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标题：Effectiveness of an Alternative Dental Workforce Model on the Oral Health of Low-Income Children in a School-Based Setting
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作者：Melanie Simmer-Beck ; Mary Walker ; Cynthia Gadbury-Amyot 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2015
卷号：105
期号：9
页码：1763-1769
DOI：10.2105/AJPH.2015.302714
语种：English
出版社：American Public Health Association
摘要：Objectives. We evaluated the effect of an alternative dental workforce program—Kansas’s Extended Care Permit (ECP) program—as a function of changes in oral health. Methods. We examined data from the 2008 to 2012 electronic medical records of children (n = 295) in a Midwestern US suburb who participated in a school-based oral health program in which preventive oral health care was delivered by ECP dental hygienists. We examined changes in oral health status as a function of sealants, caries, restorations, and treatment urgency with descriptive statistics, multivariate analysis of variance, Kruskal–Wallis test, and Pearson correlations. Results. The number of encounters with the ECP dental hygienist had a statistically significant effect on changes in decay ( P = .014), restorations ( P = .002), and treatment urgency ( P = .038). Based on Pearson correlations, as encounters increased, there was a significant decrease in decay (–0.12), increase in restorations (0.21), and decrease in treatment urgency (–0.15). Conclusions. Increasing numbers of encounters with alternative providers (ECP dental hygienists), such as with school-based oral health programs, can improve the oral health status of low-income children who would not otherwise have received oral health services. In 2000, the landmark report Oral Health in America: A Report of the Surgeon General , brought attention to the need for oral health care; the impact of poor oral health on individuals, communities, and society at large; and the disproportionate burden of oral disease among certain segments of the US population. 1 More than a decade later, oral health disparities continue to exist. 2–12 An estimated 1 out of 5 children go without dental care each year and 1 out of 6 experience toothache. 5,13 Children experience unnecessary pain, are absent from school, are less engaged in class, and have low self-esteem from a disease that is largely preventable. 7,14,15 The long-term consequences of poor oral health may lead to difficulties finding a job, other health problems such as diabetes and heart disease, and large dental bills. 7,14,16 Lack of access to oral health care is a complex problem resulting from socioeconomic, environmental, and delivery system barriers that do not provide access for individuals who are uninsured, low income, or living in dental health provider shortage areas. 1 Dental providers are frequently located in metropolitan areas and deliver care in private offices, resulting in a disproportionate number of vulnerable and underserved populations with barriers to care. 17 Geographic maldistribution of clinicians, inadequate numbers of oral health professionals treating Medicaid-eligible children, few pediatric dentists, poor population knowledge and attitudes about oral health, lack of dental insurance, and difficulties interacting with culturally diverse populations contribute to difficulties accessing oral health care. 4,9,18 A notable difference between the structure of medical and dental practices in the United States is the lack of midlevel dental providers. The medical model uses nurse practitioners and physician assistants, but dentistry has been reluctant to embrace a similar independent provider system that could expand access to dental care. 19 Midlevel dental provider models have been employed in other industrialized and nonindustrialized countries for decades and have a long history of providing access and reducing oral health disparities. 20–23 Despite the existence of national accreditation standards on education of midlevel oral health care professionals, numerous regulations and policies delineating supervision levels and scope of practice exist and vary widely from state to state. The Health Resources Services Administration estimates a current shortage of 10 000 dentists in the United States. 24 Deficiencies in the structure of the oral health work force and shortage of providers have been a chronic problem. In 2012, the former Surgeon General, David Satcher, issued a “renewed call for action to expand access to oral health care.” 25 Satcher accentuated how the Affordable Care Act provides an opportunity to increase dental benefits coverage to more than 5 million children. However, he added, “Adding dental benefits will not translate into access to care if we do not have providers in place to offer treatment.” 25 Dental providers; medical, dental, and other health organizations; advocacy organizations; policymakers; private and public insurers; researchers; and local, state, and federal agencies acknowledge that pockets of the US population have poor oral health and lack access to oral health care. The solution to resolving this problem, however, is highly disputed. 14,26–36 Numerous alternative dental workforce models have been proposed and, in some circumstances, implemented, to expand the dental workforce. The models vary in types of care that can be provided, supervision, work setting, education, and certification or licensure. In 2003, Kansas established an alternative workforce model by altering dental hygiene scope of practice and supervision regulations through the creation of Extended Care Permit (ECP) Dental Hygienists. 37 This model permits dental hygienists to have direct patient access, in a variety of settings, to the “full extent of their education and training” as recommended by the National Research Council and the Institute of Medicine. 17 The ECP dental hygienists can provide preventive services and assess the patient’s need to be further evaluated by a dentist for “dentally underserved” children aged birth to 5 years, children in public and nonpublic schools kindergarten through grade 12 regardless of the time of year, and children participating in youth organizations. The ECP dental hygienists are sponsored by a dentist, licensed in the state of Kansas, who is willing to monitor their activities. To qualify for an ECP, the dental hygienist must have performed 1200 hours of dental hygiene care within the past 3 years or have been an instructor at an accredited dental hygiene program for 2 of the past 3 academic years. 37,38 As health care expenditures continue to rise, assessing the effectiveness of care has become a national priority. 17,39–49 Multiple stakeholders have necessitated the need for well-defined oral health measures of quality to ascertain patient-centered, cost-effective care is being consistently delivered throughout the health care system. Dental Quality Alliance, an organization formed by the American Dental Association to develop performance measures that assess the quality of oral health care, declared that the most accurate predictor of quality is measuring the patient’s health status. 39 Despite these recommendations, there is minimal research that examines the relative effectiveness of oral health care provided by auxiliaries or dentists. Most of the published studies are more than 20 years old and have methodological shortcomings. 50 The objective of this study was to evaluate the effect of an alternative dental workforce model, the ECP dental hygienist, as a function of changes in oral health in low-income children in a school-based setting. We examined the following research questions: (1) How did the number of encounters with the ECP dental hygienist affect the oral health status of children? (2) How did the number of fluoride varnish applications affect the oral health status of children?