Dental Hygiene Around the World

Each day, dental hygienists across the country strive to make their profession better than it was yesterday, by solving access to care issues or working to bring about legislation that will expand the scope of practice. So it's understandable that we might forget that, in other parts of the world, dental hygiene looks nothing like the nearly 100-year-old profession we are all accustomed to. In some places, dental hygienists might offer cosmetic services only; in others, the profession may not even exist.

So how does dental hygiene differ around the world? The stories below highlight just how different people around the world view dental hygiene. And though the sample size may be small, the diversity in practice and scope is huge.

Rosie Bellert — Bolivia

The country of Bolivia is, sadly, one of the poorest in South America. As such, dental hygiene is not considered a priority, mostly due to the cost of treatment and the lack of resources. After learning of the poor health conditions there, a dental hygienist from Seattle decided to do something about it, and 12 years ago the group Smiles Forever was formed, which owns and operates a dental clinic in the central city of Cochabamba. Smiles Forever is the first dental hygiene school in Bolivia giving young indigenous women an opportunity to study to become part of the first wave of dental hygienists. The clinic also provides shelter for the homeless young women who have nowhere else to go while teaching them dental hygiene skills.

Rosie Bellert, RDH, BS, working on her Med, has served on the group's board for nearly its entire history and is close friends with the group's creator. During her time on the board, she became interested in actually traveling to Bolivia herself, but lacked the funding to do so. She decided that, as a faculty member and director of Shoreline Community College Dental Hygiene Program, she would apply for a study abroad grant, in hopes that others would see the value of her trip.

Soon, Bellert found herself preparing for her first visit to Bolivia.

"I was able to travel down there one summer to kind of put connections together, to find out where the [American] students may be able to stay and how we could visit Smiles Forever," Bellert said.

She was able to set up a return visit for the following year, and along with eight students from various dental hygiene programs across the state, made the trip back to Cochabamba, staying at the Smiles Forever clinic.

"We were able to house our students there ... which was great because we were able to make really close friends with the students down there," she said. "Even though there was a communication gap, [the students] were able to talk to the Bolivian students [about] how it is to be a hygienist in the United States and how it is to be a hygienist in Bolivia and the trials and tribulations that each one may go through."

Bellert said that the experience was eyeopening— not just for her students, but for her as well.

"The majority of people in Bolivia view dental care as something that's not really needed unless you have pain," Bellert said. "A lot of that has to do with access and having enough money to be able to see a dentist. But there is a huge gap between the people who have money and the people who don't."

Many of the people who don't have money live outside of the cities, in small villages. The goal during Bellert's first visit was to establish a relationship with a local orphanage to provide dental education, perform dental exams and apply fluoride treatments. The next year's visit the [American and Bolivian] dental hygiene students visited several orphanages and the Burn Hospital providing for the children's dental needs. Also, this time they traveled with a small team of oral surgeons, who would perform extractions while Bellert handled the educational aspects and application of fluoride.

"One village that we went to was Morochata. The Smiles program have been going there for almost four years, and there are about 300 children in this village, and none of them have seen a dentist. There is one dentist in the village, but obviously she can't take care of everything, and also the cost to them is so outrageous - the materials are expensive."

Bellert said that not only were dentists in short supply, and dental hygienists nonexistent, but their stock of supplies was alarmingly low for the number of children living in the village.

"When you look at their supplies, there are a few antibiotics, there are a few filling materials. They don't get a lot of materials and equipment to take care of the amount of decay and abscesses that are there."

Because of this, the group has gone back on multiple occasions, to ensure that the oral health habits of the children are also changing. When Bellert traveled with them, the oral surgeons extracted 156 teeth in a six-hour period. But it was the reaction of the children that struck her more than any statistic.

"The kids would not leave - they knew that if they didn't get their tooth extracted that day, they would be in pain until the next time the dentist came. Kids were lining up and watching the extractions and being queasy about it, but being the first one to be in the chair."

