HEALTH PROFESSIONS COUNCIL
RECOMMENDATION ON THE
DESIGNATION OF DENTAL HYGIENE

The Health Professions Council is a three person advisory body appointed by the Government of British Columbia to make recommendations to the Minister of Health and Minister Responsible for Seniors about the regulation of health professions under the Health Professions Act (S.B.C. 1990, c.50).

A. STATEMENT OF ISSUES

The British Columbia Dental Hygienists' Association has applied to the Health Professions Council for designation under the Health Professions Act.

There are two issues in connection with this application:

(a) should the practice of dental hygiene be designated under the Health Professions Act?

(b) how should the scope of practice of dental hygienists be defined?

With respect to the first issue, no one questions the characterization of dental hygiene as a health profession. The question that is raised is how should the profession be governed.

Dental hygienists are currently regulated as an auxiliary body under the Dentists Act (Article 10 of the Rules of the College of Dental Surgeons is reproduced as Appendix A). During the investigation, the College of Dental Surgeons opposed the application from the perspective that not only the profession but the public will be better served by retaining regulation under the Dentists Act with revisions designed to address the specific interests of the dental hygienists. For its part, the applicant expressed a strong desire for dental hygiene to have separate self-governing and self-regulating status as it does in Quebec and Alberta. Such legislation is also pending proclamation in Ontario and under consideration in other jurisdictions.

With respect to the second issue, the scope of practice, differing perspectives between the applicant and the College of Dental Surgeons were even more apparent and sharply drawn.

Current Rules under the Dentists Act delineate the activities which may be delegated to dental hygienists (Articles 10.19 and 10.20) and the circumstances under which the delegated activities may be performed (Articles 10.13, 10.14 and 10.15). Essentially, the activities can only be performed within a dentist's office and after a dentist has conducted an initial examination, made a diagnosis and defined a treatment plan.

Comment:

The Rules do provide an exception for specific delegated duties in specified institutions (Article 10.15). The scope of practice within this exception has recently been somewhat broadened. (Order in Council No. 1614, 22 October 1992 is included in Appendix A.)

To a large degree, the investigation focused on the extent to which, if at all, dental hygienists should be permitted to engage in their professional activities, within their permitted scope of practice, without the direction or supervision of a dentist and outside of a dentist's office. There did not appear to be much dispute about the scope of practice itself. The activities set out in Article 10.20 fairly describe the extent of the professional activities which dental hygienists are by training and experience qualified to perform. The hygienists themselves did not seek significant changes to the defined procedures.

Comment:

One of the procedures permitted within the dentist's office, and then only when a dentist is present and immediately available, is the administration of local anaesthetic. The Council recognizes this to be an activity which requires specific regulation.

Therefore, in simple terms, the most contentious issue in this investigation was whether the performance of these activities requires, in the public interest, that they not be undertaken unless and until a qualified dentist conducted a dental examination.

The dentists were unalterably opposed to dental hygienists practising as "primary care providers". They say no therapeutic treatment should be undertaken until a dentist conducts an examination, makes a diagnosis and defines a treatment plan.

The hygienists, on the other hand, feel qualified to perform the procedures set out within their permitted scope of practice (with some reservations concerning the administration of local anaesthetic) without a prior examination by a dentist. They submit that their training, while not sufficient to qualify them for diagnosis and independent therapeutic treatment, does enable them to recognize when there are oral health problems requiring reference to a dentist. At the same time, however, there does not appear to be any extensive demand within the membership of dental hygienists to establish practice independent of association with dentists and dentists' offices, again with some exception concerning certain institutions.

The Health Professions Council has evaluated the submissions made on each side of these issues and based its decision on what the Council perceives to be in the public interest.

(a) should the practice of dental hygiene be designated under the Health Professions Act?

Recommendations 1, 2 and 3 recommend designation of the profession of dental hygiene with a reserved title to be used only by registrants of the College.

