Protecting Total Health
Summary
Oral health and its relationship to total health underscores the need for quality education.
Recent research has linked periodontal (gum) disease to heart and lung disease; diabetes; pre-mature, low-birth weight babies; and a number of other systemic diseases. Indeed, the first-ever Surgeon General's Report on Oral Health has called attention to this important connection and concludes that, if left untreated, poor oral health is a "silent X-factor promoting clear the onset of life-threatening diseases which are responsible for the deaths of millions of Americans each year.
Set against this important recognition of the critical link between oral health and total health is a trend to weaken dental hygiene education standards. Proposals to reduce standardized formal educational preparation for dental hygienists or replace it with on-the-job training are being discussed in various states. These proposals represent a real public health hazard because they would allow oral health care workers with no or inadequate education or clinical training to treat unsuspecting oral health patients.
Organized dentistry, which has introduced these initiatives, has consistently asserted that they are needed to alleviate a shortage of dental hygienists. This is simply not borne out by the facts. According to figures recently released by the U.S. Health Services Administration (HRSA), there are more than 140,000 dental hygienists in the U.S., compared to approximately 131,000 dentists. According to the agency, between 1985 and 1996, the annual number of dental school graduates declined by 23 percent while the number of dental hygiene graduates increased 20 percent.
Even if there were a shortage of dental hygienists, it would not justify reducing or weakening the educational standards that determine the preparation needed for dental hygienists to treat patients safely.
On-the-job training is just not adequate to prepare dental hygienists to provide safe patient care. Providing a complete prophylaxis (teeth cleaning) that prevents oral disease is a complicated procedure using a razor-sharp instrument. An unskilled and inexperienced oral health care worker runs a greater risk of doing it incorrectly.
Indeed, the Commission on Dental Accreditation--dentistry's own accrediting agency--has gone on record supporting accreditation of all entry-level dental hygiene programs and opposing any reduction of educational standards and/or requirements for initial licensure of dental hygienists.
The American Dental Hygienists' Association (ADHA) has fought these initiatives to weaken dental hygiene education, and believes the only way to assure patient safety and quality oral health care for the public is by maintaining educational standards through support of accredited dental hygiene education.
ADHA will continue to fight any proposals place in danger the safety and welfare of the American public.
Background
Currently, dental hygienists are prepared for practice in dental hygiene programs housed in institutions of higher education accredited by the American Dental Association Commission on Dental Accreditation (ADA CDA).
Most dental hygiene programs are housed in community colleges or technical institutes and award an associate degree or certificate of completion. Dental hygiene programs also may offer education beyond the entry level. There are baccalaureate degree-completion programs, designed to work with community colleges to award a baccalaureate degree in any number of majors, including dental hygiene. In addition, there are four-year dental hygiene programs that award a Bachelor of Science degree upon completion. And interested dental hygienists with a bachelor's degree in dental hygiene are eligible to earn a master's degree in the discipline. Or they may choose to pursue a graduate degree in education, public health, business, or other discipline.
The accreditation provided by ADA CDA serves to ensure the quality of entry-level dental hygiene programs. The process does this by conducting extensive reviews to determine the degree to which programs meet established minimum accreditation standards. The Commission also works to encourage enhancement and improvement of the quality of accredited programs.
In order to practice, following graduation from an accredited dental hygiene program, dental hygienists are required to take a national written examination and clinical or regional state exam. After successful completion of these tests, they are awarded a registered dental hygienist (RDH) credential. Licensure is intended to protect the public from unqualified individuals providing unsafe practice.
The licensing process is administered by state boards of dental examiners. These bodies also write the statutes and rules that govern dental hygiene scope of practice, licensure, and education. These state boards influence the quality of dental hygiene education by stipulating what constitutes acceptable education and credentials for licensure.
Regional testing authorities--which administer the clinical exam--also may exert influence over the quality of education since they require specific levels of knowledge, clinical skills, and performance in order to complete the examination successfully.
