A hybrid dental hygienist
A periodontist once told me that a good dental hygienist leaves behind around 15% of calculus after initial therapy. As a dental hygiene student, I failed to appreciate what these words implied. Now, 13 years later and amid task relocation in Dutch dentistry, I often think back to those words. Whether the percentage of calculus that is not removed is actually 15% I am not going to debate in this article, as it is not very relevant in this context. It is simply accepted that a dental hygienist does not remove all calculus during initial therapy.
This has been such an unchallenged idea within the world of oral medicine that it should not cause any raised eyebrows among my peers. There may be many reasons why this policy of tolerance arose. Yet, there is one argument that is as explanatory as it is strange: the dental hygienist’s zone of activity, during initial therapy, is not visible. Thus, failure to remove all the calculus is inevitable during initial therapy.
It should not be a surprise that, for decades, dental hygienists have been held accountable for a significant zone of activity that is not visible. What does strike us as odd, however, is that, amid this experiment of task allocation, dental hygienists will be held accountable for a zone of activity that is indeed visible. The preparation and restoration of primary cavities usually is supragingival, and when it is not possible to remove subgingival calculus, it is not completely without risk. Yet, you might say it is easier to control a visible zone of activity than an invisible one. Either way, time will tell whether or not our concerns regarding this experiment of task allocation were grounded.
Let us have a closer look at initial therapy. It appears that we are settling for a treatment result which leaves behind subgingival calculus. The reason we let this happen is the lack of legal grounds to make alternative initial therapy treatment methods possible for dental hygienists. True, some factors cannot be influenced, such as tooth anatomy, furcation, single- or multiple-rooted teeth and the position of teeth—all the more reason why we should think about how we can move towards a visible zone of activity which would allow us to apply initial therapy as it was intended: the removal of calculus and root planing. Furthermore, you should be seeing what you are doing. Should we not aim for pocket elimination instead of pocket reduction?
The solution to this problem is as simple as it is controversial: gingivectomy. At the moment, we would not even think about a dental hygienist removing periodontal tissue to reveal the zone of activity or root surface. When you look at the history of dentistry in the Netherlands, and how the professions of dental hygienist and dental assistant were created, the role expansion of dental hygienists to include gingivectomy might seem less unlikely in the long term. Some of us might remember that, before World War II, oral medicine was a college level course, rather than a university level one. More recently, in Dutch high schools, we have seen more and more teachers with university level degrees teaching senior students and teachers with college level degrees teaching juniors. In the future, we might see similar educational level distinctions between vocational and academic education in the professions of dental hygienist and dental assistant in the Netherlands, so we might see dental assistants taking more control of prevention and dental hygienists specialising in initial therapy.
Future dental hygienists could have college level degree job responsibilities (bachelor’s degree) combined with university level degree tasks (master’s degree). What could the educational journey of this “hybrid” dental hygienist look like? Perhaps a three-year college bachelor’s degree in dental hygiene followed by a one-year master’s degree in periodontics with a compulsory internship in a periodontics clinic? Or a two-year master’s degree in periodontics for the dental hygiene college student with a mandatory internship in a periodontics clinic? The Netherlands, with its 17 million citizens, has 9,502 general dentists and 81 dentists specialised in periodontics. Therefore, a specialised dental hygienist could very well support a periodontist, just like a dental assistant could support the general dentist. You must visualise it—make the invisible visible.
Editorial note: This article was published in the August 2020 issue of the Dental Tribune Netherlands Edition. An English version has been reproduced here with permission from the author.