Abstract
Purpose Forty-two states to date have passed legislation to expanded the role of dental hygienists for improved access to basic oral health services for underserved populations. Recent legislative changes in the state of Kansas have created the Extended Care Permit (ECP) I, II, and III designations. The purpose of this study was to examine the experiences of registered dental hygienists in Kansas holding ECP III certificates.
Methods Secondary data analysis was performed utilizing data collected from an ECP provider survey conducted in 2021. Dental hygienists in Kansas holding an Extended Care Permit III (n=88) were sent a 39-item electronic survey and informed consent was obtained prior to beginning the survey. Descriptive data analyses consisted of frequency distributions and percentages. Inferential data analysis consisted of Fisher’s Exact and Chi-Square tests to evaluate associations between ECP III demographics, practice characteristics, and services provided.
Results A total of 22 responses were received for a 25% response rate. The majority of the respondents (77%) were employed by a Safety Net Clinic. The practice settings reporting the highest percentage of ECP III services during the period of data collection were school-based settings, using portable equipment (68%). No associations were found between ECP III personal and practice characteristics and the provision of services specific to the ECP III permit.
Conclusion Results suggest that a low percentage of ECP III permit holders are providing ECP III-specific services. Considering these findings and the outcomes of previous studies, there is speculation that barriers continue to exist that prevent permit holders from performing ECP III-specific services and providing dental hygiene services to the fullest extent of an ECP license.
INTRODUCTION
The report, Oral Health in America: Advances and Challenges released in December 2021 by United States Surgeon General Vivek H. Murthy provided health care professionals and the public with a roadmap of how to improve oral health as well as highlight the challenges that continue to exist.1 The report notes that a persisting challenge to oral health is inadequate access to care.1,2 The authors identify the need to improve access to care by developing a more diverse oral health care workforce and integrating interprofessional practice into oral health care delivery models.1 Direct access to oral care from dental hygienists is an approach to the ongoing challenges to oral health care delivery models. As of 2022, 42 states, including Kansas, have legislated versions of direct access for the practice of dental hygiene.3
Kansas Extended Care Permit
Each year thousands of Kansans visit the emergency room with dental pain and the vast majority of these visits could have been prevented.4 Reasons for these otherwise preventable emergency room visits all include inadequate access to oral health care services.4 Eighty-six percent of the 105 counties in Kansas have been designated by the federal government as dental health professional shortage areas (HPSA), which leaves the majority of rural Kansans without adequate access to dental care.4-6
The development of the Kansas Extended Care Permit (ECP) statute has been a key component of the state’s approach to addressing access to care disparities.7 In 2003, the Kansas Dental Board amended the dental practice act establishing the Extended Care Permit I (ECP I) followed by the Extended Care Permit II (ECP II) in 2007. The ECP II revisions included a reduction in the licentiate requirements to obtain the permit, and changed the patient requirement from “qualification for governmental assistance” to any individual who is “dentally underserved.” These changes were instrumental in establishing a model that could provide more equitable access to oral health services.7 In 2012, requirements for licentiates to obtain a permit were further reduced and the Extended Care Permit III (ECP III) was introduced, which increased the range of dental hygiene procedures that could be performed. Kansas legislation does not require licentiates to obtain the ECP permits sequentially; ECP III permit holders can provide ECP I and ECP II services (Table I) provided that they have completed a training course specific to their permit level delivered by certified ECP training course facilitators. In August 2022 a total of 348 permits have been issued for ECP I and ECP II, and 88 dental hygienists hold ECP III permits.8
Extended Care Permit (ECP) descriptions7
The Kansas ECP hygienist does not parallel mid-level health care provider models such as advanced practice nurses requiring a master’s and doctorate level education, or the advanced dental hygiene practitioner (ADHP) workforce models which require a master’s degree.9 However, the ECP does provide an intermediate step by allowing dental hygienists to work to the full scope of their education and credentials while expanding access to care.10
Delinger et al. explored the impact the initial ECP legislation had on increasing the public’s access to oral health care services and identified advantages and limitations of the model.11 The study results found that ECP providers were making an impact by accessing children and nursing facilitiy residents, who may not otherwise receive dental care. At the same time Brotzman-Meyers et al. examined the perceptions of Kansas ECP dental hygienists relative to the changes in oral care in Kansas.12 Most respondents felt that ECP was a viable solution to access oral health care issues in Kansas and felt that their patients had experienced improved oral health. However, they also felt that there were significant barriers preventing them from utilizing their ECP licenses to the fullest. In a similar study, McEvoy et al. reported that 92% of ECP dental hygienists believed that the ECP provides for greater access to oral health care but again noted significant barriers to utilizing the ECP to the full scope of the permit.9
As Kansas progresses to gain an understanding of which types of workforce models are improving access to oral health care, more research is necessary to evaluate how ECP III dental hygienists are using their ECP III credentials. The purpose of this study was to examine the experiences of Kansas ECP III dental hygienists providing services to underserved populations, explore whether they are practing to the full scope the ECP III license, and identify the desire for additional education/instruction.
