By Mary Otto
Millions of Americans are going without dental care. Some lack insurance or money to pay for services. Others are too young or old or disabled to get themselves to a dentist’s office. Still others live in poor or isolated places where providers are in short supply. Dental hygienists who gathered in Nashville June 17-23 for the 92nd annual session of the American Dental Hygienists Association (ADHA), stress they are ready and willing to help get care to people who now lack it.
Organization leaders are determined to further expand hygienists’ freedom to work in the field. And they say that efforts to enable hygienists to become mid-level dental providers trained to drill and extract teeth are gaining momentum nationwide.
“Dental hygienists are educated, licensed and prepared to be part of the solution,” said Kelli Swanson Jaecks, ADHA president.
Across the country, licensed hygienists working in private dental offices already provide a range of dental procedures including cleanings, dental sealants, fluoride treatments, oral cancer screenings and education. And in 37 so-called “direct access” states, hygienists are allowed to provide at least some preventive care in community settings such as nursing homes, schools and public health clinics without the dentist seeing the patient first. This report from the ADHA looks at what is allowed, state-by-state.
Highlights from the conference provide some valuable ideas on how to report on this trend. The ADHA represents the professional interests of more than 185,000 hygienists across the country. As members return to their states, now might be a good time to call to check in with your state chapter, and find out what is on the mind of local hygienists.
Some may give you their thoughts on measures that would allow them to obtain additional education to become midlevel dental providers. Minnesota and Maine already have passed legislation allowing hygienists to expand their training.
Such legislation is being considered in Connecticut, New Mexico, Georgia, Hawaii, North Dakota, South Carolina, Kansas, Texas, Massachusetts, Vermont, New Hampshire and Washington.
“There are 12 states in 2015 that have active legislation on mid-level provider legislation,” Ann Lynch, the association’s director of governmental affairs, said during a media roundtable. “In all 12 states, the legislation is hygiene-based.”
The dental health aide therapist (DHAT) is a non-hygiene-based variation on the midlevel dental provider model that is being employed on Alaskan tribal lands. DHATs are trained in that state using a two-year, post-high school competency-based primary care curriculum.
The ongoing push for midlevel dental providers is controversial. It is being met with strong resistance from organized dentistry in many places.
In Kansas, for instance, where a vast majority of counties have a shortage of dental providers, advocates have been working for several years for a bill that would allow dental hygienists with advanced training to perform procedures including drilling and filling teeth. Yet in that state, as in others, dental leaders have insisted that 18 months of additional training will not prepare auxiliaries to perform what they term irreversible surgical procedures. Check with your state dental society and dental director to learn more about what dentists are saying in your area about midlevel providers.
Speaking in Nashville, hygienists said they have reasons to feel optimistic about increasing opportunities.
Last year, California legislators acted to make permanent key features of an innovative pilot Virtual Dental Home program which enables hygienists and dental assistants to work remotely to offer care to poor and elderly and developmentally disabled patients. Cases are reviewed electronically by an off-site dentist. At the direction of the dentist, the auxiliaries are able to place temporary fillings. Patients who need more advanced care are referred to a clinic.
Earlier this year, the Commission on Dental Accreditation (CODA) adopted accreditation standards for dental therapy education programs, a step encouraged by the Federal Trade Commission. CODA, established in 1975, is the agency charged by the US Department of Education with the power to accredit dental and dental-related education programs.
Meanwhile, organizations including the National Governors Association, the Pew Charitable Trusts, Community Catalyst and the W.K. Kellogg Foundation have offered studies attesting to the safety and quality of care provided by midlevel providers.
Aside from the midlevel provider push, hygienists speaking in Nashville stressed that they could do much more to help patients if state dental practice acts were modified to allow them more independence to perform procedures they have been trained to do.
The placement of dental sealants is a good example, some say. According to the Centers for Disease Control and Prevention, dental sealants — plastic coatings placed on the chewing surfaces of teeth — can significantly reduce decay. But 13 states and the District of Columbia have so-called “prior exam” requirements that make it necessary for a dentist to examine a child before a dental hygienist in a school-based program can place a sealant, the Pew Charitable Trusts concluded in a recent report.
Hygienists, as well as Pew, contend that such rules ignore evidence that a dentist’s exam is not necessary before sealants are placed.
Six states have abolished the prior exam rule since 2012, Pew notes in its report, which concluded that for such reasons most states are failing to provide sealants to low income and at-risk children.
The ability to directly bill Medicaid for services is another big issue for hygienists in a number of states.
Currently, just 16 state Medicaid programs (Arizona, California, Colorado, Connecticut, Maine, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Mexico, Oregon, Washington and Wisconsin) provide direct reimbursements to hygienists for the oral health services they provide to Medicaid beneficiaries.
If you live in one of the 34 states that don’t, are your local hygienists mobilizing to work for direct billing for their services?
