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Expanding Kids’ Access to Oral Health Care Services

New legislation in Tennessee helps dental hygienists provide preventive care to disadvantaged children.

Dental caries is the most common chronic childhood disease, and children from low-income families are at the greatest risk.1,2 While tooth decay is entirely preventable, without widespread access to oral health care, it will continue to affect a large portion of the US population.1,2

Many strategies have been proposed and implemented to address tooth decay among children, with varying levels of success. The American Academy of Pediatrics suggests that providing preventive dental services within pediatric medical offices may help reduce the prevalence of caries because very young children (birth to age 3) are more likely to see a pediatrician than a general dentist.3For this reason, the organization suggests that pediatricians/medical personnel perform dental screenings and provide preventive therapies, such as fluoride varnish, in pediatric medical offices after completing online training programs.4 The organization has also called for state Medicaid programs to include reimbursement for medical practitioners to apply fluoride varnish and conduct dental screenings. According to a survey by Sams et al,4 42 states have enacted laws to provide reimbursement to nondental personnel who perform preventive dental treatment.

Though the use of medical personnel may ease the access-to-preventive-care problem, it is not without disadvantages. For one, the coordination between pediatric medical facilities and referrals to dentists can be problematic because the medical facility would have to remain up-to-date on which dentists in the area accept Medicaid patients. Also, the American Academy of Pediatrics’ plan does not address the need to establish a dental home by age 1, an essential component of supporting oral health in children.

An alternative solution is to bring dental hygienists into pediatric health care settings. As prevention experts, dental hygienists do not need additional training to perform services in these settings. A study conducted over 27 months with more than 2,000 subjects and five dental hygienists providing care looked at the feasibility of integrating dental hygienists within pediatric medical practices.5Results showed that the use of dental hygienists in these settings was effective in expanding access to preventive dental services for disadvantaged children.5

Tennessee has made strides to incorporate dental hygienists into pediatric medical settings. In 2012, the state passed Senate Bill 3269 into law, which enabled dental hygienists to collaborate with dentists and work outside of the dental office to provide oral services to disadvantaged populations.6 Prior to the passage of this bill, dental hygienists could only work within dental offices or for state public health departments. This law described the dental hygienist- dentist collaboration as working under a “written protocol” agreement. Nursing homes, skilled care facilities, nonprofit clinics (such as federally qualified health centers [FQHC]), and public health programs were identified as appropriate settings for dental hygienists to work outside of the traditional dental practice.


The Johnson City Community Health Center (JCCHC), an FQHC, was established in Tennessee, in 2012, and the building included a six-chair dental clinic. The budget did not include funds to hire a dentist, so dental hygiene students from East Tennessee State University in Johnson City were invited to provide preventive and therapeutic services in the clinic. It seemed an ideal setting to establish the first written protocol collaboration in East Tennessee. The plan was set in motion when Trish Mims, RN, director of the JCCHC, followed federal guidelines to develop a plan for reimbursement by the state dental Medicaid program for services provided in the clinic.7 Plans involved identifying dental hygienists and dentists in the area who might collaborate to initiate a comprehensive oral health care program for individuals who use the JCCHC for medical and dental needs. Contacts with various dental groups revealed few in the dental community were aware of the written protocol collaboration law. Mims and members of the Tennessee Dental Hygienists’ Association decided to develop a program to introduce dental professionals to the JCCHC’s dental clinic, invite dentists to volunteer, and encourage dentists to establish a written protocol collaboration with dental hygienists. The dental home would be the JCCHC and the records would be kept by the FQHC, which meets federal requirements for contracting with general dentists.7 Unemployed dental hygienists who were interested in establishing a written protocol collaboration were advised of the opportunity. The process to begin providing dental services through written protocol collaboration is ongoing. The goal is to begin the contract process with local dentists by the end of March 2015. Volunteer dentists will be used until the contract process is finalized.


Tennessee’s written protocol collaboration is one way dentistry can address the access-to-care crisis that is so endemic in the United States. It will take innovative solutions and out-of-the box thinking to ensure that all Americans receive the dental care they need. As it stands, many safety net dental clinics are unable to meet the demand for services; adults who cannot afford dental care are often seeking pain relief at hospital emergency departments; and all children covered under Medicaid still are not receiving regular dental care due to provider shortages.8,9 Dentistry can and must do better. 


  1. Centers for Disease Control and Prevention. Using Fluoride to Prevent and Control Tooth Decay in the United States. Available at: fluoridation/factsheets/fl_caries.htm. Accessed February 9, 2015.
  2. Center of Disease Prevention and Control. Healthy People 2010. Available at: fa21_oral2_ppt.htm. Accessed February 9, 2015.
  3. Section On Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2014;134:1224–1229.
  4. Sams LD, Rozier RG, Wilder RS, Quinonez RB. Adoption and implementation of policies to support preventive dentistry initiatives for physicians. Am J Public Health. 2013;103:383–390.
  5. Braun PA, Kahl S, Ellison MC, et al. Feasibility of colocating dental hygienists into medical practices. J Public Heal Dent. 2013;73:187–194.
  6. State of Tennessee. Bill 3269. An Act to Amend TN Code Relating to the Practice of Dentistry. Available at: 2013/04/Final-Bill2012.pdf. Accessed February 9, 2015.
  7. Federally Qualified Health Center. Increasing Access to Dental Care Through Public and Private Partnerships. An FQHC Handbook 2011. Available at: Files/access-todental- care_fqhc-handbook.ashx. Accessed February 9, 2015.
  8. Wall T, Nasseh K. Dental-Related Emergency Department Visits on the Increase in the United States. Available at: Science%20and%20Research/HPI/Files/HPIBrief_ 0513_1.pdf. Accessed February 9, 2015.
  9. Nasseh K, Vujicic M. Dental Care Utilization Rate Highest Ever Among Children, Continues to Decline Among Working-Age Adults. Available at: 4.ashx. Accessed February 9, 2015.

From Dimensions of Dental Hygiene. March 2015;13(3):16–17.

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