METHODS
This quantitative descriptive study was approved by the University of Missouri-Kansas City Institutional Review Board (IRB protocol number #307839).
Sample Population
All dental hygienists who were registered with the Kansas Dental Board as holding an ECP III permit (n=88) were eligible to participate in the study. Invitations to participate were distributed via email and the survey was administered via an online survey platform (Qualtrics, Seattle, WA, USA).
Survey Instrument
A 39-item survey was developed by the ECP III training course facilitators. The survey employed a combination of response formats from multiple allowable answers and open-ended written comments. Items included the following: demographics and year ECP III credentials were received (1), current employment (7), total hours practicing with an ECP III permit (1), specific procedures performed (7), materials utilized (11), dental workforce team (4), and interest in an ECP III refresher course (8). A pilot test on a convenience sample of clinical dental hygienists and dental hygiene educators (n=8) was conducted to determine clarity and understanding of the survey items. Changes to the survey instrument included the removal of questions that were repetitive and the re-wording of questions that were misleading. The cover letter, consent to participate and final version of the questionnaire were emailed to the ECP III licentiates in May 2021.
Statistical Analysis
Data were analyzed utilizing a statistical software program (SPSS version 28; IBM, Armonk, NY, USA). Descriptive data analyses consisted of frequency distributions and percentages. Inferential data analysis included the use of Fisher’s Exact and Chi-Square tests to evaluate associations of interest. Statistical significance for all testing was set at α = 0.05.
RESULTS
A total of 22 surveys were returned by ECP III dental hygienists for a response rate of 25%. Most respondents reported obtaining an ECP III permit between 2013 and 2015 (37%, n=8) and worked 31 or more hours a week (49%, n=11) (Table II). The majority reported being employed by a safety net clinic (77%, n=17), utilized their permit in school-based clinics using portable equipment (68%, n=15), and worked in the Northeast or Southcentral region of the state (79%, n=21). When asked about the type of dental services they performed, the majority reported performing fluoride treatments (91%, n=20), provided adult or child prophylaxis (86%, n=38), and placed sealants (82%, n=18). The least reported services performed were those that could only be performed with a ECP III license, such as temporary restorations (32%, n=7), denture reline or tissue conditioning (18%, n=4), and extractions on mobile primary teeth (14%, n=3) (Table II).
Descriptive characteristics of ECP III respondents (n = 22)
When asked about their dental workforce teams, respondents who reported working alongside other dental professionals either work alone (39%, n=7) or with another hygienist (39%, n=7). Most respondents who worked in an interprofessional environment with other health care professionals, work with a nurse or nursing staff (84%, n=16) and/or a physician (42%, n=8) (Table III).
Workforce team members
Associations between ECP III individual provider characteristics and the provision of ECP III permitted services (mobile primary teeth extractions, denture reline or tissue conditioning, and temporary restorations) are shown in Table IV. Current employer type was found to be signficantly associated with providing denture reline or tissue conditioning as well as temporary restorations (p = 0.02). The ECP III respondents who worked in safety net clinics as compared to those who indicated “other” employer types (e.g. private practice) were significantly less likely to provide denture reline or tissue conditioning (6% vs 60%) or temporary restorations (18% vs 80%). Among the locations where ECP III dental hygienists provide services, only long-term care facilities were significantly associated with ECP III permitted services (p = 0.05). The ECP III dental hygienists who provided services at long-term care facilities as compared to ECP III providers working in those locations were significantly more likely to provide denture reline or tissue conditioning (50% vs 6%) as well as temporary restorations (67% vs 19%). Providing ECP III services in the northeast region of Kansas was significantly associated with placing temporary restorations than those who did not work in that region (60% vs 9%, p=0.02). No significant associations were found with performing extractions on mobile primary teeth.
