Transforming Dental Hygiene Education

The American Dental Hygienists’ Association (ADHA) has a unique perspective on the status of dental hygiene education.Advancing education in dental hygiene is vital to the association’s new vision of integrating dental hygienists into the health care delivery system as essential primary care providers to expand access to oral health care. And because education is the foundation for the profession as a whole and each dental hygienist individually, the future of the profession must include the transformation of the educational preparation of those who will be part of this change.

Advancing education in dental hygiene includes raising the profession’s entry level to the baccalaureate degree, which was first proposed by the ADHA in 1986. Increasing the diversity of the dental hygiene workforce—thereby extending its reach into a wide range of communities—is also a core goal. Without evaluation and revision of the competencies required for dental hygienists to remain relevant in a complex and fast-changing health care environment, progress cannot be achieved.

ADVANCED PRACTICE

The ADHA’s policies continue to evolve and reflect an expanding profession, with the association regularly creating and updating policy to help set a clear vision for advanced dental hygiene practice. The policies defining advanced dental hygiene practice were established at the 2013 House of Delegates meeting during the ADHA’s 90th Annual Session in Boston. Advanced practice dental hygiene is defined by ADHA policy as:

1. Provision of clinical and diagnostic services in addition to those services permitted to an entry level dental hygienist, including services that require advanced clinical decision making, judgment, and problem solving.
2. Completion of a clinical and academic educational program beyond the first professional degree required for entry level licensure, which qualifies dental hygienists to provide advanced practice services and includes preparation to practice in direct access settings and collaborative relationships.
3. Documentation of proficiency, such as professional certification.

DRIVERS OF CHANGE

The ADHA’s envisioned future of the profession will require an understanding of the contextual drivers for change, examination of the core competencies for dental hygienists, and identification and management of the facilitators and barriers to such transformation. These issues were the focus of a panel at the September 2013 symposium “Transforming Dental Hygiene Education: Proud Past, Unlimited Future,” cosponsored by the ADHA, Santa Fe Group, and the ADHA Institute for Oral Health. The panel, “To Where We Are Headed: Guiding the Redefinition of Dental Hygienists’ Education and Practice,” examined the perspectives of the federal government, academic administration, research, and organized dental hygiene on the transformation of dental hygiene education. Marcia Brand, PhD, BSDH, MSDH, deputy administrator at the United States Health Resources and Services Administration, provided the federal perspective. The contextual drivers she recognized included the Patient Protection and Affordable Care Act (PPACA), which may increase demand for oral health services as well as encourage collaboration among health care providers. Another important factor cited was the triple aim described by Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services (CMS), which attempts to deliver health care that improves the individual patient experience, boosts the health of populations as a whole, and reduces the per-capita cost of care.

Brand also recognized that among the contextual drivers for transformation was the “co-occurring oral health movement,” wherein advocacy is for people, not professions, and oral health is integrated into health care. For example, the CMS established the Innovation Center to demonstrate projects that explore the effectiveness of new health care providers and delivery systems. In terms of competencies, the federal perspective looks at payers, cost, quality, and access, while seeking to provide the best care for the lowest cost. Brand cited the concept of “zero-basing” the health disciplines—which identifies basic skills to provide high-quality, cost-effective services in the settings where health care is delivered. Facilitators to change, Brand said, include openness to innovation—such as new practice patterns and providers, integration of care, and harnessing public demand. She identified professional isolation, lack of dental hygienists in policymaking roles, and a dearth of policymakers with a full understanding of access-to-care issues as barriers. Brand asked educators to encourage students to intern in government.

Pamela Zarkowski, JD, MPH, BSDH, provost and vice president for academic affairs at the University of Detroit Mercy, provided the educational and administration perspective. She recognized the need to advocate for transformation in a way that reaches multiple audiences. Students themselves have diverse backgrounds and concerns, including whether they will find work upon graduation. Faculty members have a different set of questions, and the academic administration more questions still. What, she asked, motivates academic programs to change?

In terms of new competencies, Zarkowski noted the need to consider more than just new clinicians. The need for interprofessional education will require additional coursework for faculty. Existing practitioners who want to acquire new skills may seek solutions in continuing education and re-entry into advanced education programs. She recognized that the concept terms—personalized, predictive, preventive, and participatory—could also serve as a starting point for designing competencies that are guided by patient need. Zarkowski’s facilitators for transformation included professionals within and outside of dental hygiene and dentistry, such as educational and institutional colleagues, as well as legislators and administrative boards. She also identified communities with the three characteristics of purpose, need, and power as facilitating change. Zarkowski cited lack of vision and commitment on the part of the dental hygiene education and practice community, fear of change and risk, inability to gain support from colleagues and academic institutions, and difficulties associated with licensure and certification as barriers. 

