CALIFORNIA EXPANDS ACCESS TO DENTAL CARE

Volume 27, Issue 477 October 16, 2006

Matthew Gever

The medically underserved in California may soon have greater access to dental care.

A new law (AB 1334) expands the ability of dental hygienists to practice in free-standing settings. Hygienists in so-called “alternative practice” who have undergone special training are authorized to provide specified services, such as teeth cleaning and preventive care, in selected settings, such as underserved communities. The new law eliminates a 1997 requirement that patients obtain a prescription from a dentist or physician before being treated by a hygienist outside a dentist’s office.

Some advocates had complained that the prescription requirement was a barrier to care because too few low-income persons had access to a dentist or physician. Also, they said, few dentists were willing to write prescriptions. Dentists said prescriptions were needed to ensure that the hygienists provided appropriate high-quality care, and succeeded in amending the legislation to require a prescription for patients after they have been treated by a hygienist for 18 months.

The legislation will expand access to oral health services by increasing the pool of people available to serve, said Assemblyman Simon Salinas, sponsor of AB 1334. “A lot of underserved communities don’t have a dentist,” he explained.

In California, as elsewhere, few dentists see Medicaid patients because reimbursement rates do not cover dentists’ overhead costs, and the paperwork is burdensome. Most dentists operate as independent businesses, meaning they do not have the same access to capital as a physician working in a hospital.

Support for AB 1334 was boosted by a recent report from the Dental Health Foundation—a research organization focused on California oral health issues—on the state of children's oral health in the state. The survey found that two-thirds of children have significant tooth decay by 3rd grade, and three-fourths of low-income elementary school children have had a cavity, compared to about half of kids who are not low-income. The report ranked the Golden State 24th out of 25 states surveyed.

Nationwide, poor oral health is an “epidemic,” according to a landmark report by former Surgeon General David Satcher. Tooth decay is the most prevalent childhood disease, affecting 59 percent of children. By comparison, 11 percent of children have asthma.

Expanding Access

A large number of states have increased access to dental hygienists in an effort to improve oral health. Currently, 49 states allow dental hygienists to perform certain authorized services without a dentist being physically present on the premises. The settings and levels of supervision required vary from state to state. In 20 states, the dental hygienist can initiate treatment and provide hygiene services based on his or her assessment of patient need. (For more on state actions, go to http://www.adha.org/.)

California’s dental hygienists in alternative practice may provide care in dental health professional shortage areas, as well as in residential facilities and schools, and for homebound clients. Their allowable duties include preventive and prophylactic services, such as cleanings and sealants.

California first tested the concept of “alternative practice” ten years ago. Under the pilot program, 20,000 patients were seen by the hygienists without a single problem, according to Assemblyman Salinas. “There was no indication this would jeopardize the safety of patients.”

The California Dental Association (CDA) expressed concern about AB 1334, saying that the number of hygienists currently practicing in alternative settings (about 150) is too few to assess the impact of the prescription requirements. “Until data indicates otherwise, CDA believes that requiring a level of involvement by a dentist is not unreasonable for [the hygienists], who can provide a limited scope of services to patients,” said a CDA policy statement.

CDA persuaded legislators to amend the bill by allowing patients to be treated by a hygienist in alternative practice without a prescription; however, 18 months from the initial date of seeing the patient, a prescription for services must be obtained from a dentist or physician. That prescription is valid for 24 months, after which a new prescription must be obtained. Failure to follow the new provision would be considered unprofessional conduct and subject the hygienist to penalties.

“The intent is not to have hygienists be dentists,” said Assmeblyman Salinas.