Designing a New Tier of Dental Professional in California

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TOPIC ALERT:

About two million California kids will gain access to dental coverage over the next few years as a result of the Affordable Care Act and the state's decision to shift children from Healthy Families to Medi-Cal, California's Medicaid program. ACA also will provide more dental coverage for some adults.

That's generally considered good news in the dental and children's health communities ... but who's going to do the work?

In many parts of California, there aren't enough dentists now, let alone with millions of new mouths to look after. Fifty-three of California's 58 counties have at least one area with too few dentists, according to HHS' Health Resources and Services Administration.

That's not to say California doesn't have enough dentists. According to the California Academy of General Dentistry, California has more dentists per capita than any other state -- one dentist for every 1,250 residents, compared with the national average of one dentist for every 1,639 residents.

It's a problem of distribution, not quantity.

The California Legislature this month will consider a bill aimed at improving dental care for underserved children. SB 694, by Sen. Alex Padilla (D-San Fernando Valley), would:

  • Create a statewide office of oral health that would help California get federal money for subsidized dental programs; and
  • Authorize a project to explore new workforce training and delivery models with the goal of providing oral care for underserved children.

The bill would launch a project to train a new level of oral health care professional in California -- people less educated than dentists but with enough training to perform some dental procedures. The bill would establish the framework for a study -- probably about three years long -- but it does not spell out the details of how the new tier of providers would be trained or what levels of procedures they'd be able to deliver.

Is California ready to explore new ways to deliver dental care? How should this new tier of dental provider be designed?

We got responses from:

  • Daniel Davidson | President, California Dental Association

    'Important First Step' in the Right Direction

    The need for dental leadership and effective dental prevention programs in California is more critical now than ever before, as more than one million additional children and some adults are expected to gain access to dental coverage under the Affordable Care Act.

    Currently, California lacks the state-level dental leadership necessary to develop policies, coordinate resources, promote best practices, secure federal funding and ensure there is the infrastructure necessary to deploy California's dental workforce where it is needed most -- in programs that offer oral health services to the 30% of the population that experiences barriers to care.

    Barriers to care are multifactorial and complex, including geography and transportation, language and culture, finances and more. They are further compounded by the state's 2009 decision to eliminate funding for adult Denti-Cal services as well as funding for the state's only school-based dental disease prevention program for low-income children, the California Children's Dental Disease Prevention Program.

    Despite these challenges, it is important to remember that the current oral health care system provides regular dental care to more than 70% of the population and has some of the most highly trained dental professionals in the nation, including advanced trained dental hygienists (known as registered dental hygienists in alternative practice) and advanced trained dental assistants (known as registered dental assistants in extended functions). While we look for new solutions to bring care to underserved individuals, we must also fully utilize available resources and promote effective strategies for reaching those in need of care.

    SB 694 is an important first step toward addressing oral health disparities in California, advancing CDA's top priority -- hiring a state dental director to begin the essential work of building effective public programs. Additionally, SB 694's proposal to research the safety, quality, cost-effectiveness and patient satisfaction of specific types of care provided by alternative dental providers is consistent with CDA's position that this research is necessary before any proposal for a new provider model in California is considered. Specifically, the study called for in SB 694 is a rigorous academic study involving registered dental hygienists and registered dental assistants in extended functions, as described above, and will contribute essential data to the evidence base on which to consider any potential future dental workforce changes in California.

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  • Guy Acheson | President-elect, California Academy of General Dentistry

    SB 694: Dangerous, Discriminatory, Unnecessary

    SB 694 is dangerous because it may lead to allowing dental assistants and hygienists with limited training to give local anesthesia injections, extract teeth and drill teeth for fillings and stainless steel crowns. With remote supervision there would not be a dentist physically present to handle complications.

    General dentists often refer children to pediatric dentists, oral surgeons and endodontists if they are uncooperative, have decay into the nerve of the tooth, or have ankylosed baby teeth. These procedures on our vulnerable children should not be entrusted to a non-dentist.

    SB 694 is discriminatory because it establishes a two-tiered standard of care. The Hispanic Dental Association, the National Dental Association, the American Dental Association, the American Academy of Pediatric Dentists and the Academy of General Dentistry oppose this concept. They all feel that a two-tiered standard of care -- where children from minority and low-income families see a non-dentist and everyone else gets care from a dentist -- is unfair.

    SB 694 is unnecessary because studies have already been done in various places around the U.S. and in the countries that developed this model. This concept is not economically viable. There is no need for these under-trained personnel when California has more dentists than anywhere else on the planet. No reason to believe that these new providers will actually practice in underserved areas. There are underemployed/unemployed dentists, as well as many new dental school graduates who leave California for other states because there are no jobs here. 

