A Comparison of Nursing and Dental Hygiene: Part II

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.¹

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.² Currently, 42 states authorize dental hygienists’ direct access to the public to serve low income and underserved populations.³

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.⁴ 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.⁵

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.⁵ 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.⁶

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.⁷ 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.⁸ 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.⁹ 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.¹⁰

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.

References

1. Advanced Practice Registered Nurse (APRN). American Nurses Association. Accessed May 2, 2024. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/aprn/
2. Scope of Practice. American Dental Hygienists Association. Accessed May 2, 2024. https://www.adha.org/advocacy/scope-of-practice/
3. Direct Access – ADHA. American Dental Hygienists Association. Accessed May 2, 2024. https://www.adha.org/advocacy/scope-of-practice/direct-access/
4. 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
5. 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;
6. Standard Occupational Classification. American Dental Hygienists Association. Accessed May 2, 2024. https://www.adha.org/hypac/self-regulation/standard-occupational-classification/
7. 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.
8. 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
9. Data Reports 2022-2023. American Association of Colleges of Nursing. Accessed May 2, 2024. https://aacnnursing.org/news Data Reports 2022-2023.
10. 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-/