Dental hygienists have long been used in alternative practice settings to provide oral care for those who otherwise would not receive it. By utilizing the advanced practice or expanded practice permit, hygienists can provide services in schools, rehabilitation facilities, hospitals, medical clinics, and more. This area continues to be expanded as more public health organizations attempt to bridge the gap between medical and dental services.
Having a dental hygienist in a hospital setting is a newly emerging area of practice. A few states employ hygienists to provide care in hospitals, such as Oregon, Minnesota, and Arizona.
One can follow several different models when developing a medical-dental integration program in a hospital setting. One could be the hospital itself employing the hygienist, another could be employment by a dental organization that contracts with the hospital, or they could be an independent practitioner who has gained privileges to provide services on-site.
The integration of oral health services in a hospital setting has arisen out of necessity due to the number of nontraumatic dental emergencies, dental pain, and hospital-acquired infections (HAI).
So, what does it look like to have a dental hygienist serve different departments in a hospital?
Emergency Department
Many patients present to the emergency department (ED) for dental pain. Over two million patients a year are seen in the ED for nontraumatic dental problems.1 Many patients have not had access to a dental provider for preventive or regular care. These patients usually present because they do not have a dental home, they have tried their dental home already and were unable to be seen, or because a medical provider told them to come in due to symptoms of infection.
Patients with dental problems will go to the ED and be seen by a physician, and they are typically given antibiotics and pain medications and then sent away. As a physician told me, “We spend about one day learning about oral health.” This lack of education on oral care is echoed by various professions in the medical community, including nurses, physician’s assistants, and CNAs.
Though this is unfortunate, it is ultimately the only option for some patients. One might think they should stop giving out antibiotics, as we all know how antibiotics for dental infections can contribute to bacterial resistance, but the doctors can’t do much else. One might also discourage pain medications. However, many patients have already taken the maximum recommended dose of ibuprofen or acetaminophen. Without some sort of intervention, the patient will come back to the ED, requiring more time, finances, and resources. This forces physicians to do the only things they can, which are typically not ideal.
This is where dental hygienists come in!
A dental hygienist has a plethora of knowledge on dental pain, infection, abscesses, fractured teeth, and oral conditions such as candidiasis, herpetic lesions, stomatitis, and more. After all, many of us are reporting our findings of areas of concern during hygiene treatment to our dentists.
In an ED setting, a dental hygienist is able to evaluate the mouth, perform limited testing on the tooth in question, and possibly provide some sort of relief. This can come in the form of a temporary restoration, silver diamine fluoride, or local anesthetic (depending on the scope of practice determined by the state). We can also take radiographs if necessary and give our opinion on pain meds or antibiotics for a doctor to consider.
After the patient is adequately provided for, a hygienist may also help with care coordination. A patient in pain may need help getting a dental appointment since the ED treatment/response was probably unsuccessful. A dental hygienist calling from the ED with information and a radiograph on the tooth may be helpful in acquiring an emergent dental appointment.
Inpatient Care and Hospital-Acquired Pneumonia
In addition to the ED, dental hygienists can also provide care for inpatients. Hospital-acquired infections (HAI) can include catheter-associated UTIs, infection of surgical sites, C. dificile infections, and hospital-acquired pneumonia (HAP), which can be ventilator or non-ventilator-associated.2
Inadequate oral care in a hospital is a way patients can contract HAP.3 Though many hospitals have procedures and guidelines for administering oral care, it often does not get done or is completed but is lacking in effective biofilm removal. Nurses cite this lack of completing oral care as being a low priority compared to other nursing duties, lack of oral health knowledge, and being too busy.4
A dental hygienist can play a large role in providing oral care to patients in acute care or intensive care units. In larger hospitals, a hygienist may focus on ensuring that CNAs and nurses are educated on the importance of oral health, the connections to HAIs, and how to evaluate the mouth and effectively remove food debris and biofilm with brushing, interdental cleaning, mouthrinse, and/or suction. They can also educate on the association between oral and systemic health and even provide an explanation for some systemic issues that could be originating in the mouth.
Due to a smaller patient load, a hygienist may be able to carry out these procedures in a smaller hospital. When a dental hygienist can see patients, it allows them to provide an oral assessment, oral cancer screening, caries risk assessment, OHI, and any treatment procedures the patient may need (i.e., temporary restoration, SDF, local anesthetic).
