Delivering Smiles
How enterprising hygienists are improving oral health outside the practice
Fred W. Michmershuizen
Many people are unable to visit a dental practice for routine oral care, often due to factors such as economic status or geographic barriers. But these patients—there are many millions of them, in fact—still need and deserve care. The good news is that there are many settings in which dental hygienists can provide treatment outside the practice. These alternative hygiene solutions can include options like mobile dentistry, pop-up clinics, volunteering for mission trips, and even providing house calls. In addition, high-tech possibilities, such as at-home wellness tests and virtual patient consults via the internet, can improve access to care as well.
The Centers for Disease Control and Prevention reported that in 2022, 35.9% of adults in the United States had not received a dental exam or cleaning in the past year and that in 2019, 13.1% of children had not had a dental visit in the past year.1 Furthermore, a report published by CareQuest Institute for Oral Health estimated that 76.5 million adults in the United States lack dental insurance, and those aged 60 and older were found to be the most likely to be uninsured. The report also found that 25% of those with Medicare said that their dental coverage was insufficient to maintain oral health.2
These—and similar—statistics paint a bleak picture; however, with a bit of creative thinking and ambition, delivering smiles to more people is still achievable. Take Jennifer Geiselhofer, RDH, for example. This forward-thinking caregiver has taken her show on the road—literally—with a mobile dental hygiene practice, Dental At Your Door, based in the Denver, Colorado, area. It all started in 2009, when Geiselhofer was working at a dental practice and one of her patients asked if there might be a way for her bedridden spouse to receive hygiene care at home. With the encouragement of her employer at the time, Geiselhofer gathered some equipment together and made a much-appreciated house call. That experience, plus a day she spent volunteering at a large local charitable event, inspired her to launch what would become a thriving, mobile-based hygiene practice.
Today, Geiselhofer has a staff of five, two vans, a website, contracts with facilities, and a mission—to provide high-quality preventive oral care to patients who are unable to receive such care in traditional settings. Dental At Your Door offers pop-up care in homeless shelters, domestic violence shelters, residential substance abuse treatment facilities, and long-term care facilities. They even visit private homes to treat patients with mobility challenges or receiving hospice care. To care for underserved patients who do not receive federal or state assistance, Geiselhofer also founded a separate venture, Deserving Dental, a 501(c)(3) nonprofit organization. Deserving Dental allows for all patients living below the poverty level to receive free care regardless of state assistance or their ability to pay. Because many of the patients have not been to a dentist in many years, 90 minutes are allocated for each appointment. Treatment is thorough and includes preventive and therapeutic care ranging from prophylaxis to intense scaling and root planing with local anesthetic, digital x-rays, silver diamine fluoride (SDF) to obliterate decay, interim therapeutic restorations (ITRs), exams, and oral cancer screenings. Those who need advanced care are referred to a network of willing dentists, specialists, and medical providers.
"It is a very strict hiring process to become a hygienist with Dental At Your Door and Deserving Dental because we need hygienists who have advanced care credentials, are meticulous clinicians, are able to problem solve without a dentist, and are skilled with trauma-informed care," Geiselhofer says. "We are faced with the most clinically challenging patients a hygienist will ever have in their career, often those who have not had their teeth cleaned in decades. You have to be proficient at administering local anesthetic, and then, of course, you need to have your license to place ITRs. We need hygienists who can practice at the tip-top of their scope."
Not all hygienists are able to care for patients the way Geiselhofer does, in large part because many states do not permit hygienists to own their own practices. Geiselhofer is based in Colorado, one of only two states—Oregon is the other—in which dental hygienists are permitted to own their own dental hygiene practice, accept direct reimbursement from insurance, and provide a dental hygiene diagnosis. Currently, 42 states (and counting) now allow some form of direct access for dental hygiene services, but each state has different parameters and requirements, which is why it's very important to understand each state's laws.3-6
"I wish that every state allowed the autonomy that Colorado has, so that hygienists could reach so many more of these deserving patients who are not getting care," Geiselhofer says.
That said, other dedicated hygienists, no matter what state they are in, are not deterred from championing the oral healthcare needs of the underserved. Many who hold traditional day jobs in dental practices occasionally donate their services by volunteering at pop-up clinics held throughout the country. Many others go on charitable mission trips, many of which are held outside the United States.7 Quite a few other enterprising hygienists have turned their passion for serving vulnerable populations into full-time careers. Crystal Spring, BDSH, RDH, LAP, for example, runs Smiles Across Montana, an organization that focuses on delivering care in health provider shortage areas, known as HPSAs. Other hygienists have become full-time educators, including Angie Stone, RDH, BS, who has provided education and resources intended to improve the lives of dependent adults and currently is educating on reducing the risks of Alzheimer's disease.8,9 Another hygienist-turned-educator, Jill Meyer-Lippert, RDH, founded Side Effect Support, a company that provides products, information, and resources geared toward oncology patients.
Meyer-Lippert launched her venture in part because of personal experience. Her mother was diagnosed with breast cancer and faced numerous challenges related to her own oral health. Today, an important way Meyer-Lippert reaches new patients is by educating oncologists, some of whom may be unaware of the urgent need for their patients to address oral health before cancer treatments commence. "There is still such a disconnect between the medical and dental fields," Meyer-Lippert says. "I am having too many patients tell me that nobody mentioned a general oral exam before they started treatments, much less making sure they did not have caries or infection."
