Dental hygienist

A dental hygienist is a licensed dental professional who is registered with a dental association or regulatory body within their country of practice. They are a primary healthcare professional who works independent of, or alongside dentists and other dental professionals in a team to provide full oral health care. They have the training and education that focus and specialise in the prevention and treatment of oral disease. They can choose to work in a range of dental settings from independent practice, private practice, specialists practices to public sector; and can also work in residential aged care facilities.^[1][2]

Dental hygienists have a specific scope of clinical procedures they provide to their patients. They assess a patient's condition in order to offer patient-specific preventative and educational services to promote and maintain good oral health. The use of therapeutic methods assists their patients in controlling oral disease, while providing tailored treatment plans that emphasize the importance of behavioral changes .^[3] In most jurisdictions, hygienists work for a dentist or dental specialist, and some are licensed to administer local anesthesia and perform dental radiography.^[4] The major role of a dental hygienist is to perform periodontal therapy which includes things such periodontal charting, periodontal debridement (scaling and root planing), prophylaxis (preventing disease) for patients with periodontal disease. In addition dental hygienists are able to perform examinations, make diagnosis, take intraoral radiographs, dental sealants, administer fluoride, and provide patient specific oral hygiene instruction.^[5] They are also able to work at an orthodontic clinic and can perform many tasks there. Such as selecting and sizing of orthodontic bands for dental braces, the removal of orthodontic appliances and are able to make dental impressions for the construction of study casts and mouthguards.^[3]

Dental hygienists work together with other dental professionals, with a higher number working at general practices with dentists, Dental therapists and oral health therapists. A smaller number work at specialist practices alongside orthodontists and periodontists. They help with the contribution of an interdisciplinary approach, aiming to provide optimum oral health care to their patients. Dental hygienists also aim to work interprofessionally to provide holistic oral health care in the best interest of their patient. Dental hygienists also offer expertise in their field and can provide a dental hygiene diagnosis, which is an integral component of the comprehensive dental diagnosis.^[6]

Other areas that relate to dentistry that dental hygienists can be involved in are:

• Research: They can carry out clinical studies and trials alongside specialists in teaching institutions.

• Professional education: They are able to provide education by teaching and training dental hygiene students and dental assistants. They can also choose to present research at a variety of different events and seminars within their industry.

• Community health: They provide assistance and group talks in community dental clinics, residential care, hospitals and nursing homes. For example: helping clients that suffer from medical and mental disorders.

• Military dentistry: They are able to provide dental care to service members and their dependents or to civilians during humanitarian disasters.

• Marketing and sales: They can promote dental products and services through dental companies as a dental company representative.

^[3]

Treatment phases of periodontal therapy

Periodontal therapy is a continuous cycle requiring regular evaluation and maintenance to optimise treatment outcomes. The treatment is normally carried out by a dental hygienist or oral health therapist, but involves all members of the dental team and can include specialists throughout the course of care. There are six phases undertaken by dental professionals when undertaking periodontal therapy, which are as follows;^[7]

Systemic pre-phase

This includes, but is not limited to;

• A full review of the patient's medical history to identify the patient's systemic health, as well as establishing a provisional diagnosis. The provisional diagnosis is generated following a comprehensive oral examination, data collection and radiographic interpretation.
• An ASA physical status classification system is used to indicate future treatment options for the patient, whilst considering the implications of risk factors, such as medical conditions (i.e. endocarditis, diabetes, smoking). This also allows the dental clinician to begin planning all non-surgical therapy.
• All emergency treatment should be addressed first, this includes emergency periodontal treatment;^[7]
• The patients compliance should be established during this phase as optimal oral hygiene practices need to be employed in order to assist with treatment planning and, long-term goals and results;^[7]

Initial phase: non-surgical periodontal therapy

Non-surgical periodontal therapy is concerned primarily with disease prevention, and is accomplished through patient and clinician cooperative interaction. It is normally accomplished with the incorporation of patient education and motivational interviewing, and if appropriate may include discussions regarding nutrition and smoking cessation.^[7] The various treatments involved in this phase include;