This is also an excellent time to make referrals, help with care coordination, or address any dental issues the patient may have. This is generally accomplished by developing networks with dentists in the community and/or partnering with public health resources. If patients do not have a dental home, they can be referred somewhere to get set up for a comprehensive oral evaluation and/or the treatment they may need.
As a dental hygienist specializes in oral health and biofilm/debris removal, the patients get to experience more effective hygiene treatment, and hospitals may see lower rates of HAP.5
Because of the immense knowledge of biofilm removal techniques, not only will brushing be more effective when done by hygienists, but if appropriate, more in-depth hygiene treatment may be performed, such as prophylaxes or non-surgical periodontal therapy.
Hygienists also have a wealth of knowledge on appropriate products to recommend for managing oral microbes based on type (bacteria, fungi, and/or viruses), thus having the capacity to reduce the oral pathogenic burden.
Additional Hospital Departments
In addition to the inpatients at the hospital, a dental hygienist might also have access to other departments in which we can provide OHI for people who need it most. This can include labor and delivery, OB/GYN, drug treatment and rehabilitation, cancer infusion, diabetes clinics, and pediatric departments.
Many people trying to control their diabetes don’t understand the bidirectional relationship between the mouth and controlling their disease. Many patients about to undergo cancer treatments have not developed a preventive dental treatment plan. Expecting mothers are given so much knowledge on nutrition, prenatals, and pregnancy restrictions but yet are not given any recommendations on oral health.
This workflow may be accomplished in different ways depending on the hospital and the dental professional. It can be a consult basis, where medical professionals put in an order to the hygienists for specific patients based on certain conditions, or it could be determined as the hygienist reviews patient lists and evaluates who would be appropriate for an evaluation.
What an excellent way for hygienists to impart all the prevention knowledge we have and reach more people than we would in a dental office!
Challenges for Medical-Dental Integration
The dental and medical fields have long been separated and not treated as one. Though many professionals are trying to bridge this gap, our health care infrastructure presents many challenges that impede an individual’s ability to receive care for their whole body.
These challenges include lack of oral health literacy (both patient and provider), perception of the importance of oral health within the medical community, lack of training, and probably the biggest barrier, finances.
Finances are obviously the foundation for any sort of program development, and without them, it may seem impossible to move forward. Funds are necessary to support personnel salary, necessary technology (i.e., radiology unit), and product acquisition, like toothbrushes, toothpaste, and floss.
However, insurance and patient coverage also play a prominent role in ensuring a program is profitable and effective. Lack of dental insurance or reduced coverage for patients on Medicaid/Medicare and suitable billing techniques for dental procedures hinders the ability to be reimbursed for dental procedures and thus affects the long-term stability of any program.
Though these barriers may seem insurmountable, dental professionals are a sturdy bunch, and we have seen amazing progress toward our goals. This includes grants subsidizing integration efforts, insurance funding dental positions in a medical setting, and the transition to value-based care in dentistry.
We may have a great deal of work in front of us, but the progress that has already been made is undeniable.
In Closing
As we continue to fight for the inclusion of dental health into whole body health, having hygienists in medical facilities is just one of the ways this can be done. Building relationships with physicians, respiratory therapists, nurses, speech-language pathologists, and many other hospital workers improves our collaborative efforts to provide a patient with the best possible care they can receive.
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References
- Sun, B.C., Chi, D.L., Schwarz, E., et al. Emergency Department Visits for Nontraumatic Dental Problems: A Mixed-Methods Study. American Journal of Public Health. 2015; 105(5): 947-955. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386544/
- Monegro, A.F., Muppidi, V., Regunath, H. (2023, February 12). Hospital Acquired Infections. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441857/
- Kanzigg, L.A., Hunt, L. Oral Health and Hospital-Acquired Pneumonia in Elderly Patients: A Review of the Literature. Journal of Dental Hygiene. 2016; 90(Suppl 1): 15-21. https://jdh.adha.org/content/90/suppl_1/15
- Salamone, K., Yacoub, E., Mahoney, A.M., Edward, K.L. Oral Care of Hospitalised Older Patients in the Acute Medical Setting. Nursing Research and Practice. 2013: 2013: 827670. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683489/
- Baker, D., Giuliano, K., Thakkar-Samtani, M., et al. The Association Between Accessing Dental Services and Nonventilator Hospital-acquired Pneumonia Among 2019 Medicaid Beneficiaries. Infection Control and Hospital Epidemiology. 2023: 44(6): 959-961. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10262156/
