The Role of the Dental Assistant in Addressing Access to Care

 

 By Judith Tuthill, RDH, MA, Director of Dental Assistant Program at Stony Brook University , School of Dental Medicine, Stony Brook, N.Y.

 

Access to Care

In 2000, “Oral Health Care in America: A Report of the Surgeon General,” highlighted the problems in oral health care for many Americans – problems that are particularly acute for America’s children.

Thirteen years later many children still do not have the benefit of oral health.  Disparities exist between the economically advantaged and the economically disadvantaged. ¹ 

As a result, children are dying due to lack of care.

Deamonte Driver was a seventh grader from Prince George’s County, Maryland, who died of complications from an abscessed tooth on February 25, 2007. Deamonte’s life could have been saved by routine dental visits and an $80 extraction. Deamonte complained of a headache. His mother was unable to find a dentist to see him who would accept Medicaid patients, so she took her son to a hospital emergency room where he was given medicine for a headache, sinusitis and a dental abscess and sent home. He quickly got much sicker and was rushed to surgery, where it was discovered that the bacteria from his abscessed tooth had spread to his brain. Efforts were made to save him including two major operations and eight weeks of additional care costing about $250,000 - all too late. ² 

Deamonte’s story is not unique:

• 80 percent of the dental disease in children is found 20-25 percent of children, and these are primarily children from low income and minority families, and there is a growing epidemic of early childhood caries.³
• In 2008 fewer than half of the dentists in 25 states treated any Medicaid patients.⁴
• In 2009 only 12.9 million (44 percent) of the more than 29 million Medicaid enrolled children received any dental services.⁴
• Fewer than one in three of Maryland’s 500,000 children who are Medicaid recipients received any dental services last year. ²
• only about 900 of the state’s 5,500 dentists accept Medicaid patients because of the program’s low reimbursement rate and bureaucratic red tape. ²
  

Just arranging a dental appointment can be a major challenge for families that lack transportation or may be periodically homeless and have erratic telephone and mail service.

Millions of children have dental coverage through either private insurance or a public program such as Medicaid or Children’s Health Insurance Program (CHIPS). Unfortunately this does not mean they receive care.

The Affordable Care Act of 2010 includes provisions to improve availability of dental care for at risk children. By 2014 more children will have some form of dental insurance.⁵ Who will provide treatment for these children?  Most dentists work in private practice, away from Dental Health Professions Shortage Areas (DHPSAs).⁶

A Shortage of Dentists.

Over the next ten years two dentists will retire for every new one that graduates.  Fewer dentists graduated in 2009 than in 1980. In that period of time the population in the U.S. increased by 78 million.⁵

Forty-Seven Million, or 1 in 7, Americans live in an area with a shortage of dentists.⁶

16,511,502, or 1 in 5, children went without seeing a dentist in 2009.⁴

29 states permit expanded function dental assistants.⁷

As a result of the expansion of the Children's Health Insurance Program and the Affordable Care Act, 40 million of America's 78.6 million children—the majority—are becoming eligible for public insurance.⁸

Fewer than 25 percent of America's dentists will treat a patient with public insurance; and of those who do treat children with public insurance, only 9.5 percent bill more than $10,000/year.^9-10

Lack of access to care is multi-faceted and includes:

1. lack of insurance coverage,
2. lack of dentists who will accept Medicaid patients,
3. shortage of dentists,
4. unreasonable restrictions placed on auxiliary dental health care providers,
5. lack of diversity in the oral health work force,
6. lack of awareness of the impact of poor oral health (low dental IQ), along with other cultural, language and socio-economic barriers.

Those hardest hit are the low-income, racial and ethnic minorities, the elderly and disabled and those residing in rural communities.  Authorizing new types of providers can help insure that children receive oral care.¹¹

The enrollment in accredited dental hygiene and dental assisting programs has risen. In the period between 2001-2011 dental hygiene enrollment has increased 22.5%, while dental assisting enrollment has increased 61.5 in the same period. These dental auxiliaries are an underused resource in providing dental care in underserved areas. ¹²

The Importance of Prevention.

There is evidence that prevention practices are effective in controlling dental disease, pain and cost.¹³

These practices include:

• regular examinations,
• oral hygiene instruction,
• risk assessment for caries and periodontal disease,
• prophylaxis,
• application of fluoride
• sealants
• appropriate radiographs. 

Alternative Training Models:

The American Dental Association’s (ADA) has proposed two workforce models in pilot programs at this time.

The Oral Preventive Assistants (OPAs)

Certified dental assistants with the expanded duties of placing sealants and scaling supragingivally in private offices allowing the dental hygienist time to do more complicated procedures.¹⁴

The Community Dental Health Coordinators (CDHCs)

Liaisons with the ability to refer patients to dentists and provide minimal palliative treatment, such as fluoride treatments, sealants, supragingival prophylaxis, and temporary fillings after 1,872 hours of training.¹⁵

The ADA models are redundant because these models already exist in expanded function dental assistants and dental hygienists.

The American Dental Hygienists’ Association (ADHA) has proposed a model which was adopted in Minnesota and is being considered in other states.

