As a Registered Dental Hygienist practicing in Virginia, I strongly oppose allowing dental assistants to perform supragingival scaling with hand instruments or ultrasonic scalers. My concern is not about protecting a profession or a job title. My concern is protecting patient and maintaining an appropriate stand of care. 

Scaling is not simply the removal of calculus that can be seen above the gingival margin. Dental hygienists are educated to assess the entire periodontal condition of a patient, including probing depths, bleeding on probing, inflammation, recession, attachment loss, radiographic bone loss, calculus location, tissue characteristics, and other signs of periodontal disease. We are trained not only in how to remove calculus, but in how to determine what is occurring beneath the gingival margin and when a patient's condition requires a different level of periodontal treatment. 

This raises an important question: What happens to the calculus below the gingival margin?

Removing supragingival calculus does not mean the tooth is free of subgingival calculus or periodontal disease. A patient may leave believing that their teeth have been adequately "cleaned" because the visible calculus has been removed while pathogenic deposits and inflammation remain below the gingival margin. That creates the potential for a false sense of health while periodontal disease continues to progress.

The distinction between supragingival and subgingival instrumentation is also not always a simple visual boundary. Gingival inflammation, pseudo-pocketing, true periodontal pocketing, recession, tooth anatomy, restorations, and calculus extending toward or beneath the gingival margin can complicate instrumentation. Determining where calculus ends and whether additional periodontal therapy treatment is indicated requires clinical judgement, tactile sensitivity, periodontal assessment, and education in periodontal disease. 

I am particularly concerned about allowing dental assistants to use ultra sonic scalers. An ultrasonic scaler is not simply an instrument that removes calculus faster. Proper use requires an understanding of tip selection, adaptation, angulation, power settings, water flow, lateral pressure, tooth and root anatomy, restorative materials, contraindications, and periodontal tissues. Improper instrumentation can result in incomplete calculus removal, unnecessary tissue trauma, patient discomfort, and damage to tooth or restorative surfaces. 

There is also a fundamental issue of disease recognition. What happens when an assistant begins removing supragingival calculus and encounters bleeding, inflammation, deeper pocketing, or calculus extending subgingival? At what point is treatment stopped? Who determines whether that patient actually qualifies for a prophylaxis vs. periodontal therapy? Removing only what is accessible supragingival without adequately addressing the patients periodontal condition risks turning preventative care into incomplete care. 

A workforce shortage does not justify lowering the education standard required to perform a clinical procedure. Dental hygienists complete extensive accredited education in periodontology, oral pathology, radiology, pharmacology, anatomy, instrumentation, infection control, medical emergencies, patient assessment, and supervised clinical care before becoming licensed. Twenty supervised scaling experiences cannot reasonably replicate that depth of education and clinical experience. 

I am also concerned that this policy may worsen the very workforce problem it is intended to solve. Hygienist may increasingly inherit patients who have received repeated supragingival-only treatment while subgingival deposits or periodontal disease remained untreated. Those patients may eventually require more extensive periodontal treatment, additional treatment, referrals, or longer hygiene visits. Rather than decreasing the burden on hygienists, this could simply postpone necessary care and transfer a more complicated patient to the hygienist later. That has the potential to contribute further to workload demand and professional burnout. 

It may also lead to patients to leave practices once they discover that the "cleanings" they believed were comprehensive preventive care did not address developing periodontal conditions. This creates additional work for hygienists and dentist who subsequently assume responsibility for those patients.

There is an ethical and legal concern as well. If a patient repeatedly receives supragingival scaling while clinically significant periodontal disease or subgingival deposits go unidentified or untreated, and the patient later experiences preventable periodontal destruction, questions of informed consents, standard of care, documentation, supervision, and professional negligence will inevitably arise. As a hygienist receiving such a patient, I would fully document the patient's periodontal condition, educate the patient regarding the findings and previous treatment limitations, and encourage patients who believe they have suffered preventable harm to understand their rights and seek appropriate professional or legal guidance. 

Patients should also clearly understand who is treating them and what treatment they are actually receiving. A patient hearing the word "cleaning" may reasonably assume that the clinician is assessing and treating their periodontal needs- merely removing deposits that happen to be located above the gingival margin. 

Dental assistants are invaluable members of the dental team, and this apposition should not be interpreted as diminishing their importance. Their role is essential. However, expanding access to care should not mean assigning clinical procedures. to providers without he same comprehensive periodontal education that licensure requires of dental hygienist. 

Virginia should address the dental hygiene "shortage" by investing in the hygiene workforce, expanding educational opportunities, improving retention, and addressing the causes of hygienist burnout-not by lowering the educational threshold for scaling. The questions should not be, "Can someone by taught to remove visible calculus?" The questions should be, "Does the person holding the scaler have the education and clinical judgement necessary to recognize what they cannot see?"

For the protection of Virginia patients and the preservation of appropriate standards of dental care, I strongly oppose allowing dental assistants to perform supragingival scaling with hand or ultrasonic instruments.

Brittany Wheelbarger, RDH