RD327 - Report on Services Provided by Virginia Department of Health (VDH) Dental Hygienists Pursuant to a Practice Protocol in Lenowisco, Cumberland Plateau and Southside Health Districts


Executive Summary:
In 2009, the Virginia General Assembly passed legislation to revise § 54.1-2722 “License; application; qualifications; practice of dental hygiene” in Chapter 27 of Title 54.1 of the Code of Virginia (Appendix A). The changes to the practice of dental hygiene pertain specifically to those hygienists employed by the Virginia Department of Health (VDH) that work in the Cumberland Plateau, Lenowisco, and Southside Health Districts, all dentally underserved areas. The practice changes, in effect through this legislation until July 1, 2011, will enable this cohort of dental hygienists to provide preventive dental services in selected settings without the general or direct supervision of a dentist. This effort will improve access to preventive dental services for those at highest risk of dental disease, as well as reduce barriers and costs for dental care for low-income individuals. The legislation also has potential for significant changes to the practice of public health dentistry in the Commonwealth, a model that has not changed since the state dental program was established in 1921.

In July 2009, a committee was formed to develop the new practice protocol comprised of representatives from VDH, the Virginia Board of Dentistry, the Virginia Dental Association, and the Virginia Dental Hygienists’ Association. Definitions and guidelines for the new remote supervision practice protocol were drafted by the committee, approved by the State Health Commissioner and provided to the Virginia Board of Dentistry. The committee defined remote supervision to mean that “a public health dentist has regular, periodic communications with a public health dental hygienist regarding patient treatment, but who has not done an initial examination of the patients who are to be seen and treated by the dental hygienist, and who is not necessarily on-site with the dental hygienist when dental hygiene services are delivered.” The committee met and made minor revisions to the protocol in 2010. The current Protocol for Virginia Department of Health Dental Hygienists to Practice in an Expanded Capacity Under Remote Supervision by Public Health Dentists is included as Appendix B.

When the legislation passed, there were only one full-time and one part-time VDH dental hygienists located in the targeted health districts. Therefore, efforts were made to secure funds through grants and other opportunities to increase staff that could work under this new protocol. As a result, by early 2010 there were six full or part-time VDH dental hygienists practicing under remote supervision in the three health districts and one part-time hygienist who works exclusively with the fluoride varnish program under existing regulations. By comparison, in 2010 there are currently 4,081 dental hygienists licensed in Virginia who have addresses in the state.

The primary prevention services currently provided by VDH using the remote supervision protocol are through newly established school-based dental sealant programs in the targeted health districts. Dental sealant programs are evidence-based and cost-effective means to reduce the dental disease burden of a population. The hygienists were also able to provide many other additional preventive services for the individuals in these communities under existing practice protocols, including screenings, fluoride varnish, education and referrals. Although a small pilot program started in September 2009, due to the need to hire and train staff, as well as the inherent scheduling limitations and other barriers associated with providing school-based services, the provision of sealants under remote supervision occurred primarily in spring of 2010. All other preventive and educational services described in the report are for the entire pilot project period up to September 1, 2010.

Forty-two out of 63 schools in the three health districts agreed to participate in the school-based sealant program. Information about the program and permission forms were distributed to approximately 3,573 children; 494 returned a permission form to receive a screening by a dental hygienist. Because of confidentiality, all children in a grade received the forms, although the school-based sealant program specifically targets children enrolled in the National School Lunch Program. When free and reduced lunch participation is used as the total eligible population, the response rate for the program in all three districts was 22%. These 494 children in kindergarten through seventh grade were screened, with second and sixth grade children being the primary focus. Of those children screened, 71% received dental sealants on permanent molar teeth. The average number of dental sealants placed on permanent teeth was 3.7 per child. A child could be screened and not be a candidate for a dental sealant due to the status of the permanent molar teeth, including filled, decayed or not fully erupted into the mouth. The dental hygienists referred 253 (51%) children from the sealant program to a dentist for evaluation or treatment for fillings, root canals, and/or extractions.

The cost per child to apply 3.7 sealants was 23% more under general supervision than under remote supervision ($86.76 vs. $69.35). On average, the cost per sealant was $23.45 under general supervision and $18.74 under remote supervision. According to the American Dental Association Fee Schedule for the South Atlantic Region, the average charge in private dental offices is $44.25 (range $30.00 to $64.00) for a dental sealant.

In addition to the sealant programs provided under the pilot remote supervision protocol, preventive services were provided under existing practice protocols in the target health districts. These include the fluoride varnish program in Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinics; dental education programs; and a newly developed referral program that uses home visitors. Screenings and fluoride varnish application were provided for approximately 1,000 infants and young children; 881 of these children were referred to a dentist to establish a dental home. The dental hygienists also provided dental health education to 6,632 individuals in settings such as schools and Head Start centers, as well as professional trainings for health providers. Although referrals were made from the dental sealant and fluoride varnish programs, the dental hygienists also worked with local home visiting programs in the Cumberland Plateau and Lenowisco Health Districts. These specially trained home visitors provided care coordination for families that included assistance with obtaining a dental home, making and keeping dental appointments and oral health education. As of September 1, 2010, 121 high risk children and pregnant women had received this service.

The recommendations regarding this practice protocol for VDH dental hygienists are to extend the sunset date for the pilot program from July 1, 2011 to July 1, 2012 for the three existing areas, and explore the potential for expanding the protocol to other VDH health districts.