The National Dental Association (NDA) has been concerned about access to Oral Health Care since our inception. Oral Health Care has broader health implications and those hardest hit are the low-income, racial and ethnic minorities, the elderly and disabled and those residing in rural communities. Lack of access to care is multi-faceted and includes lack of insurance coverage, low reimbursement rates by government programs, shortage of Dentists, Dental Hygienists and Dental Assistants, lack of diversity in the oral health work force, lack of awareness of the impact of poor oral health (low dental IQ), along with other cultural, language and socio-economic barriers.
The utilization of Evidence Based Dentistry (EBD) developed through Practice Based Research Networks (PBRN) can assist the dental community in developing viable workforce options. The dental community has previously addressed increasing access to care in many states by introducing the Expanded Function Dental Assistant (EFDA) and the Expanded Duty Dental Hygienist (EDDH). These providers are experienced Certified Dental Assistants or Licensed Dental Hygienists who are recommended by their dentist for further training. They are trained in an accredited program to do procedures, such as, place direct dental restorations (fillings), after the dentist has cut and removed the decay from the tooth, and making temporary crowns after the dentist has prepared the tooth and taken the impression for the permanent crown. This allows the dentist to have more time to see other patients. These providers work under the direct supervision of the licensed dentist which ensures patient safety and quality control. No irreversible procedures to hard or soft tissues are performed, such as extractions or cutting teeth, gums or mucosa. This model is similar to the Dental Technician model used in the U.S. Military.
There is evidence that Prevention Practices are effective in controlling dental disease, pain and cost. These practices include Regular Examinations, Oral Hygiene Instruction, Risk Assessment for Caries (Decay) and Periodontal Disease, Prophylaxis (cleaning), application of fluoride and appropriate radiographs. These procedures should be valued as much as any other procedure performed by a dental professional with appropriate compensation. Many of these procedures can be performed by Dental Hygienists to extend the reach of the dentist. Hygienists were successful in assisting to prevent dental disease when employed in the public school system which is an approach that should be revisited.
The existing EFDA and EDDH models should be expanded to become pipeline positions to a DDS or DMD degree. Dental Hygienists have either an associate or bachelor’s degree upon graduation and many hygienists have continued their studies to become dentists. There are currently few Dental Assisting programs that offer an associate degree making it difficult to rise from that position. We propose that the current EFDA training programs be advanced to award an associate degree allowing for an easier rise to a bachelor’s degree. Another concern is the level of compensation for these new members of the dental team which should be commensurate with the required education and the duties performed. The pipeline issues for identifying and training these additional workforce members are as complex as for dentists.
The NDA has always and continues to support an increase in the recruitment and matriculation of underrepresented minorities from underserved areas into the field of dentistry. These individuals have a vested interest in serving their community and have demonstrated a strong tendency to return to their community for long term service upon graduation. Support of these individuals from grade school through Dental School, as well as support as they develop their practices, is a good investment in the future of Oral Health Care.
While we recognize the need to close the gap as it relates to access to oral health care for underserved populations, it is also the position of the National Dental Association that the resources designated for a new category of Oral Health Workforce would be better utilized to support the infrastructure of existing practitioners and adjunct Oral Healthcare Professionals. We believe that increasing the number of practitioners, and allied oral health professionals currently providing service, along with upgrading facilities and expanding services would be more cost effective and prudent.
The National Dental Association believes that with appropriate policy, legislation, provider and patient incentives, and support for recruitment of underrepresented minorities into dentistry, that the existing framework of oral health care delivery can be improved to provide health equity for the underserved.
Therefore, the National Dental Association makes the following recommendations:
1. The NDA recommends funding Pipeline Initiatives to recruit underrepresented minorities into dentistry starting at the middle school level and provide preparatory courses to instill them with the skills and knowledge to perform well on college admissions tests as well as the Dental Admissions Test (DAT) and to successfully matriculate through dental school.