(b) how should the scope of practice of dental hygienists be defined?

Recommendations 4, 5 and 6 provide for maintenance of the present scope of practice for dental hygiene but with removal of the restriction confining the practitioner to the "central office core".

The requirement for "direction" by a dentist, as that term is defined in the Dentists Act, would continue to be a requirement subject to three qualifications:

(1) administration of local anaesthetic would be permitted under the supervision of a qualified health professional (not necessarily a dentist) and then only by registrants who have completed approved training as established by their College,

(2) direction would not be required for those registrants who meet qualifying standards set by their College permitting certain activities to be done, without direction, within designated institutions, and

(3) the direction or supervision of a dentist would not be necessary for those dental hygienists working in dental public health programmes, where health promotion activities are carried out and the provision of dental treatment is excluded.

The requirement for "supervision" by a dentist for procedures enumerated in Article 10.19 would continue as a restriction on the practice of the profession.

Comment:

The Rules of the College of Dental Surgeons of British Columbia under the Dentists Act permit a dentist to employ a dental hygienist to perform certain procedures under the dentist's "personal supervision" and certain procedures under the dentist's "direction". As defined, personal supervision includes a requirement for the presence of a dentist in the dental office where the procedures are being performed. Direction does not require the actual presence of a dentist provided the procedures are in accordance with the specific and appropriate instructions for treatment given to the dental hygienist by a dentist. The rules also restrict the dental hygienist from performing any activities other than in the "central office core" of a dental office, or in institutions such as extended care hospitals or group homes. The special needs of such institutions require specific arrangements to address these needs. The College of Dental Surgeons also recognizes this and has made steps in this direction through Order In Council No. 1614, 22 October 1992. The Recommendations of the Council extend the changes initiated by the Order In Council.

In brief:

(1) The activities described in Article 10.19 would continue to require "personal supervision", that is, a dentist must be present in the office. No supervision would be required for the activities described in Article 10.14.

(2) The activities described in Article 10.20 would (subject to the following exception) continue to require "direction" meaning the activity is prescribed by a dentist but does not have to be performed within a dental office.

(3) The activities described in Article 10.20 may be performed without direction in a designated institutional setting by specially trained dental hygienists who have completed approved training and who have been certified by their College as such.

The Health Professions Council recommends to the Minister of Health and Minister Responsible for Seniors that:

1. the profession of dental hygiene be designated under the Health Professions Act;

2. the College established under section 15(1) for the health profession be named the College of Dental Hygienists;

3. the title "dental hygienist" be reserved exclusively for registrants of the College of Dental Hygienists;

4. the services which may be performed by dental hygienists are those described in Articles 10.14, 10.19 and 10.20 of the Rules of the College of Dental Surgeons of British Columbia under the Dentists Act;

5. the following limitations be placed on the performance of services by registrants, namely;

(1) the practice of dental hygiene does not include diagnosis for comprehensive dental care, prescribing drugs and the cutting of hard tissue,

(2) the performance of services described in Article 10.19 shall be done only under the personal supervision of a dentist, as that term is defined in the Rules of the College of Dental Surgeons of British Columbia under the Dentists Act,

(3) subject to Recommendation 5(4) the performance of services described in Article 10.20 shall be done only under the direction of a dentist, as that term is defined in the Rules of the College of Dental Surgeons,

(4) the services described in Article 10.20 may be performed by registrants who have completed approved training and who have been certified by their College to perform such services without direction by a dentist in institutional settings designated by the College of Dental Hygienists,

(5) the administration of local anaesthetic shall be limited to those registrants who have completed approved training as determined by the College of Dental Hygienists and only when a dentist, physician or other qualified health care professional is immediately available in the facility.

6. that scaling teeth, root planing, orthodontic and restorative procedures and administering local anaesthetic be considered "controlled acts" or part of an exclusive scope of practice which shall only be performed by registrants of the College of Dental Hygienists or registrants of another College authorized to perform them pursuant to either another Act or regulations under the Health Professions Act.

