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Examining the Access-To-Care Problem

Many Americans go without professional oral health care services, but both public and private efforts are underway to change this.

Improving the oral health of Americans remains a challenge for dental professionals. Caries is the most common chronic disease in children and remains at epidemic proportions.1 An estimated one in five children in the United States between the ages of 1 and 18 go without dental care each year.2 Almost half of adults age 30 and older have some form of periodontal disease, while 70% of adults age 65 and older have periodontitis.3 Morbidity and mortality statistics related to oral and pharyngeal cancer have not improved significantly in five decades.4

Disadvantaged populations are particularly vulnerable to oral disease, as their access to oral health care is limited. Further, children, older adults, and those living in rural areas are most likely to experience a significant gap in oral health, which is attributed to limited or no access to dental care.5,6 According to a report by the Institute of Medicine, millions of disadvantaged children are receiving below-standard dental care or experiencing reduced access to care, leading to serious consequences that last into adulthood. The report notes that children do not have access to sealants and community water fluoridation; too few dentists are willing to treat Medicaid-enrolled children; and there are not enough dentists to provide care.5

Part of the problem stems from the current dental practice system. This model of care does not provide the same level of outreach in all settings. Dentists want thriving practices in areas that are convenient for them and their patients. Further, the Medicaid insurance system does not allow for adequate financial reward for dental providers. What is the incentive for dentists to provide outreach to the disenfranchised if there is limited or no reimbursement? Couple these issues with an antiquated regulatory system that controls dental hygiene providers, limiting their capacity to offer preventive care in all settings, and it is no wonder that the US is in this oral health care situation.

SOLUTIONS TO THE PROBLEM

There are workable solutions to address the oral health care crisis, including school-based sealant programs; community water fluoridation; Medicaid improvements to motivate dentists and dental hygienists to treat low-income children and families; and innovative workforce models that expand the number of qualified dental providers, including medical personnel and dental hygienists.5,7 These concepts are not new. The question remains, at what point will the US government and health care providers decide that public health deserves to be more important than the barriers they choose to impose? It is important to be clear on this point: the barriers that exist are artificially imposed and center on issues of finance and control. These are not issues of health and safety.

For dental hygiene, the most promising solution may be the advancement of workforce models designed to improve the public’s oral health. The American Dental Hygienists’ Association (ADHA) has been a driving force in developing and implementing innovative models to position dental hygienists outside of the private dental office system. Currently, 39 states allow dental hygienists to provide patient care in settings without the presence of a dentist. More than 185,000 licensed dental hygienists graduated from accredited educational programs in the US. This workforce could provide a broad range of preventive and therapeutic treatments, including limited restorative services. The ADHA has advanced the concept of a midlevel oral health practitioner, sometimes referred to as an advanced practitioner, as one who provides primary oral health care directly to patients to “promote and restore oral health through assessment, diagnosis, treatment, evaluation, and referral services. The midlevel oral health practitioner has met the educational requirements to provide services within an expanded scope of care and practices under regulations set forth by the appropriate licensing agency.”8

States that have passed midlevel practitioner legislation include Minnesota, Maine, and Vermont. Several other states have legislation proposed or pending. Each state has its own requirements and terminology. Some practitioners are dental hygiene therapists, advanced dental therapists, advanced dental hygiene practitioners, dental therapists, or dental practitioners. Regardless of the terminology, studies of pilot programs have demonstrated that these providers deliver safe and effective outcomes without the presence or direct supervision of a dentist.

Equally important, 18 states recognize and reimburse dental hygienists as Medicaid providers.10 Additionally, numerous states are now incorporating teledentistry and telehealth models into their oral health care delivery systems. Telecommunication systems increase access to care by enabling the transmission of findings to dentists so that dental hygienists can collaborate and work in dental health professional shortage areas. In Oregon, expanded practice dental hygienists will be able to integrate interim therapeutic restorations into virtual dental homes as part of a pilot project by collaborating with a remotely located dentist through telehealth communication. These legislative initiatives show that barriers can be broken when practitioners put the care of the public first. When models are carefully designed and monitored, collaboration and health and safety can be achieved.

