Workforce Strategies to Improve Children’s Oral Health

By Kristine Goodwin | Vol . 22, No. 46 / December 2014

NCSL NewsDid you know?

  • Tooth decay is the most common chronic disease for children.
  • As millions receive dental coverage under the Affordable Care Act, the demand for dental services is expected to strain the current workforce’s ability to meet their needs.
  • States have adopted various workforce approaches to improve access to dental care for underserved populations.

Tooth decay is the most common chronic disease for children. According to a 2014 report by the Centers for Disease Control and Prevention, nearly one-quarter of children between the ages of 2 and 11 have at least one primary (baby) tooth with untreated decay. Although dental coverage is a required benefit for children enrolled in public or private plans, a scarcity of dentists in some areas and other barriers prevent many children from receiving dental care. Only 44 percent of Medicaid-enrolled children received a preventive dental service in 2011. Without regular dental care, preventable dental issues can become costly to states. In 2010, 1.2 million Americans were treated in emergency rooms for preventable dental problems, costing up to $2.1 billion nationally. Most of these visits are covered by Medicaid.

A shortage and uneven distribution of dentists in states and communities contribute to the problem. According to the U.S. Health Resources and Services Administration, 49 million Americans live in the nation’s 4,900 dentist shortage areas; more than 7,300 new dentists would be needed to eliminate these shortages. As millions of children and adults receive dental coverage under the Affordable Care Act (ACA), the demand for dental services is expected to further outpace the current workforce capacity.

State Action

States have adopted strategies to promote access to high-quality, safe and accessible services.

Expanding Workforce Capacity. Several states are exploring options that enable the existing dental team to provide additional services and meet the needs of underserved populations. According to a 2013 report published by The Pew Charitable Trusts, about 15 states are exploring expanding the existing workforce capacity by training hygienists and other providers to perform additional services, licensing mid-level providers such as dental therapists, and using telehealth technology to serve patients not located near providers.

Dental Therapists. Dental therapists—licensed primary oral health professionals whose role is similar to that of medical physicians’ assistants—perform preventive care and routine, restorative procedures, such as placing permanent fillings. They currently practice in Alaska and Minnesota, and were recently authorized to practice in Maine. Working as part of the dental team, these practitioners have expanded access to services in underserved areas and populations, such as for low-income children and seniors. All practice under varying levels of supervision by dentists, allowing dental therapists to meet needs in nontraditional and community settings. Telehealth technology also is often used to connect these providers when needed.

Dental Hygienists. Many states have expanded the services that dental hygienists can provide. In 2014, 37 states allow dental hygienists to provide certain preventive services to patients, often without direct supervision by a dentist, and 16 states allow direct Medicaid reimbursement to hygienists, according to the American Dental Hygienists’ Association.

Community Dental Health Coordinators—educators and community health workers in underserved areas - educate patients about oral health, help them manage treatment and provide limited clinical services, such as screening and fluoride treatments. In 2011, New Mexico formally authorized community dental health coordinators, who work under the general supervision of a licensed dentist.

Offering Incentives to Treat Underserved Populations. Several states have adopted policies that expand the pipeline of incoming dental professionals, provide financial incentives, or remove barriers that may prevent dentists from providing care in underserved areas. To increase dentists’ participation in Medicaid, some states have increased reimbursement rates or reduced administrative barriers. A six-state study by the California Healthcare Foundation found that provider participation in Medicaid and the State Children’s Health Insurance Program increased by at least one-third following reimbursement rate increases.

States can use student loan repayment programs to attract or retain dentists and other providers in areas that most need them. Under these programs, eligible providers agree to work in an underserved area for a period of time in exchange for loan repayment. At least 39 states and the District of Columbia offer such programs, according to the American Dental Association.

Engaging Non-Dental Providers. Enhancing access to oral health services can involve non-dental providers. Pediatricians can provide diagnostic dental services, refer patients to dentists, educate children and parents about the importance of oral health care, and apply fluoride varnish. Engaging pediatricians is effective because children see primary care providers earlier and more frequently than they do dentists. Forty-six state Medicaid programs reimburse medical providers for preventive dental care.

Other Approaches. States have adopted other strategies to strengthen the dental workforce, including investing in telehealth pilot projects, which link practitioners in underserved communities with supervising dentists located elsewhere. A 2014 California law included teledentistry as a specialty service for which in-person contact is not required for Medicaid reimbursement. Some states are using data to gather baseline information about workforce training and adequacy, assess unmet needs, and direct investments and policies to address those needs.

Federal Action

The Affordable Care Act requires dental coverage for children as an “essential health benefit,” but this may strain the dental workforce when millions of additional children gain dental coverage by 2014. Other provisions of the ACA aimed to strengthen the dental workforce, although most—including creating an alternative dental provider demonstration program—have not been funded

PDF Version