The Health Professions Council has also considered the impact of these recommendations on other legislation and recommends sections 64 and 65 of the Dentists Act and Article 10 of the Rules of the College of Dental Surgeons be reviewed for necessary consequential amendments.

In the opinion of the Council, it is in the public interest to designate dental hygiene under the Health Professions Act. Not only does the profession meet each of the public interest criteria set out in the Health Professions Regulation (see the detailed analysis included as Appendix B), but it was never disputed by any of the participants to the investigation that dental hygiene is a profession and is entitled to self-regulation. Indeed, the then President of the College of Dental Surgeons stated at the public hearing into the application, ".... dental hygiene is a profession and by being a profession deserves full self-regulation" (transcript, page 15). The College of Dental Surgeons did however, take the position that dental hygienists could achieve self-regulation under a revised Dentistry Act.

Throughout the investigation it was made abundantly clear to the Council that the dental hygienists themselves did not accept revisions to the Dentists Act which would provide them with a registrar and other aspects of self-regulation as sufficiently addressing their concerns. Nothing short of complete self-governance as envisaged by the Health Professions Act will address their concerns.

The College of Dental Surgeons was repeatedly invited to provide the Council with some meaningful basis for deciding that the public interest would be better served by retaining regulation of the hygienists and dentists under a single Act. The only reason presented to the Council was that if a member of the public had reason to lodge a complaint with respect to services provided by a dental hygienist they would not know to whom the complaint should be addressed as they would be unaware of the separate regulation of the two professions.

Comment:

This concern seems more apparent than real. The representatives of the College of Dental Surgeons did not cite any instance of a complaint involving negligence or incompetency on the part of a dental hygienist within the past 20 years in this jurisdiction or any other jurisdiction. One example was provided from Ontario concerning a complaint investigated by the College of Physicians and Surgeons but which should more properly have been directed to the governing body of the nurse involved. If this analogy is apt, it implies that nurses should be regulated by physicians. However, members of different health care professions do routinely work together although separately governed without apparent problems (oral surgeons and anaesthetists, for example).

The Council is of the opinion that it would serve the public interest to establish a separate regulatory body for dental hygiene. It would ensure that there would be two separate organizations, one dealing with membership promotion and the other dealing with the regulatory functions of the professional body, as recommended by the Royal Commission on Heath Care and Costs (which was critical of the combined responsibilities of the College of Dental Surgeons). It would also alleviate the inherent difficulties of the present situation whereby the competing interest of dentists acting as employers as well as regulators for dental hygienists may interfere with decisions being made in the public interest. In addition, it would address the very real concerns of the dental hygienists who see themselves not as equal partners under the Dentists Actbut rather, as described therein, as auxiliaries to dentists. In the absence of any significant benefit to be derived by maintaining the status quo, self-governance and self-regulation are, in the opinion of Council, in the public interest.

The applicant has proposed the following names for the College: the College of Dental Hygienists of British Columbia and the College of Dental Hygiene of British Columbia. The Council prefers the former name as it is more in keeping with other professional colleges which tend to be named after the registrants rather than the profession itself.

The Council considers that a reserved title for dental hygienists is in the public interest. In this way the public and other health professions will be assured that anyone calling themselves a dental hygienist is a registrant of the College. Alternatives such as registered dental hygienists and licensed dental hygienist have been suggested, but it is again in keeping with other professions as well as with the nomenclature of the Health Professions Act to reserve the title "dental hygienist".

The applicant did not seek any modification to the current scope of practice of dental hygiene, although it did request that the "Clinical Practice Standards for Dental Hygienists in Canada" (1988) be used to describe the practice of dental hygiene. These standards were developed by an Advisory Committee to the Working Group on the Practice of Dental Hygiene established by the Department of National Health and Welfare in 1981. They have been endorsed by the Canadian Dental Hygienists' Association. The applicant argued that the scope of practice described in Article 10.20 of the Rules of the College of Dental Surgeons does not adequately describe the process of care which is provided by dental hygienists. Article 10.20 sets out an enumerated list of duties and procedures which may be delegated by a dentist to a dental hygienist.

