20/21 Vision on the Essential RDH: A State of the Operatory Address

-Abraham Lincoln, 1862 State of the Union Address

Dentistry has notoriously been a profession lacking in perceived resilience to change. Whereas other healthcare professions upgrade to product innovations with relative ease and adapt to new protocols, paradigms, and principles gracefully, dentistry's "that's just how we do things around here" mentality had garnered a protective layer of acceptance and subsequent ambivalence with regard to professional standards.

The steadiness and ensuing tolerance of the dental profession was observed in the licensed professionals who would intentionally discontinue seeking continuing education opportunities once minimum requirements were achieved, in the overt absence of high infection control standards despite well-known Centers for Disease Control and Prevention guidelines, and in the hamster wheel of 6-month bloody prophylaxis recare appointments to the general patient population despite evidence of the high prevalence of periodontal diseases across the United States. In the face of a standardized approach to patient care, dental practices regulated the annual frequencies of periodontal charting and dental radiography, in defiance of comprehensive research around the value and importance of individualized patient care based on risk assessment.

Patients presented to the hygiene chair in a perceived state of optimal oral health, the 76% prevalence of stages I and II periodontitis notwithstanding. The societal trend of accepting the occasional bleeding from the mouth, paired with the relatively asymptomatic nature of early oral disease, not only created a toxic cocktail for patients to devalue their dental hygiene services, but also clearly outlined patient values in adhering to insurance reimbursement as a priority.

Fears about patients' responses to advanced treatment plans, including concerns over their ability to commit to their care with finances, time, and dedication to self-care, raised concern for dental professionals when it came to planning appropriate treatment plans that aligned with their diagnosis and met patient needs. Dental patients became more conditioned to look to their dental insurance as the beacon for dental work that was truly warranted to render their oral status as healthy.

Differing standards and inconsistent protocols led to a widespread practice of fear-based dentistry, a transient term used to describe clinical decision-making that is blindly guided by the perpetual apprehensions of legal ramifications, negative patient feedback, an extreme focus on third-party payer reimbursement, and ultimately a lack of perceived value in the evidence-based work of the dental professional.

For most dental practices, everything was "just fine." Enough patients were presenting routinely for their hygiene visits to keep the dental hygienist occupied, a decent number of patients were accepting treatment to keep the doctor and restorative team busy, and the unending narratives required by third-party payers kept administrative teams swamped. Things, as dental professionals knew them, were comfortable, repetitive, and unchanging; one might even say, perfect.

And then the world fell apart.

A virulent and potentially lethal virus swept across the United States with a vengeance. Dentistry responded by continuing to treat patients as COVID-19 cases began to increase within communities. By mid-March of last year dental practices were maintaining patient care standards without regulatory standards, such as patient screenings, while generating aerosols in haphazard personal protective equipment (PPE).

With the wave of a regulatory wand, the dental profession was quickly deemed nonessential, with dental hygienists removed from the list of crucial professionals looked upon to maintain the health of US citizens during the health crisis.

As dental professionals hung up their loupes and folded their scrubs in isolation, desperately waiting for permission from their states to "return" to work, it became abundantly clear that the dental profession itself was about to walk through an immense transformation.

The dental hygiene community became divided. Perhaps it was the combination of social distancing, furloughs, filing for unemployment, and uncertainty; nevertheless, hygienists across the country overtly shared their opinions about the essential or nonessential aspects of their work over social media platforms-and the world was listening.

Through online forums, dental hygienists learned that the proximity to patient care, aerosols generated during patient care, and length of interaction with a maskless community placed their profession at the top of professions at risk for contracting COVID-19 in the workplace. The early unknowns of the virus fueled an underlying sense of validated fear for hygienists with regard to the perceived safety in "returning" to work while doctors and practice owners held their breath as their income seized and expenses amassed.