Using Technology to Reach Patients
The patients Meyer-Lippert focuses on often have urgent needs, which necessitates reaching out to them in innovative ways. One resource that Meyer-Lippert partners with is The TeleDentists, a virtual service that offers patients the ability to consult with dentists in 10 minutes or less, 24 hours a day, via their smartphones, tablets, and home computers.
Many other companies are also using technology in innovative ways to connect patients with dental care. MouthWatch offers a teledentistry platform, TeleDent™, which connects patients with dental practices, dentists, hygienists, and their referring providers, as well as a virtual-first oral healthcare solution called Dentistry.One, which, through a nationwide network of dentists, aims to increase access and transform the patient experience with dental care.
"I believe dental hygienists working outside of traditional practice settings are one of the most underutilized provider role types. Hygienists can significantly increase access to care and support improved oral and systemic outcomes for patients," says Brant Herman, founder and CEO of MouthWatch and Dentistry.One. "With Dentistry.One, we are employing hygienists to act as ‘Care Advisors' and engage directly with patients for the best possible care experience. Also, through our national network of dentists, we can provide supervision and collaborative practice agreements, so hygienists can provide services in those care settings where it is allowed by their state."
According to Tina Saw, DDS, founder of Oral Genome, a startup company that offers a direct-to-consumer dental wellness testing kit, virtual healthcare options eliminate limitations and expand care to more people—even the uninsured-offering affordability and convenience. "With access to remote consultations, educational resources, and personalized healthcare plans, patients take more control over their oral health," Saw says. "There is increased engagement and patient empowerment, leading to better oral hygiene practice, oral health literacy, and overall better health outcomes."
The Value of Alternate Hygiene Solutions
There are many reasons for hygienists to consider offering care in alternate settings. In addition to feelings of personal accomplishment, working outside the practice might also bring more variety to a hygienist's everyday schedule. But it is ultimately the fulfillment of treating patients for whom dental care can be life-changing that can really make a difference.
"It's a very rewarding way to practice hygiene," Geiselhofer says. "We get many hugs and God-bless-yous after appointments. Our patients are extremely grateful and verbally thankful for our care. Many patients walk back 20 minutes after their appointment just to tell us how great they feel. We've had men return clean shaven because they are no longer hiding their smile behind an overgrown mustache. Many think their teeth were hopeless, but most just needed to have a thorough cleaning and SDF treatment. Scaling and root planing is the most needed service in shelters and long-term care facilities. It feels amazing to provide life-enhancing care to a patient in whom you can see an improvement, both clinically and in their confidence, immediately after an appointment."
For hygienists who are interested in venturing beyond the in-office practice to reach patients in alternate settings, Meyer-Lippert has one piece of advice: go for it. "If you know something needs to be done, step up and do something," she says. "That is definitely a motivator for me because there is way more of a need out there for oral care than there should be."
Ideally, patients should see a hygienist twice a year in a dental practice as part of their routine care. But patients who are unable to present themselves in an office are in great need of care as well, and there are many ways to reach these people. Caring for them can mean the world to them, as well as the hygienists who are willing to step outside the box.
References
1. Centers for Disease Control and Prevention. Oral and dental health. CDC website. https://www.cdc.gov/nchs/fastats/dental.htm. Reviewed May 16, 2023. Accessed June 23, 2023.
2. CareQuest Institute for Oral Health. A snapshot of the 76.5 million Americans without dental insurance. CareQuest Institute for Oral Health website. https://www.carequest.org/resource-library/snapshot-765-million-americans-without-dental-insurance. Published September 2021. Accessed June 26, 2023.
3. American Dental Hygienists' Association. Medical reimbursement. ADHA website. https://www.adha.org/advocacy/scope-of-practice/direct-access/reimbursement/. Accessed June 26, 2023.
4. American Dental Hygienists' Association. Direct access. ADHA website. https://www.adha.org/advocacy/scope-of-practice/direct-access/. Accessed June 26, 2023.
5. American Dental Hygienists' Association. Direct access states. ADHA website. https://www.adha.org/wp-content/uploads/2023/03/ADHA_Direct_Access_Chart_2022-08-1.pdf. Revised August 2022. Accessed June 26, 2023.
6. American Dental Hygienists' Association. Dental hygiene practice act overview: permitted functions and supervision levels by state. ADHA website. https://www.adha.org/wp-content/uploads/2023/05/ADHA-Practice-Act-Overview-5-2023.pdf. Revised May 2023. Accessed June 26, 2023.
7. Dental team serves hundreds of underprivileged people on Trinidad mission trip. Inside Dentistry. 2020;16(2). https://www.aegisdentalnetwork.com/id/2020/02/dental-team-serves-hundreds-of-underprivileged-people-on-trinidad-mission-trip. Published February 2020. Accessed June 26, 2023.
8. Stone A. Dying From Dirty Teeth: Why the Lack of Proper Oral Care Is Killing Nursing Home Residents and How to Prevent It. Oceanside, CA: Indie Books International; 2015.
9. Stone A, Gutkowski S. Novel approach to oral care for dependent adults. Integrative Medicine. 2013;12(5):26-34.
