Pandemic Prompts Evolution of Dental Hygiene

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Hygienists are continually looking for advances that make their lives easier, their work faster, and care more effective. Innovations in materials, fluctuating patient expectations, and an evolving view of the profession as a whole are constantly changing the landscape of hygiene, the role of the hygienist, and how patient care is approached.

Although the industry and its protocols are always changing, the past year put many adaptations into overdrive. The COVID-19 pandemic necessitated increased infection-control awareness and shifted how dental clinicians practice. Despite the challenges, many of these changes have been beneficial, pushing the industry forward and opening new doors.

“We have to make changes, and we have to evolve based on what is going on,” says Katrina Sanders, MEd, BSDH, RDH, RF, a dental educator, and speaker. “And this pandemic has, of course, done that—it’s pushed dentistry to evolve. Dentistry can be very reticent about integrating new products; newness can be a very difficult thing. But the pandemic has pushed us outside of our comfort zone because we’ve had to invest in new technologies, such as [personal protective equipment] or patient communication software. We’ve certainly seen big movement.”

The pandemic, Sanders believes, has given clinicians the unique opportunity to make changes or shift procedures they may have been uncomfortable altering in the past. Whether that’s upgrading instrumentation or utilizing new protocols, with so many changes happening, the door has opened to make a few more.

“The pandemic has cracked open this concept of, ‘Hey, if I was ever going to make changes in my practice, now’s the time,’” Sanders says. “If you wanted to shift the way that you’re diagnosing or educating patients, now’s the time to do it because patients are expecting dentistry to look and feel different. They are expecting to walk into the dental operatory and have changes come at them—in fact, they’re hoping for it in many ways.”

Hygiene in the Time of SARS-CoV-2

One of the largest and most visible changes has been the adoption of increased personal protective equipment (PPE), aerosol mitigation strategies, and high-volume evacuators.

“Right now, I think a big consideration is obviously infection control—does a product have the ability to be sterilized, and does it solve the current problems that we are facing?” says Alyssa Aberle, MBA, BSDH, RDH, the executive administrator for the Colorado Dental Hygienists’ Association. “There are lots of options for suction and aerosol reduction on the market now, and these developments are critical in keeping both hygienists and patients safe.”

Aerosol reduction in particular has taken many forms, both extra- and intraorally. From the external chairside Dental Aerosol Extractor (Dental Safety First) and The Aerosol Solution System (Aerosol Solutions) to the chair-mounted AeroSol Away, extraoral vacuums capture aerosols before they can disseminate through the air. Intraoral options such as the Mojave dry-vacuum system (Air Techniques) take aerosol reduction to the source, providing high-volume suction in the mouth. But even with the array of current options, Aberle says there is still room for further development.

“There are a couple of things I’d love to see in the future,” she says. “A Cavitron with built-in aerosol reduction would be amazing, especially in the face of [COVID-19]. Bendable or flexible HVEs [high-volume evacuators] would make the job a lot easier and more ergonomic as well.”

One of these wishes will soon be granted: Flexible HVEs like this are already hitting the market. Released this year, the finger-mounted ErgoFinger helps reduce excessive twisting of the wrist and craning of the neck. The HVE attaches to the clinician’s finger, allowing suction to be focused at the aerosol origination point and simplifying 2-handed dentistry.

In addition to aerosol reduction, products and protocols that promote minimally invasive and same-day procedures have taken center stage.

“It’s been great to see lots of products focusing on minimally invasive procedures,” Aberle says. “This is especially important with [COVID-19] and because patients are looking for [other] options to traditional drill/fill dentistry. Patients want to maintain their tooth structure as long as possible, and we have the opportunity to rethink the way we’ve always done things. This also [creates] more opportunities for hygienists to practice at the top of their scope and serve our patients in more community settings.”

Sanders agrees, adding that due to the pandemic, patients are eager to spend even less time in the dental chair than before. And with visits being more time-consuming due to temperature checks, preprocedural rinses, and the donning of many, many layers of PPE, minimally invasive and same-day procedures hold benefits for clinicians as well.

