The Scaling Assistant

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.¹ 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.”²

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.

References

1. 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

2. 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