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We must champion dental hygienists after Covid-19

By Dr. Mike Heffernan

I was in a meeting yesterday with a group of local dental health practitioners discussing the practicalities of opening up our surgeries after lockdown. We were discussing the best way to do this while minimising risks to patients and staff. Surprisingly, one very important question never came up: how will dentistry’s brave new world apply to hygienists.

Hygienists make up 25% of our clinical workforce, playing a vital role in communicating with patients and are at the heart of every thriving practice. So why are they being ignored?

For my research partner Toby Edwards-Lunn and me, preventative dentistry is the only truly effective way to deliver oral health. This was our inspiration for inventing Dr Heff’s Remarkable Mints, a dental health supplement that helps our patients keep their teeth and mouths clean and healthy throughout the day. But we also still work as dentists in practice. We dentists often get the plaudits for creating the perfect smile or relieving patients’ pain but it is hygienists who keep those teeth and smiles looking good for longer.

Unfortunately, hygienists could well be under even greater threat from the fallout from the coronavirus outbreak than dentists. Indeed, the US Department of Labor found that dental hygienists were the most in jeopardy of all frontline medical personnel.

Toby’s practice has a large number of Denplan patients. The Denplan model works very well because remuneration is linked to the prevention of dental disease rather than for restorative interventions. And it is often our patients’ regular interactions with hygienists that allows them to achieve excellent levels of plaque and biofilm control in the longer term.

However, we are at risk of losing all of these vital benefits by failing to develop a robust return-to-work plan for hygienists. This is certainly no simple task because hygienists face a number of additional challenges:

Many hygienists work without an assistant. Putting on appropriate PPE could be an issue when working single-handed.

Hygienists’ rooms are often smaller than conventional dental surgeries. They may lack access to windows for ventilation or share a partitioned room with other clinicians.

Hygienists’ appointment times are typically 30-45 minutes with a high daily turnover of patients.

Hygienist interventions routinely involve aerosol or droplet-generating procedures (AGP) on each patient. This aerosol may remain airborne and currently requires 60 minutes to ensure it has cleared the operatory.

Given the common single-handed approach there may not be routine use for high volume aspiration. This is recommended for any AGP but is practically difficult for a hygienist alone.

Unlike routine fillings where we can enhance the patient/staff protection by implementing protective aids such as rubber dams, this is impossible for subgingival cleaning procedures

What makes this situation even more worrying is the fact that many hygienists are self-employed and therefore facing additional economic challenges, some of which are potentially beyond their control. As well as the cost of PPE, will there be capacity in the practice to give a hygienist adequate time after an appointment to disinfect the operatory and allow the room to be ventilated? Can the practice provide an assistant to help create a safe working environment with suction and other cleaning measures?

The British Society of Dental Hygiene and Therapy (BSDHT) is running a survey to gather information on these important issues and I would urge all hygienists to respond: http://www.bsdht.org.uk/dhcontact/ifdh-global-survey-covid-19

There are also some more creative solutions of how best deploy hygiene teams at this unprecedented time. We already know the key to maintaining dental health is through motivating patients, dietary advice and self-administered oral hygiene measures. Some of this invaluable guidance can be given to patients remotely and could be something that the practice, if receiving a capitation fee such as Denplan, will be able to pay hygienists to take on. This will also provide greater value to patients for their monthly Denplan payments.

We should also recognise that some patients will require face-to-face treatment regardless of social distancing. Among these cases, there will be patients (such as those with dexterity issues or an active infection) who will need treatment from a hygienist. Historically, hygienists worked with mainly hand instrument scaling and root planing. These are non-AGP so can still be carried out. Extending hygienist appointments would also allow more time for motivational advice designed to change patients’ behaviours beyond the surgery.

We are familiar with the importance of “Guided Biofilm Therapy” by EMS and on-going disruption of the biofilm after the hygienist appointment can also be achieved by methods such as better oral hygiene and use of adjuncts such as fluoride, xylitol/green tea extract, as we found in our university research when creating Dr. Heff’s Remarkable mints.

Are all dental practices up to speed with the latest treatment options?

Ultimately, of course, there is not one simple or single answer to the question of how best to support hygienists. We know they are crucial to our patients’ dental health and that they are truly working on the front line. For all of these reasons, hygienists cannot be ignored. Instead, they should be at the heart of the plan for dentistry’s return and an integral part of the new normal that will evolve into the preventative dentistry of the future.

It certainly seems clear to me that if we want to have healthy patients with stable mouths, who are engaged and evangelical about their own oral health, we need our dental hygienists and therapists now more than ever.