The Clinical Practice Standards are not suitable for inclusion in legislation as a scope of practice statement for a health profession. A scope of practice statement is intended to be a brief description of the profession stating what the profession does, the methods it uses and the purpose for which it does it. The Clinical Practice Standards, being over six pages in length and consisting of three different topics (structure, process and outcome), are more akin to the detailed practice standards which would be enacted in bylaws by the board of a college.

The Council recommends that a descriptive scope of practice statement be formulated along the lines of the new Ontario Dental Hygiene Act, 1991. This should include all the duties and procedures set out in Articles 10.19 and 10.20 of the current governing legislation.

The current Rules of the College of Dental Surgeons (Article 10.14) permit dental hygienists to work in dental health programmes under the "distant supervision" of a dentist -- i.e. the day to day supervision of a dentist is not required. The activities performed by hygienists in dental public health programmes are strictly in the nature of health promotion and do not include the provision of dental treatment.

The Council is of the view that such activities by dental hygienists do not require any supervision at all. Clearly, the risk of harm in the performance of such activities is minimal. Moreover, hygienists have adequate training and education to carry out health promotion activities without supervision from a member of another health profession. It should be noted that this recommendation may facilitate the delivery of prevention programs for improving the dental health of children which were recommended by the Royal Commission on Health Care and Costs.

The Council recognizes that the services described in Article 10.19 are, by their very nature, services which require expanded training and which are directly related to the services performed by a dentist in carrying out a treatment plan following examination and diagnosis. As such, the Council is of the opinion that the restrictions on such activities currently incorporated in the Rules of the College of Dental Surgeons which require personal supervision by a dentist are reasonable and in the public interest.

The services described in Article 10.20 do not at present require personal supervision of a dentist but do require "direction". As defined in the Dentists Act, direction means that a dentist must examine the patient during the course of the appointment except with respect to follow-up treatment which the dentist has specifically authorized and in that event, an examination must be done within 365 days after the first appointment.

It is obvious that dentists have confidence in the professionalism of hygienists and that the hygienists will, in practice, refer patients for examination by a dentist, should such an examination be indicated. We agree that this confidence is well placed, and the dentists are entitled to rely on the hygienist to require a more immediate examination if, in the words of the rule itself, it "would be considered necessary or appropriate in accordance with good dental practice" (Article 10.13(e)).

The Council recognizes that by qualification and training dentists must be considered the primary care givers with respect to oral health. They are the only ones qualified to perform comprehensive examinations, diagnoses, and therapeutic treatment. For this reason, it is important to preserve the role of the dentist as reflected in the requirement for "direction" with respect to the activities of the dental hygienists while at the same time recognizing that certain segments of the public have special needs.

There can be no doubt from the many submissions made to the Council during the course of its investigation that there is a public need for dental services in institutions such as long-term, extended care, and senior citizen facilities. As matters currently stand, the difficulty in providing those services rests largely with the unavailability of dentists and the reluctance of the residents of such facilities to access dental treatment, either because of physical difficulties or because of cost.

The specific problems related to this segment of the population have been recognized by the College of Dental Surgeons, which initiated the recent changes to its Rules. Order in Council No. 1614, 22 October 1992, amended Article 10.15 by deleting the requirement for "direction" in connection with certain delegated duties or procedures carried out in designated institutions. The protocols provided by the College of Dental Surgeons in this connection define certain preventive services which may be provided by a dental hygienist without an initial dental diagnosis by a dentist.

In the opinion of the Council, the protocols defined by the College of Dental Surgeons do not go far enough towards addressing the specific needs of those in such institutions.