Respondent demographic characteristics and ECP III services provided
Associations between the health care providers that ECP III dental hygienists work with and the provision of ECP III only services (extractions of mobile primary teeth, denture relining or tissue conditioning, and temporary restorations) are shown in Table V. The ECP III hygienists who worked with physicians were significantly less likely to place temporary restorations than those who do not work with physicians (0% vs 64%, p=0.01). No significant associations were found with extractions of mobile primary teeth or denture relining and tissue conditioning.
Types of providers working with the ECP III respondents and the ECP III services provided
When asked about interest in attending an ECPIII refresher course, the respondants were nearly equally divided with being interested (n=6) and not interested (n=7). If a ECPIII refresher course were to be offerd, most (n=12) preferred having the course offered in blended format and offered on a Saturday. The inclusion of decay removal and placement of temporary resorations were the most (n=11) requested topics to be included in a refresher course.
DISCUSSION
The purpose of this study was to explore the experiences of dental hygienists holding an ECP III in the state of Kansas. The data was also collected in an effort to evaluate the effectiveness of the ECPIII credentialing and training course. The ECP III training course has been offered since 2013 and no follow-up study has been conducted on the utilization of the credential. The ECPIII course is the only course approved by the Dental Board of Kansas and it is important to understand whether the training is meeting the needs of the ECP III licentiate.
Similar to previous research on ECP providers, respondents to this study felt strongly regarding the contributions of ECP dental hygienists to improving oral health outcomes and increasing access to care in Kansas. Outcomes of this study parallel those of McEvoy et al. with the majority of ECP dental hygienists working full time in a Federally Qualified Healthcare setting such as a safety net clinic.9 Consistent with previous ECP studies, the majority of ECP services were provided to school-aged children.9,11,12 Although the ECP III legislation was designed to go beyond the preventative scope of practice and increase access to care, results in the current study suggest that the services being provided by providers with an ECP III certification appears similar to the services provided by ECP I and ECP II dental hygienists in previous studies,9,11,12 as the majority of respondents reported that they did not perform restorative services.
Considering the outcomes of previous studies as well as this current study, there is speculation that barriers continue to exist preventing ECP providers from performing ECP III-specific services and providing services to the fullest extent of an ECP license. Barriers such as reimbursement, financial viability, administrative support, and physical space have all been noted in previous studies.9,11,12 Future research examining why ECP III dental hygienists are not performing restorative services and barriers to providing all ECP procedures would serve to further inform the population of Kansas about the ongoing barriers to access to care in the state.
Limitations to this study include the self-reporting nature of survey research as well as the low response rate by ECP III dental hygienists, which impacts the generalizability of the results. The ECP III is specific to Kansas, and describing experiences specific to ECP III may not be generalizable to direct access dental hygienists in other states. However, the results contribute to the understanding of this phenomenon more fully and suggest areas for further empirical exploration.
CONCLUSION
Results suggest that a low percentage of ECP III dental hygienists are providing ECP III specific services. Previous research has indicated barriers to providing ECP specific services due to strict scope of practice requirements and limitations. Additional research is needed to identify whether it would be beneficial for policymakers to consider less restrictive supervision requirements, the need for direct reimbursement for dental hygiene services and the drafting of specific implementation guidelines creating new policies focusing on increasing access to dental care for vulnerable populations in Kansas.
ACKNOWLEDGMENTS
The authors would like to acknowledge Cynthia C. Gadbury-Amyot, MSDH. EdD, who worked tirelessly to develop, credential and direct the ECP III training course at the University of Missouri Kansas City, School of Dentistry.
Footnotes
NDHRA priority area, Professional development: Regulation (scope of practice).
DISCLOSURES
The authors have no conflicts of interest to disclose.
- Received May 25, 2023.
- Accepted August 8, 2023.
- Copyright © 2023 The American Dental Hygienists’ Association
