-surgical periodontal therapy with use of the dental endoscope.

Ms. Newkirk is the national and international dental endoscopy instructor for Zest Dental Solutions and is a professional speaker. Her website is: 

Suzanne Newkirk, RDH

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

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 

Periodontitis is largely preventable, but access to affordable periodontal care—especially for older adults—is woefully lacking. A 2012 study published in the 

 found that 47.2% of adults 30 years and older have some form of periodontal disease.

 The Centers for Disease Control and Prevention reports that periodontal disease increases with age, and 70.1% of adults 65 years and older have it.

 About one-third of adults forego dental care.

 Among elderly patients, 29.2% have dental insurance and 65.5% had a dental visit in the past 12 months.

Nonsurgical treatment of periodontitis by a dental hygienist is time consuming if done well, and periodontal care is viewed as a “profit center” in many general practices.

 Hygienists on social media often cite inadequate time and instruments for periodontal and other procedures. Because such complaints are not seen on dentists’ blogs, it appears that hygienists are sometimes stuck with inferior equipment and insufficient time simply because they are employees who do not make these decisions. It also may indicate that some dental practices may not value clinical excellence and good outcomes the way they should.

Sottosanti and Cobb, both periodontists, emphasize the complete removal of subgingival calculus to resolve inflammation but state that in recent decades clinicians and educators have diminished its significance in favor of a “’biocompatible root surface’ as a necessary requirement to eradicate the periodontal disease process.”

 They compare calculus to a porous, spongelike material, mineralized and dry, that allows periodontal pathogens to live within its framework. Further, Sottosanti and Cobb say multiple studies show a relationship between calculus and inflammation of the adjacent soft tissue wall of the periodontal pocket. The pathogens living in biofilm that also live within the calculus may over time release toxins into the periodontal pocket, causing the disease to progress.

For dental hygienists to remove as much subgingival calculus as possible, they need time and effective instrumentation. In addition, hygienists need patient cooperation and a working knowledge of root anatomy, including furcations. There are 3 main ways calculus attaches to a root surface.

The cemental surface of a root has a rough surface with tiny mounds as seen under a powerful microscope. As pockets deepen, each mound is a former insertion site for periodontal ligament fibers. Sticky pellicle layer forms on the surface of cementum and as early subgingival microbes accumulate, they form a biofilm that thickens and calcifies, often surrounding bacteria-filled channels and spaces. According to Sottosanti and Cobb, these mounds are easily removed by overlapping strokes of sharp curettes and ultrasonic scalers.

Root surfaces with lacunae (cavitations) are defects that sometimes penetrate cementum into dentin and may lock in calculus to these undercuts.

Calculus can be directly attached to the crystalline structure of cementum. When removed, some will remain, becoming residual and undetectable. This happens because the attachment of the calculus to cementum is stronger than the calculus itself. This smooth, residual calculus fuels future pocket increases and ultimately tooth loss. Burnished calculus is the main reason periodontal diseases progress after scaling and root planing.

The goal of scaling and root planing is to remove subgingival calculus and biofilm, but it is a very demanding procedure for even the most accomplished clinicians.

 The cementoenamel junction (CEJ) is a common site for residual calculus.

 Following subgingival instrumentation, microbial colonization begins almost immediately, and posttreatment bacterial counts can return to pretreatment levels within a week.

 Intervals necessary for the site to return to pretreatment levels of subgingival microflora depend on disease severity, thoroughness of debridement, and supportive care including meticulous self-care and appropriate intervals of repeated removal of subgingival biofilms during periodontal maintenance.

In a 2021 CE by Rethman, et al, the authors summarize studies comparing manual to ultrasonic instrumentation with or without surgical flaps.

 Combined use of sharp curettes and ultrasonics appears more effective than either method alone and experienced clinicians do better in removing subgingival calculus.

 Residual calculus is usually found in furcations, CEJ, interproximal root flutings, in deeper pockets, and in multirooted teeth.

 Air powder polishing using glycine or erythritol powders combined with manual and ultrasonic instrumentation seems to provide better outcomes.

 Periodontal endoscopes, when used by a skilled clinician, provide visualization of the root surface while scaling, reducing the need for traditional periodontal surgeries.

