A Bold Vision for the Future

Dental hygienists are elevating the profession, embracing new technologies, and expanding roles in the realm of medicine

Fred W. Michmershuizen

Among all dental professionals, the hygienist plays a key role—some would say the most important role of all—in helping patients achieve and maintain good oral health. In addition to performing scaling and root planing procedures, assisting the dentist in caries detection, and coaching patients in maintaining periodontal health and performing at-home care, many hygienists today also carry out additional tasks. These include administering anesthetic injections, whitening procedures, clear aligner therapy, treatment with lasers, and often much more. Today, there is also a greater emphasis on how oral health affects the whole body, creating even more possibilities for hygienists to expand their functions.

As these trends evolve, experts consulted by Inside Dental Hygiene—those knowledgeable in the areas of education, oral-systemic health, access to care for the underserved, and regulatory issues affecting scope of practice—say positive strides are within reach. These visionary leaders are all excited about new technology coming online, they believe strongly that hygienists are needed as part of every medical team, and they encourage hygienists to take the lead in making positive change a reality.

With these thoughts in mind, let's gaze into the crystal ball to see where we are now and what lies in store for hygienists in the months and years to come.

The Job of Hygienist is Evolving

According to a survey conducted by Inside Dental Hygiene in 2022, hygienists are performing many more procedures beyond scaling and root planing. Of the respondents, 54% said they administer anesthetic injections, 40% perform whitening and bleaching, 13% are involved in clear aligner therapy, and 13% perform laser therapy. The list of treatments offered by hygienists is growing.

"I'm super interested myself in airway and myofunctional therapy," says Crystal Spring, BSDH, RDH, LAP, a care provider whose mobile nonprofit organization, Smiles Across Montana, offers preventative dental treatment to those in health professional shortage areas (HPSAs). "Airway in dentistry is huge right now, and I think that's somewhere dental hygiene is going."

Spring says that in their regular scope of practice, hygienists can be recording each patient's Mallampati score, which can be used to detect sleep apnea, and that this can be done as part of routine oral cancer screenings. If the practice isn't treating airway issues, she says, patients needing care in this area can be referred out. Spring says one of her own children, a son, needed myofunctional therapy and she brought him to various specialists, but it was one of her hygienist friends who helped "call it" in the first place.

For Spring, it's a prime example of the importance of integrating dental care into whole body health. "We know that dental hygiene is needed in medical settings," she says. "A big part of what I do is medical-dental integration. We need to be in more medical settings because hygienists are medical professionals."

"Our job is not just to scrape teeth," Spring says. "We're actually healthcare providers. We've started looking at people's medical histories and figuring out what is going on and what this inflammation is showing us."

"If you have inflammation in your mouth, you're going to have inflammation throughout the rest of your body," Spring says.

Angie Stone, RDH, BS, a lecturer and author who has worked extensively with nursing home facilities, memory care units, and oral care specialists to improve the oral health of elderly patients with dementia, appreciates the importance of oral care and how it affects the entire body. "Oral-systemic health is a huge opportunity for us as clinicians to make a difference in the lives of our patients and also elevate our careers," Stone says. "We are much more than teeth cleaners. We bring value, and when we help get mouths clean and work with patients to reduce bacteria and biofilm in their mouths, we are keeping their other body systems healthier."

Stone says that most hygienists talk to their patients these days about the link between oral health and heart health as well as oral health and diabetes, but she also wants hygienists to know how oral health affects the brain.

"Certain bacteria are crossing the blood-brain barrier and causing inflammation in our brains," Stone says. "There are nerve pathways in the mouth through which oral bacteria enter directly into the central nervous system and into the brain." Stone says that published research shows that oral inflammation is associated with the progression of Alzheimer's disease, thus underscoring even more the importance of maintaining good dental health. "My message to hygienists is that they have a front row seat in helping people keep their brains healthy," Stone says.

Marianne Dryer, RDH, MEd, a clinical educator, curriculum developer, and lecturer, says it's time for hygienists to think differently about themselves and how they relate to other dental professionals as well as other medical care providers.

"We are really oral health specialists now, and my hope is that this title becomes embedded into what we do," Dryer says. "Hygienists are doing so much more these days, both diagnostically and from a technology standpoint. Things have changed dramatically just within the past ten years or so."

Dryer says she is encouraged that hygienists today are required to receive inter-professional education, interacting as part of their certification programs with nursing professionals and respiratory therapists, because everything today is so interconnected.

At the same time, Dryer says, more intra-professional education is required. "With the advancement of dental hygiene training, and new regulations, often the dentist doesn't really know the amount of things that a hygienist can do and the value they can bring to the practice, if they may be underutilized," Dryer says. "On the flip side of the coin, I think most hygienists don't always know the intricate difficulties of being a dentist."

"It's time that the dental hygienist understood a little bit more about what the dentist actually does," she says.

Dryer is a strong advocate for the new staging and grading system developed in 2017 and 2018 by the American Academy of Periodontology (AAP) in conjunction with the European Federation of Periodontology (EFP). This system, which borrows from phrasing long used in oncology, allows a patient to be categorically diagnosed. The classifications, Dryer says, allow hygienists to communicate more effectively as a profession to medical doctors as well as with their patients.

"All of these changes are based in the evidence," Dryer says. "It's a very powerful communication tool. You are now able to sit your patient up and say, ‘Mr. Jones, you have Stage III periodontal disease, and we need to look at your individual risk factors.'"