In assessing this aspect of the scope of practice of dental hygienists, the Council has attempted to determine with some precision the degree and sources of potential risk of harm to the public in permitting the full scope of practice covered by Article 10.20 without the requirements of "direction". After carefully considering the representations and submissions from the applicant, the College of Dental Surgeons and a very useful interview with the President of the B.C. Society of Periodontists and with the Director of Dental Health Services for the Province, the Council has come to the conclusion that specially qualified dental hygienists could be permitted to perform all of the services outlined in Article 10.20 in designated institutions without direction.

Such additional qualifications may be years of related experience (eg. working in a dentist's office with elderly patients) or further training in community dental health care such as is offered in the Bachelor of Dental Sciences degree program at the University of British Columbia.

The primary risk to which the public could be exposed by permitting such dental hygiene services without direction is two-fold:

a) the risk of performing dental hygiene services on teeth which do not, because of other dental problems, merit such care, and

b) that other oral health problems will be overlooked or not recognized by the dental hygienist.

It was suggested to the Council that patients in long-term care facilities might utilize the services of dental hygienists instead of, rather than as part of, full dental examination, diagnosis and treatment. However, when one considers that if there is a present need which is not being addressed and there are no prospects for the need being addressed in the immediate future, the services of a dental hygienist would surely be preferable to no dental services at all. As it was put to us by a representative of the Society of Periodontists, as between the choice of no dental treatment or treatment by a dental hygienist, obviously the latter is preferable.

In view of the contrary opinions as to whether the ordinary training of dental hygienists qualifies them to determine whether their services are appropriate, the Council has concluded that it is in the public interest to require special qualification. To enable the hygienist to perform the therapeutic services described in Article 10.20 without direction, they should have more than the training required to qualify as a registrant. They must know whether the treatment which their training qualifies them to give is or is not appropriate, and when to refer the patient elsewhere. Accordingly, because there is the need, which may be addressed to some extent by those who are prepared to undertake whatever training is required for special qualification, the Council recommends that the College of Dental Hygienists define the additional training and designate the institutions in which such services may be performed.

Comment:

Ideally, all such care facilities should have made available to the patients and residents the services of a dentist who would then provide the same examination, diagnosis and treatment plan as is provided in the dental office. As that does not appear to be realistic, the Council has turned its attention to assessing to what degree there is a significant risk of harm for such patients if they are allowed to avail themselves of the services of a properly qualified dental hygienist who is sufficiently trained to be able to say whether or not treatment within the hygienists' scope of practice is appropriate or not appropriate. Given the alternative (of no dental care), the risk of harm is not, in the opinion of Council, of sufficient significance to warrant limiting the services which can be provided by a dental hygienist to those set out in the protocol.

With respect to the administration of local anaesthetic, the Council has recommended expanding the circumstances under which a properly trained hygienist can perform such procedures by reference to physicians and other health care professionals. Local anaesthetic is at present administered in a variety of circumstances in the presence of a dentist or medical doctor and the Council considers that the parameters described are sufficient to address the risk of harm to the public.

Because of the significant risk of harm involved in the scaling of teeth, root planing, and orthodontic and restorative procedures these tasks should only be performed by dentists and dental hygienists. In addition, the administration of local anaesthetic is sufficiently dangerous that the procedure should be within an exclusive scope of practice for dental hygienists. This, of course, would overlap with the scope of practice of other health professionals permitted to administer local anaesthetic by their governing legislation.

While the submissions indicate an intensity of the feelings between the College of Dental Surgeons and the Association of Dental Hygienists, the Council accepts and endorses certain principles with respect to the practice of dentistry:

(1) It is in the public interest for all those associated with oral health care to work as a team.

Having said this, the Council could not help but recognize that at present the participants do not perceive themselves to be equal players. The Council, however, is only concerned with how their respective roles affect the public interest. We see nothing in establishing a College of Dental Hygienists which will interfere with the functions of the dental health team and in fact, we are of the opinion that the results can only be beneficial as they will reduce or minimize an apparent source of conflict.

