15 Trends Impacting Dental Hygiene Practice and the Profession
Kristy Menage Bernie, RDH, MS, RYT
The fast pace of innovation, technology, and research impacts the profession of dental hygiene more today than ever, and as such it is critical for the progressive clinician to be up to date on these changes. An understanding of trends impacting daily care strategies, clinical practice, and professional development will arm clinicians with the resources to maximize patient care and professional growth.
How Do You Clean Between?
When the Associated Press broke the news that daily flossing may not be necessary or an evidence-based practice, you could hear the collective gasp from the dental community. The American Dental Association (ADA) and the American Academy of Periodontology (AAP) were swift to respond, and as a result there has been a shift away from floss-exclusive recommendations to ones that are inclusive of the plethora of interdental cleaning aids available. Instead of focusing on the daily use of floss, clinicians may instead ask patients how they clean between their teeth, taking away the "floss guilt." The ADA's consumer site Mouth Healthy™ now recommends the following: Brush your teeth twice a day, clean between your teeth daily, eat a balanced diet, and schedule regular dental visits for a lifetime of healthy smiles.1 The timeless adage "brush and floss" is now being replaced by "brush and clean between."
A recent search on YouTube for "do it yourself dentistry" resulted in over 2,520,000 results. Everything from tooth extraction to filling cavities to do-it-yourself orthodontics is shown in graphic detail. These posts have alarmed oral healthcare professionals who have seen the results. While many of these activities do not cause irreversible damage, they do cause confusion, especially in preventing or curing decay and gum disease. For example, breaking open activated charcoal capsules onto a toothbrush has not been shown to provide any benefit and may in fact cause abrasion of enamel.2 Savvy clinicians are encouraged to monitor trends and be prepared to provide patients with evidence-based education.3
There's an App for That
An estimated 165,000 apps are specifically aimed at health and wellness, with 70% designed for the general population, offering tools to reach and maintain wellness and to improve physical activity. The remaining 30% are for health care professionals or those with specific diseases.4 Dental-related apps range from symptom checking to connecting with oral hygiene devices. Additionally, there are apps specific for tobacco cessation, oral health tips, tracking oral health habits, and dental health education. Connected app technologies such as power toothbrushes provide patients with real-time feedback and tracking of oral hygiene routines, including goal setting and incorporating clinician recommendations. Clinicians should become familiar with app technologies relating to daily care, health, and well-being to make appropriate recommendations.5 Future research will include evaluation of these technologies and their impact on oral health.
Smell Good, Look Good
Patients continue to be interested in fresh breath and whiter teeth. The significance of societal aspects has been acknowledged in definitions of oral health from the American Dental Hygienists' Association (ADHA) in 1999 and the FDI World Dental Federation in 2016.6 The ADHA defines optimal oral health as a standard of health of the oral and related tissues that enables an individual to eat, speak, and socialize without active disease, discomfort, or embarrassment and that contributes to general well-being and overall health.7 Clinicians understanding this social connection can leverage treatment and daily care recommendations with fresh breath and stain-free teeth in mind. Recently launched innovations include a sonic-irrigating power toothbrush, a whitening irrigating system, and app-connected power technologies with whitening or fresh breath modes that will change daily care recommendations. Moving from manual toothbrushes to plaque-busting, breath-freshening, tooth-whitening powered technologies not only provides patients with what they want, but also improves their oral health.
Defining Standard of Care
In 1985, the ADHA developed the Standards for Clinical Dental Hygiene Practice, now in its 3rd revision, as a guide for the individual dental hygienist's practice.8 Revised in 2016, this document, a must for every dental hygiene clinician and employer, provides the foundation for the standard of dental hygiene care, which includes assessment, dental hygiene diagnosis, planning, implementation, evaluation, and documentation standards. As "standard of care" continues to be refined, this is an invaluable resource.
End of Drill and Fill?
In April 2018, the ADA put out a call for comment on its proposed clinical practice guidelines on the Use of Nonsurgical (Nonrestorative) Treatments for Caries Management.9 The proposed guidelines include the utilization of silver diamine fluoride to arrest caries lesions, along with sealants, fluoride varnish, and resin infiltration, and focus on arresting or reversing caries infection vs "drill and fill." The final guidelines will be presented at the upcoming 2018 ADA Annual meeting in Hawaii in the "Be a Nonsurgical Caries Matchmaker" continuing education session.