• Debridement
• Antimicrobial therapy
• Correction of local risk factors
• Fluoride therapy
• Caries control and placement of temporary restorations
• Occlusal therapy
• Minor orthodontic treatment

If disease is present, secondary prevention may be necessary, the cause of disease should be identified and noted, and the relevant professional movement should be identified and patient instruction for dental plaque control established in an attempt to reinstate a healthy oral condition. Therefore, mechanical and chemical plaque control are involved in this phase. This may be via;

• Plaque disclosing agents
• Manual or electric toothbrushes
• Toothbrushing techniques
• Interdental aids
• Dentifrices
• Chemical plaque control (antimicrobial mouthwashes)

Re-evaluation of non-surgical periodontal therapy

This phase is continuous throughout treatment, allowing the dental professional along with the patient to monitor the patients oral health status and assists in recognising the need for change or amendment to the previously formulated treatment plan, according to the patients specific needs.^[7] Treatment is monitored using accurate periodontal charting and clinical observation of hard and soft tissues by the dental professional. The results of the periodontal charting and clinical observation dictates what follows the non-surgical periodontal phase. The three generalised outcomes that may result are essentially;

• The patient progresses straight to the maintenance phase
• The patient returns to the non-surgical periodontal therapy phase, until such a time as their periodontal status is satisfactory
• The patent advances to the corrective phase

Corrective phase: surgical periodontal therapy

The corrective phase is not needed for all patients, but is dictated by the outcomes of the re-evaluation phase, encompassing all indicated;^[7]

• Periodontal surgery
• Endodontic surgery
• Placement of dental implants

Supportive periodontal therapy and restorative therapy

As with the corrective phase, supportive periodontal therapy is not needed for all patients, but is too dictated by the outcomes of the re-evaluation phase. It includes all required;

• Dental restorations
• Fixed and removable prosthesis

A re-evaluation of the overall response to treatment should be conducted at the end of this phase before continuing onto the maintenance phase.

Maintenance phase

The maintenance phase involves continuous care, at patient specific levels. It includes all measures used by the dental team and patient to stop the disease reoccurring, with the objective of keeping the dentition functioning for was long as possible in the oral cavity.^[7]

History of dental hygienist

• In the late 1800s dental disease prevention methods became popular amongst dentists and dental nurses, with dentists being trained to perform routine prophylaxis treatment in the fight against dental disease. During this period D. D. Smith of Philadelphia demonstrated the prophylactic methods to his colleagues and patients and the acceptance of his theories become increasingly popular.^[8]
• In 1898 Smith presented a lecture on his system of periodic oral prophylaxis, which required patients to attend regular visits for prophylactic treatment and education sessions around oral home care.^[8]
• In 1906 one of his followers Alferd C. Fones took a great interest into Smith’s theories and began to train his cousin, Irene Newman, to act as an apprentice, scaling and polishing teeth as well as giving instructions on how to keep their mouths clean with daily home care practices. She was then to become the first recognised dental hygienist.^[8]
• In 1910 the Ohio College of Dental Surgery offered a formal course for dental nurses. However, dentists in Ohio strongly opposed the formal training school, and those who completed the coursework were never allowed to practice. The course was soon to be discontinued in 1914 due to the backlash from the dental community.^[8]
• In 1913 the term dental hygienist was devised and Alfred Fones began the first school for dental hygienists in Connecticut^[8]
• 1914 the first legal dental hygienists graduated from Dr. Fones’ dental hygiene program and legally allowed to provide patients with prophylaxis treatment.
• In 1915 Connecticut amended the dental practice act to include the regulation of dental hygienists and other states followed amending dental hygiene regulations outlining the scope of practice of a dental hygienist.^[8]
• 1923 the first meeting of the American Dental Hygienist Association took place ^[8]
• 1939 There were 8000 dental hygienists in the USA^[9]
• 1950 Dental hygienists were recognised in Canada and the University of Toronto established the first dental hygiene program in the country.^[10]
• 1965 The first male Jack Orio graduated from The University of New Mexico ^[9]
• 1965 over 15,400 dental hygienists were working in America ^[8]
• 1974 Dental hygienists were employed by the government of New Zealand to treat members of the New Zealand army.^[11]
• 1975 Dental hygiene profession was introduced in Australia.^[12]
• 1980 There were 204 dental hygiene programs across America^[13]
• 1988 The Journal of Dental Hygiene celebrates 75 years of commitment to care^[14]
• 1994 dental hygienists in New Zealand to work publicly and privately.^[11]
• 2006 Auckland University of Technology Bachelor of Health Science (Oral Health):3years (dual-degree in Dental Hygiene and Dental Therapy)^[11]