(2) The current requirement for restricting dental hygiene practice to the "central office core" is a restriction which cannot be justified. Provided the requirements for direction and supervision are met, the setting itself should not determine the activity to be performed. While the Council is of the opinion that it is impractical to contemplate the practice of dental hygiene with its present requirements for direction and supervision outside of the dental office, such restrictions should not be determined by the legislation, but rather by both professions determining together in a spirit of cooperation what parameters should be set.

(3) The issue of independent practice, free of any direction or supervision by a dentist, was raised with respect to this application and may well require further study in the future.

At the present time, the dental hygienists themselves do not indicate any widespread interest within their membership for independent practice. Studies of the experience in Colorado (which permits independent practice), and California (which established independent practices on a pilot project basis) do not indicate there is any great demand either amongst the profession or the public.

The Council does not see that allowing independent practice will lead to any significant change from current practice. The qualifications and standards which would be required to permit independent practice without direction or supervision were beyond the scope of this investigation.

(4) The College of Dental Surgeons recognizes that residential care facilities and other institutions catering to the elderly or disabled require special consideration.

A recent amendment to the Rules of the College of Dental Surgeons establishes a protocol whereby certain dental hygiene services may be provided to long-term care facilities by hygienists without the necessity of direction or supervision by a dentist. Although it may give the appearance of addressing the needs of the long-term and elderly care facilities, it does not actually provide a significant service. It did not include those tasks which the dental hygienists consider the most significant services they are qualified to provide - - scaling and root planing. Apparently, the Committee which initiated the resolution has subsequently recommended that the protocol be amended to include initial scaling.

In the opinion of the Council, allowing specially qualified dental hygienists to perform such services in institutional settings without requiring the direction or supervision of a dentist will serve the public interest.

The British Columbia Dental Hygienists' Association submitted an application for designation, together with the application fee, to the Health Professions Council on December 9, 1991. In its application, the Association explained that designation is a natural evolution for a growing profession such as dental hygiene and gave the following specific reasons for seeking designation.

• To ensure that the public interest is protected, in that dental hygienists would be accountable for their services rather than having the accountability lie with another profession (i.e. dentists).

• To simplify access to dental hygiene care for individuals unable to attend private dental offices (i.e. hospitalized and institutionalized patients).

• To give dental hygienists an effective voice in making decisions regarding dental hygiene education, quality assurance, licensure and practice.

• Allowing dental hygienists to regulate the profession of dental hygiene appears to be a trend.

As previously stated, dental hygienists are currently regulated as an auxiliary body under the Rules of the College of Dental Surgeons of British Columbia under the Dentists Act. Article 10 of the Rules sets out the registration requirements, scope of practice and supervision requirements for dental hygiene.

The British Columbia Dental Hygienists' Association wishes to maintain its current scope of practice but would prefer that it be redefined in terms of a process of care rather than as an enumerated list of tasks and services. The Association has proposed that dental hygienists would provide all the services within this scope of practice without the supervision of a dentist. Limitations on practice would include diagnosis for comprehensive dental care, prescribing drugs and cutting of hard tissue.

The Health Professions Council was satisfied that the applicant met the definition of "health profession association" in the Act and decided to conduct an investigation of dental hygiene on the basis of the application. Notice of the investigation was placed in the Gazette as required by section 9 of the Health Professions Act.

Associations, related professions and other organizations having some knowledge about the practice of dental hygiene were solicited for their opinions about both designation and an appropriate scope of practice for the profession, including supervision requirements. Other jurisdictions were also contacted for comparative information regarding the regulation of dental hygiene. (A list of participants in the consultation process is at Appendix C and a summary of the positions taken by the primary stakeholders is set out in Appendix D). The Council also received letters from individual dentists, dental hygienists, and students of dental hygiene expressing their views with respect to the application.