Consumer awareness of the oral-systemic connection has increased exponentially through social media and advertising. For example, a recent television commercial for dental implants features a patient explaining how his cardiologist insisted that he take care of his oral health for the sake of his heart health. This messaging is repeated throughout many platforms, educating consumers about the importance of optimal oral health. Interestingly, one of the most impactful YouTube videos trending on this topic is not produced by the profession, but by Business Insider's video channel, Tech Insider: "What Happens if You Don't Floss" (December 29, 2015). Infographics have also been beneficial in educating consumers: A recent search using the terms "oral health infographics" yielded countless educational materials on dental-related topics. Progressive practices would be well-served to utilize these resources in maximizing patient education.
Deplaquing has become an integral part of clinical intervention, as it is not enough to remove obvious calculus and stain, but the microbiome must be disrupted as well. Powered scalers with thinner tips have played a major role in clinical deplaquing, along with the more recent use of air polishers subgingivally. Therapeutic benefits of subgingival air polishing using glycine and newly launched erythritol powders include removal of biofilm and reduction of pathogens in periodontal pockets.10 Erythritol powder is indicated for light-to-moderate stain removal, supra and subgingivally, and is safe to use on all surfaces, including soft or hard tissue, restorative materials, orthodontic appliances, and implants. At a minimum, every patient should be deplaqued with power scaling and thin inserts or via subgingival air polishing. Rethinking the use of technologies that impact biofilm (beyond manual instrumentation or rubber cup polishing) is an important part of overall care, patient comfort, and efficacy.
Telemedicine and teledentistry have ramped up in recent years in response
to the demand for access to care. Telehealth is the term more commonly used as it describes the wide range of diagnosis, management, education, and other related fields of health care. These include, but are not limited to, dentistry, counseling, physical and occupational therapy, home health, chronic disease monitoring and management, disaster management, and consumer and professional education. The Health Resources and Services Administration defines telehealth as:
"The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration."11 Currently telehealth programs are running in California, Alaska, and Minnesota, and these opportunities will
likely expand as the convenience is realized and access to care issues are
addressed. Watch for this trend to have a direct impact on opportunities for dental hygienists.
With more states "legalizing" recreational and medical use of cannabis, it will be critical for dental hygienists to gain knowledge and understanding of the use and types of this drug, and its impact on oral health. The ADA has an excellent overview on its website in the Member Center that includes an introduction, oral effects of cannabis use, dental care implications, references, and resources.12 The key points include:
• Cannabis smoking is associated with periodontal complications, xerostomia, and leukoplakia, as well as increased risk of mouth and neck cancers.
• Historically, cannabis has been smoked as marijuana, but it is increasingly available in other forms, including edible and topically applied products.
• Cannabis use is increasing, along with state legalization, although it remains federally banned.12
Clinicians should consider taking continuing education courses to become fully educated to address this growing trend. Furthermore, cannabis-containing oral care products may be available in the near future.
Virtual Continuing Education
Virtual platforms for education have become popular as the technology has improved. From entry-level programs to continuing education, these platforms provide convenience for learners. There are many sources providing exceptional continuing education, from associations to dental publishers to oral healthcare companies. Clinicians should check state statutes to confirm what types of virtual education platforms count toward required continuing education credits for renewal. For some, the best option is a live webinar that offers an interactive component. Convenience aside, it is difficult to match the energy and interactive opportunities of live continuing education.
Opportunities Beyond the Chair
As private practice settings decline in favor of dental service organizations (DSO), even the clinical practice of dental hygiene is providing opportunities "beyond the chair." DSOs offer dental professionals a way to focus on patient care versus the business and administration of the practices. Dental hygienists are being sought for their expertise in a variety of areas, including oversight of the DSO's dental hygiene program, administration, infection control, and continuing education to name a few. Moreover, there are expanding opportunities within the oral healthcare industry (eg, consulting, administration, sales, professional educator, research, training, and marketing); in academic/education, public health, and research organizations; as a business owner; and even within medical facilities. With expanding roles and the establishment of midlevel providers throughout the country, dental hygiene's future is solid.
With the expanding roles for dental hygiene, more of the profession is heading back to school, with good reason. At a minimum, a BS degree (ideally an MS) will be required in settings beyond the traditional clinical operatory. Those interested in expanding their professional opportunities can look to virtual/online programs as well as on-campus accelerated programs (for example, a 1-year MS in Dental Hygiene program at the University of California San Francisco School of Dentistry) to complete their degrees. Additionally, a number of entities, run by dental hygienists for dental hygienists, have recently emerged that specifically address career coaching. Women Rocking Leadership (kristineberry.com), CE RDH (CERDH.com), and ADHA provide individual coaching services and resources. Janice Hurley, while not a dental hygienist, has consulted with many of today's leading RDH speakers and consultants, offering executive coaching services (JaniceHurley.com). Finally, the Speaking Consulting Network (SpeakingConsultingNetwork.com), CAREERfusion (CareerFusion.us), and Think Beyond the Prophy (BeyondtheProphy.com) offer workshops focused on developing speaking, sales, and writing skills.