Global oral hygiene education and legislation timeline

Country	First Year of Training	First Year of Legislation of Practice	No. of programmes in 2001
USA	1913	1907ȸ 1917†	234
Norway	1923	1979	3
Canada	1951	1947ȸ 1952†	27
Japan	1948‡ 1951	1948	125
United Kingdom	1954	1954	19
Nigeria	1961	1993	none
R. of Korea	1965	1973	27
The Netherlands	1968	1974	4
Sweden	1968	1991	9
Denmark	1972	1986	2
South Africa	1972	1969	6
Switzerland	1973	1975§ 1991§	4
Australia	1975	1972	5
Finland	1976	1972	2
Italy	1978	1988	17
Israel	1979	1978	3
Iceland	Educ. Abroad	1978	none
China (Hong Kong)	1982	1982	1
Portugal	1983	1983	1
Spain	1989	1986	25
New Zealand	1993	1988	1
Latvia	1996	1996	1
Czech Republic	1996	1996	1
India (भारत)	1972	1972	NA

• ȸLegal recognition of profession in first State or Province.
• †First license issued.
• ‡First training at US Allied Headquarters.
• §For selected cantons first; in 1991 for all cantons.

^{[8] [11] [15] [16]}

Training

Australia

Dental hygienists in Australia must be graduates from a dental hygiene program, with either an advanced diploma (TAFE), associate degree, or more commonly a bachelor's degree from a dental hygiene school that is accredited by the Australian Dental Council (ADC).^[17]

In Australia it is a legal requirement for dental hygienists/ oral health therapist graduates to be registered with the Dental Board of Australia before practising their scope in periodontology in any state or territory in Australia.^[18]

The Dental Hygienists’ Association of Australia (DHAA) Inc., established in 1975, is the peak body representing registered dental hygiene service providers in Australia. A dental hygienist does not need to be employed by a dentist but can independently assess patients and make treatment plans within their scope of practice whilst working in the community. Practising as an autonomous decision maker, and working within the scope of only what they are "formally" trained in. The National Law requires the same level of professional responsibility from dental hygienists, oral health therapists and dental therapists as it does from dentists, dental specialists and dental prosthetists in that all practitioners must have their own professional indemnity insurance and radiation licences. They are also required to complete 60 hours of mandatory continuing professional development in a three-year cycle.^[19][20]

A Bachelor of Oral Health is the most common degree program. Students entering a bachelor's degree program are required to have a high school diploma or equivalent. Most Bachelor of Oral Health programs now qualify students as both dental hygienists and dental therapists, collectively known as oral health therapists.^[21]

Canada

Dental hygienists in Canada must have completed a diploma program, this can be 19 months to 3 years. All dental hygiene students must pass a NDHCB (NDHCB) examination after graduation. This examination is offered three times per year, January, May and September. Three universities in Canada offer Bachelor of Science degrees in Dental Hygiene: Dalhousie University, University of Alberta, University of British Columbia.

Dental hygiene across Canada is a well-respected career with many opportunities. These possibilities include working in clinical, administration, education, research and public health positions. The wages vary throughout the country; from approximately $32 per hour in some areas to as high as $55 per hour in others. A surplus of new dental hygiene graduates in recent years has resulted in a decrease in wages in some regions.