Harold Slavkin, DDS, a professor in the Ostrow School of Dentistry at the University of Southern California in Los Angeles, provided the research perspective. He cited the fact that people are living longer lives, with the concomitant expectation of healthy lives as a contextual driver. For dental hygienists, he said, there is an opportunity to play a part in the management of chronic conditions that older adults face. New technology will bring nonmechanical biofilm removal, guided tissue regeneration, and increased use of personalized health care, including salivary diagnostics—all of which have a potential role for oral health practitioners. Slavkin said that competencies for the future dental hygienist will include an understanding of the inflammatory response, immunity, and management of the effects of microbial activity on oral and systemic health. He said that the scientific environment in which health care providers will work will require a profession able to represent its own perspective in social, economic, and political contexts while integrating expertise with other professions.

Slavkin identified the fact that dental hygienists can readily be educated and trained to participate in biomedical and behavioral research as a facilitator for transformation. Whether associate, baccalaureate, master’s, or doctoral, all programs need to contribute to evidence-based health care, and all dental hygienists need to be “sophisticated consumers of science.” He encouraged dental hygienists to review the history and evolution of other allied health professions to see how they expanded their scope of practice alongside the revision of education and competencies. Federal, state, and foundation-driven opportunities, Slavkin noted, can facilitate transformation of dental hygiene education, research, and clinical practice to address inequalities to achieve wellness for all Americans. State-controlled scope of practice/health care boundaries and perceptions of other health professions were among the barriers Slavkin identified.

ADHA Executive Director Ann Battrell, MSDH, provided a perspective from organized dental hygiene. In discussing contextual drivers, Battrell acknowledged that a profession must have the infrastructure in place to implement plans and maximize opportunities. Any transformation proposed, she said, must be relevant to the current environment. As an example, she pointed to the ADHA’s adoption of a definition of advanced practice dental hygiene, which includes provision of diagnostic services.

Battrell sees the dental hygiene diagnosis as the central issue with respect to competencies. “Competencies imply responsibility,” she said, adding that dental hygiene diagnosis is part of the “Standards for Clinical Dental Hygiene Practice,” yet this is something most dental hygienists have not been able to do because of restrictive scopes of practice. Battrell said that this kind of limitation is changing, facilitated by market forces including trends in the delivery of health care and provisions in the PPACA. She characterized facilitators for transformation as those that have the greatest impact on the public, such as changing economic factors and collaboration between community-based providers, as well as between community colleges and universities. Societal demands on state legislatures and state dental boards have increased the number of direct-access states. As legislation moves forward, the educational system will need to keep pace. As for barriers, Battrell identified lack of integration of the dental team. “Only 23 of 335 dental hygiene programs are located in dental schools,” she said. “‘Interprofessional education’ is a more contemporary topic, but what about intraprofessional education?”

WHAT THE FUTURE HOLDS

In the first 100 years of dental hygiene and dental hygiene education, there were dramatic changes in the number, length, scope, and type of educational programs (including entry-level, degree completion, and graduate level). There have also been dramatic changes in overall health care related to knowledge, technology, and the provision of services.

What will happen in dental hygiene education and practice in the next 100 years? Although the specifics remain unknown, it seems likely that the next century will experience faster and greater change than the past century. It is clear that the dental hygiene profession and the educational community must embrace these opportunities and challenges, just as the field’s pioneers did in the previous century. A key theme will be the need to provide care to diverse populations in a variety of settings. To accomplish this, dental hygienists must be prepared to function as part of a broad-based team, and obtain additional skills and knowledge to function in these different environments. Content and experiences must be provided during the educational program and disseminated in new ways. To meet the demands of the future, dental hygiene education will need to respond—and respond quickly—so that graduates possess the skills, knowledge, and attitude to optimize the changes the dental hygiene profession envisions and improve the oral health of the public they serve.

ACKNOWLEDGEMENTS

This article contains content that appeared in “Advancing Education in Dental Hygiene,” published in the June 2014 supplement to The Journal of Evidence-Based Dental Practice and “Where Are We Headed?” published in the March 2014 issue of Access.

From Perspectives on Dental Hygiene, a supplement to Dimensions of Dental Hygiene. November 2014;12(11):48–51.