Your dental hygienist might prevent a trip to the emergency room

New research shows dental hygienists can dramatically improve the amount and quality of dental care provided, especially in underserved populations. However, what dental hygienists are allowed to do by law varies from state to state. For example, in states like Oregon and Minnesota dentists may authorize a task but need not be present at the time of service delivery. Other states like North Carolina and Alabama require a dentist’s direct supervision of preventive dental services provided by dental hygienists, even in public health settings.

Published in the journal Community Dentistry and Oral Epidemiology, the study found that states where dental hygienists were allowed to perform more services autonomously had fewer emergency department (ED) visits for dental problems not related to accidents or other trauma (non-traumatic ED visits). This research was conducted by Marvellous Akinlotan, PhD, BDS, while completing her doctorate in Health Services Research from the Texas A&M University School of Public Health, Alva O. Ferdinand, DrPH, JD, associate professor and director of the Southwest Rural Health Research Center at the School of Public Health, and others.

Prior research has identified dental conditions that are likely to be prevented or treated through preventive care or primary dental care, which typically includes access to the services of a dental hygienist. These include dental caries (also known as tooth decay or dental cavities), pulpitis, chronic gingivitis, acute and aggressive periodontitis, gingival recession, periodontitis, unspecified gingival and periodontal disease. The researchers studied the patterns in emergency room visits for these conditions, and investigated how these visits vary across 16 states with different scope of practice regulations for dental hygienists. To measure dental hygienist scope of work, Akinlotan and colleagues relied on the Dental Hygiene Professional Practice Index (DHPPI). The DHPPI quantifies how dental hygienists can provide care based on their training and a state’s regulations on what tasks they can legally perform. The scale includes the state’s level of regulation, number and types of tasks allowed, the required degree of supervision by dentists and hygienists’ ability to directly bill insurers for work performed. Generally, a higher DHPPI score indicates greater autonomy for dental hygienists.

The researchers looked at the number of preventable non-traumatic dental ED visits per 1,000 people in each county in 10 U.S. states (Arizona,  Florida,  Massachusetts,  North  Carolina,  Nebraska,  New Jersey, New York, Rhode Island, Vermont and Wisconsin) and the corresponding DHPPI scores from each state. In addition, Akinlotan and colleagues classified the counties in the dataset based on how rural or urban they are and included data on whether the counties are an area where there’s a shortage of dental professionals. The researchers analyzed the correlation between DHPPI score and ED visits overall and with populations grouped by age.

As expected, the study found that states with higher DHPPI scores—that is, states where dental hygienists had more autonomy at work—had fewer preventable non-traumatic dental ED visits. This finding is in line with prior research showing that higher DHPPI scores correlate with increased access to preventive dental care and better oral health outcomes.

The study also found that the improved outcomes in higher DHPPI states were present for patients younger than 65, but not for those older than 65. In addition, the youngest adult cohort of ages 20 to 34 years had the strongest relationship between hygienist scope of work and health outcomes. This is important because people between the ages of 20 and 35 typically have the highest rate of dental-related ED visits and lowest rates of regular dental care. Lastly, higher DHPPI states had fewer dental-related ED visits in rural counties.

These findings reinforce prior research showing that dental hygienists can dramatically improve the amount and quality of dental care provided, especially in underserved populations, if their scope of work permits. This may be due to an increase in the number of alternative sources of dental care in states with higher DHPPI scores. The importance of alternative care options is especially important for uninsured populations and rural areas where there may be fewer dentists available.

However, a limitation to the study is that even though researchers sought to capture preventable dental conditions, it was difficult to determine from the data whether patients who presented in the ED for these conditions had received the services of dental hygienist previously.

“Improvements to scope of work regulations that allow dental hygienists more autonomy could dramatically improve dental care in the United States, especially in rural areas and regions with dentist shortages,” Akinlotan said.

– by George Hale