Independent Dental Hygiene Practice
More Avenues for Patient Care
Susanne Kuehl, BS, CPHDH, IPDH
Teledentistry is a hot topic in legislative circles, especially after the year spent adjusting to the restrictions of COVID-19. Suddenly medical conferencing from remote locations has become not only viable but also necessary. Patients can video conference with their therapists for emotional support and check-in on their diabetes status based on data provided by wearable technology. Through my Independent Dental Hygiene Practice, I routinely send digital x-rays and intraoral images of my clients to restorative dentists. I believe that if we pivoted from the idea that dental hygienists need "supervision" and focused instead on the fact that we are already independent primary care providers, we would see the opportunities before us.
The aspects of my practice that are "independent" are my ownership of all the equipment and my management of the business. Other than that, I provide the same dental hygiene services as I do in a private practice: x-rays, periodontal charting, risk assessment, and oral cancer screening, followed by the dental hygiene diagnosis and execution of my treatment plan. My role as dental hygienist is to document, communicate, and collaborate with both the patient and the restorative dentist. After all, it is the patient-clients who make the final decision, based on values, finances, and other factors that sometimes require them to delay recommended treatment (this is not unique to dentistry, as plenty of people are also not losing weight to control diabetes nor able to quit smoking, even though it would be in their best interest), As oral healthcare practitioners, we advise. We coach. We collaborate.
Currently, there is a state-by-state alphabet soup of supervision rules and regulations for the 40 states that have some form of direct access: EPDH, RDHAP, CPHDH, IPDH, CPHDH, and RDHEP, to name a few. In New Hampshire, for example, I can work as a Certified Public Health Dental Hygienist (CPHDH) and place sealants without an examination by a doctor, but in a private practice in the same state, the dentist must do the examination first. This system is not logical. If hygienists work in nursing home settings or school-based programs, that is perceived as expanding access to care, but if that same hygienist wants to open his/her own practice, the dentists protest and lobbyists are launched to nip independent practice in the bud. That double standard propelled me to challenge the restrictive IPDH regulations in Maine.
In 2017, even with over 30 years of clinical experience, a marketing degree, and numerous corporate sales/professional relations roles on my resume, I still did not qualify for the IPDH license in Maine that was passed in 2008. Why? The old rule required 5000 hours in the previous 4 years, which meant those who work part-time (90% of us) could not qualify. My strategy was to reduce the requirement to 2000 hours. Period. No time constraint. My testimony focused on my status as a single mother of four children, demonstrating that my "part-time" hours did not reflect the extent of my experience. (I added that I hadn't had a baby in the last four years either, so did that mean I wasn't an experienced mother?) The legislators agreed with me, and once my bill was successful, I began ordering supplies for my teledentistry-based practice.
To numerous restorative dentists and specialists (endodontic, orthodontic, and periodontic), I am a remote collaborating partner. I perform within my scope of practice, and I refer out for them to provide their services.
I say that I cannot fix/repair teeth, so the negative old-fashioned dentists who are opposed to independent practice must not want new patients. Luckily, a new crop of dentists not threatened by independent practice have become my advocates, and some even come to me for their dental cleanings.
As business owner, I decide how much time to spend with each client. Every hygienist knows quality care takes time to accomplish. I don't have to "wait" for the dental examination, instead I can give myself extra time to reappoint, process insurance, or accept payment, followed by all the infection control necessary between patients. I especially enjoy building relationships with my clients and doing all I can to bring them to optimal health. The downside? Navigating insurance companies, whose benefit plans often don't know what to do when the owner is a hygienist. Direct payment by third-party payers is an uphill battle. Even though I am a preferred provider with NE Delta Dental for example, I still must make calls to numerous insurance companies explaining how the state law works in Maine and fight to become in-network. My biggest frustration is that the federal government doesn't follow state rules and recognize me as a provider. In other words, they don't pay me. Because there are large federal employers in my region, I have reached out to my senator for help. Being a trailblazer can be exhausting, but necessary.
Health care is changing, and my vision is on the future. I look forward to a dental world where direct access is the norm, all hygienists practice to the full scope of their license, and all business models from public health to independent practice are recognized. The pandemic taught us that we must utilize technology to access health care. No one is independent. Like amalgam, we are a mix of practitioners made stronger by the blend of our different strengths. Where we provide services doesn't really matter. We need more places where hygienists can work in order to reach more people. Independent Dental Hygiene Practice is not radical. It is an idea whose time has come.
