By Anne Blythe

Many of North Carolina’s school children in rural and low-wage areas who have never seen a dentist could have greater access to oral health care soon.

On Jan. 16, the legislative rules review commission adopted a long-telegraphed change to scope of practice rules for North Carolina dental hygienists, an amendment that goes into effect on Feb. 1.

The commission’s approval came after the North Carolina State Board of Dental Examiners unanimously approved the suggested amendment, which was several years in the making.

In just a few days dental hygienists will be able to do screenings and cleanings in some public schools and elder-care and special-needs facilities even if a supervising dentist has not done an in-person, comprehensive exam of the patient. Dental hygienists working in public health or private practice hygienists deemed as public health practitioners through fledgling public-private partnerships will be eligible to provide the services.

Dentists taking part in the program also can supervise more than two hygienists, which had been the limit for years. Dentists can also issue standing orders that give those public health hygienists a broader practice scope without having to revisit the necessity with each patient.

2.4 million in underserved areas

The dental board has not always been keen on giving hygienists more authority to work without a dentist on-site. Hygienists have argued they can clean teeth, take X-rays, apply sealants, and in some cases stave off further tooth decay with silver diamine fluoride without dentists nearby.

But in recent years, there has been a sharper focus on remote regions of the state that have persistent shortages of health professionals. There are 175 such designations for dental care, areas in North Carolina where some 2.4 million people live, according to data compiled by the U.S. Department of Health and Human Services.

Hygienists who might have been able to help with some of the more basic oral health needs in those areas have been stymied from setting up practices of their own or going out in the communities. North Carolina has had some of the most restrictive scope of practice rules in the country.

“That’s a big step,” Crystal Adams, the immediate past president of the North Carolina Dental Hygienists’ Association, said of the rule change. “I’m happy to see some action, although we have many steps to go.”

dentists are lacking in two far eastern counties of the state, but really, dentists are concentrated where the people are: Wake, Durham, Orange and Mecklenburg counties.
98 of North Carolina’s counties have dentists, but still, the statewide rate of dentists to the population is still around 5 per 10,000 people. Map, data courtesy: Sheps Center for Health Policy Research, UNC Chapel Hill.

The act of loosening the lid on hygienists’ scope of practice came only after dentists, hygienists and others got around a table together to look at the broader picture and mission of giving all North Carolinians an avenue to oral health care, Adams noted.

More and more, providers are realizing that problems inside the mouth can lead to or signal systemic health issues, such as heart disease or diabetes. If more attention is paid to oral health, particularly in the young, it could go a long way toward better overall results as the children become adults.

‘Bit of a kumbaya moment’

“This is positive for our state because many stakeholders are at the table now,” Adams added. “I feel like we’re working in our state for other things to happen. We do have restrictive rules, and there are big access issues in rural North Carolina. It definitely will take some education to understand this rule change.

“I think it may be a slow process but once [dentists and hygienists] see it can help their community, I think it will go a long way.”

A map of dental hygienist availability in the state.
Source: Sheps Center for Health Policy Research, UNC Chapel Hill.

Alec Parker, executive director of the N.C. Dental Society, which played a large role in getting the many professionals together to chart a path forward, acknowledged the difficulties of the past. He said he was optimistic of more togetherness in the future.

“We’re all of a sudden at a kumbaya moment,” Parker said.

It’s unclear how much of an impact the rule change will have immediately.

There are several public-private models in place that can be expanded upon. Frank Courts, a dentist in private practice in Rocky Mount, has been involved in a partnership put in place several years ago to test whether such an expansion of a hygienist’s practice could help bring more care to underserved areas.

Bill Milner, a dentist with Access Dental Care, a non-profit mobile on-site provider for people with special needs, is excited about the rule change, but not just because it will open access for children in underserved areas.

Much of the heralding of the program has focused on what it can do for children in underserved areas, but Milner said there’s a great need to provide more care to people in nursing homes, special-needs facilities and to people who might have behavioral or mental health issues that make it difficult to visit a dentist’s office. The model his non-profit built could also be replicated, he said.

“When we think of public health, we think of kids,” Milner said. “But there’s a whole community out there.”

Zachary Brian, director of the North Carolina Oral Health Collaborative, an organization that backed the expanded scope of practice, said the change is a step “in the right direction.”

“It’s increasing access by debilitating barriers,” Brian said last week.

But predicting how quickly the dental care shortage areas would dissipate was more difficult for him to answer. It will take a big push to educate hygienists and dentists in private practice across the state that such a change happened and any benefits to their business for establishing such partnerships.

“There will be a little bit of a learning curve, I think,” Brian said.

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Anne Blythe, a reporter in North Carolina for more than three decades, writes about oral health care, children's health and other topics for North Carolina Health News.

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