Some of the downfalls to practicing in different provinces are the different regulations. For instance, in BC, the hygienist cannot provide treatment without the patient receiving a dental exam in the previous 365 days unless the practicing hygienist has an extended duty module (resident-care module). In AB, BC, MB and SK, hygienists also administer local anesthesia if qualified to do so. In Ontario, dental hygienists may take further training to become a restorative dental hygienist. Registered dental hygienists must register every year by December 31. Ontario dental hygienists must also prove continuing competence by maintaining a professional portfolio yearly. In Ontario, dental hygienists are registered with the College of Dental Hygienists of Ontario (CDHO). ^[22]

Dental hygienists in BC, ON, NS and AB are able to open their own private clinics and practice without a dentist on staff.

New Zealand

Since 2006,^[11] New Zealand dental hygienists are trained at either University of Otago in Dunedin (at the country's only Dental School) or at Auckland University of Technology.^[23] The qualifications (Bachelor of Oral Health at Otago, Bachelor of Health Science in Oral Health at AUT) enable graduates to register and practise as both a dental hygienist and a dental therapist.^[11]

Prior to this, dental hygienists were first domestically trained in 1974 for use in the New Zealand Defence Force. The one-year course was taught by the Royal New Zealand Dental Corp at the Burnham army base outside Christchurch.^[11] Hygiene training was briefly offered at the Wellington School for Dental Nurses in 1990 as 2 week a supplement to Dental Therapy students training.^[11] However, this was quickly discontinued.^[11]

The first independent non-military training began in 1994.^[11] Otago Polytechnic began offering a 15-month Certificate in Dental Hygiene in Dunedin.^[11] In 1998, the programme was modified to be a 2-year Diploma.^[11] Otago Polytech stopped offering the course in 2000.^[11] The following year, University of Otago began offering a 2-year Diploma in Dental Hygiene qualification.^[11] In 2002, the university added a 3-year Bachelor of Health Sciences (endorsed in Dental Hygiene) degree alongside the Diploma.^[11] This course was discontinued in 2007, when the current 3 year Bachelor of Oral Health commenced.^[11]

In order to practise, all hygienists must annually register with the Dental Council.^[24] For the 2014-2015 cycle, the cost of this is $669.07.^[25] One hygienist is represented on the Council for a three-year term.^[26]

Dental hygienists can become members of the New Zealand Dental Hygienists' Association.^[27] The association was founded in 1993,^[28] and is affiliated with the International Federation of Dental Hygienists.^[29]

United States

Dental hygienists in the United States must be graduates from a dental hygiene program, with either an associate degree (most common), a certificate, a bachelor's degree or a master's degree from a dental hygienist school that is accredited by the American Dental Association (ADA).^[30]

All dental hygienists in the United States must be licensed by the state in which they practice, after completing a minimum of two years of school and passing a written board as well as a clinical board exam.^[31] State requirements vary by state, and are controlled by state dental boards.^[32]

Dental hygienists school programs usually require both general education courses and courses specific to the field of dental hygiene. General education courses important to dental hygiene degrees include college level algebra, biology, and chemistry. Courses specific to dental hygiene may include anatomy, oral anatomy, materials science, pharmacology, radiography, periodontology, nutrition, and clinical skills.

A Bachelor of Science in Dental Hygiene is typically a four-year program. Students entering a bachelor's degree program are required to have a high school diploma or equivalent, but many dental hygienists with an associate degree or certification enter the bachelor's degree programs to expand their clinical expertise and help advance their careers.

Graduate degrees in the field of dental hygiene are typically two-year programs and are completed after the bachelor's degree. Common graduate courses in dental hygiene include Healthcare Management, Lab Instruction, and Clinical Instruction.

After completing one of the more than 200 accredited dental hygiene programs in the United States, dental hygienists must be licensed in the state in which they work. Licensure requirements for becoming a Registered Dental Hygienist (RDH) vary from state to state, but most require a two-year degree, a written examination, and a clinical examination. The National Board Dental Hygiene Examination is intended to fulfill the written examination requirements. The clinical examination is typically administered by the state licensing board.