2. The National Dental Association supports greater use of Expanded Function Dental Assistants and Expanded Duty Dental Hygienists, under the direct supervision of a licensed dentist in that state as a measure to increase the efficiency and capacity of the dental care delivery team. The states will limit the number of EFDA’s and EDDH’s operating under one licensed dentist to ensure the safety of the patients. The primary role of the EFDA and EDDH will be to serve in Public Health Facilities in severely underserved areas. The NDA recommends increasing subsidized training opportunities to increase the numbers of underrepresented minority Expanded Function Dental Assistants and Expanded Duty Dental Hygienists in underserved populations. Furthermore, we propose that the current EFDA training programs be advanced to award an associate degree allowing for an easier rise to a bachelor’s degree.
3. The employment of Dental Hygienists in the public school system to educate and screen students should be reinstituted.
4. The following measures have been proven to increase dentist participation in Medicaid networks.
(A) Medicaid rates should be increased minimally to the 65th percentile of usual customary and reasonable (UCR) fees.
(B) Streamlining Medicaid administrative processes makes the system more “dentist friendly” to providers.
(C) Having a single Medicaid benefits manager within a state translates into one set of program policies, one claims processor, and one organization responsible for contract deliverables within a state.
(D) National Loan Forgiveness Programs for dental graduates whose practices are at least 30% Medicaid or practice in aseverely underserved area.
5. Provide investment tax credits for dentists who locate in underserved communities, as an incentive to dentists to offset lower fees and investment risk in underdeveloped communities. Provide business models for social entrepreneurism as blueprints for success for dentists establishing in underserved areas; and provide mechanisms for obtaining start-up capital.
6. Provide sustainable community grants to address the issue of dental healthcare deserts and promote investments in underserved communities to improve the quality of life.
7. The NDA recommends that underrepresented minority clinical dentists be part of all Institute of Medicine Panels and hearings to improve access to care. The NDA calls for the involvement of underrepresented minority clinical dentists in the recommendation and formulation of policy drawing upon our historic experience of providing care to underserved populations. After all, we have been the caregivers for many of these patients when no other provider would care for their oral health needs.
8. Facilitate more efficient use of uniformed Public Health Service (PHS) and Health Services Corps (HSC) Dentists for rotating deployment to areas of need. Promotions should be linked to efficiencies and capacity building.
9. Reconfigure placement of Indian Health Services Corps Dentists to remote areas with the collaboration of Native American Dentists.
10. Require that Public Health Service (PHS), Health Services Corps (HSC) and Indian Health Services Corps Dental Scholarship Recipients be identified for a specific assignment prior to acceptance of the scholarship and that there be significant financial penalties should the graduate not honor the commitment to the location for which they were contracted.
11. Revival of an emphasis on Preventive Dentistry
- Initiate data collection and analysis to update and determine needs assessment and health literacy in underserved areas.
- Develop cultural and linguistic competency components structured with NDA input and oversight.
- Promote interdisciplinary education to increase awareness about the oral-systemic link; promote the inclusion of the oral cavity as an integral component of the physical examination; and increase referrals from physicians and nurses to the dentist and dental team.
- Increase the dental IQ of the community at large.
The National Dental Association believes that comprehensively trained dentists supervising properly trained auxiliaries in a reformed Oral Health Care System with appropriate medical-dental interdisciplinary cooperation and communication is the standard of care for all Americans. The National Dental Association considers it critical that, in meeting the needs of the underserved community, the quality and standards of care are always maintained. Therefore, it is our position that to improve access to care, increased efforts to support the dental pipeline should be combined with increasing the training and utilization of Expanded Function Dental Assistants (EFDA) and Expanded Duty Dental Hygienists (EDDH). This supports models that have been accepted for years in several states. The National Dental Association also believes that further research and dialogue should occur to develop a concrete policy to address access to care.
Last Updated ( Thursday, 12 April 2012 05:45 )
The National Dental Association (NDA) seeks to provide continued advancement of the highest quality of oral health care and safety for the public. As a resource to key decision makers and the public on a variety of oral health issues, it is our goal to provide timely, evidenced and researched based perspectives. Position papers are reviewed periodically by our policy committee for reaffirmation, updating or expiration. An update concerning a specific recommendation in a paper is released when warranted.