RD299 - Final 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. The changes to the practice of dental hygiene pertain specifically to those hygienists employed by the Virginia Department of Health (VDH) who work in the Cumberland Plateau, Lenowisco, and Southside Health Districts, all dentally underserved areas. These practice changes are in effect through July 1, 2012, due to additional legislation in the 2011 Session.

This legislative action has enabled a small cohort of dental hygienists to provide preventive dental services in selected settings without the general or direct supervision of a dentist. This effort has improved access to preventive dental services for those at highest risk of dental disease, as well as reduced barriers and costs for dental care for low-income individuals.

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 in 2009 and again in 2010 after minor revisions. 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 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 C.

This report documents the services provided by a total of six full- or part-time dental hygienists who have worked under remote supervision in these three districts. Because of staff changes, the hygienists have not all worked continuously during the reporting period (September 2009 to June 2011). By comparison, in 2011 there are currently 4,198 dental hygienists licensed in Virginia who have addresses in the state.

Because VDH received funding for an Oral Health Workforce Grant from the U.S. Health Resources and Services Administration for many of the dental hygiene positions in the three districts, a majority of prevention services provided by VDH using the remote supervision protocol are through newly established school-based dental sealant programs in keeping with grant objectives. 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.

During the 2010-2011 school year, 64 of the 75 (85%) targeted elementary and middle schools in the three districts participated in the school-based sealant program. Forty-one of these schools participated in 2009-2010, and 23 additional schools participated in 2010-2011. The school-based sealant program specifically targeted children enrolled in the National School Lunch Program in these schools. Over 1,500 children returned a permission form to receive a screening by a dental hygienist; an average response rate of 19%.

Of the 1,514 children screened, 59% received dental sealants on permanent molar teeth. A total of 3,186 permanent molar teeth were sealed for an average of 3.6 sealants per child. During the two-year period, the dental hygienists referred 722 children (48%) from the sealant program to a dentist for evaluation or treatment for fillings, root canals, and/or extractions. Of the 248 children referred during the first year of the program, follow-up status is available for 81. As of this report, 23 of these children (28%) had all of their treatment needs completed.

The cost calculated per child to apply 3.6 sealants was 25% more under general supervision than under remote supervision ($86.76 vs. $69.35). On average, the cost per sealant was $24.10 under general supervision and $19.26 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 over 1,700 infants and young children; 1,263 of these children were referred to a dentist to establish a dental home. The dental hygienists provided dental health education to 13,105 individuals in settings such as schools and Head Start centers, as well as professional trainings for health providers. 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. In 2011, an oral health home visiting program was developed in the Southside District utilizing a dental assistant. As of June 30, 2011, 422 high-risk children and pregnant women in the three districts had received home visiting services.

As this report indicates, the remote supervision model offers the potential of an alternative method of delivery for safety net dental program services and increased access for underserved populations. Increasing availability to preventive services such as sealants and fluoride has been proven to significantly reduce the dental disease burden, which is a priority need for those populations at highest risk. With an aging public health workforce and difficulties in recruiting dentists into safety net positions, the remote supervision model could offer an alternative for VDH programs as dentists retire and cannot be replaced. Preventive services could be provided to more individuals at a lower personnel cost, with referrals to public health dentists primarily for treatment services from a greater geographic area. The potential for program sustainability improves as costs for delivering services are reduced with this model compared to those provided under general supervision. The remote supervision protocol has also proven successful in increasing the ability of VDH to successfully compete for federal grant funding for staff to work under this model.

Therefore, the recommendations regarding the future of the remote supervision practice protocol for VDH dental hygienists are as follows:

• Extend the provisions in § 54.1-2722 “License; application; qualifications; practice of dental hygiene” in Chapter 27 of Title 54.1 of the Code of Virginia for one year (to expire July 1, 2013) as an exemption to the existing regulations for the practice of dentistry and dental hygiene. This provides for the continuation of remote supervision in the three existing health districts (Cumberland Plateau, Lenowisco and Southside).

• Expand the above provision to include additional VDH health districts with adequate resources (e.g., staff and funding) to provide care to individuals who qualify for services according to VDH eligibility guidelines. Determine the need, if any, for limiting additional VDH clinics operating under this protocol to dental Health Professional Shortage Areas (HPSA), ensuring that these clinics can continue with the program for the entire extended period (to expire July 1, 2013).

• Consider a statutory change in § 54.1-2722 “License; application; qualifications; practice of dental hygiene” in Chapter 27 of Title 54.1 of the Code of Virginia to make this protocol within the scope of practice by July 1, 2013.

• Maintain the VDH committee for an annual revision and/or review of the protocol.

• Explore options for increasing participation in programs as well as increasing the number of children with dental treatment completed.