Wouldn’t you think acquiring the knowledge and skills necessary to manage the diagnosis, prevention and treatment of early childhood dental caries would require more than a three-hour continuing education training session?

Not so—at least not in North Carolina.

In sections of that state, pediatricians and family practitioners, aided by their physician assistants, are actively involved in the delivery of preventive dental services. Targeting a Medicaid population of 0- to 3-year-olds, these nondental health care providers are offering screening for oral disorders, fluoride varnish applications and counseling of the children’s caregivers.

Encouragement for these medically supplied dental services arose from public concerns regarding inadequate access to dental services for certain segments of North Carolina’s Medicaid-eligible children. In 1998, only 12 percent of the state’s Medicaid-enrolled children aged 1 year to 5 years visited a dentist.¹ The Health Care Financing Administration (now the Center for Medicare and Medicaid Services) responded by initiating a demonstration program called "Smart Smiles" for 1,000 preschool children in North Carolina. Plans to extend the program to include more than 100,000 children are under way.

The irony: medical auxiliary personnel, with minimal training, are performing preventive dental procedures. Meanwhile, state-employed dental hygienists cannot participate, since their dental practice act requires them to be under the direct supervision of dentists.

This is not the only state in which medical personnel are offering dental services. Missouri recently enacted a law that permits physicians to provide preventive dental services when children receive their immunizations.

Previously, the Washington State Medical Quality Assurance Commission decided that application of fluoride varnish to teeth by physicians and physician assistants was within those disciplines’ scope of practice.

Why this medical intrusion into an area where dentistry has been the undeniable leader—the promotion of preventive dentistry for children? It’s the need to ensure access to dental services, or the lack of that access, that is the stimulus.

Difficulties in accessing dental care, especially for underprivileged children and older adults, have received nationwide attention with the publication of "Oral Health in America: A Report of the Surgeon General."¹ While citing dramatic improvements in oral health during the past 50 years, the report pointed to a "silent epidemic" of oral disease that "burdens" some population groups.

Specifically, while disadvantaged children’s oral health has dramatically improved, a study of unmet health needs of children found those requiring dental care topped the list with 5.3 percent (3.4 million); the percentage with unmet medical needs was only 1.6 percent.²

One solution to this problem, cited in both the surgeon general’s report, as well as other associated documents, calls for dentistry to partner with other professions and agencies to increase access to dental services.

The North Carolina Smart Smiles program is an example of such a partnership—or is it?

On the surface, it appears to be a "do-good" situation. After all, isn’t some prevention better than none at all? Actually, no—not when there isn’t evidence of a "true" dental/medical partnering agreement that ensures continuity of care for the child. Sure, having the pediatric assistant paint fluoride varnish on the child’s teeth can be a positive interaction by socializing parents to the importance of obtaining dental treatment for their children. But as an isolated, singular event, it easily could lull the caregiver into a false sense of security, believing his or her child is receiving all necessary dental care. If the perceived lack of access to dental care for underprivileged children continues, can it be expected that additional dental services will be offered by medical personnel?

In previous years, the answer would have been that physicians had more than enough to do without adding dental procedures to the service mix. But now, with mean incomes of dentists greater than those of their pediatric and family physician counterparts—significant differences when hours worked are divided into net income—I could foresee a willingness to expand their dental services offerings.

Interestingly, in many states, these physicians could deliver dental services without taking any additional training. Indeed, they might even consider augmenting their dental offering by hiring a dental hygienist. But can they legally hire a dental hygienist? Considering how careful dental practice acts are in specifying what services and what supervision is required of dental auxiliaries, medical practice acts allow physicians a wide latitude as to what services they and their auxiliary personnel can perform. In contrast, the majority of dental practice acts exempt physicians who deliver dental services.

Will physician-delivered dental services increase? With up to 29 percent of dental service output characterized as "preventive dental procedures,"³ the entrepreneurial physician might be tempted to venture forth. I wouldn’t be surprised to see continuing education offerings for physicians and their staffs featuring instruction in preventive dentistry. Who knows, we may eventually see medical residencies offering clerkships in dentistry—and perhaps even the development of a full-fledged residency in dentistry consisting of a one-year general medicine internship plus two years dedicated to learning dentistry. This would produce an interesting medical practitioner able to have a step up in the practice of geriatric or pediatric dentistry.

Public solutions to the dental care access issue continue to spring up. Note the present legislative initiative in California, which would allow physicians and dentists from Mexico to "cross the border" without meeting California licensure requirements to expand services to "poor, largely Spanish-speaking patients."⁴

Breaking down cultural and language barriers also are cited as reasons to employ these health professionals, who will be paid at rates commensurate with the clinic’s regularly licensed doctors. The California Dental Society opposes the legislation on potential "quality issues," indicating that it allows foreign-trained dentists to practice without any means of evaluating their training. If their training is not comparable to that of U.S. dentists, this initiative could foster a two-tiered health care system, with substandard care being offered to some.

If this proposed legislation passes, will the California legislature be receiving similar legislative requests to allow licensed dentists from other countries to come to the United States to treat underserved people with whom they share similar ethnic backgrounds?

All in the name of access!