The Reseda office where Tobelle Segal was leaning over a patient, scraping tartar from teeth, seemed every inch the dentist's office--from the streamlined vinyl reclining chairs in the pastel examination rooms to the posters touting brushing and flossing.
Only two things were missing: the shrill whine of a dentist's drill and the dentist himself.
The office, which opened last month, is the cornerstone of a novel statewide experiment to determine if dental hygienists can clean teeth safely and profitably without supervision. Hygienists, 90% of whom are women, have long labored as employees.
Segal and four other licensed hygienists at the Reseda office, and others in Van Nuys, La Canada, the Central Valley and Northern California, are doing almost every task that hygienists already do in a dentist's office--cleaning teeth, taking X-rays, administering fluoride treatments. At the slightest sign of tooth decay or other problems, patients are referred to a dentist.
Off to Rocky Start
The project, sanctioned by the state and directed by a public health specialist at California State University, Northridge has gotten off to a rocky start. Six years in the making, it was stalled by a lack of financing and by growing opposition from organized dentistry, especially the California Dental Assn., which represents 14,000 dentists in the state.
"They kept threatening that they would work with all their might to stop us," said Myrna Kalman, one of Segal's colleagues at the Reseda office. "They've followed through on their threat."
The dental association filed a lawsuit in February against the state, the 15 hygienists who were starting unsupervised practices and the trustees of the California State University system. The lawsuit claimed that the state did not use the correct procedure when it approved the project and alleged that the unsupervised hygienists are a threat to public health.
The dental association got a split decision. Sacramento Superior Court Judge Eugene T. Gualco refused to stop the project, saying the dental group failed to offer evidence that the project would irreparably harm the public. But Gualco granted the request for a hearing at which the dental association would have to prove that the state violated the law.
"We've all marked the date on our calendars," said Nancy Chesler, the hygienist working in Van Nuys. The hearing is scheduled May 29 in Sacramento.
Colorado is the only other state in which dental hygienists can practice without a dentist's supervision. Six hygienists there have set up practice since independent dental hygiene was legalized last year. They are involved in a prolonged battle with that state's dental association.
The CSUN project, called the Dental Hygiene Independent Practice Prototype, was created under guidelines of the Health Manpower Pilot Projects Act of 1972. The act sanctions experiments in alternative health care that would otherwise be illegal, said Jean Harlow, chief of the Alternative Personnel Resources Development Branch of the Office of Statewide Health Planning and Development.
The pilot projects are designed to assess novel ways of administering health care in a carefully monitored way before legislation is proposed to legalize the new practices, Harlow said. More than 100 projects have been approved by the state to test otherwise illegal methods of providing health care.
Lacked Adequate Financing
First proposed and approved in 1981, the hygiene project languished for lack of adequate financing until last year, when the California Dental Hygienists' Assn. and other dental hygienist groups around the country contributed money to underwrite the project, said Jerome Seliger, a professor of public health at CSUN and the project director.
The main allegation of the lawsuit by the dental association is that the approval process undertaken in 1981, which included public hearings, is no longer valid and must be repeated for the project to be legal.
"No review occurred in 1986, when the project was resubmitted," said Paul Lombardo, legal counsel for the dental association "We're trying to ensure that the state goes through all the procedures so that public health and safety can be assured."
Seliger said the study was carefully designed to collect the first data on independent dental hygiene and to do it safely.
All the hygienists enrolled in the project are licensed, and most have been practicing for 10 years or more. Besides the two to four years of training they underwent to get their licenses, the 15 hygienists who have begun to practice without supervision had to take 470 hours of specialized instruction in medical office management and extra clinical training before they were approved, Seliger said.
The hygienists are working in a variety of settings around the state, Seliger said. The idea is to test the feasibility of independent hygiene in as many settings as possible.
Three hygienists are running a group practice out of a clinic in Los Banos, about 35 miles from Merced; two hygienists in La Canada and one each in Sacramento and San Francisco are providing care at nursing homes, in office buildings or to home-bound patients; Nancy Chesler, in Van Nuys, is renting a room in a dental clinic.
Segal, Kalman and the rest are working in the Reseda office, in a medical building on Canby Street that doubles as the records center for the project.
The hygienists are observed and their records inspected every two months by Dr. Richard Willis, a dentist with offices in Santa Monica. Overall responsibility for assessing the quality of care rests with Dr. James Freed, a professor of dentistry and public health at UCLA. The economic performance of the hygienists will be monitored over the next four years by researchers at the University of California, Davis.
Patient Load Described
Since early March, the Reseda group has had two or three patients every few days, most of them friends or acquaintances who want to support the effort, Segal said. Chesler has seen 135 patients since the project began. A goal of the project is to attract patients from communities that have avoided or lacked access to dental care--for instance, recent immigrants or the home-bound elderly, Chesler said.
"The goal of the whole thing is to give the patient freedom of choice," Chesler said. "I start seeing patients at 7 a.m. and see patients late in the evening one night a week." Not many dentists can match that, she said. If an independent hygienist can offer a lower price, or better office hours, or more careful service than other providers of dental hygiene, a patient should have that option, she said.