The lack of dental care throughout the country stuck with Bellert and her students. Many who traveled with her want to go back, and Bellert is hoping she can return every other year.

"I am invested in it because, it being the one and only dental hygiene program in all of Bolivia ... being a new profession in that country, it's just kind of exciting to see it all start to break the cycle of poverty. By providing an education to young women gives them a chance to build a career particularly in a field where the need is so great and so they can in turn provide and take care of their families."

Julie Carranza — Australia

Although dental hygiene as a profession is approaching its 100th anniversary, it is still a relatively new practice in other parts of the world, as Julie Carranza, RDH, BscDH, learned. Carranza is now a permanent resident of Australia, where she works as both a clinical hygienist and as a consultant. But the transition from working in the U.S. to Australia was not an easy one.

"Dental hygiene in Australia is only 20 years new, so it isn't a household name like it is in America," Carranza said. In fact, the profession is still so young that many people do not know what a dental hygienist does, dentists included.

Carranza describes the role many Australian hygienists find themselves in as "a luxury for the community." Part of this is, of course, the age of the profession. But unlike dental hygiene in America, the profession has different roots—the profession started out more in line with what we would consider a dental therapist.

"In Australia, the dental therapist was born through the dental association to alleviate the burden of community socialized dental care," she said. "So they pretty much just did "drill and fill.'"

Over time, the profession has grown in both popularity and need. Where Carranza sees dental hygiene in Australia as being ahead of the curve is in how associations have helped shaped the profession. State branches are getting more involved each day, both on the local and national scales. Despite this, Carranza says that the system is very similar to America's, and that there is still room for growth.

"You can get a dentist on almost every corner, but not many practices have a dental hygienist in the team."

Initially, Carranza was not aware of how differently her profession was perceived in Australia, compared to the U.S. For her, there was no sudden moment of realization—her culture shock lasted for nearly two years.

"Just the lack of knowledge of our profession within the dental community," she said. "Not knowing how to utilize us properly and to the fullest of our capacity."

Instead of accepting the situation as it was, she decided to do something about it. Her current jobs go far beyond the typical clinical setting.

"I am a passionate volunteer within the local association, and I have also developed my own business consulting," she said, adding that consulting with other oral health businesses has been an effective way to get the message out there for her fellow dental hygienists. "I work clinically three days a week and volunteer almost every hour past that."

Though she has seen progress, there is still much work to be done.

"Within the industry, dentists get very excited about what dental hygienists can bring to the team. A lot of times theyjust don't know where to start, and because they don't know where to start, they sometimes just jump in a hire without having processes in place."

Carranza hopes that dental hygiene will be as common in Australia as it currently is in America, and that other Australians will be inspired to take on the role of preventive oral health care providers for their community.

Heidi Glastetter — Switzerland

For Heidi Glastetter, BSDH, international work has meant many things. She has toured Switzerland frequently for the last 25 years, practicing clinical dental hygiene on two separate occasions and helping her fellow dental hygienists locate work. During this time, she has moved back and forth between the two countries. After her first move back to the States, she recognized that many other dental hygienists were expressing interest in a work-abroad experience. This, combined with what was—at the time—a need for more dental hygienists overseas, gave her the impetus to create PerioConcepts, PLLC, a dental placement agency.

Glastetter said she enjoyed her time practicing in Switzerland, but noted that there are differences. The three areas that stand out as different in Switzerland, in comparison with how dental hygiene is practiced in the States, were: 1) Dental insurance for preventive or restorative services does not exist, 2) all children legally living in Switzerland receive dental exams on a yearly basis, and 3) employed dental hygienists in Switzerland have more job security than their employed dental hygiene colleagues in the U.S.

