The American Dental Hygienists’
Association (ADHA) represents the professional interests of dental hygienists
in the United States. Access to oral health care is one of the highest
priorities of the ADHA.
Position
It is the position of the American Dental Hygienists’ Association
that oral health care—a fundamental component of total health care—is
the right of all people. Lack of access to oral health care is a critical
issue in the United States due to disparities in the health care delivery
system. Dental hygienists must play a vital role in the solution to
eliminate these disparities and assure quality oral health care for
all.
Background
The burden of oral diseases is spread unevenly throughout the U.S. population.
According to the first-ever Surgeon General’s Report on Oral Health,
serious disparities exist in access to oral health care, especially
among low-income populations. One in four American children is born
into poverty (annual income of $17,000 or less for a family of four).
Children and adolescents living in poverty suffer twice as much tooth
decay as their more affluent peers while their disease is more likely
to go untreated.
Serious oral health problems also
occur among adults. Each year about 30,000 Americans are diagnosed with
oral and pharyngeal (throat) cancers, and more than 8,000 people die
of these diseases. In addition, almost 30% of elderly adults no longer
have their natural teeth due to tooth decay and gum disease.1
There are a number of factors that
inhibit access to care, the most obvious is the lack of ability to pay
for care. However, millions of Americans in both rural and inner city
areas are unable to obtain care because there are not enough dentists
practicing in those areas. The federal government estimates that more
than 31 million people live in areas designated as dental shortage areas
where there is less than one full-time equivalent dentist for a population
of 4,000 to 5,000 people. Over 21 million of this population are considered
underserved.2 In addition,
many people who live in areas with an adequate supply of dentists and
who have the ability to pay do not get services because they are homebound
or institutionalized and cannot access the facilities where dental services
are provided.
A number of states have undertaken
various strategies to address the access-to-oral-health problem by providing
incentives to health care pro-viders to serve people enrolled in Medicaid
or the State Children’s Health Insurance Program (SCHIP). If improvement
in the nation’s health care system is to occur, more equitable
access to basic quality oral health care at affordable costs is necessary.
Licensed dental hygienists are educated and qualified to perform oral
health care services, furthermore, dental hygienists serve as an efficient
pipeline for identifying and sending on those who need the care of a
dentist. For example, as early as 1929 in Maine, dentists served only
one-fifth of communities. Many of the remaining communities and territories
were more than fifty miles from the nearest dentist. The state’s
Division of Dental Hygiene compensated for this maldistribution by employing
dental hygienists to identify children with urgent dental needs. These
dental hygienists then negotiated with school departments to contract
with dentists to provide the needed restorative care.3
Today initiatives to expand funding
programs that help people pay for dental services, and that include
the means to reimburse dental hygienists’ services, are necessary
to address the financial barriers to oral health care. However, it is
just as important to remove unnecessary restrictions on dental hygiene
practice and to take measures to encourage dental hygienists to practice
in underserved areas and in settings where patients’ ability to
reach dental facilities is the problem.
Profile of Dental Hygienists
Dental hygienists are licensed,
preventive oral health care professionals who provide educational, clinical,
research, administrative, and therapeutic services that support total
health by promoting optimal oral health.
Dental hygienists are required to
graduate from an accredited dental hygiene program that is at least
two years in length. Graduation from an accredited program housed in
a college or university is followed by successful completion of the
National Board Dental Hygiene Examination. This qualifies graduates
to take a state or regional licensing examination that includes both
a written and clinical component. Dental hygienists must be licensed
in the state in which they work and must practice in accordance with
regulatory laws and dental hygiene practice acts.
Dental hygienists work in places
such as private dental hygiene offices; private dental offices; hospitals;
managed care organizations; federal, state and municipal health facilities;
long-term care facilities; nursing homes; and schools. Licensed dental
hygienists work as clinical practitioners, educators, researchers, administrators/managers,
consultants and business owner/operators.