“Patients don’t want to have to come back for multiple steps,” Sanders explains. “Same-day treatment is becoming key—and if that same-day treatment is not as invasive or offers a nonsurgical approach, patients will be more attracted to that. It’s something the sales team used to say and maybe we’d brush it off, but now it means one less round of PPE if the patient isn’t coming back—it eliminates so many steps—so noninvasive has been huge.”

One step-removing innovation has been glass-ionomer sealants. In addition to releasing fluoride, these sealants don’t require the field to be entirely dry before placement. This means hygienists aren’t spending excess time trying to dry the field on emerging molars of squirmy, saliva-filled 6-year-old patients and can get the patient out of the chair sooner with reliable results.

“Glass ionomer sealant options are a game-changer,” Aberle says. “I’m looking to start using Fuji Triage from GC America since it’s able to be applied to partially erupted molars, can be done without aerosols and can be placed over SDF [silver diamine fluoride]the same day.”

Sanders concurs that sealants and placement techniques have come a long way and increase providers’ ability to provide preventative measures that require fewer steps and are incredibly effective.

“We’ve seen an evolution of whether or not something truly requires a dry field,” she says. “Can we remove some steps in the sealant placement process, or can we remove a few seconds off the cure time? We want to meet their preventative needs without creating additional problems down the road, but in an expedient manner. And we oftentimes forget that we have these accouterments in our arsenal.”

Shifting Patient Expectations

With the changes in the dental practice, patient expectations have evolved. In addition to interest in same-day treatment and minimally invasive procedures, patients are becoming more aware of and concerned about the products and ingredients being used in their mouths. This means product selection has become increasingly important.

“Before selecting new products, what’s most important to me is whether or not the product will do what the company claims it will,” says Lynne Slim, MS, RDH, a dental hygienist speaker, and consultant. “It is of utmost importance to be objective when looking at a product and to determine efficacy. You can’t just rely on internet chats with peers; it’s important to review online sources, where a lot of the bias is removed and clinical trials have been conducted. As part of the saying goes, ‘You can’t fool all of the people all of the time.’”

Organic and gluten-free options in foods have been buzzworthy for years, and patients are now extending those preferences and concerns to dental materials. Concerns about chemicals, fluoride, and allergens mean that many practices now have to stock multiple product options to meet patient needs.

“Now everybody wants to know if things are gluten-free or organic or natural,” says Tina Clarke, MEd, RDH, a dental hygiene educator and continuing education speaker, clinician, and owner of Teacher Tina RDH, a professional development resource for hygienists. “So, you need to be aware of those types of marketing labels and what products contain, which could help alleviate the patient’s concerns.”

Sanders also sees the push for natural products, noting that more patients are researching dental materials and looking for alternative options to some of the traditional treatments.

“There’s a big call for more natural products,” she says. “For a long time, it’s been all about fluoride, and because of that, we haven’t been able to connect with patients who are concerned about some of the chemicals or controlled substances. I think we need to be better about integrating products that are going to align with what our patients are asking for.”

Concerns about fluoride have become a hot-button issue that Aberle thinks could be remedied with increased product availability.

“I’d like to have more non-fluoride options for remineralization,” Aberle says. “It would help reach a lot more patients and give them options, potentially leading to greater treatment acceptance and compliance.”

Clarke agrees, adding that the role of the clinician is to serve patients to the best of their ability and the clinician's role meet patient needs while understanding the research to provide patients with educated recommendations.

“Some patients that I serve absolutely do not want fluoride but need some sort of remineralization process,” she says. “Being able to have access to that information and high-quality products is important, regardless of where one stands on the fluoride debate. I’m pro-fluoride, but if I have a patient that says they don’t want a fluoride product, I need to be able to understand and know which fluoride-free products are available that can still provide the care they need. So, for example, right now the prophy paste I use has both a fluoridated and non-fluoridated version.”

Advances in Home Care

Hygienists are also seeing a growing array of all-natural, chemical-free home care products, making personal oral hygiene more accessible—but only if patients know about them. Sanders says she’s now seeing hygienists spending a lot more time focusing on oral hygiene instructions and making recommendations for different home care products like toothpastes, electric toothbrushes, water flossers, and other components.