There will be opposition to whichever workforce model is attempted. The primary arguments relate to assuring the health and safety of the public, concerns that the underserved may have more complex health issues, dental hygienists are less educated than dentists, and dental drills produce irreversible outcomes.11 Studies examining these issues have demonstrated that these concerns are unwarranted. Dental hygienists practicing in alternative settings, diagnosing conditions, and even performing irreversible procedures (supervised and unsupervised) provide care that is comparable to dentists in a safe, effective manner, with no health risks to the public.12–17 Though limited data are available on this topic, public perception related to dental therapists is positive with respect to access to care, quality of care, less fear of care, reduced cost for services, less travel time, and time saved for scheduling appointments.12,18

CONCLUSION

The US is at another crossroad with a major political change about to occur this November. An opportunity exists to advance health care reform and expand workforce models to improve access to oral health care. Data demonstrate that dental hygienists are capable of providing important preventive services that significantly impact health. Evidence shows that the current system is inadequate to meet the needs of all Americans, and one of the biggest changes must occur within dentistry itself. Reform is not just about new models of care; it is also about pushing the reset button on the mindset of providers. New leaders should be afforded an opportunity to make evidence-based decisions that will benefit the public.

The public does not want another position paper detailing their oral health needs. They need change, and they need it now. Watching oral disease worsen is not the answer. Advanced dental hygiene practitioners may be one of the answers. Let’s utilize them fully and see what occurs over the next 5 years. Perhaps these midlevel practitioners will provide a reawakening of oral health care that leads to a new preventive care system that works.

References

  1. Colak H, Dülgergil CT, Dalli M, Hamidi MM. Early childhood caries update: a review of causes, diagnoses, and treatments.J Nat Sci Biol Med. 2013;4:29–38.
  2. Pew Charitable Trusts. The Cost of Delay: State Dental Policies Fail One in Five Children. Available at: pewtrusts.org/en/research-and-analysis/reports/2010/02/23/the-cost-of-delay-statedental-policies-fail-one-in-five-children. Accessed September 19, 2016.
  3. Eke P, Dye B, Ewi L, Thornton-Evans G, Genco, R. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91:914–920.
  4. The Oral Cancer Foundation. Oral Cancer Facts: Rates of occurrence in the United States. Available at: oralcancerfoundation.org/facts. Accessed September 19, 2016.
  5. Institute of Medicine of the National Academies. Improving Access to Oral Health Care for Vulnerable And Underserved Populations. Available at:
    nationalacademies.org/hmd/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx. Accessed September 19, 2016.
  6. Rhea M, Bettles C. Dental hygiene at the crossroads of change: environmental scan 2011-2021. Available at: adha.org/resources-docs/7117_ADHA_Environmental_Scan.pdf. Accessed
    September 19, 2016.
  7. Healthy People 2020. Oral Health. Available at: healthypeople.gov/2020/topics-objectives/topic/oral-health. Accessed September 19, 2016.
  8. American Dental Hygienists’ Association. The Benefits of Dental Hygiene-Based Oral Health Providers Model. Available at adha.org/resourcesdocs/
    75112_Hygiene_Based_Workforce_Models.pdf. Accessed September 19, 2016.
  9. National Governors Association. The Role of Dental Hygienists in Providing Access to Oral Health Care. Available at: nga.org/files/live/sites/NGA/files/pdf/2014/1401DentalHealthCare.pdf.
    Accessed September 19, 2016.
  10. American Dental Hygienists’ Association. Reimbursement. Available at: adha.org/reimbursement. Accessed September 19, 2016.
  11. Edelstein BL. Examining whether dental therapists constitute a disruptive innovation in US dentistry. Am J Pub Health.2011;101:1831–1835.
  12. Nash DA, Friedman JW, Mathu-Muju KR, et al. A review of the global literature on dental therapists. Comm Dent Oral Epid. 2014;42:1–10.
  13. Wetterhall S, Burrus B, Shugars D, Bader J. Cultural context in the effort to improve oral health among Alaska Native people: the dental health aide therapist model. Am J Pub Health.
    2011;101:1836–1840.
  14. Bolin KA. Assessment of treatment provided by dental health aide therapists in Alaska: A pilot study. J Am Dent Assoc.2008;139:1530–1539.
  15. Battrell AM, Gadbury-Amyot CC, Overman PR. A qualitative study of limited access permit dental hygienists in Oregon. J Dent Ed. 2008;72:329–343.
  16. Reitz M, Jadeja R. The collaborative practice of dental hygiene. Int J Dent Hyg. 2004;2:36–39.
  17. Brocklehurst P, Ashley J, Walsh T, Tickle M. Relative performance of different dental professional groups in screening for occlusal caries. Comm Dent Oral Epid. 2012;40:239–246.
  18. Wetterhall S, Bader J, Burrus B, et al. Evaluation of the dental health aide therapist workforce model in Alaska: Final report prepared for W.K. Kellogg Foundation, Rasmuson Foundation,
    and Bethel Community Services Foundation. Available at: rti.org/sites/default/files/resources/alaskadhatprogramevaluationfinal102510.pdf. Accessed September 19, 2016.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental HygieneOctober 2016;3(10):8-10.

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