Dryer encourages hygienists to enthusiastically embrace this system, to "own it," and to take the lead in getting dentists and medical doctors to adopt it as well. In her lectures, Dryer encourages hygienists to download cards summarizing the system from the AAP website, which can be laminated and used chairside as a matter of routine.

Dryer says that among the many newer technologies available to hygienists, one in particular stands out. "Artificial intelligence (AI) is going to be a game changer in correlation with the classification updates," Dryer says. "The AI software puts a graphic on the screen in color and gives great visuals, and treatment acceptance and patient understanding increases. I would say AI technology goes hand in hand with the ability to communicate to the patient their own personal disease level."

Probiotics, laser therapy, and subgingival air polishing will also be utilized more by hygienists in the future, Dryer says, provided they are used properly. "We're getting good results with these alternative treatments and different technologies, but you can't add these technologies if you don't have a good foundation," she says. "Do you know where the disease is, and do you know why it's progressing in this individual person? The new technologies and the new staging and grading go hand in hand."

Other newer technologies that may be utilized more by dental hygienists in the future include tools for salivary diagnostics, guided biofilm therapy, and even the use of microscopes and oral cameras.

Scope of Practice for Hygienists

With all these new therapies and technologies, it can be difficult for a hygienist to determine what is and is not allowed, as each state has its own laws. For its part, the American Dental Hygienists' Association (ADHA) undertakes advocacy efforts to enable hygienists to practice to the full extent of their education and licensure.

"ADHA is committed to leading the transformation of the dental hygiene profession to improve the public's oral and overall health," the association states on its website. "ADHA advocacy efforts are focused on advancing the profession of dental hygiene at the state and federal level."

Charts listing which functions and supervision levels and which restorative duties dental hygienists are allowed to perform in each state are available for download from the ADHA website. In addition, a scope of practice graphic published by the Oral Health Workforce Research Center (OHWRC) is available as a downloadable PDF, and a state-by-state reference chart on allowable laser use by dental hygienists is published online by the Academy of Laser Dentistry.

A New Mindset for the Future

Those interviewed by Inside Dental Hygiene say they expect hygienists will think of themselves in a new light as they endeavor to elevate their chosen profession. "I think that hygienists will start to look at themselves as healthcare providers," Spring says. "I think that when they change that mindset from tooth scraper to healthcare provider, things will change significantly."

"After all," she says, "you are not just a tooth scraper, your education far surpasses that."

Spring, whose own career focuses on serving the underserved, also says that in the future there will be a greater focus on offering mobile care to patients who might not otherwise be able to travel to a practice. "When you're in a health provider shortage area, which is most of our country, for a lot of the patients you might be the only health professional they see that year, so you need to be looking at everything that's within our scope," she says.

Stone makes similarly bold predictions for the future. "I don't know if I'll see it in my career or in my lifetime, but eventually hygienists need to be in every medical doctor's office," she says. "Physicians and medical specialists need to have access to a hygienist right in that same space. We need to be employed by these medical entities. Every nursing home and every memory care center needs a hygienist on board. We need to be everywhere, just like nurses are."

"The hygienists should also have the ability to have their own practices, and in some states that is possible," Stone says. "Hygienists operate in one of the biggest prevention spaces, and the fact that we're housed under a roof with a dentist boggles my mind because our way of working is completely different. Dentists get paid for fixing problems, but a hygienist's whole goal is to prevent the problems in the first place."

Dryer, too, has lofty visions for the future. "I dream that going forward dentistry becomes one with the medical community. That we have one health insurance combining dental insurance and medical insurance. That we are viewed as oral disease prevention specialists and that we are part of the medical equation to keep people healthy."

She adds, "Being in the game, getting a prognosis, obtaining remission, all of those things will become second nature and will roll off our tongues as we partner with the medical community: that's what I dream will happen."

Making Change a Reality

The bottom line is that as we move into the future, it's likely that the job of dental hygienist will become even more vital in establishing and maintaining overall health. But how will these changes come about? It will only be possible if hygienists themselves take the lead, the experts say.

"The first thing is to open up our minds and determine what we want," Stone says. "Do we want to sit in the office for 20 years and clean the teeth? That's fine if that's what we want, but if we want to do more, then we've got to start looking, because no one's going to hand it to us. We've got to get off our tushies."

"I think the sky is the limit," Stone says, "but it's going to take hygienists who are thinking outside the box and willing to take action."

Additional Resources

American Academy of Periodontology:

• Staging and Grading Periodontitis
www.perio.org/wp-content/uploads/2019/08/Staging-and-Grading-Periodontitis.pdf

American Dental Hygienists' Association:

• Dental Hygiene Practice Act Overview: Permitted Functions and Supervision Levels by State
www.adha.org/wp-content/uploads/2023/01/ADHA_Practice_Act_Overview_8-2022.pdf

• Dental Hygienists Restorative Duties by State
www.adha.org/wp-content/uploads/2022/11/7516_Restorative_Duties_by_State.pdf

Oral Health Workforce Research Center:

• Variation in Dental Hygiene Scope of Practice by State
https://oralhealthworkforce.org/wp-content/uploads/2019/01/Single-Page-Layout-Final-2019.pdf

Academy of Laser Dentistry:

• State by State Quick Reference Chart on Laser Use by Dental Hygienists
https://acld.memberclicks.net/assets/docs/Resources/Hygienist%20Laser%20User%20by%20State%20021821.pdf

American Academy for Oral Systemic Health:

• Organization website
https://www.aaosh.org