Currently there are 261 entry-level
dental hygiene educational programs and more than 73 baccalaureate degree-completion
and master’s programs.4,5
The dental hygiene curriculum encompasses
general education, biomedical sciences, dental sciences, and dental
hygiene sciences. According to the accreditation standards for dental
hygiene education programs, these subjects prepare dental hygiene students
to communicate effectively, assume responsibility for individual oral
health counseling, and participate in community health programs. The
accreditation standards also require that dental hygiene students be
prepared to assume responsibility for the assessment, planning and implementation
of preventive and therapeutic services. They must also be taught how
to assimilate knowledge requiring judgement, decision-making skills,
and critical analysis.6
Oral Health Workforce
in the United States
According to the federal government,
there are 140,750 licensed dental hygienists and 130,836 dentists in
the United States.7 Since
1990, the number of dentists per 100,000 U.S. population has continued
to decline. This decline is pre-dicted to continue so that by the year
2020 the number of dentists per 100,000 U.S. population will fall to
52.7.8 However, since 1990,
the number of dental hygiene programs has increased by 27%.9
In addition, from 1985–86 to 1995–96, the number of dental
hygiene graduates has increased by 20%, while the number of dentist
graduates has declined by 23%.10
The United States Health Resources
and Services Administration’s Bureau of Health Professions National
Center for Health Workforce Information and Analysis has studied dental
and dental hygiene workforce issues. Two of the regional centers for
health workforce studies have cited and made policy recommendations
to consider expanding the role of dental hygienists to include the delivery
of oral health care services in shortage areas and to children on Medicaid.11,12
It is clear that the numbers of
dental hygiene programs and graduates are increasing and that licensed
dental hygienists are well educated to provide preventive and therapeutic
services to the public. The American Dental Hygienists’ Association
believes that dental hygienists who are graduates of accredited dental
hygiene programs are competent to provide services without supervision.13
To increase the number of dental
hygienists practicing in underserved areas of the country, dental hygiene
students should be qualified to participate in the National Health Service
Corps Scholarship (NHSC), Loan Forgiveness, and other programs covered
under Title VII and VIII of the Public Health Service. These programs
assist students with the increasing costs of their professional education
while promoting access to care in underserved areas.
Health Promotion/Disease Prevention
Oral health is a critical component
of total health. Recent research has linked periodontal disease to heart
and lung disease; diabetes; pre-mature, low-birth weight babies; and
a number of other systemic diseases.14
Indeed, the first-ever Surgeon General’s Report on Oral Health
has calledattention to this important connection and states, that if
left untreated, poor oral health is a “silent X-factor promoting
the onset of life-threatening diseases which are responsible for the
deaths of millions of Americans each year.”
The early detection and treatment
of oral disease is critical to saving lives. During oral health examinations,
dental hygienists can detect signs of many diseases and conditions like
HIV, oral cancer, eating disorders, substance abuse, osteoporosis, and
diabetes. In addition, dental hygienists can work with patients to develop
oral health care treatment plans that manage oral infection so it does
not exacerbate serious diseases.
Oral Health Care Economics
It is not only socially responsible,
but fiscally prudent, to increase access to preventive services. Each
year millions of productive hours are lost due to dental diseases. A
survey conducted in 1989 showed that children missed nearly 52 million
hours of school, or an average of 1.17 hours per child, due to treatment
problems. That same year, more than 164 million work hours were lost,
an average of 1.48 hours per worker.15
The financial barrier to oral health
care is considerable. More than 150 million Americans, 55 percent of
the population, have no dental insurance. Studies show that those without
private dental insurance are less likely to have seen a dentist recently
than those with insurance. The uninsured tend to visit a dentist only
when they have a problem, are less likely to have a regular dentist,
to use preventive care, or to have all their dental needs met.15
Dental caries (decay) is the most
common chronic disease nationally affecting 53% of 6-8 years olds and
84% of 17 year olds.16
The cost of providing restorative treatment is more expensive than providing
preventive services. Caries is preventable through the use of fluoride
and dental sealants. In 1993, the Coalition for Oral Health, representing
a wide spectrum of oral health associations, reported that one-dollar
spent for prevention saves from eight to fifty dollars in restorative
care. For example, the 2001 Centers for Disease Control and Prevention,
Recommendations
for Using Fluoride to Prevent and
Control Dental Caries in the United States, reports that in 1991, the
annual cost of water fluoridation in the United States was $0.72 per
person. In addition, the average cost of applying one dental sealant
is less than half the cost of one silver filling.17
The average cost for one-surface
filling in 1999 was $65.09, compared to the average cost for placement
of a dental sealant ($29.09).18
The utilization of fluorides and dental sealants clearly demonstrates
significant cost savings.