On-the-Job Training Proposals
This rigorous preparation of dental hygienists described above is consistent with the critical role oral health has in total health and is designed to protect consumers from care provided by oral health workers who are inadequately prepared to deliver safe care.
However, a disturbing trend in dental hygiene education over the past decade has been a series of initiatives, proposed by organized dentistry, to reduce or eliminate the formal education and licensure requirements dental hygienists receive prior to being allowed to deliver care to patients.
Organized dentistry has consistently asserted that the initiatives are needed to alleviate a shortage of dental hygienists. This argument has been offered as the justification for a variety of proposals intended to reduce or weaken formal education or replace it with on-the-job training of dental hygienists.
However, a shortage is simply not borne out by the facts. Today, the number of accredited dental hygiene programs stands at 255. This number has steadily increased in recent years and is at its highest ever. Moreover, the number of dental hygiene program graduates has exceeded the number of dental school graduates and the trend is expected to continue.
According to figures recently released by the U.S. Health Services Administration (HRSA), there are more than 140,000 dental hygienists in the U.S., compared to approximately 131,000 dentists. The agency reports that between 1985 and 1996, the annual number of dental school graduates declined by 23 percent while the number of dental hygiene graduates increased 20 percent.
On-the-job training initiatives, often called preceptorship or dubbed "innovative, flexible alternatives," refer to having a practicing dentist train a worker to perform dental hygiene duties in the dental office, instead of preparation though the formal, standardized educational process described above.
The problem is that on-the-job training is just not adequate to prepare dental hygienists to provide safe patient care. Providing a complete prophylaxis (teeth cleaning) that prevents oral disease is a complicated procedure using a razor-sharp instrument. An unskilled and inexperienced oral health care worker runs a greater risk of doing it incorrectly and jeopardizing a patient's health.
In addition, a practicing dentist doesn't have the time to train a dental hygienist adequately in the office and typically doesn't know very much about the preventive skills in which dental hygienists specialize. Dentists have much more education and experience in restorative procedures like filling cavities and placing crowns and bridges.
Usually, dentists spend very little practice time on periodontics--the diagnosis and treatment of gums and the bones that support teeth. In fact, in many dental schools, it is dental hygienists who teach preventive procedures to dental students and preventive topics are a small portion of a dental student's course of study.
Indeed, the Commission on Dental Accreditation--dentistry's own accrediting agency--has gone on record supporting accreditation of all entry-level dental hygiene programs and opposing any reduction of educational standards and/or requirements for initial licensure of dental hygienists.
Currently, there is only one state, Alabama, which allows preceptor-trained individuals to work as dental hygienists without attending a formal, ADA CDA-accredited program. However, as stated above, during the past decade, there has been a movement in organized dentistry to initiate such programs in other states.
ADHA has fought these initiatives vigorously and believes that the only way to assure patient safety and quality oral health care to the public is maintaining educational standards through support of accredited dental hygiene education.
Periodontal Disease and General Health
The trend toward reduced or diluted educational standards and on-the-job training is especially worrisome because it is now known that oral health is inseparable from overall health. As a case in point, the signs and symptoms of many potentially life-threatening diseases appear in the mouth first. Dental hygienists routinely screen for these signs and symptoms during regular oral health examinations and explain their observations to patients, urging them to follow up with a medical visit for a definitive diagnosis. When necessary, dental hygienists also provide therapy for the oral manifestations of systemic diseases.
Heart Disease
A major disease with an oral health connection is heart disease--the number one killer of men and women--claiming more victims than all forms of cancer and AIDS combined. Cardiovascular disease affects more than 58 million people in the U.S. each year and kills almost a million. Numerous research studies have shown a connection between heart disease and key bacteria in periodontal disease. While research continues to explore this link, dental hygienists are instrumental in identifying the presence and extent of the periodontal infection and work with patients, both to treat existing periodontal problems and to prevent future complications.
