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reprint or license thisDental hygienists fight to work on seniors
By Sandy Kleffman
CONTRA COSTA TIMES
The sight stunned dental hygienist Darci Trill.
It had been years since anyone looked inside the mouth of the elderly woman, who had dentures. The dentures had rubbed the woman's gums so raw that her bone protruded.
She must have been in excruciating pain, yet because she had dementia, she could not articulate it.
Trill is part of a small cadre of dental hygienists in California who have obtained special licenses to address a growing need: the thousands of nursing home residents, shut-ins, disabled people and others who have difficulty getting to a dental office.
Often, such people forgo dental care entirely. That can lead to decay, swelling and serious disease.
A 1998 bill by Senate President Pro Tem Don Perata, D-Oakland, enables specially trained hygienists to work without direct supervision by a dentist.
Armed with mobile equipment, these hygienists travel to nursing homes, schools and private homes to clean teeth.
But despite the need, only a handful of hygienists provide such services in the Bay Area.
Many say they find it tough to set up independent practices because of a flood of paperwork, including a requirement to obtain prior approval from each patient's dentist or physician.
Adding to the difficulties: Some insurance companies refuse to pay for the care, and some dentists balk at signing the consent forms.
Just two schools - the University of the Pacific in San Francisco and West Los Angeles College - offer the curriculum needed to obtain the "registered dental hygienist in alternative practice" license.
"There's still a lot of barriers to this thing working well," said professor Paul Glassman of the University of the Pacific Arthur A. Dugoni School of Dentistry.
"But we're at the beginning of something that has lots of long-term potential," he said. "There are already people out there doing good things for underserved populations."
The need for such services is expected to expand rapidly as the nation's baby boomers age.
Demand also has increased because many disabled people now live in small group homes rather than large institutions that have a dentist on contract.
For 18 years, the California Dental Hygienists' Association lobbied for the new licensing category against fierce opposition from those who complained that "unsupervised" hygienists would be acting as "junior dentists."
The new license restricts hygienists to perform only their typical duties, but allows them to do so without a dentist's supervision.
Some say it isn't surprising that few schools offer the curriculum, which adds 150 hours to the regular dental hygienist program.
"This was a very controversial new license category and a lot of people didn't want to get in the middle of that kind of controversy," Glassman said.
By 2003, only 15 hygienists had obtained the license, and they had all participated in a previous pilot program, said JoAnn Galliano, director of the Chabot College dental hygiene program.
As of June 30 of last year, only 118 hygienists had such licenses statewide.
The first Northern California class graduated in 2004 from the University of the Pacific. The class included Castro Valley resident Trill.
Trill paid $10,000 to purchase equipment for her weekend mobile practice. She also works four days a week for an Oakland dentist, but does not regret her busy schedule.
"I'm 43 years old and this is the closest I have ever come to what people describe as a calling. I wanted to help empower the dental hygienist.
"I've seen people that haven't been looked at, haven't had their mouth opened, in 25 years."
Trill has 30 contracts with assisted living and skilled nursing facilities in Alameda and Contra Costa counties and treats a few people in private homes.
She does not take X-rays, but cleans teeth and checks visually for signs of infection, decay or disease, then refers patients to dentists if they need additional work. She charges about $150 per patient.
To clean her instruments, Trill has set up sterilization equipment in her garage designed to meet state standards.
The paperwork for her independent practice can be daunting.
Before she arrives at a nursing home, administrators there must obtain "prescriptions," essentially consent forms, from each patient's dentist or physician, including information about any medication needed.
She employs a dental assistant to help hold up heads, open mouths and meet other needs. But that adds to the paperwork, so she has hired a payroll service to ensure workers compensation and other documents are filled out properly.
After she gets home, she spends hours handling the billing and notifying caregivers about her findings.
"It's overwhelming," she said with a sigh.
Critics voice concerns about setting up a two-tiered system of dental care, with some people receiving top-notch treatment from dentists and others being seen only by hygienists.
But supporters note that for growing numbers of people, the choice may be between seeing a dental hygienist and having no care at all.
While the California Dental Association says it now backs the new licensing category, some hygienists complain of negativity from individual dentists.
In a letter to Sen. Deborah Ortiz, D-Sacramento, one hygienist said that a dentist who had an exclusive contract with a skilled nursing facility threatened to have her arrested if she treated patients there.
Eight other hygienists, in a February letter to Sen. Carole Migden, D-San Francisco, complained that some dentists routinely refuse to sign consent forms.
"This allows them to keep a stranglehold on our ability to fulfill our mission -- despite the law on the books," they wrote.
Edmund Carolan, manager of legislative and regulatory affairs for the California Dental Association, said many dentists aren't familiar with the legislation. He said the organization will work to educate them.
But the Dental Association opposed a bill by Assemblyman Simon Salinas, D-Salinas, that sought to remove the requirement to obtain dentist or physician approval.
Many of the patients are medically compromised and need antibiotics or other medications before a hygienist dislodges bacteria in the mouth, Carolan said.
"Just to have someone go in there and start treating them could put the patient at great risk," he said.
Not everyone has encountered hostility. Trill notes that a dentist donated a large piece of sterilization equipment to her.
"The dentists that I know personally are unbelievably supportive in cheering me on. They're taking their hats off to me for trying this difficult task."
Many of the kinks in the program may be resolved as it grows.
"I'm hopeful it will continue to expand and as we expand, then a lot of these issues will take care of themselves," said Galliano, the Chabot College professor who oversees government relations for the California Dental Hygienists' Association.
Although Trill barely makes ends meet, she has no plans to abandon her mobile practice. She hopes more hygienists will join her.
"Clearly, people who go through this are not doing it to make money," Glassman said. "They're people who see a need out there in our society."
• Find out about the University of the Pacific program at pacificspecialcare.org/ed_program_spneeds.htm