    There is good news. With the Affordable Care Act, most of these children will be covered by dental insurance. That means there will be more resources to support community health centers and community-based dental residencies will be able to offer dentists more jobs treating the underserved. Rather than trying to reinvent the wheel, California should look at programs that work and implement best practices. 

    Ultimately, constructing, running and assessing the study, setting up the training curriculum, the training, the licensing and regulation of this new provider would be expensive and take many years. In the effort to deal with dental decay in children, this is just kicking the can down the road. Supporting our existing cadre of dentists would make a difference almost immediately. We should use proven concepts that work to allow dentists and existing dental personnel within their current scope of practice to address disparities in dental care for California's children.

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  • Jenny Kattlove | Director of Strategic Health Initiatives, The Children's Partnership

    Getting Dental Care to Children Who Need It Most

    For Tina Infante's one-year-old son, Joseph, what began as a broken tooth ended nine months later with two visits to an emergency room in Humboldt County and four extractions by a pediatric dentist. It is an expensive solution that still leaves Joseph's dental health in question for many years to come. Joseph's experience was extreme, but it is a glaring example of the consequences of the state of children's dental care in California. Instead of cost-effective and stable preventive dental care, many children end up with temporary and expensive care through ERs, as Joseph did.

    Alarmingly, the access problem is poised to get worse. While we applaud the federal government for ensuring that millions of additional children obtain dental coverage under the Affordable Care Act, many parts of California do not have the supply of dental care providers to meet current demand, let alone this growing demand. Fifty-three of California's 58 counties have at least one area with a federally designated shortage of dentists. These communities are usually poor and are home to more than one million children. Even when parents can find a provider covered by their insurance in other areas, they often face transportation problems and months-long waiting lists for their children to be seen. It's not surprising that nearly a quarter of California's children under age 12 have never once been to a dentist. The ensuing dental problems result in school absences and can lead to more serious health problems.

    So what's the solution? Later this month, the California Assembly will consider SB 694, a bill that looks to address these problems through innovative approaches. The bill, by Sen. Alex Padilla (D-San Fernando Valley), would authorize a study to evaluate a new dental workforce model, which would train dental professionals to provide preventive and restorative dental care to underserved children in schools and other community sites. While some problems will always require a dentist, similar models have increased access to high-quality dental care in places like Alaska, Canada and more than 50 other countries. Such a solution is urgently required to help close the gap in dental care for California's children.

    In addition, SB 694 would strengthen California's office of oral health. Led by a dental director, the office will provide state leadership and implement much needed oral health programs and would allow California to access millions of federal dollars to provide these critical programs to vulnerable populations.

    A broken tooth or a simple cavity in childhood should not lead to a lifetime of dental problems. Nor should parents be unable to access affordable dental care for their children. SB 694 would help ensure these problems become a thing of the past and that California's kids have a healthy future.

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  • Sen. Alex Padilla | Democrat, San Fernando Valley

    Barriers to Dental Care Multiple, Complex

    Nearly a quarter of California children under the age of 12 have never been to a dentist. In Los Angeles County, 81% of children lack access to dental care. So it should be no surprise that dental decay is the most common unmet chronic health care need of children and that statewide more than 70% of children experience tooth decay by the time they reach third grade.

    The barriers to dental care in California are multiple and complex. Among them is a mismatch between the demand for services and the supply of providers. The U.S. Department of Health and Human Services reports that California has 333 federally designated dental health professional shortage areas.

    The recent U.S. Supreme Court decision upholding the provisions of President Obama's Affordable Care Act will provide dental insurance to an additional 1.2 million children, but will these children have access to care? These developments bring California's health access crisis into sharp focus.

    I introduced Senate Bill 694 to help address the oral health access issue. SB 694 would create a state dental director to provide oral health leadership. It would also authorize a university-based study on oral health care access.

    The scientifically rigorous study would examine expanded procedure capabilities for both Registered Dental Hygienists and Registered Dental Assistants in Extended Functions 2. Under the supervision of a dentist, Registered Dental Hygienists and Registered Dental Assistants in Extended Functions 2 would be recruited to participate in the study and would be trained in a limited set of seven procedures outlined in the bill, such as filling a cavity, placing a stainless steel crown and primary tooth extraction. After receiving this training, the study participants would, under the supervision of a dentist, provide dental care to children in public health settings in underserved areas throughout the state. I believe the study findings will prove valuable and inform future policy proposals and decisions.

