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.