RD318 - 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 for FY 2012

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 were in effect through July 1, 2012, due to additional legislation in the 2011 Session. As of July1, 2012, Virginia Code as amended by Senate Bill146 and passed in 2012, permits any VDH dental hygienist throughout the commonwealth to practice under the “remote supervision” protocol.

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. This protocol was adopted in the language of Senate Bill 146 by the 2012 General Assembly, as the practice standard now in the Code of Virginia for “remote supervision” practice.

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. This report documents the services provided in FY 12 by the hygienists and assistants employed in the pilot Districts identified above.

Funding received in 2009 from a U.S. Health Resources and Services Administration Oral Health Workforce Grant was used to support the majority of the dental hygiene positions in the three pilot project districts. Therefore, the majority of prevention services provided by VDH using the remote supervision protocol are through relatively newly established school-based dental sealant programs and keep with grant objectives. A dental sealant is a plastic material that is applied to the chewing surfaces of the back teeth (molars) to act as a barrier to bacteria and to prevent cavities. 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 additional preventive services for the individuals in these communities under existing practice protocols, including screenings, fluoride varnish applications, education, and referrals.

During FY 12, forty-seven elementary and middle schools participated in the school-based sealant programs specifically targeted to children enrolled in the National School Lunch Program. Over 1,200 children returned a permission form and were screened by a dental hygienist; 746 received sealants. A total of 819 children were identified as having other oral health needs and referred to providers for comprehensive care.

In addition to the sealant programs provided under remote supervision protocol, preventive services provided under existing practice protocols in the target health districts were also significant. The fluoride varnish program, operated in Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinics and in three Care Connection for Children clinics, provided screenings and fluoride varnish applications to over 500 infants and young children; 296 of whom were referred to a dentist to establish a dental home. WIC eligible children are too young to have permanent molar teeth appropriate for sealants. However, topical fluoride varnishes benefit all teeth and are the primary direct preventive service appropriate for the very young, WIC eligible child. Fluoride varnish is an evidence-based application for the primary (baby) teeth that reduces decay from 40% to 60%. The dental hygienists also provided dental education programs on topics including proper oral hygiene, oral fads, nutrition, oral health for overall wellbeing and oral care for persons with special health care needs; these educational programs were provided to 7187 individuals in targeted health districts. Referral and care coordination for individuals without a dental home was the focus of the dental referral program. The program initially used specially trained home visitors to provide care coordination for families that included assistance with obtaining a dental home, making and keeping dental appointments, and oral health education. As this program evolved, home visitors and specially trained dental assistants provided these services.

As this and previous reports indicate, 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 a national shift from individual clinical care to population based preventive services, 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 public health dentists retire and cannot be replaced. Preventive services could be provided to more individuals, over a wider geographic area, at a lower overall cost, with referrals to dentists primarily for treatment services and to establish a dental home. 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 now codified “remote supervision” practice protocol for VDH dental hygienists are as follows:

• VDH should optimize the opportunity this new practice protocol creates to provide needed services to the most people at the lowest cost to taxpayers.

• VDH, utilizing dental hygienists under the new protocol, should continue to emphasize preventive efforts in the state to reduce the burden of oral disease in the population over time.

• Stakeholders should work with legislators and the Virginia Board of Dentistry to refine the language of the legislation codifying “remote supervision”, such that the protocol can be amended as needed based on continued VDH experience with the practice model and evolving standards of care and practice.

•VDH should periodically consult with stakeholders in the dental care access community to evaluate the effectiveness of the new protocol practice model.