Demand for health care professionals like registered dental hygienists (RDHs) will grow, according to the US Bureau of Labor Statistics.

 This is mainly due to an aging population that will have greater need for health care services. During the pandemic and postpandemic have seen a lot of health care services move into patients' homes. In addition to the pandemic, an aging population and renewed focus on preventive care may shift nonsurgical periodontal therapy and maintenance by RDHs into on-site primary care facilities connected to senior housing. As individuals age, chronic health care problems multiply and it is common for seniors to have anywhere from 4 to 8 such issues.

 As more senior living facilities offer primary care, consumers are demanding that senior housing deliver and manage that care, including dental services.

Economic conditions during COVID-19 have affected the delivery of dental hygiene services. During the first wave of the pandemic, dental practices were forced to close. When they reopened, stringent infection control measures increased overhead costs and patients were reluctant to return. As patients return and as practices get busier, patients are still avoiding regular preventive recare. After a year of disrupted dental care and treatment there may be less demand for dental care, especially with inflation rearing its head. With inflation and COVID-19 come higher cost of doing business and lower profitability.

Most RDHs in privately owned dental practice settings or dental service organizations are employees working under general or direct supervision. They are not business partners but licensed providers hired to perform a service to patients as nurses do. Running a successful dental practice means providing a high standard of care and investing in a top-notch dental hygiene department. Present and future dental hygiene departments will require meeting patients’ expectations that support their well-being. The future outlook and successful delivery of nonsurgical periodontal therapy is a critical component of care and clinical excellence will drive revenue goals. Here are some positive ways to achieve a healthy future outlook.

Be sure to diagnose gingival and periodontal diseases using the new classification system. Diagnosis and treatment planning must be accurate and can only be made by a thorough evaluation of data collected. Future malpractice claims will continue to include failure to diagnose and treat/refer periodontal diseases.

 In many general dental practices, only probing depths are recorded even in patients at high risk for periodontitis. Use the American Academy of Periodontology comprehensive periodontal evaluation checklist and give it to the patient to follow along as you collect data.

Refer to a qualified periodontal specialist when limited periodontal care under the facade of a full scope of periodontal treatment fails to control inflammation and unnecessary tooth loss.

Nonsurgical periodontal therapy in general dental practices should exceed the norm, including reevaluation and periodontal maintenance.

 RDHs and periodontal specialists are trained with the equipment needed to perform this service and educated to attain therapeutic endpoints consistent with a pattern of health.

There are no shortcuts to the delivery of effective nonsurgical periodontal therapy.

 Manual and ultrasonic instrumentation take adequate time and hand curettes must be selected based on access to root anatomy. Ultrasonic equipment and scalers must be checked regularly for wear with a wear guide.

Continue to invest in technological systems like Perioscopy to achieve consistency and improved clinical outcomes. This minimally invasive periodontal endoscope allows clinicians to see magnified details of root anatomy; the unit and component parts will become more affordable over time.

Don’t call biofilm and dental calculus “buildup on teeth.” Managing biofilm subgingivally is necessary to promote healing of periodontal pocket wounds. Wound debridement protocols, like those used in medicine to eradicate chronic wounds, will continue to change based on biofilm research on hard-to-heal chronic wounds.

The future of nonsurgical periodontal therapy remains challenging, given the overall percentage of adults who cannot afford private dental care. Comprehensive periodontal treatment regimens are ideal but unattainable for many, especially older adults with limited incomes and little to no dental care under Medicare. Dental benefits for low-income Medicare recipients would help, especially as thousands of Baby Boomers are losing company-sponsored dental benefits. Oral health improvements occur when there is better access to dental care and when financial barriers are removed. Maybe someday, dental care, including periodontal care, will become essential in US policy.

Eke PI, Dye BA, Wei L, et al; CDC Periodontal Disease Surveillance workgroup. Prevalence of periodontitis in adults in the United States: 2009 and 2010. 