The ability to maintain postural health throughout one's clinical career has greatly improved with the availability of technologies that address ergonomic issues. From lighted loupes to saddle-style operator stools to powered instrumentation with illuminated tips, there are a myriad of options to enhance ergonomics. Furthermore, the profession has begun to embrace wellness strategies such as yoga to alleviate carpal tunnel symptoms, along with neck and lower back issues. A greater understanding of clinician and patient positioning combined with technology offers proven methods to extend pain-free clinical practice.
The only formal organization that brings dental hygiene professionals together through membership is the ADHA. In its 2017-2018 annual report, the organization reviews the numerous accomplishments and challenges facing the association and the profession.13 For example, in the newly revised 2018 Standard Occupational Classification (SOC) from the United States Office of Management and Budget, dental hygienists are now classified as Healthcare Diagnosing or Treating Practitioners, which is the same grouping as dentists (in contrast to the 2010 SOC, which classified dental hygienists as Health Technologists and Technicians). This is an important classification as the role of dental hygiene continues to expand, addressing access-to-care issues.
Declining membership is also reported, and it's important to note that ADHA is not alone. As membership declines, many organizations have had to rethink their entire structure and purpose. As ADHA is the only national voice of dental hygiene, it will be valuable to understand how they can respond, revive, and evolve. Regardless of membership in ADHA, every dental hygienist should read this report-it's the foundation for collegial collaboration, future growth, and progress.
1. Brushing Your Teeth. Mouth Healthy™. American Dental Association Website. https://www.mouthhealthy.org/en. Accessed June 14, 2018.
2. Brooks, JK, Bashirelahi, N, Reynolds, MA. Charcoal and charcoal-based dentifrices: A literature review. J Am Dent Assoc. 2017;148(9):661–670. 3. Zini A, Sgan-Cohen HD, Vered Y. Media exposure and oral health outcomes among adults. Quintessence Int. 2013;44(2):e147-156.
4. Recio GM, García‑Hernández L, Luque M, et al. The role of interdisciplinary research team in the impact of health apps in health and computer science publications: a systematic review. BioMed Eng Onine. 2016;15(Suppl 1):77.
5. Kelsh N, Bernie KM, Forst M. Optimal oral health: the impact of real-time feedback on daily oral health behavior. Key Opinions in Medicine. 2016;4(1). https://keyopinions.info/downloads/optimal-oral-health-the-impact-of-real-time-feedback-on-daily-oral-health-behavior/. Accessed June, 14, 2018.
6. Glick M, Williams D. Vision 2020 Think Tank. A New Definition for Oral Health. FDI World Dental Federation Website. https://www.fdiworlddental.org/sites/default/files/media/images/oral_health_definition-exec_summary-en.pdf. Accessed March 28, 2018.
7. American Dental Hygienists’ Association. Policy definition of optimal oral health. ADHA House of Delegates, 1999.
8. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Revised 2016. ADHA Website. https://www.adha.org/resources-docs/2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf. Accessed June 22, 2018.
9. Call for Comments for New ADA Clinical Practice Guideline on the Use of Nonsurgical Treatments for Caries Management. American Dental Association Website. https://www.ada.org/en/member-center/leadership-governance/councils-commissions-and-committees/call-for-comments-for-new-ada-clinical-practice-guideline?utm_campagin=best. Accessed June 14, 2018.
10. Pieren, J, Bowen, DM. Time to rethink air polishing: therapeutic for the subgingival environment. Access. 2018;32(5):13-15.
11. What is telehealth? The Center for Connected Health Policy. The National Telehealth Policy Resource Center Website. http://www.cchpca.org/what-is-telehealth. Accessed June 14, 2018.
12. Cannabis: oral health effects. American Dental Association Website. https://www.ada.org/en/member-center/oral-health-topics/cannabis. Accessed June 14, 2018.
13. American Dental Hygienists’ Association. 2017/2018 ADHA Annual Report. www.adha.org/resources-docs/2018_ADHA_Annual_Report.pdf. Accessed June 26, 2018
About the Author
Kristy Menage Bernie,
RDH, MS, RYT
Director of Educational Designs, Inc.
San Ramon, California
Assistant Clinical Professor
University of California
San Francisco, California