Diabetes
Another disease that has an important relationship to periodontal disease is diabetes--the fourth leading cause of death in America. Diabetes and its complications cause more than 169,000 deaths in the U.S. per year. As many as 16 million people in the country have the disease and half are unaware of their condition. Periodontal disease has long been considered a major complication of diabetes. Approximately 95 percent of Americans who have it also have periodontal disease and research shows that people with periodontal disease have more difficulty controlling their blood sugar level. Severe periodontal disease also can increase the risk of developing diabetes. After a conclusive diagnosis has been made by a physician, it is critical that patients with diabetes receive professional oral health care regularly and follow a customized home-care routine to help keep their blood sugar levels in check.
Babies
Periodontal disease also has been linked to premature, low-birthweight babies. Studies have found that expectant mothers with periodontal disease are up to seven times more likely to deliver premature, low-birthweight babies. And, oral infection also has been implicated in respiratory ailments. Bacteria in periodontal disease can travel from the mouth to the lungs and lower respiratory system, where it can aggravate respiratory conditions, particularly in patients who already have other diseases.
Other Connections
A routine oral health exam also can uncover signs and symptoms of osteoporosis, a condition that affects 25 million Americans and accounts for 1.5 million fractures per year; eating disorders, such as anorexia nervosa and bulimia, which can be detected during a routine oral exam by thin tooth enamel, and a red mouth; and HIV, which often shows itself in the mouth first.
Oral Cancer
One of the most serious diseases found in the mouth is oral cancer. Often curable in its early stages, oral cancers are a major cause of death and disfigurement in the United States, according to the National Cancer Institute. Oral cancer is more common than leukemia, skin melanoma, Hodgkin's disease and cancers of the brain, liver, thyroid, gland, stomach, ovaries, and cervix. If caught early it can be treated successfully in more than 90 percent of cases; however, if not detected early, it can spread into other parts of the body and become difficult, if not impossible, to treat. The oral cancer screening constitutes one of the most important components of a routine dental hygiene and dental exam.
Approximately 75 percent of American adults have some form of periodontal disease and the majority don't realize they have it, because in its early stages, it's usually painless. In view of the critical relationship of periodontal disease to overall health, and the staggering number of Americans who develop it, it's essential that the disease be prevented or detected early and treated aggressively.
Enhancing the Educational Standards
For this reason, and because periodontal disease is so essential to overall health, it is critical that preventive oral health services--particularly the oral prophylaxis--be provided only by rigorously educated and properly licensed dental hygienists.
Changing demographics and practice environments require that teaching methods be adapted to the needs of both patients and practitioners. However, it is essential that such adaptations in teaching methods and formats be undertaken without weakening or reducing educational standards. In fact, it should be the goal of all those involved in preparing dental hygienists for practice to enhance and strengthen the education dental hygienists receive.
Conclusion
Oral health is a critical component of total health. Recent research has linked periodontal disease to heart and lung disease; diabetes; pre-mature, low-birthweight babies; and a number of other systemic diseases. Indeed, the first-ever Surgeon General's Report on Oral Health has called attention to this important connection and calls untreated poor oral health a"silent X-factor promoting the onset of life-threatening diseases which are responsible for the deaths of millions of Americans each year.
Reduced educational standards and on-the-job training are not necessary because there is an adequate pool of dental hygienists and graduating dental hygiene students to serve the needs of the public now and in the foreseeable future. More important, on-the-job training is just not adequate to prepare dental hygienists to provide safe patient care. Providing a complete prophylaxis (teeth cleaning) that prevents oral disease is a complicated procedure using a razor-sharp instrument. An unskilled and inexperienced oral health care worker runs a greater risk of doing it incorrectly.
ADHA has fought vigorously and will continue to fight any initiative designed to reduce or eliminate dental hygiene educational standards and believes that the only way to assure patient safety and quality oral health care to the public is to maintain educational standards through support of accredited dental hygiene education.