A Two-Tier Standard
Do the Youngest Citizens of the United States of America Deserve a Two-Tier Standard of Dental Care?
Second opinions are common in health care; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine,
the first opinion will always belong to the reader. This feature will allow fellow dental professionals to share their opinions on various topics, providing you
with a "Second Opinion." Perhaps some of these observations will change your mind; while others will solidify your position. In the end, our goal is to create
discussion and debate to enrich our profession. — Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine
The 2000 Surgeon General's report on "Oral Health
in America" identified a "silent epidemic" of dental disease
in certain large groups of disadvantaged children.¹
This report identified dental decay as the most common
chronic disease of children in the United States, the
majority of this disease found in segments of the population
that live in poverty or low-income households
and lack access to an ongoing source of quality dental
care. Sadly, not much has changed since this report was
published. We know that dental disease in children has
a negative impact on a child's capacity to learn, receive
adequate nutrition, attend school or even achieve a good
night's sleep. Untreated dental disease in children also
affects their home life, their parents' ability to go to
work and their family's health. When a child has dental
disease, everyone in the household experiences a lower
quality of life. As dentists, we know that optimum oral
health is highly correlated with optimum overall or systemic
health, and we also know that the reverse of this
is true – poor oral health in children has a negative
impact on their overall health.
The American Academy of Pediatric Dentistry
(AAPD), the recognized authority in children's oral
health, advocates for optimum oral health and healthcare
services for all children, including those with special
health-care needs. The AAPD has long focused its
attention, resources and advocacy efforts on improving
the oral health and access to high quality dental services
within the context of a Dental Home for those children
who have the highest risk of developing dental decay.
The idea has been proposed that access to care is the
root cause of these high-risk children's problems. While
access issues, and specifically access to dentists who
treat Medicaid or State Children's Health Insurance
Program (CHIP) recipients, are a part of the problem,
it is not the only concern. Other issues, such as lack of
parental knowledge about good oral health practices
and the importance of primary teeth, inadequate access
to nutritious foods and the belief in oral health "myths"
such as "they are only baby teeth, they will fall out anyway,"
are well documented contributors to poor oral
health in this population of children.
A recent AAPD survey showed that more than 70
percent of members treated children who are at the
most risk for high rates of dental decay. Because pediatric
dentists account for approximately three percent
of all dentists in the United States, there are not enough
pediatric dentists to treat these children. It's imperative
that our profession increase its emphasis on the prevention
and early therapeutic treatments to truly impact
the high decay rates present in our nation's most vulnerable
children.
Inequities often result from underutilization of
available dental services. There are numerous barriers to
adequate utilization of oral health services, the most
notable include:
- Lack of oral health literacy
- Cultural beliefs and influences
- Lack of knowledge of existing services
- Financial and job-related barriers
- Geographical barriers
- Transportation difficulties
Assisting parents in overcoming these challenges will
result in an increase in utilization rates and a positive
impact on lowering the oral disease rates in children. In
addition to the treatment of existing dental disease, dental
providers must emphasize education and prevention.
Only by following this directive will we have any influence
on the "silent epidemic" of oral disease that is affecting
our nation's children.
A major component of AAPD's advocacy efforts are
focused on the development of oral health policies and evidence-based clinical practice guidelines that promote
access to and the delivery of safe, high quality
comprehensive oral health care for all children, including
those with special health-care needs, within a
Dental Home. A Dental Home is defined as the ongoing
relationship between the dentist and the patient,
inclusive of all aspects of oral health-care delivery; in a
comprehensive, continuously accessible, coordinated
and family-centered way.² Such care takes into consideration
the patient's age, developmental status and psychosocial
wellbeing, and is most appropriate to the
needs of the child and family. Children who have a
Dental Home are more likely to receive appropriate
preventive and therapeutic oral health care.³
The AAPD, American Academy of Pediatrics (AAP),
American Dental Association (ADA) and Academy of
General Dentistry (AGD) all support the establishment
of a Dental Home as early as six months of age and no
later than 12 months of age. The early establishment of
the Dental Home provides time-critical opportunities to
offer education on preventive health practices and, subsequently,
reduce a child's risk of preventable oral disease.
Within the Dental Home, prevention can be
customized to an individual child's and family's risk factors.
In fact, growing evidence supports the effectiveness
of the early establishment of a Dental Home in reducing
early childhood caries. Each child's Dental Home should
include the ability to refer to other dentists or medical care
providers when all medically necessary care cannot
be provided within the Dental Home. The AAPD
strongly believes that a Dental Home is essential for
ensuring optimal oral health for all children.³
The Dental Home model is based on dentist directed
care; meaning the dentist performs the examination,
diagnoses disease and establishes a treatment
plan that includes the full range of services that meet
a child's individual needs, including preventive services.
All services are carried out under the dentist's
direct supervision in this model (i.e., physical presence
during the provision of care). The dental team
also might include allied dental personnel (i.e., dental
hygienist, expanded function dental assistant/auxiliary
(EFDA), dental assistant) who work under the direct
supervision of the dentist to increase the dental office's
capacity to serve more children while preserving quality
of care.
