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Reshaping Professional Boundaries and Organizational Forms in American Dentistry: A Case Study of Registered Dental Hygienists in Alternative Practice


During the past century the field of dental care has evolved to be stable, mature, and highly oriented to a set of institutional logics, particularly entrepreneurship and autonomy, that support the traditional organizational archetype (ideal type model) of solo private-practice dentistry. Since the 1970s, dental hygienists have been working to realign the occupational structure in oral health by challenging both the professional dominance of dentistry and the traditional organization of dental care services.

The study combines insights from the sociology of the professions on the agency of emerging occupations seeking to advance a professional project with insights from organization theory on institutional entrepreneurship to explore a case study of the development of Registered Dental Hygienists in Alternative Practice (RDHAP) in California. This mixed-method case study was developed from qualitative data, including key informant interviews, archival data, media analyses, and two quantitative surveys examining the RDHAP work force. A theoretical model for understanding the institutional agency of emerging professions was developed that provides a link between the study of professions and the study of organizations in health care.

This study explores the movement for independent hygiene practice, which entailed a politicized battle between organized dentistry and dental hygiene that played out in their respective professional associations, the legislature, the courts, the business community, and the media. This conflict led to the development of a new category of hygienists who are allowed to work independently in underserved areas and to the introduction of an alternative practice archetype that now co-exists in the field and is underpinned by a unique interpretive scheme (values and beliefs), structures, and systems. The alternative archetype is built on providing mobile preventive dental hygiene care in a collaborative manner within underserved communities and institutions. This new organizational form has not yet been fully institutionalized as it does not yet have the resources and legitimacy of the traditional model. Expansion of the specific model is hampered by a regulatory structure that inhibits the diffusion of innovation across state lines; however, similar efforts are underway in other states, contributing to the wider adoption of this general practice model.

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