According to the National Center for Health Statistics 2010 study by the U.S. Department of Health and Human Services, 26 percent ofthe U.S. population under 65 has no dental coverage. This equates to 45 million persons living in the U.S. who are fully responsible to pay for their own dental treatment. Switzerland, which is approximately the size of Washington State and a population of nearly 8 million, does not offer their citizens private dental insurance. These plans are nearly nonexistent, which means that patients have never gotten used to relying on a third-party provider to assist them in covering their dental costs. "I believe that dentistry in the United States is becoming more and more insurance-driven, and the patient is lost in the process," Glastetter said.

"You never hear patients in Switzerland complain that they couldn't visit the dental office because they ran out of their dental insurance benefits," she continued. Glastetter believes that American patients tend to have less personal ownership in their own treatment needs. "[Dental patients in America] will agree to nearly any treatment that their insurance plan covers and focus their attention on what portion of payment they are responsible for, rather than evaluating their perceived need for the treatment. Swiss patients, on the other hand, tend to listen to treatment proposed by their dental providers and either accept or reject dental recommendations decisively, while still sitting in the chair. They expect the practitioner to know and quote fees, rather than waiting to leave the operatory and discuss insurance concerns and payment options with the front desk."

Glastetter admits that this system sometimes leads to more patients than she would like waiting long intervals between their appointments. "With dental hygiene, a lot of the patients ... will stretch their appointments out. When I was practicing, I saw patients that would come every two years. Not everyone, but there were significant amounts ofthe population that would come every two years, and so you're starting from scratch and you need anesthesia for everyone."

Nevertheless, Glastetter saw a certain advantage to providing fee-for-service dentistry without the influence ofthe dental insurance company. "It made my presentation of advanced periodontal treatment options easier for the patient to understand. If I needed to break the appointments down into multiple sessions with anesthetic, the client was simply charged by the hour, not re-coded as a diseased patient for insurance purposes and forever charged a higher fee for all future dental hygiene services. If I needed more time to properly debride a patient, I presented this to the patient and they were scheduled for quadrant therapy follow-up appointments. My decision to use anesthesia was not based on if I could charge them for quadrant therapy. My decisions to use anesthesia was based on keeping the patient comfortable."

Caries is the number one dental concern for children in many countries, and Switzerland addresses this issue by holding comprehensive annual screenings of all children legally living there, including children of temporary workers. Radiographs are taken and dental screenings are performed by local dentists. Areas of decay are noted in records kept in the dental office, the child's school and with the local community (City Hall). A report ofthe exam is sent home to the parents, as well. A bill for this exam is later sent from the Community to the parents, with instructions that they are to follow up on any restorative treatment needs for their children. The parents have the choice to see any dentist of their choice for this treatment, or for a second opinion. If the parents are experiencing financial difficulties, they can appeal to the Community to cover the expense of the exam and restorative treatment needs for their child. This comprehensive method of providing restorative treatment to children is egalitarian, according to Glastetter. "None of the children feel that they are being treated because they are 'poor' or in a disadvantaged group. All children, in all socioeconomic levels, are examined and provided with follow-up treatment, as needed." The impact this has on the attitudes of children is tremendous, and it stays with them into adulthood, as evident by the research that has been conducted on the overall oral health of Switzerland residents. "It really has made a huge difference in as far as reducing DMF index scores," Glastetter said.

Glastetter acknowledged that it is much more difficult for foreign hygienists to find employment in Switzerland now than in the past; however, dental hygienists currently employed there have greater job security than their counterparts in North America. "Employers in Switzerland are required to vest their employees in the company retirement plan, starting from the first day of employment, and vacation time typically ranges from four to six weeks of holiday leave per year." Employers are required to give three months' notice, or equivalent severance pay for termination. "Dentists in the U.S. can let their hygienists go on a whim and without prior notice", she said. "In Switzerland, the job of a dental hygienist can be challenging, but it is secure employment."

Keiko Sakagami — Japan

Most oral health care systems in the world go through farreaching, drastic changes that take travelling dental hygienists some time to get use to. And even though Japan has its fair share of these big changes, Keiko Sakagami, RDH, EdD, MCHES, learned that it's not always the big changes you have to be mindful of - the small ones can have just as big of an impact.