That is just what Dale Redig, executive director of the California Dental Assn., said he does not want. He has led the opposition to the CSUN project, describing it as an assault on dentistry. In a recent editorial in the CDA Journal, the association's magazine, he put it this way:
"There is a war going on in our profession, between dentists and hygienists. . . . Hygienists developed a national master plan more than 15 years ago, with the ultimate purpose to achieve total independence from the dentist." The headline to the editorial, topped by an illustration of a dart board riddled with darts, reads: "Which side of this war are you on?"
Described as 'Sham'
In a letter sent to the state's dentists after the suit was filed, Redig charged that "the project is a sham that evades provisions of the law designed to protect the public health." He and other representatives of the dental association have repeatedly said that patients seen by the independent hygienists are "guinea pigs" in a research project.
"Patients are no more guinea pigs here than they are when a dentist is on vacation or goes to lunch or takes a day off," said Chesler, who rents a room in a large, modern dental clinic on Victory Boulevard from the dentist owner, Dr. James Goldman. She does her own bookkeeping, makes her own appointments and cleans up after she is finished. "I wear all the hats," Chesler said.
The services provided by Chesler and the other independent hygienists are the same as those hygienists are allowed to provide in a dentist's office without direct supervision, Chesler said. They can take X-rays, scrape plaque and tartar, seal the craggy tops of teeth with a substance that prevents the deposition of cavity-forming bacteria, administer fluoride treatments, scrape rough spots from the roots of teeth so that bacteria cannot infect the gums.
They cannot use local anesthesia, fill a cavity or offer a diagnosis of a dental problem, Segal said. As in a dentist's office, the hygienist's role is to flag possible problem areas for later inspection by a dentist. Almost every patient seen by the independent hygienists is referred to a dentist, she said.
Goldman has received several referrals of new patients from Chesler's practice. "Everyone benefits," Chesler said. "I have referred patients already to 10 different dentists, periodontists, oral surgeons," Chesler said. "I am not doing dentistry. I am doing a $35 cleaning. They get a chance to do fillings, crowns, services ranging from $35 up to hundreds of dollars," she said.
Responding to dentists' charges that hygienists want to displace them, Chesler said, "We're not competing with dentists. The project is designed to see if we can bring in some of the 50% of the population out there that has no dental care."
Along with the dentists who are accepting referrals from the independent hygienists, others have supported the hygiene project in various ways. For example, the sleek pink chairs and instrument stands sprouting the tooth-polishing and cleaning probes at the Reseda office were donated by a Glendale dentist who was closing his practice, Segal said.
The dentists who have agreed to take referrals would speak only if their anonymity was guaranteed. A Sepulveda dentist who has been practicing 33 years has agreed to take referrals from the Reseda group. "When they asked me, I said, 'Sure, why not?' " he said.
He predicted that independent hygienists would be a boon to dentistry because hygienists tend to be better at "selling dentistry" than dentists themselves. "A lot of them are good sales people," he said. "People tend to listen to them more. Sometimes, when a dentist tells somebody he needs dental care, people don't believe him."
A North Hollywood dentist who requested anonymity said he supports the hygiene project because it is bound to fail. "I think it's great because I think they're going to fall flat on their face," he said. "They have no idea how much it costs to run an office, to keep a business going."
If the legal challenge to the project fails, the program is supposed to run about four years before any conclusions are drawn, Seliger said. At that point, legislation could be written allowing hygienists to practice on their own.
Even if the legal challenge is overcome, the going will not be easy, the hygienists acknowledged. The field is already highly competitive, with cut-rate dental clinics offering fast, cheap cleanings. And finding new sources of patients is difficult.
'Start From Scratch'
"We have to start from scratch," she said. "It could be that we won't be able to prove it's economically feasible. Maybe it will only work in nursing homes, where there's a ready-made base of patients. All we're saying is we want an opportunity to try."
The prices the hygienists are charging are set to match the costs in each community, Segal said. The Reseda clinic is running a $25 special for cleanings--their normal fee is $30--that is lower than some fees in the Valley and higher than others. Chesler, in Van Nuys, is charging $35. If the project were to undercut standard fees, "we would not be able to prove that hygiene practice is feasible in the real world," Segal said.
Besides providing a crucial test of hygienists' ability to work on their own, the project is instilling a sense of self-esteem in a licensed profession that has traditionally suffered from its image of offering a subservient, usually female underling to the male-dominated dental profession, Segal and many of the other hygienists in the project said.
"There are tremendous frustrations on the part of many hygienists who want to work up to the limits of their training," Chesler said.
"We are certainly able to recognize developing dental problems. That's what the dentist usually relies on when he walks in at the end of a cleaning. . . . As it is now, in many dental offices, the dentist walks in at the end, says hello to the patient, and then leaves."
As Chesler cleaned her instruments and straightened out the examination room after finishing a cleaning last week, she said, "As recently as three years ago, I was not excited about dental hygiene. Now I can be a full preventive health professional. I love it."