Going Back To Dental Hygiene’s Roots

The most prevalent workforce model for dentistry is the independent, fee-for-service, solo-practitioner private practice.¹ Within the American regulatory system, dental care is delivered in accordance with each state’s practice acts, which dictate both the profession’s scope of practice and supervision requirements. The statistics that follow provide evidence of how this system of oral health care delivery is failing to meet the needs of a third of the United States population. This paper will discuss a model for oral health care delivery that has been shown to address disparity and access for the underserved and unserved youth in the US through direct access to dental hygienists. The impact of expanded scopes of practice for dental hygienists will provide evidence of how these models are improving access to care and, most importantly, improving the oral health of America’s most vulnerable citizens.

DISPARITY AND ACCESS TO ORAL HEALTH CARE IN AMERICA

In a recent report, the National Center for Health Statistics (NCHS) examined the prevalence of youth dental caries and sealant placement in the US by race and Hispanic origin.² The authors, using data from the National Health and Nutritional Examination Survey 2011-2012, determined that approximately 25% of children age 2 to 5 had dental caries in primary teeth.² Untreated tooth decay in the primary teeth of children between the ages of 2 and 8, however, was twice as high for Hispanic and non-Hispanic black children compared to non-Hispanic white children. In children between 6 and 11, 27% of Hispanic children had dental caries in permanent teeth compared to 18% of non-Hispanic white and Asian children. Dental sealants were also more prevalent in non-Hispanic white children compared to non-Hispanic black and Asian children. Sixty percent of adolescents between the ages of 12 and 19 experienced dental caries in permanent teeth, with 15% presenting with untreated tooth decay. The first report on oral health was published in 2000 by the US Surgeon General, yet 15 years have brought little resolution to the issues surrounding children’s oral health status. These statistics serve to validate the inadequacy of our current oral health care workforce model in the US.

Many states have begun to consider new alternatives for the delivery of oral health care to their citizens, and today 37 states allow dental hygienists to provide care directly to patients. In 2015, the Health Resources and Service Administration reported that there are approximately 185,000 dental hygienists in the US. That number is expected to grow to 236,800 by 2025.³ The same report predicts a 6% increase in the number of dentists by 2025.

In the National Governors Association report published in 2014,⁴ the governors suggest increasing the oral health workforce through the expansion of dental hygienists’ scope of practice. One strategy with demonstrated efficacy and efficiency in providing access to underserved and vulnerable populations is the school-based model of oral health care delivery.

SCHOOL-BASED ORAL HEALTH CARE BY DENTAL HYGIENISTS

The concept of dental hygienists providing school-based oral health care has a long history. The Connecticut-based Bridgeport Demonstration Project was started in 1914 by placing dental hygienists in the public schools. At the end of a 5-year trial period, the reduction of decay in children’s teeth averaged 33.9%.⁵ Miles of Smiles (MOS) is a school-based collaboration between administrators from the University of Missouri-Kansas City School of Dentistry, a local school district, and a dental hygienist, who together deliver comprehensive, on-site preventive oral health care to students within a school. This program was established in 2008 due to regulatory changes in the state, which expanded the scope of practice for dental hygienists, enabling them to provide care directly to patients.⁶ Research documents the positive outcomes that have resulted from this school-based oral health care delivery model.^6–8 Even with documented and positive results, organized dentistry continues to reinforce dentists’ professional dominance and avoid debate regarding access-to-care problems.

Resistance from organized dentistry is one of the biggest barriers to dental hygienists with expanded scopes of practice providing care to directly to patients; however, other barriers also exist. Sustainable funding can be problematic. A MOS study found that of the underserved and unserved children being cared for in the program, only 42.5% had Medicaid coverage with Medicaid reimbursement resulting in a mere 1.5% of the total costs for operating the program.9 Other barriers include the physical lifting required to move and work with portable equipment and achieving sustained commitments from community sites.

Action is underway to address issues related to disparity and access to oral health care services for underserved and vulnerable US children. Data confirm that much work is needed to reach a greater degree of oral health equality. Continued support of legislation that allows for direct access to dental hygiene services, legislation that expands dental hygienists’ scopes of practice so they can treat underserved and unserved populations, and funding to sustain such public programs is crucial. School-based programs, where the nation’s youth can receive direct access to dental hygienists including those with expanded scopes of practice, are a model that needs to be established across the US. Dental hygiene started with the provision of oral health care in schools—let’s get back to our roots.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2015;12(10):48–49.