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Wed 11 Jun 2008 04:00 AM

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Independence day

Unsupervised dental practice is slowly becoming a reality for dental hygienists worldwide.

Unsupervised practice is slowly becoming a reality for hygienists worldwide. MED asks: could the Middle East's hygienists go solo?

Louise has worked as a dental hygienist for five years. Although she works from a general dental clinic she runs her own schedule, which is separated from radiographic and restorative exams.

She can administer local infiltration and block anaesthesia, and is assisted by a dental nurse. Most importantly, her appointments are unsupervised.

If you worked as a hygienist in Britain, courtesy of a ruling that allows you to be your own boss, your practice might look something like this too.

Using independent hygienist clinics in underserved areas could reduce the amount of pressure on existing practices.

Worldwide, the debate is in full swing as to whether dental hygienists should be allowed to practice independently (meaning without the supervision of a dentist) or not.

In Britain, parts of Europe, and one US state, Colorado, the answer has been yes. In 49 other US states - including, as of last month, Minnesota - and the Middle East, the answer is no. And that's just the tip of the iceberg.

The subject of unsupervised hygienists is a touchy one for dentists. In the US, for example, state dental associations have opposed almost all bills proposing independent dental hygienists. Dentists argue it's an issue of patient safety; hygienists believe it's a turf issue.

On a local scale, neither camp would disagree that the establishment of independent hygienist clinics would require a radical volte-face by the Middle East's conservative health ministries. But is it a switch that could spell a partial solution to the region's dental problems, and a much-needed industry boost?

Coming of age

The knotty question of where, when and how hygienists should practice is long overdue. As an independent profession, hygienists are required to attend accredited schools, receive degrees, become registered and then licensed. Still, in the majority of the world - and across the Middle East - they are banned from carrying out their duties unsupervised.

In the UK and America, the number one argument in favour of freeing-up hygienists is the potential impact it could have on access to care. Supporters of the change argue that independent hygienist clinics in underserved areas could reduce the pressure on existing practices.

Remove the rule that says hygienists have to work in the same premises as a dentist, and they could be incentivised to work in rural areas that lack oral care provision (a fitting description for large hunks of Saudi Arabia and the United Arab Emirates).

For the critics who argue that hygienists are just as unlikely as dentists to set up outside main cities, research in the US has proved otherwise.

A review of Oregan hygienists, who had taken advantage of a Senate decision to expand their remit, found a "commitment to underserved populations" and "no evidence of lower quality of care".

One of the key issues facing dental care in the Middle East is the public's reluctance to spend money on oral care. Bar a boom in the demand for aesthetics, the oral health status of the majority of residents remains poor.

The chief lure of independent hygienist services - whether in a stand-alone clinic, or as a contract business within a dental practice - is likely to be price. With fewer overheads and less outlay on pricey equipment, the cost of a visit can be 25 to 30% cheaper for patients - enabling RDHs to reach out to patients who would otherwise go untreated.

Money versus status

While money isn't the primary factor for most hygienists (despite the amount they generate for dental clinics), few would turn down the opportunity for advancement.

As the British market has shown, professional autonomy hasn't led to a clinic on every corner but it has allowed hygienists to take control of their careers.

From simple steps such as being able to set their own appointments, to being able to provide hygiene services to patients not registered with their in-house dentist, the move has been a boost to the industry.

Locally, awarding independent status to RDHs would mean creating a higher earning capacity, a new rung on the career ladder and an edge for the Middle East in the global recruitment market - not least among resident hygienists who would be encouraged to stay on.

As importantly, it would also give hygienists a voice in licensing issues, and increased recognition of the role they play in healthcare. The move might not put the profession on a par politically with organised dentistry; but it would at least guarantee a seat at the bargaining table.

Adding to the case for change is the need to position dental hygiene as an attractive career choice. As any health minister will confirm, the issue of homegrown talent is as pressing in the dental industry as any other and nationalisation schemes, such as those seen in Kuwait and the UAE, will soon be a reality for the entire dental team.

Currently, almost all Middle Eastern dental hygienists are expatriates. If that is to change, local governments need to make the profession a more attractive career choice for school leavers. Marking dental hygiene as a recognised, independent career in its own right is a step in the right direction.

Going it alone

Admittedly, the Middle East is a tough test market for independent practice. Its lengthy licensing procedures and layers of red tape make it an unlikely candidate for this fairly radical practice.

But it's also one of the few regions worldwide undergoing a radical overhaul in healthcare, leaving it perfectly placed to break with the past and take a modern approach to the dental team.

Independent practice will not be suitable for all hygienists. But for those who make the grade, there's no reason why it shouldn't be an option.

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