Meanwhile, research began postulating and subsequently publishing discovered links between declined oral health and advanced risks for contracting the virus. Many dental hygienists saw this as a key factor in the essential quality of their work, viewing it as an opportunity to begin a candid conversation about what this newly found information would mean for the profession, dental patients, and ultimately the community. Perhaps what the dental profession truly needed was a better conversation, a collaborative conversation, around calibrating professional standards of excellence; perhaps instead of fear-based dentistry labeling the profession as "nonessential," the opportunity was presenting itself to step outside the operatory wall partitions, break through barriers, and create a much-needed "better late than never" dialogue around where the profession must evolve from here.

And so, despite the isolation, the dental profession came together. Through countless webinar course offerings, online forums fixated on next steps, and more, dental professionals across the country and around the world united, working together to better understand. The events of 2020 forced dentistry to critically evaluate every layer of the patient experience, coercing practice owners to institute great change and encouraging team members to demonstrate strength and flexibility in their work.

As a result, dentistry experienced a complete pivot and with it, many practices across the United States and around the world experienced a renaissance.

Infection control standards improved, with modalities such as high-volume evacuation, preprocedural mouthrinses, OSHA- and OSAP-compliant PPE, and advanced disinfection/sterilization procedures being instituted. Patient education evolved as dental professionals utilized online and social media platforms to instruct patients on home care during self-isolation; newsletters were written on healthy habits during a global health crisis; and complimentary phone calls were made to at-risk patient populations to ensure their health and safety. Many dental professionals utilized their stay-at-home orders to review and revitalize their protocols around oral disease, looking to evidence-based research to integrate new protocols within their clinical decision-making model.

The standards, paradigms, and protocols with which patients were treated in January 2020 and those applied in December 2020 were dramatically different. In less than 365 days, the dental profession drove itself further than it had ever gone before. Perhaps the fears, lack of communication, and dread of change that had been carefully swept under reception area rugs had finally been exposed; perhaps the accumulation of apprehensions, the cautious concerns, and timeless trepidation that led to the practice of fear-based dentistry had finally subsided. As such, dental professionals worked through these fears and like the aggregation of dental aerosols in the face of high-volume evacuation, an organization was observed; this organization was overcome by heightened standards, improved protocols, and, most importantly, a new resilience.

Dentistry lost some of its own along this journey, and it is with grace that those who suffered with mental health challenges during this crisis are remembered and honored. Others saw this as an ideal time to hang up their scrubs for good and sought retirement.

And yet, now more than ever, it is acknowledged that the work of the dental professional has never been more impactful than it is today; and for that, the dental profession is better and stronger together.

The year 2020 thrust a number of expectations for dramatic change upon the dental profession. The uncomfortability of pivoting the profession gave way to a massive resilience that has garnered a fresh outlook in where the profession goes from here.

Specifically, there is little within our standards that we "returned" to upon the return-to-work orders, and as such, it is widely accepted that dentistry will simply never be the same.

With a greater awareness of professional standards, dental professionals are able to look to continuing education as a respected source of evidence-based content. With candid conversations came the opportunity to curate situational leadership styles in which collaborations within dental teams required a coming together for the betterment of the community. With new layers of PPE, practitioners are able to better navigate the delicate work they do within the petri dish of dentistry. And with loupes on, we have the ability to magnify and illuminate the work we do while critically approaching our work with clarity of the 20/21 vision for our future.

Maybe this is our chance to approach our profession with an intentional and united voice.

Maybe we needed to take this as a lesson that some of the things that divided us previously are now the very things that have united us. Maybe this will permit us to appreciate the "new" instead of the "normal," to focus on elevating the "work" instead of the "return" to our former standards, and to embrace the "essential" nature of the good work for which we are called and compelled to do.

Perhaps, this is dentistry's opportunity to think anew and act anew.

Katrina M. Sanders, RDH, BSDH, MEd, RF
Founder, The Dental WINEgenist, Phoenix, Arizona