    The Affordable Care Act offers tremendous potential to meet the current unmet dental care needs of children in California, but only if we simultaneously increase the capacity of our pediatric dental care system. Working together we can ensure that our children have true access to proper oral health services.

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  • Susan Lopez | President, California Dental Hygienists' Association

    Bill Builds on Existing Supply of Providers

    California is ready to take another step toward addressing the unmet dental health needs of our children and provide some solutions for the 83,000 emergency room visits at the cost of $55,000,000 as well as the $30,000,000 lost to our schools due to 874,000 missed school days due to dental problems in a recent year with the anticipated passing of SB 694. SB 694 with the support of both the California Dental Hygienists' Association and the California Dental Association, will bring leadership to the state's oral public health agencies with the establishment of a dental director and will bring services to the one-quarter of this state's children under 12 who have never been treated by a dentist.

    Rather than creating a new workforce entity, this bill builds upon existing licensed dental health care providers. Only registered dental hygienists and registered dental assistants in expanded functions will be included in this study bill. Other states are investigating a two-year post-high-school dental therapist program, but California's bill chose to build a program with dental hygienists, whose education includes years of both preventive and dental disease course work and hygienists in expanded roles who are extensively educated in dental procedures. 

    California's first step was the licensure of the Registered Dental Hygienist in Alternative Practice, allowing preventive and therapeutic dental care to be provided to underserved populations in defined areas without the general supervision of a dentist.

    The study will be conducted through a California dental school and take place in public health settings throughout the state. Specified expanded dental procedures provided under various levels of supervision will be carefully evaluated for safety, quality, cost-effectiveness and patient satisfaction.

    Access to care is a complex problem that will require many methods to address all of the causes. The California Dental Hygienists' Association and the California Dental Association support Senator Padilla's bill as an important step in the investigation of methods that will improve the health of the children of California.

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  • W. Frederick Stephens | President, California Association of Oral & Maxillofacial Surgeons

    Bill Would Create Two-Tiered System for California Children

    SB 694, authored by Sen. Alex Padilla, has proven to be a significant topic of division within the leadership of California dentistry. The most controversial part of this bill calls for the development of a study to examine the potential for, and ability of, traditional and non-traditional (mid-level) dental providers to perform safe and effective dental care for the reported "underserved" children in California. The bill has recently modified this category of "non-traditional providers" to now only include registered dental hygienists and expanded duty dental assistants. This potential new level of provider would be allowed to perform irreversible dental and surgical procedures on children such as tooth preparation and placement of direct restorations and the extraction of deciduous teeth, all with the application of local anesthesia.

    Let's look at this legislation critically. It was not developed, as legislators will attempt to lead us to believe, because of a shortage of dentists in California. California leads the country in dentist-to-patient ratios. This legislation was really developed in response to various hot topic political pressures, including those from the Affordable Care Act. In many ways this is not an "access to care" problem, it is an "access to free care" issue. 

    Children are the most challenging population of dental patients, not only with respect to their care, but also with their management. How can we permit providers with training and experience less than the minimum requirements of a full dental education to treat these difficult patients?  Would you want your children treated as such? Dentistry is not just "tooth carpentry." It is a complete profession of generalists and specialists, extensively trained to provide a full scope of oral and facial care. This requires a formal four-year doctoral training program after an undergraduate college education, and in the case of some specialties, extends as much as six to seven more years to complete training.  

    The profession has presented a number of options to serve truly needy populations, without creating a substandard level of care for these patients. As an example, the California Association of Oral & Maxillofacial Surgeons has aligned with Remote Area Medical, which this year provided humanitarian care to 4,893 needy patients at two events. The events provided just short of $1.8 million worth of free dental care. Similar programs actively exist and are promoted by the California Dental Association and other dental organizations.

    Other options offered to address these care issues have included;

    • Requirement of a fifth internship year for dental school graduates, part of which would be served in low-income facilities;
    • Supervised externship programs for students in their last year of dental training; and
    • Developing programs for underserved populations in dental schools.

    Why not establish state-run, privately funded dental centers with fairly paid dental supervisors and dentists to provide care to this, so-called, underserved population? This would guarantee proper geographic placement, staffing and access for probably less money than developing a new level of provider who will require reasonable compensation. And that's not even considering the malpractice issues. 

    All of these options utilize dental providers who are already available, and most importantly, properly trained. The development of a "study to explore the possibility" of a new level of provider when providers already exist, in spite of it being financed by private funds, is yet another example of how inefficient and blind the California Legislature has become and why California is at the brink of bankruptcy. Any of these options would improve access to care, not just give the appearance of addressing the issue politically.

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