Does It Take A Village to Treat A Child?

May 2, 2003
Many States Recruit Physicians, Dental Hygienists to Address Access to Care.

Access to dental care continues to be the "silent epidemic" described in the Surgeon General's "Oral Health in America" report.

Dentistry has responded to the multi-faceted problem in several ways, including licensure reform, oral health literacy initiatives, loan forgiveness, volunteerism, and lobbying for increased Medicaid reimbursement. But some health care professions, legislators, and the public believe more needs to be done, according to an article in the May issue of AGD Impact, the newsmagazine of the Academy of General Dentistry (AGD).

In response, many states have implemented alternative models of oral care delivery, which are collaborations of various health care professions, including dentists, dental auxiliaries, physicians, pediatricians and registered nurses. The idea behind many of the programs is akin to a "health care village" to meet the oral health needs of indigent and low-income residents. Collaborations vary in scope and partnerships, but most are statewide and commonly depend on one of two professions: physicians and dental hygienists.

Many of theses collaborators say dentists are instrumental in shaping the programs. They also are one of they key factors in the success or failure of a given program. "Without dentists' support, [alternative models] just aren't going to happen," says Walt Wolford, DDS, former dental director of New Mexico. The state's alternative model has met enormous barriers in large part because organized dentistry was unhappy with it.

Within dentistry, there is friction over the need for-and the safety of-alternative programs. Some dentists believe all dental care should begin and end in the dental office. Other dentists give their blessings to alternative models, but are divided over which models are acceptable. A fluoride varnish program launched in North Carolina has met with considerable success. The project's goal was to train private-practice physicians, pediatricians, and registered nurses to apply fluoride varnish to the teeth of Medicaid-dependent children from birth to age three.

Supervision Causes Friction:
In New Mexico, the state legislature passed a bill allowing qualified dental hygienists to practice in rural and underserved areas without the supervision of a dentist. Called collaborative practice, the law allows dental hygienists to own and manage a practice while consulting with one or more dentists who provide treatment recommendations, prescriptions and diagnostic services for certain procedures.

While North Carolina had the advantage of being one of a majority of states with physician-based models, New Mexico is one of only seven states that allow the unsupervised practice of dental hygienists.

American Dental Association (ADA) policy recognizes that many state medical boards define limited preventive oral health care as being within a physician's scope of practice. The ADA, however, frowns on dental hygienist-based projects because in order to work many of them require hygienists to provide services without the general or direct supervision of a licensed dentist.

"Traditionally, the team approach has been the most efficient and beneficial to the patient," says Jon Holtzee, director of state government affairs at the ADA. For years, the American Dental Hygienists' Association (ADHA) and its components have fought for relaxing restrictions on dentists' supervision. "If dentists and dental hygienists work in a collaborative team role, [the number of] patients seeing dentists actually increases," says Ann Battrell, director of education at the ADHA.