Furthermore, the dental team can be expanded to
include auxiliaries who go into the community to provide
outreach to families who might not be familiar
with the current dental delivery care system and increase
oral health literacy through education to parents, children
and other caregivers. Allied personnel can also
assist families in accessing a Dental Home through
coordination of care and case management. Using allied
personnel to improve the oral health literacy of this
nation could decrease individuals' risk for oral diseases
and mitigate a later need for more extensive and expensive
therapeutic services.³
The AAPD is supportive of state practice laws that
would allow EFDAs who are currently employed by
dental practices in the community and schools for the
provision of limited preventive services and screening;
parent and caregiver education; and coordination/case
management to build the family's relationship with the
Dental Home. An increase in early prevention and oral
health instruction, facilitated by outreach into the community
to children and caregivers, will decrease decay
rates in children most at-risk for oral disease. The
AAPD believes by utilizing allied personnel to improve
oral health access and literacy and the subsequent
decrease in risk for oral disease, this will decrease the
need for more costly restorative treatments, thereby
reducing the overall cost for dental care. The few available
peer-reviewed studies of the use of EFDAs and a
great deal of anecdotal information from our members
support this hypothesis.4,5,6
The idea of EFDAs practicing within the context of
a true Dental Home, under the supervision of a dentist
is contrary to other proposed non-dentist provider
models purported by some to improve the access to care
for disadvantaged children. Some of these models have
even been implemented in a few select states, which has
allowed for the limited study of these models.
Unlike the EFDA model, these proposed models
need this – others are employed based on independent
practice models, whereby the allied personnel are
allowed to perform diagnosis and treatment normally
reserved for the dentist. These models offer no assurances
that independent non-dentist providers will be
located in underserved areas. In fact, in countries that
have employed such models, evidence shows these
providers often end up practicing in less remote areas,
decreasing their impact on access to the underserved.
In all existing and proposed models, the non-dentist
provider receives significantly less education and training
than a dentist. General dentists attend four years of
dental school after completing their college education.
Dentists who specialize in pediatric dentistry must
spend an additional 24 months or more in a full-time
postdoctoral program, which provides advanced skills in treating conditions and disease unique to children, as
they grow into adulthood.
The few, limited studies addressing the technical
quality of restorative procedures performed by non-dentist
providers have found, in general, that within the
scope of services and circumstances to which their practices
are limited, the technical quality is comparable to
that produced by dentists. There is, however, no evidence
to suggest that they deliver any expertise comparable to a
dentist in the fields of diagnosis, pathology, trauma care,
pharmacology, behavioral guidance, treatment plan
development and care of special needs patients.³
It is essential that policy makers recognize evaluations
that demonstrate comparable levels of technical quality
which merely indicates that individuals know how to
provide certain limited services, not that those providers
have the knowledge and experience necessary to determine
whether and when various procedures should be
performed, or to manage individuals' comprehensive oral
healthcare safely. The AAPD supports the use of EFDAs
in providing this technical competence as a part of the
dental team representing a true "Dental Home."
The New Zealand model is often looked at as a successful
model for non-dentist providers as it has been
in existence for many years. However, in New Zealand's
recent official government report of the oral health
status survey, the caries rate in New Zealand is higher
than that of the United States, United Kingdom and
Australia.7 Given this data, why do some individuals
and organizations continue to view this model as successful?
The AAPD believes the greater use of EFDAs,
under the direct supervision of a dentist, will help
increase the volume of services provided within a
Dental Home. This will have a much greater impact on
access to care, prevention of dental disease and lowering
the cost of treatment to at-risk children.
The AAPD strongly believes that a two-tiered standard
of care should not exist for our nation's most vulnerable
children. Services to this high-risk group should not
be provided independently by non-dentists or "mid-level
providers" with less education and experience, especially
when evidence-based research to support the safety, efficiency,
effectiveness and sustainability of such delivery
models is not available.
Ask yourself – would you allow your children or
grandchildren to be treated by a non-dentist provider
with less education and training than a dentist? My
guess is the answer to this hypothetical question would
be a resounding "No!"
In closing, I implore you to reject a two-tiered standard
of dental care for our country's youngest and most
vulnerable citizens. AAPD members believe every child
deserves a healthy smile and all infants, children and
adolescents, including those with special health-care
needs, deserve access to high quality comprehensive
preventive and therapeutic oral health-care services provided
through a dentist-directed Dental Home.
References
- US Dept of Health and Human Services. Oral Health in America: A Report of the
Surgeon General. Rockville, Md: US Dept of Health and Human Services.
National Institute of Dental and Craniofacial Research, National Institutes of
Health, 2000.
- American Academy of Pediatric Dentistry. Definition of Dental Home. Pediatric
Dent 2010; 32(special issue):12.
- American Academy of Pediatric Dentistry. Policy on workforce issues and delivery
of oral health care services in a Dental Home. Available at: http://www.aapd.org/
media/Policies_Guidelines/P_Workforce.pdf
- Bailit, H, Beazoglou, T, Drozdowski, M. Financial feasibility of a model schoolbased
dental program in different states. Public Health Reports 2008 (123). 761-
767.
- Beazoglou, T, Brown, J, Ray, S, Chen, L, Lazar, V. An Economic Study of
Expanded Duties of Dental Auxiliaries in Colorado.
- American Dental Association. 2009. Available at: http://www.ada.org/1620.aspx
- Gillies A. NZ children's dental health still among worst. The New Zealand Herald.
March 6, 2011. Available at: "http://www.nzherald.co.nz/nz/news/article.cfm?c_id=
1&objectid=10710408". Accessed March 14, 2011.
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