Sakagami worked in Tokyo as a dental hygienist at a company that produced oral health care products. She joined the team that performed the company's historical oral health care activities, which included dental health education for school children of all ages, oral health education to parents and communities and oral health care for adults. Through these activities, she was able to help over 20,000 people per year.

Sakagami said the experience of going from America to Japan to practice was exciting, and a bit scary. The changes from an American health care system to a Japanese one were surprising - everything seemed different, even what students were taught regarding clinical practices was unlike anything she experienced before. The differences led her to appreciate both systems. For example, in Japan dental hygienists cannot open their own offices and dental hygienists can not perform local anesthesia. However, most dental hygiene programs in Japan have become three-year programs, and include courses for senior care. Although America does not have a universal health care system in place, its education system is more robust - Japan does not have graduate programs in dental hygiene and only few dental hygiene programs are four-year programs.

Sakagami said she looks back at her experience and sees international work as a great way for all hygienists to learn how to become better educators, not just to fellow dental hygienists, but to patients as well. Her time in Japan has been a tremendous benefit to her career, and she recommends others strive to do the same.

Amy Soss — Grenada, West Indies

As a dental hygiene student at New York University (NYU), Amy Soss, RDH, clinical instructor at NYU and private practice dental hygienist, envisioned a career composed mostly of clinical work and treating patients. Public health work and advocacy were not on the agenda, until an opportunity to travel to Grenada on a dental outreach arose.

A clinical manager of the University who was from Grenada approached the dental outreach department of NYU and told them that Grenada had a huge problem with access to care because there are a very limited number of dentists on the island. There are eight dentists on the whole island and about 100,000 people, so people weren't getting care.

That number shocked Soss - she couldn't believe that a community of that size could have so few health care workers. So she decided to see for herself, flying to Grenada to assess the situation and determine if annual visits to the country fell in line with NYU's global outreach program.

Her first trip contained little in the way of actual dentistry, and her results were eye-opening.

"My first experience there, the kids really had never been to a dentist, and if they had, the only reason they ever went was to pull out their teeth. The children were terrified of us for the most part, because their association with the dentist was thought of as a punishment."

It became clear that the goal was to change the perception of oral health care in the country, even if it meant just going into some of the area schools. Soss quickly learned that oral health care was far from a priority to these children.

"When we saw the children, we asked them a few questions, and one of the questions was 'Do you have your own toothbrush?' Most didn't have their own toothbrush, and a lot of the ones that said they did said they shared it with their siblings."

Once Soss learned how oral care was administered, it was no surprise that the children thought of the whole thing as punishment.

"Since there are only eight dentists on the island, and one is an orthodontist, they are run like a mill. The dentist would line them up, give injections, and then go in and extract, and that was it. And it's scary to them - they're little kids."

Their reaction to Soss and her team spoke volumes, putting the gravity of the scene into context for her.

"Their initial instinct was to be scared when they met us."

In the years since her initial visit, Soss has returned to the community to deliver basic oral health care and education. The numbers are staggering - in one visit, her team sealed 6,000 teeth and provided fluoride varnishes for 26,000 children. The average decay rate among the children was approximately 86 percent.

But the persistence of Soss and the NYU program has paid off. Soss has gone with the group once a year over the past three, despite the fact that she is no longer a student. And in that time, the change in attitude has been remarkable.

"It's completely different now," she said. "Having gone back afull two years later, almost every single child has a toothbrush; they're brushing at least once a day due to the program that NYU has implemented."

Perhaps the biggest award, other than a decrease in decay rate and more children brushing their teeth, is to know that, when she visits, the children of Grenada will no longer be afraid of her and the dental team. And though proper oral care is still lacking, it is this shift in attitude that Soss hopes will help the citizens of Grenada change the way they live their lives.

Josh Snyder is staff editor of the Journal of Dental Hygiene.