In addition, the American Dental Hygienists' Association has defined a more advanced level of dental hygiene, the Advanced Dental Hygiene Practitioner otherwise known as a dental therapist.

Direct access to care with a dental hygienist

The dental hygienists in some parts of North America can provide oral hygiene treatment based on the assessment of a patient’s needs without the authorization of a dentist, treat the patient in absence of a dentist, and also maintain a provider-patient relationship.

India

The Dental Hygienist Course in India is a full-time 2-year diploma course. The Dental Hygienist Regulation course is controlled by the Dental Council of India. After completion of the course a dental hygienist should be register with a state dental council. Any person who is a registered dental hygienist in a one state may practice as such in any other. The India Dental Hygienist Association is the primary national body representing the dental hygienist profession in India, however some state dental hygienist associations also work at state level. In India dental hygienists do not need to be employed by a dentist but can have their own clinic.

Canada

British Columbia

1995 - A client must have seen a dentist within the previous 365 days in order for the hygienist to provide dental hygiene treatment.

2012 - New bylaws offers an exemption from the 365-day rule if hygienists are registered in the Full Registration (365 Day Rule Exempt) class.^[33]

Alberta

2006 - Dental hygienists are able to offer their services in many practice settings including independent practice.^[34]

Manitoba

2008 - If the dental hygienist has practiced for more than 3000 hours, and the client does not have a complex medical condition then the hygienists do not require the supervision of a dentist. ^[35]

Ontario

2007 - Registered dental hygienists in Ontario who have been approved by the College of Dental Hygienists of Ontario can practice independently.^[36]

United States

California

1998 - Registered dental hygienist in alternative practice (RDHAP): RDHAPs may provide services for homebound persons or at residential facilities, schools, institutions and in dental health professional shortage areas without the supervision of a dentist. RDHAPs can provide patient care for up to 18 months and longer if the patient obtains a prescription for additional oral treatment from a dentist or physician .^[37]

Colorado

1987 - Unsupervised practice: Hygienists may have their own dental hygiene practice; there are no requirement for the authorization or supervision of a dentist for most services. ^[38]

Connecticut

1999 - Public health dental hygienist: dental hygienists may practice without supervision in institutions, public health facilities, group homes, and schools as long as they have two years of work experience.^[39]

Maine

2008 - Independent practice dental hygienist: A dental hygienist licensed with an independent practice may work without the supervision of a dentist, providing that the dental hygienist has to complete 2,000 work hours of clinical practice during the two years prior to applying for an independent license, as well as a bachelor's degree from a CODA accredited dental hygiene program or complete 6,000 work hours of clinical practice during the six years prior to applying for an independent license, as well as an associate degree from a CODA accredited dental hygiene program. ^[40]

Michigan

2005 - PA 161 Dental hygienist: hygienists with grantee status can work in a public or nonprofit environment, a school or nursing home that administers dental care to a low-income population. Dentists collaborating with dental hygienists do not need to be present to authorize or administer treatment. However, dental hygienists must have the availability to communicate with a dentist in order to review patient records and establish emergency protocols. Hygienists need to apply to the state department of community health for grantee status.^[41]

Washington

1984 - Unsupervised practice: dental hygienist practice without the supervision of a dentist is allowed in hospitals, group homes, nursing homes, home health agencies, Health and Human Service state institutions, jails, and public health facilities as long as the hygienist refers their patients to a dentist for treatment. Hygienists must have at least two years of work experience within the last 5 years.^[42]

See also

• Dental nurse
• Dental assistant
• Periodontal disease
• Gingivitis
• Periodontitis

Further reading

• Mueller-Joseph, L., & Petersen, M. (1995). Dental Hygiene Process: Diagnosis and Care Planning. Albany, NY: Delmar.
• Dental Hygienists' Association of Australia Inc. (2014). "What is a Dental Hygienist?" Retrieved from http://www.dhaa.info/information-1/information-brochure/

References

External links

• Important Facts About Dental Hygienists on American Dental Hygienists' Association