Following Council's consideration of the written submissions, a public hearing was scheduled in order to provide the Council with an opportunity to ask questions and clarify the parties' positions. The hearing was held in Vancouver during the afternoon of September 1, 1992. Presentations were made by the College of Dental Surgeons, the Certified Dental Assistants Society of British Columbia, the College of New Caledonia, the British Columbia Health Association and the British Columbia Dental Hygienists' Association. A transcript of the hearing was taken for the benefit of the Council.

Several supplementary submissions were received subsequent to the hearing and the Council held additional meetings as it considered necessary. The Council also reviewed recent literature with respect to the delivery of dental hygiene services, analogous legislation in other jurisdictions, and studied the independent practice models developed in California and Colorado.

1. Risk of physical, mental or emotional harm to the health, safety or well being of the public.

The applicant cited the following aspects of dental hygiene practice as involving a risk to patients:
• providing direct patient care involving potentially harmful irreversible procedures and medicaments

• administering local anaesthetic agents

• managing infection control for procedures involving blood and saliva

• exposing dental radiographs with ionizing radiation

• assessing and planning dental hygiene care for patients

The applicant also provided examples of the harm which may be caused if the practitioner performs these services in an incompetent, unethical or impaired manner -- introduction of harmful microorganisms into the patient's blood stream, disease transmission, impaired function or tooth loss and increased root sensitivity.

The College of Dental Surgeons agreed that there is a substantial risk of harm from incompetent, unethical or impaired delivery of services.

(a) services performed by practitioners

The services currently performed by dental hygienists are those described in Articles 10.14, 10.19 and 10.20 of the Rules of the College of Dental Surgeons.

(b) technology (instruments and materials) used by practitioners

The instruments and materials used by dental hygienists include hand instruments (mouth mirror, explorer, periodontal probe, curette and scaler); rotary, sonic and ultrasonic instruments; intra and extra-oral radiographs; local anaesthetic agents; various therapeutic agents and preventive education materials.

The methodology of dental hygiene consists of intra and extra-oral assessment, radiographic assessment, analysis of medical, dental and dietary records, clinical skill in the removal of supra and sub-gingival calculus and consultation with other health care professionals, patients and/or caregivers regarding oral health care.

(c) invasiveness of the procedure or mode of treatment used by practitioners

The mode of treatment includes preventive consultation and clinical skills using local anaesthetic agents, hand instrumentation, rotary, sonic and ultrasonic instruments and various therapeutic agents.

(d) the degree to which the health profession is practised under the supervision of another professional in a currently regulated environment

Dental hygienists must work in the central office core from which a dentist conducts his practice under "direction" as that term is defined in Article 10.13 of the Rules of the College of Dental Surgeons. Dental hygienists working in public health programs may work under distant supervision.

2.(a) public interest in ensuring the availability of regulated services

Dental hygienists are well-recognized members of the dental health care team and there is a public demand for dental hygiene services. The applicant and several respondents opined that designation may improve the availability of dental hygiene services, particularly for institutionalized patients.

(b) services provide a recognized and demonstrated benefit

As stated by the applicant, "the services provided by a dental hygienist focus on the prevention and treatment of oral disease and contribute to the overall health of the individual."

(c) body of knowledge that forms basis of standards of practice

The "Clinical Practice Standards for Dental Hygienists in Canada" (1988) integrates basic science, dental sciences, and behavioral sciences.

(d) members awarded certificate or degree from a recognized post-secondary educational institution

There are three two-year Community College Diploma Programs in British Columbia (at Camosun College, College of New Caledonia and Vancouver Community College) and a two-year Bachelor of Dental Science Degree Program at the University of British Columbia.

(e) importance of monitoring continuing competence

Seventy-five hours of continuing education over a three-year period is currently required by the College of Dental Surgeons.

(f) leadership with a commitment to regulate in the public interest

The applicant stated it is seeking designation "to ensure that the public interest is protected, in that dental hygienists would be accountable for their services rather than having the accountability lie with another profession". Several respondents to the consultation process noted the professional growth, maturity and development of dental hygienists.