Periodontal disease. CDC. Updated July 10, 2013. Accessed April 1, 2022. 

https://www.cdc.gov/oralhealth/conditions/periodontal-disease.html

Reinberg S. Even before pandemic, one-third of U.S. adults went without dental care. U.S. News & World Report. July 9. 2021. Accessed April 19, 2022. 

https://www.usnews.com/news/health-news/articles/2021-07-09/even-before-pandemic-one-third-of-us-adults-went-without-dental-care

Seidel-Bittke D. Six steps to making the dental hygiene department a profit center. DentistryIQ. February 22, 2013. Accessed April 1, 2022. 

https://www.dentistryiq.com/dental-hygiene/career-development/article/16355072/six-steps-to-making-the-dental-hygiene-department-a-profit-center

Sottosanti JS, Cobb CM. Guest editorial: dental hygienists play a critical role. 

https://dimensionsofdentalhygiene.com/article/guest-editorial-dental-hygienists-play-critical-role/

Rethman MP, Cobb CM, Sottosanti JS, Sheldon LN, Harrel SK. The importance of effective scaling and root planing. 

https://dimensionsofdentalhygiene.com/article/importance-effective-scaling-root-planing/

Healthcare occupations. US Bureau of Labor Statistics. Updated April 18, 2022. Accessed April 19, 2022. 

https://www.bls.gov/ooh/healthcare/mobile/home.htm

Silverstein J. 4 reasons why onsite primary care is mission-critical for senior living. Senior Housing News. January 31, 2019. Accessed April 1, 2022. 

https://seniorhousingnews.com/2019/01/31/4-reasons-why-onsite-primary-care-is-mission-critical-for-senior-living/

Huot RA. Inflation affects both dentists and patients: prepare your practice now. Ontario Academy of General Dentistry. August 23, 2021. Accessed April 1, 2022. 

https://www.agd.org/constituent/news/2021/08/23/inflation-affects-both-dentists-and-patients-prepare-your-practice-now

Tipton P. Dental negligence and the rise of litigation. 

. Updated March 31, 2020. Accessed April 1, 2022. 

https://www.lawyer-monthly.com/2020/03/dental-negligence-and-the-rise-of-litigation/

. March 1, 2012. Accessed April 1, 2022. 

https://www.rdhmag.com/pathology/periodontitis/article/16405895/periodontal-referral-gone-awr

Demand for registered dental hygienists is likely to continue to grow, especially with an aging population that requires more involved dental care.

Evolution of Nonsurgical Periodontal Therapy Part 3: Future Outlook

Adjunctive Therapeutic Agents: Systemic and Locally Delivered Antimicrobials

Periodontitis is understood to have a multifactorial origin that results from a complex interaction between the host’s immune system and dysbiotic plaque biofilms. Before scientists were able to comprehend biofilm presence and its role in chronic inflammation, a commonly accepted theory (specific plaque hypothesis by Loesche) advocated diagnosing and treating periodontitis based on prominent bacterial types.

 Nonsurgical periodontal therapy for the “gums” became increasingly popular with the public, and it was a movement that started in the late 1970s by Dr Paul H. Keyes, even though it wasn’t scientifically tested at the time. Microscopic examination of plaque with a phase contrast microscope, scaling and root planing (SRP), and assiduous daily home care involving antibacterial agents like baking soda and hydrogen peroxide and systemic antibiotics were part of the Keyes technique.

Over the last 4 to 5 decades, clinicians have used various local or systemic agents including host modulation agents. In assessing the effects of systemic antimicrobials as an adjunct to SRP for nonsurgical periodontal treatment, the Cochrane Oral Health Group published a systematic review (SR) in 2020.

 It reported on a range of antibiotics with different dosages and combinations. No serious adverse effects from the various combinations of systemic antibiotics were reported, but there were adverse events such as nausea, vomiting, diarrhea, mild gastrointestinal disturbances, and metallic taste. Unfortunately, there is insufficient evidence to decide whether 1 combination of antibiotics is better than another and there is very low certainty of evidence (for long-term follow-up) to inform clinicians and patients if adjunctive antimicrobials are of any help in the nonsurgical treatment of periodontitis.

In 2015, The American Dental Association (ADA) Council on Scientific Affairs convened a panel of experts to formulate clinical practice guidelines on nonsurgical treatments of patients with periodontitis by means of SRP with and without adjuncts.

