Kansas Health Institute | Information For Policy Makers. Health for Kansans.

TOPEKA — Kansas dentists plan to ask the 2011 Legislature to allow dental hygienists to provide more types of care to patients.

Hygienists currently are allowed to provide preventive care such as cleanings and fluoride treatments in a dentist’s office.

If they want to see patients in nursing homes, senior centers, safety-net clinics, jails, schools and other locations where dental care otherwise might be hard to get, they’re expected to apply for an extended care permit.

To work with children outside a dentist’s office, hygienists are required to have at least 1,200 hours of experience; to work with patients over age 65: 1,800 hours.

Details of the legislative proposal are still being worked out, but the Kansas Dental Association is leaning toward trying to expand hygienists’ scope of practice to include temporary fillings and denture adjustments, according to Kevin Robertson, the group’s executive director.

More case management

“The idea, basically, is to allow for more case management, more in the way of preventive care, and to do some temporary relief kinds of things that could buy some time so patients could get in to see a dentist,” Robertson said.

The proposal is patterned after an American Dental Association pilot project that trains lay people in underserved communities to perform similar tasks.

“What the ADA project is doing is taking non-hygienists out of the community, training them, and putting them back in the community,” Robertson said. “We’d like to do something similar but instead of starting from scratch, we think it makes sense to build on the hygienist system we already have.”

A spokeswoman for dental hygienists said ideas or initiatives aimed at broadening their scope of practice would be welcome.

“It’ll help a little,” Maggie Smet, president of the Kansas Dental Hygienists’ Association, said of the developing dentists’ plan. “All of us, I think, want what’s best for the patient who’s uninsured or underserved. The challenge is how we agree to make that happen.”

Studies have shown (PDF) that 91 of the state’s 105 counties don’t have enough dentists to keep pace with residents’ dental needs. Fourteen counties are without a dentist.

“That tells me we need to be looking for ways to get more services out of the system we have now,” Smet said.

A way to do that, she said, is to let dental hygienists take on some tasks now reserved solely for dentists.

Many people in "crisis mode"

Reports show increasing numbers of Kansans are losing their health insurance and consequently viewing dental care as unaffordable.

“Dental care is expensive – even with our reduced fees it’s expensive,” said Linda Branstrom, executive director at the nonprofit Douglas County Dental Clinic in Lawrence, which accepts low-income, uninsured patients.

“We see a whole lot of people who are in crisis mode,” she said. “They don’t have enough money to go to a dentist, so they wait until they’re in pain and then they come here. We extract a lot of teeth that, with a little preventive care, could have been saved.”

Douglas County Dental Clinic has two hygienists with state-issued “expanded care permits,” or ECPs, which allow them to provide some services without direct dentist supervision at sites such as public schools.

“Sadly, we also see a fair number of children who, even though they may have a medical card (Medicaid), their parents can’t get them to the dentist’s office because they can’t get off work or because of transportation issues,” Branstrom. “That’s where the ECP program has been very successful.”

One of the clinic’s hygienists examines and cleans children’s teeth in schools in Lawrence, Baldwin, and Eudora.

“That has really, really helped remove a lot of barriers to care,” Branstrom said. “We don’t do diagnoses but if we see that there’s a problem we can make a note of it, contact the parents and then figure out how to get the child in to see a dentist.”

The clinic’s success with ECP-approved hygienists apparently is unique. Across the state, most hygienists’ extended care efforts are, at most, part-time.

Short of full potential

Last year, a Kansas Department of Health and Environment survey (PDF) found that in 2008, two-thirds of the then-89 dental hygienists with extended care permits used them only one to eight hours a week.

“It was pretty clear that most ECP hygienists are not being utilized to their full potential,” said Kathy Weno, director of the Bureau of Oral Health at KDHE.

Today, 118 dental hygienists have extended care permits.

Branstrom, Smet and others say that while they’re likely to support the dental association’s proposal, they expect to be more supportive of an initiative being put together by the Kansas Dental Project, a foundation-funded effort led by the Kansas Health Consumer Coalition, Kansas Association for the Medically Underserved, and Kansas Action for Children.

“The legislation hasn’t been drafted yet but we will be proposing what’s called a mid-level practitioner,” said Shannon Cotsoradis, chief executive at Kansas Action for Children.

A mid-level practitioner’s work would be supervised by a dentist, she said, much as the work of a physician’s assistant is overseen by a physician.

“The scope of practice has yet to be determined, but it will be much broader than what’s covered by the ECPs now,” Cotsoradis said. “I suspect – but I cannot say for sure at this point – that it will include things like basic restorative services, drilling and filling, and more in the way of education and prevention.”

Cutting edge

Mid-level practitioners, she said, would allow dentists’ offices to provide more services to more patients.

“We’ve talked about a number of other solutions (to meeting the needs of the underserved) and the one that comes up most often is how we need more dentists – that’s the solution,” Cotsoradis said. “But the reality is having more dentists doesn’t mean they are going to serve in underserved communities or in rural communities…the reality is that we’ve reached a critical point where we’ve got to think outside the box and look at other strategies.”

Similar initiatives, Cotsoradis said, are underway in Minnesota and Alaska.

“This is cutting edge,” she said. “If we’re successful, Kansas will be one of the first states to do this.”

The Kansas Dental Project initiative is being underwritten by the United Methodist Health Ministry Fund, Kansas Health Foundation, and REACH Healthcare Foundation.

Dentists are expected to oppose creating a mid-level position.

In the KDHE survey last year, several dentists said they “...feel strongly that a new mid-level professional is entirely unnecessary and that a focus on producing more dentists...” would better meet the state’s needs.

“That’s still the case,” Robertson said.