To make preventive oral health services
affordable, they need to be included in the benefit package of every
reimbursement plan, whether it be Medicaid, SCHIP or a private insurance
plan. It is important that Congress and the Administration recognize
the role dental hygienists can play in addressing the nation’s
access-to-oral-health-care problem. Dental hygienists must be reimbursed
for the services they provide by Medicaid and third-party payers, whether
working under contract, employed by an institution or clinic, or working
as independent practitioners.
Barriers to Care
In addition to financial barriers,
there are bureaucratic and legal barriers that prevent dental hygienists
from providing access to care. There are numerous sources that document
these barriers. For example, the inability to pay for care may result
from having no dental insurance (one source notes that 55% of pre-school
age children and 50% of school age children have no private dental insurance)
or from being ineligible for Medicaid due to income level).19,20
Low rate of payment was cited as the primary reason that dentists did
not treat more Medicaid patients.21
There are also ways that state
laws and regulations restrict access to care—one is by limiting
the type of practice settings, and the other is by imposing restrictive
supervision require-ments. Here are a few examples of limitations on
practice settings outside of the private dental office. In West Virginia,
dental hygienists are limited to industrial clinics and schools; in
Illinois, to mental health institutions and nursing homes; and in Arkansas,
to prisons.
In most states dental hygienists
practice under what is known as general supervision. This means that
a dentist has authorized a dental hygienist to perform procedures but
need not be present in the treatment facility during the delivery of
care. Usually this is conducive to increased access; however, since
the definition in some states may vary depending on state practice act
language, there are restrictions to general supervision. For instance,
in Ohio, dental hygienists are limited to a 15-day period without dentist
supervision.
In other states, such as Georgia
and Illinois, dental hygienists are required to practice under direct
supervision. This means the dentist must be present in the office while
the care is being provided.
In yet another fourteen states,
dental hygienists can practice under less restrictive or unsupervised
practice models. Unsupervised practice means that the dental hygienist
can initiate treatment based on his/her assessment of patient needs
without the specific authorization of a dentist, treat the patient without
the presence of a dentist, and maintain a provider-patient relationship
without the participation of the patients’ dentist of record.
For example, Oregon and California
have expanded dental hygiene practice through creation of limited access
permits and special license designations of a Registered Dental Hygienist
in Alternative Practice (RDHAP’s). Maine and New Hampshire have
a separate supervision for settings outside of the dental office—public
health supervision—which is less restrictive than general supervision.
And New Mexico allows for a collaborative practice agreement between
dentists and dental hygienists in outside settings.
Conclusion
The recent Surgeon General’s
Report on Oral Health identified barriers which keep people from needed
care—inability to pay for care and inability to travel or physically
access the places where care is delivered, or a lack of dentists practicing
in the area. Dental hygienists can play a role in resolving these problems.
ADHA advocates that the services
of dental hygienists who are graduates from an accredited dental hygiene
program can be fully utilized in all public and private practice settings
to deliver preventive and therapeutic oral health care safely and effectively.
Licensed dental hygienists, by virtue
of their comprehensive education and clinical preparation, are well
prepared to deliver preven-tive oral health care services to the public,
safely and effectively, independent of dental supervision.
In addition, dental hygienists are
competent to provide services in a variety of settings more accessible
to patients—residences of the homebound, public health and school
based programs, community clinics, and more.
Recommendations
To increase access to oral health care, the American
Dental Hygienists’ Association recommends the following:
- That oral health care providers continue to
educate the public about the need to maintain their oral health and
the importance of preventive care.
- That dental hygiene education programs provide
dental hygiene students with the knowledge and skills necessary to
deliver oral health care services in a variety of practice settings
and encourage the utilization of externships in underserved areas.
- That federal government funding/grant programs
(Title VII and VIII of the Public Health Service) include dental hygiene
provisions.
- That partnerships be developed among health
care organizations, state and federal government, and other interested
groups to educate the public on the importance of oral health and
the integral role of oral health in total health.
- That licensed dental hygienists be recognized
by the state and federal government as Medicaid providers.
- That state governing bodies eliminate statutory/regulatory
language that restricts the public’s access to oral health care
services provided by licensed dental hygienists.
References
