By Anne Blythe
Hygienists in North Carolina have been lobbying for years to be able to clean teeth, take X-rays, check gum health and apply sealants when a dentist is not on-site with them.
At long last, they seem to be one step closer to being able to do just that in certain schools, elder care facilities and special-needs centers in some parts of the state.
The N.C. Board of Dental Examiners recently endorsed a rule change that could give hygienists a slightly broader scope of practice in one of the most restrictive states in the country.
That proposal must survive a months-long process that calls for review by legislative staff, public comment periods, hearings and a rules commission review before troops of hygienists can fan out to underserved regions of the state.
If all that happens, other counties could build on a public-private partnership experiment started two years ago in Edgecombe and Halifax counties.
Frank Courts, a dentist in Rocky Mount and chair of the North Carolina Dental Society Council on Prevention and Oral Health, has been involved with the Edgecombe program and the effort to create similar ones elsewhere.
“We were looking for a way to provide direct services without state funding,” Courts said in a recent telephone interview. “It turns out it’s a pretty innovative idea.”
For a little more than two years, dentists in private practice in Edgecombe and Halifax counties have contracted with county health departments to allow their hygienists to work as “public health” providers.
“Most dentists don’t work on Fridays,” Courts said. In the program, the hygienists and dental assistants who would normally be off on those Fridays are free to provide screenings, cleanings and preventive services at high-needs settings such as schools with a high percentage of students from low-income households.
Hygienists in an experimental public-private partner program provide sealants to a child at Coker-Wimberly Elementary School in Edgecombe County. The program is a model that could be expanded to other counties in the coming months. Video courtesy: Frank Courts, a Rocky Mount dentist and chairman of the North Carolina Dental Society Council on Prevention and Oral Health. Used with permission.
They also can paint sealants on children’s teeth, adding the thin coating to help stave off decay.
If there is decay, hygienists cannot drill, but they can apply silver diamine fluoride to fight further deterioration, a treatment option approved almost five years ago by the Food and Drug Administration.
If patients need more care than hygienists and dental assistants can provide in the public settings, the private dentists in the program will welcome them into their offices, offering what they describe as “a dental home” for routine checkups.
The push to expand the program comes as the state wrestles with how to ensure oral health care access in counties and communities described as Health Provider Shortage Areas.
Unmet oral health needs ‘profound’
North Carolina, according to the federal Department of Health and Human Services, had 165 Dental Health Provider Shortage Areas at the end of last year, encompassing more than 2.5 million residents.
About three-quarters of the state’s 100 counties are designated as having a shortage of dental health providers.
In those areas, too, there is an added hurdle for low-income people in need of oral health care.
Many dentists do not take Medicaid patients because of the low reimbursement rates.
The North Carolina Oral Health Collaborative compiled information from the American Dental Association, showing that only 29.7 percent of North Carolina dentists participated in Medicaid as of 2016, compared to the national average of 39 percent.
Many of the students and others cared for through the Edgecombe and Halifax counties public-private partnership are eligible for Medicaid.
Hygienists in North Carolina cannot bill for Medicaid reimbursements, but the dentists they work for can and do so through the model program the Dental Society and North Carolina Dental Board hope to expand.
Courts, who takes Medicaid patients at his private practice, said the reimbursements help him pay the salaries for his staff who have participated in the pilot project.
Zachary Brian, director of the North Carolina Oral Health Collaborative, described the proposed rule change for hygienists as a step in the right direction toward opening access to better dental care for a large swath of the state.
“The unmet oral health needs in our state are profound, however, not insurmountable,” Brian said.
Goal is oral health, ‘not filling a bunch of teeth’
If the legislative staffers do not sign off on the rule change or if it makes it to public hearings but does not receive favorable review there, Brian and others are ready to push for statute changes that could open a broader discussion on whether the state is ready to expand the scope of practice for hygienists.
There long has been friction between dental hygienists fighting to get out from under some of the most restrictive scope of practice laws in the country and dentists unwilling to budge on their push for expansion.
Hygienists, for the most part, are prohibited from looking inside someone’s mouth unless a dentist is on-site with them, and that’s limited to only two hygienists at a time.
Under the proposed rule change, the hygienists in the public-private partnerships could provide screenings and cleanings without a dentist right there. If drilling is not necessary, they could also treat for decay in some instances without a prescreening by a dentist.
The rule-change proposal was put forward after oral health advocates from state offices, private foundations, the state’s two dental schools and the North Carolina Dental Society met in the summer of 2018 and formed the Council on Prevention and Oral Health.
The council evaluates evidence-based data and endeavors to engineer and push for cost-effective solutions for improving oral health care.
Courts, chairman of the council, said the goal of expanding the pilot project in Edgecombe and Halifax counties, which was funded with grants from Blue Cross Blue Shield and the Duke Endowment, is to empower hygienists already trained to do much of the needed work so they can help at state and federally qualified facilities. (Note: Both the BCBSNC Foundation and the Duke Endowment provide grant funding to NC Health News)
The council also is advocating for teledentistry, which uses technology to connect dentists and other clinicians to patients outside their offices, perhaps at schools, nursing homes and other state or federal facilities.
The idea is to get to children and others in underserved areas into a dentist’s or hygienist’s chair before they’ve experienced problems.
Some of that preventive care used to fall to the state’s public health hygienists, a workforce that has been cut by state lawmakers over the past 10 years, to 24 from the 54 in the state Division of Public Health in 2009.
“There’s not enough money in the state budget to fix everybody’s teeth,” Courts said. “The goal of the committee is oral health, not filling a bunch of teeth. Every dollar you invest in preventing disease, you end up saving a lot of money in the long run.”