“I believe this increased education trend is because there is a group of patients who delayed dental care during the shutdown and [feared] returning to the dental practice so home care has become their only hygiene care,” Sanders explains. “We have this challenge now where we’re trying to play catchup, so to speak, and hygienists just are spending a lot more time trying to drive home oral hygiene instruction for the patients.”

For patients neglecting oral hygiene due to concerns about products not being all-natural. Clarke has an arsenal of recommendations at the ready.

“I have patients that want a toothpaste that is vegan or gluten-free, that doesn’t have irritants in it that will affect the tissue—but it needs to get the job done as effectively as a traditional toothpaste,” Clarke says. “I want to have recommendations for them that are scientifically proven to be healthy as well natural. For example, I’ve seen that Twice Toothpaste is doing a good job of that; they’ve incorporated clean ingredients and are really bridging the gap between being natural and [having] scientific evidence to back up its efficacy. Being able to articulate all of that to a patient can be extremely beneficial.”

In addition, recommending products that patients will actually use is critical. If the taste or feel of a product isn’t good, patient compliance will plummet. Although finding home care products that are easy to use and inoffensive to taste buds may be a challenge, a growing number of options is becoming available.

“Finding products with great flavors is especially important with kids,” Aberle explains. “Tanner’s Tasty Paste is the best toothpaste I recommend for kids—good flavors, and it doesn’t contain fluoride, SLS [sodium lauryl sulfate] or xylitol.”

Taste isn’t just important for children; Slim believes it is often a deciding factor for adults too.

“I personally love the new stannous fluoride dentifrices for adults that target a specific use like dry mouth, gum detoxify, or sensitivity,” Slim says. “The packaging of these toothpastes is pleasing to the eye, and I even put it in my occlusal guard at night because I like the taste of these dentifrices so much.”

Options such as these are becoming increasingly more accessible to a wider range of patients as prices have dropped. With so many patients not prioritizing oral health care (or even viewing it as particularly necessary), they are much more likely to invest in good oral care products if they aren’t going to break the bank.

“It’s been great to see more options for affordable home care,” Aberle says. “Electric toothbrushes, toothpastes, interdental brushes—all of these are now more accessible. Electric toothbrushes are now available at a $40-to-$60 price point instead of a $250-plus price point.”

Increased convenience is further reinforcing home care. The pandemic heralded a huge increase in delivery services for products and an expansion of subscription-based deliveries.

“We’re starting to see dental companies step into that with subscription-based models for, say, toothbrush heads,” Sanders says. “It’s a really great way to not only deliver this to the patient on a routine basis but to continue to remind them, ‘Hey, your oral hygiene is important. You just got the shipment, so don’t forget to brush your teeth tonight.’”

The Evolving Profession

As hygienists increasingly focus on patient education and explore new patient-friendly treatment options, the profession becomes a more valuable resource for patients. This increased awareness and evolving view of hygienists as clinicians rather than assistants is reshaping the influence hygienists can have on patients and expanding the array of services hygienists can provide.

Slim mentions that she gets really excited to see television ads that mention the hygienist as a provider because hygienists are preventative therapists trained and educated in ways that dentists are not and can provide unique, critical services to patients.

“I would like to see dental hygienists referred to as therapists,” says Slim. “I’d like to see a schedule where patients schedule the routine exam and radiographs with the dentist at another time that is separate from the appointment with the oral therapist. Valuable time is wasted when dental hygienists sit and wait for the dentist to enter the operatory.”

And perhaps with the way things are trending, this isn’t far off.

“I’m a dental hygiene educator, and I’m a clinician,” Clarke says. “Putting on my educator hat, I think that expanded education has been one of the things that have made me really happy about the pandemic—education for both patients and hygienists [allows] us to grow, learn, and advance oral hygiene. I think it speaks highly to what hygienists can do and who we are that we were able to adapt to this [past] year so quickly as a profession. And I’m sure this is just one step in continued development.”