(g) likelihood that a college would be capable of carrying out duties imposed by the Act

Seven hundred and forty-four of the eight hundred and fifty dental hygienists in British Columbia belong to the applicant Association. The applicant has represented hygienists since 1965. Practitioners already have the experience and knowledge of the responsibilities related to professional regulation.

(h) designation likely to limit the availability of services

Services are already regulated and therefore designation in itself will not affect their availability.

1. Associations

Alberta Dental Hygiene Association
British Columbia Health Association
British Columbia Society of Periodontists
Canadian Dental Hygienists Association
Certified Dental Assistants Society of British Columbia
Council of Senior Citizens Organizations
International Dental Hygienists Federation
Juan de Fuca Hospital Society

2. Health Professions

College of Dental Surgeons of British Columbia
College of Physicians and Surgeons of British Columbia
Corp. Professionnelle des Hygienistes Dentaires du Quebec
Dental Technicians and Denturists Board of British Columbia
The Royal College of Dental Surgeons of Ontario

3. Education Programs

Camosun College
College of New Caledonia
University of British Columbia (Faculty of Dentistry)
Vancouver Community College

4. Other Ministries

Advanced Education, Training and Technology Education

5. Other Provinces

Alberta Health
Alberta Professions and Occupations Bureau
Manitoba Health Services Commission
New Brunswick Dept. of Health and Community Services
Newfoundland Department of Health
Northwest Territories Department of Health
Nova Scotia Department of Health and Fitness
Ontario Ministry of Health
P.E.I. Department of Health and Social Services
Office des Professions du Quebec
Saskatchewan Department of Health
Yukon Department of Health and Human Resources

6. Other

Department of National Health and Welfare (Ottawa)
State of Washington

1. ASSOCIATIONS

British Columbia Health Association
Supports removal of dental hygienists from the confines of the Dentists Act in order to increase the availability of dental hygiene services in particular and oral care in general for residents of long term care facilities.

British Columbia Society of Periodontists

Recommends collaborative model for regulating dental hygiene under the Dentists Act; current scope of practice and level of supervision is appropriate.

Canadian Dental Association

Believes management of dental care delivery best carried out under one piece of legislation; less opportunity for confusion as to who is responsible for care. Overall responsibility for dental care belongs with dentist who has education and training to supervise and manage all care.

Canadian Dental Hygienists Association

Supports regulation of profession as separate from dentistry (as in Quebec, Alberta and Ontario). Supervision requirements should ensure alternate delivery of services, dental hygiene participation in decision-making and multi-disciplinary approach.

Certified Dental Assistants Society of British Columbia

It is not in the best interest of the public for dental hygienists to practise independently; would increase expense of dentistry, inconvenience patients, reduce quality of dental care, and increase risk of medially compromised patient.

2. RELATED HEALTH PROFESSION

College of Dental Surgeons of British Columbia
The public is best served by having all dental care delivered under one Act, where there is a clear identification of the ultimate responsibility for care, and where care providers with a professional level of expertise in specific duties deliver delegated services.

3. EDUCATIONAL INSTITUTIONS

Camosun College
Self-governance is an appropriate expectation of the profession in terms of their development; probably inappropriate to have another profession responsible for program accreditation, licensure and registration, especially since they are also the employers.

College of New Caledonia

Dental hygienists should have the responsibility of determining dental hygiene practice and educational standards. Conflict of interest when one profession arbitrarily controls another. As dental hygiene has matured, so must the legislation.

Vancouver Community College

Graduating students have knowledge and skills necessary in self-regulating profession; degree attainment opportunities supports proposed changes.

University of British Columbia, Faculty of Dentistry

History of education and practice has always provided for a team approach within dental profession. Primary care aspect of self-regulation requires further consideration for the well being of the public and overall management and interaction within the profession.