 The clinical practice guideline is based on a SR of 72 research articles providing clinical attachment levels on clinical trials of 6-month duration and published through July 2014. SRP showed a moderate benefit for patients with periodontitis. Systemic subantimicrobial-dose doxycycline and systemic antimicrobials showed similar magnitudes of benefits as adjunctive therapies to SRP but the systemic antimicrobials were recommended at different strengths. The panel recommended systemic subantimicrobial-dose doxycycline because of the higher potential of adverse effects with higher doses of systemic antimicrobials. Other adjuncts that were evaluated and were labeled weak included chlorhexidine chips and photodynamic therapy with a diode laser. Evidence was lacking and level of certainty of evidence was low for doxycycline hyclate gel and minocycline microspheres and other lasers as SRP adjuncts.

In summary, none of the systemic antimicrobials or local delivery antimicrobials have high-certainty evidence to support their use as adjuncts to SRP with the exception of subantimicrobial dose doxycycline.

The primary objective of SRP is to restore periodontal health by removing pathogenic materials and products (eg, biofilm, calculus, and endotoxins) that induce inflammation from periodontally involved root surfaces. Calculus has been shown to contain bacterial products that contribute to the inflammatory response and can perpetuate periodontal infection.

Numerous studies, however, indicate clinical difficulty in determining the thoroughness of subgingival instrumentation as well as clinical limitations in instrumenting subgingival root surfaces in a closed pocket, particularly in pocket depths greater than 5 mm.

The periodontal endoscope facilitates visualization of the subgingival environment via a 1 mm­diameter, flexible, fiber-optic probe with real-time video imaging capabilities. This fiber-optic system enlarges the image 20 to 40 times while delivering light and irrigation to the working field.

An early study by Stambaugh et al evaluated the periodontal endoscope and the ability of the clinician to develop skills in using fiber optics to accurately visualize the contents of the subgingival sulcus.

 Results from other studies demonstrated that adjunctive use of the periodontal endoscope for nonsurgical periodontal therapy resulted in improved visibility of deposits for calculus removal.

Wilson et al found that root surfaces treated endoscopically with a single course of closed subgingival SRP demonstrated no histologic signs of chronic inflammation 6 months after therapy.

The 2015 ADA Center for Evidence-Based Dentistry clinical practice guidelines on the nonsurgical treatment of chronic periodontal disease note that SRP IS still the gold standard for non-surgical therapy.

 The periodontal endoscope supports this therapeutic approach and has been found to be a minimally invasive technology that provides visualization with magnification and illumination within a closed pocket to aid in the diagnosis and treatment of chronic periodontitis and peri-implant disease.

Loesche WJ. Clinical and microbiological aspects of chemotherapeutic agents used according to the specific plaque hypothesis. 

Canadian Academy of Periodontology. CAP position on Keyes Technique. Accessed March 2022. 

https://www.cap-acp.ca/en/public/keyes.html

Khattri S, Kumbargere Nagraj S, Arora A, et al. Adjunctive systemic antimicrobials for the non‐surgical treatment of periodontitis. 

Smiley CJ, Tracy SL, Abt E, et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis with and without adjuncts. 

Allen DL, Kerr DA. Tissue response in the guinea pig to sterile and non-sterile calculus.

Tan BKT, Mordan NJ, Embleton J, Pratten J, Galgut PN. Study of bacterial viability within the human supragingival dental calculus. 

Blue CM, Lenton P, Lunos S, Poppe K, Osborn J. A pilot study comparing the outcome of scaling/root planing with and without Perioscope technology. 

Rabbani GM, Ash MM, Caffesse RG. The effectiveness of subgingival scaling and root planing in calculus removal.

Caffesse RG, Sweeney PL, Smith BA. Scaling and root planing with and without periodontal flap surgery. 

Sherman PR, Hutchens LH Jr., Jewson LG, Moriarty JM, Greco GW, McFall WT Jr. The effectiveness of subgingival scaling and root planing. I. Clinical detection of residual calculus.

Stambaugh RV, Dragoo M, Smith DM, Carasali L. The limits of subgingival scaling. 

In this 3-part series, we examine the history and evolution of nonsurgical periodontal therapy.