A quick fix to access to care

March 1, 2010
In many areas of the country the shortage of dentists has become a crisis ...

by Christine Nathe, RDH, MS
[email protected]

In many areas of the country the shortage of dentists has become a crisis; therefore, many communities are looking for solutions to this shortage. Subsequently, the advent of simple preventive scaling (supragingival scaling)/gross debridement, which is basically providing a partial oral prophylaxis, has been advanced as a solution to this issue.

This is a very different solution to increasing access to care than has been proposed the past several years. Frequently, solutions aimed at increasing access to care include increasing the number of licensed providers. Mechanisms to implement this solution include loan repayment programs targeted to dental hygienists and dentists who would practice in underserved areas, increasing the number of dental or dental hygiene graduates in a state by opening new schools or setting up distance education sites, or permitting dental hygienists to deliver care outside of the private practice arena in settings such as schools and nursing homes.

There are several concerns regarding a provider model that permits the delivery of “partial oral prophylaxes” as a means of increasing access to care. First and foremost, simple preventive scaling/gross debridement does not adhere to the current standard of care. For over two decades periodontal diseases have been treated either by a comprehensive prophylaxis that can be completed in one appointment, or by quadrant scaling for patients with more need. The extent of the appointments depends on the amount of calculus and infection, and can entail two to four appointments and a referral to a periodontist.

Current research supports that periodontal diseases are infections initiated by microorganisms within oral biofilm, combined with the body's host response. Partial removal of bacterial pathogens does little to reduce the infection. Specifically, we now realize that incomplete removal of bacteria actually does more harm than good by partially removing large deposits of calculus in which bacterial pathogens flourish. Simple preventive scalings/gross debridements increase the occurrence of acute periodontal infections such as abscesses because of the partial removal of calculus. I doubt that any surgeon would propose partially removing an infection at a patient's initial visit, and then reappointing the patient at a later date to remove the rest of the infection.

A simple preventive scaling/gross debridement proposed for those patients with large amounts of plaque and calculus followed by a comprehensive examination also seems ineffective. If an abundance of bacterial deposit is covering the teeth and only part of it is removed during a gross debridement, then the dental provider will be able to perform only a partial examination, not a comprehensive one. When a patient presents with heavy deposit, the comprehensive examination should not be completed until the entire deposit is removed after quadrant scaling. We all realize that probe readings are more accurate when there are no ledges of subgingival calculus, and it is much easier to detect caries without complete or partial deposit covering the teeth.

Evidently, insurance companies realize that simple preventive scalings/gross debridements are not money well spent, as they typically do not cover this procedure. I do not know of any dental hygiene school that teaches this philosophy, as it is not recommended in college textbooks or promoted by professional associations.

Moreover, how will the specific use of simple preventive scaling/gross debridement increase access to care? Some newly proposed providers, working under the direct physical presence of a dentist, have been suggested by some as the group to provide this procedure.

This implies that providing out–of–date treatment, under the direct supervision of a dentist, in communities with shortages of dentists, will increase access to care. When developing solutions for providing care to underserved populations in the U.S., it is important to use sound, evidence–based practices that truly advance access to care.

Christine Nathe, RDH, MS, is a professor and graduate program director at the University of New Mexico, Division of Dental Hygiene, in Albuquerque, N.M. She is also the author of “Dental Public Health” (www.prenhall.com/nathe), which is in its third edition with Prentice Hall. She can also be reached at (505) 272–8147.