The Advanced Dental Hygiene Practitioners (ADHPs);

Midlevel provider requires a master’s degree education expanding roles in providing preventive, diagnostic, therapeutic, and restorative care in less restrictive settings.¹⁶

The Dental Therapist:

The dental therapist model began in the 1920s in New Zealand as a worldwide profession to help address the oral health needs of underserved populations.  Dental therapists provide preventive and diagnostic care, treatment of caries, extractions and pulpotomies without direct supervision.

A report by the W.K. Kellogg Foundation published in April 2012 concludes and that dental therapists provide technically competent, safe care, improve access to care, and have the potential to decease the cost of care, especially for children.¹⁷

The Expanded Function Dental Assistant

The role of the dental assistant in addressing access to care is as the Expanded Function Dental Assistant. The designation can be confusing. No simple answer. There are at least 41 different job titles for dental assistants in the United States. Every state has different education, exam and experience requirements. Each state defines the duties classified as expanded functions differently. Some states have up to five levels and job titles. The scope of practice, required education and level of supervision needs to be fully defined and uniform nationwide.

• EFDAs are trained to do procedures, such as, coronal polish, sealants, topical fluoride and topical anesthetic. In some states they can place direct dental restorations after the dentist has cut and removed the decay from the tooth, and make temporary crowns after the dentist has prepared the tooth and taken the impression for the permanent crown.  This allows the dentist and dental hygienist to have more time to see other patients.
• These providers work under the direct supervision of the licensed dentist.
•  No irreversible procedures to hard or soft tissues are performed, such as extractions or cutting teeth, gingiva or mucosa. ⁷

The Dental Assisting National Board, Inc. (DANB) has compiled the dental assisting requirements for each state. To read about each state’s job titles, requirements and allowable duties, visit the “State-Specific Information” section of DANB’s website at www.danb.org.

A multi-tier system of dental care is preferable to no care.  It is not necessary to develop new workforce models as proposed by the ADA.

Increasing the number of practitioners, and allied oral health professionals currently providing service, along with upgrading facilities and expanding services would be cost effective and prudent in increasing access to care.

In order to improve access to care, increased efforts to support increasing the training and utilization of the newer workforce models, such as expanding the duties of dental assistants,  is imperative.  

Notes Page

1. U.S. Dept. of Health and Human Services. Oral Health in America: a report of the surgeon general. Rockville, Md.: U.S. Public Health Service, Dept. of Health and Human Services, 2000. 
2. Otto, Mary. “For Want of a Dentist.”  The Washington Post. 28 February, 2007. Accessed  Nov 2012.
   
3. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. JDentRes 1996:75 Spec No:631-41.
4. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, "Medicaid Early & Periodic Screening & Diagnostic Treatment Benefit – State Agency Responsibilities" (CMS-416).  Accessed Nov 2012.
5. U.S. Government Accountability Office. Efforts under way to improve children’s access to dental services, but sustained attention needed to address ongoing concerns. Nov 2010. Available at: www.gao.gov/products/GAO-11-96. Accessed Nov 2012.
6. U.S. Department of Health and Human Services, Health Resources and Services Administration, Designated HPSA Statistics Report, Table 4, "Health Professional Shortage Areas by State, Detail for Dental Care Regardless of Metropolitan/Non-Metropolitan Status as of September 1, 2011," U.S. Census Bureau. "Table 1. Monthly Population Estimates for the United States: April 1, 2010 to December 1, 2011" (December 2011). Accessed Nov 2012.
7. Available at: www.danb.org. Accessed Nov 2012. 
8. Kasier Commission on Medicaid and the Uninsured. Oral health coverage and care for low-income children: The role of Medicaid and CHIP. Kaiser Family Foundation, 2009.
9. Office of the Inspector General. Children's dental services under Medicaid: Access and utilization. U.S. Department of Health and Human Services, PHS: Office of the Inspector General, 1996.
10. Gehshan S. Hauck P. Scales J. Increasing dentists' participation in Medicaid and SCHIP. Denver and Washington: National Conference of State Legislatures, 2001.
11. D.A. Nash and R.I. Nagel, “Confronting Oral Health Disparities among American Indian/Alaska Native Children: The Pediatric Oral Health Care Therapist .” American Journal of Public Health. 95 (no. 8, 2005): 1327.
12. ADA 2010-20122 Survey of Allied Dental Education. www.ada.org/esctions/professionalResources/pdfs/survey_allied.pdf. P.15. Accessed March 2013.
13. Pew Commission on the States. The cost of delay: state dental policies fail one in five children. Washington DC and Philadelphia. 2010.
14. Oral Preventive Assistant. Available at: www.ada.org/3207.aspx#personal. Accessed Nov 2012.
15. Community Dental Health Coordinators. Available at: www.ada.org/cdhc.aspc. Accessed Nov 2012.
16. McKinnon M, et al. Emerging allied dental workforce models: considerations for academic dental institutions. J Dent Educ. 2007; 71(11): 1476-91.
17. A review of the global literature on dental therapist. W.K. Kellogg Foundation, April 2012.