Advancing Oral Health Equity through Medical-Dental Integration: Dental hygienists as catalysts for change in an evolving health care system

Facilitators of MDI Care Models

Medical Dental Integration care models in the primary care setting present an enormous opportunity to increase access to oral health care, particularly for vulnerable population groups, improving both care delivery and outcomes, while reducing health care costs.⁴ Medical Dental Integration should not be viewed as a one-size-fits-all. A model of care that promotes MDI should be chosen based on the specific needs of the patient population as well as the capacity of its providers.

Although numerous MDI care models exist,⁶ the need for interprofessional collaborative practice between dental and medical providers is central to this discussion.⁷ The disconnection of oral health care from the broader health care system began when medical and dental education systems became compartmentalized, consequently giving rise to structural barriers such as separate systems for care delivery and reimbursement.⁸ A multi-state analysis that examined how primary care providers and staff view dentists amid such structural barriers found that dentists are frequently not even considered part of the health care team.⁹ Unfortunately, the prevailing narrative in the dental literature has normalized dentistry’s separation from medicine, and so it is imperative that policy prioritizes oral health care integration as a way to reduce oral health disparities.⁸ However, fostering integration in primary care is a complex process involving stakeholders across multiple levels.

The Rainbow Model of Integrated Care (RMIC) is a conceptual framework that was created to examine the complexities of care integration from various perspectives. The framework includes level-specific domains: clinical integration (micro level), organizational/professional integration (meso level) and system integration (macro level).¹⁰ Harnagea et al. utilized this framework to identify level-specific facilitators of MDI in primary care. At the macro level, supportive policies, particularly those emphasizing reimbursement, contributed to the infrastructure needed for the sustainable implementation of MDI care models. At the meso and micro levels, interprofessional education was found to play a crucial role, specifically focusing on collaborative practices to empower providers with the understanding necessary for effective MDI. Other notable facilitators included the incorporation of appropriate case management to ensure shared health care responsibilities within the team and incremental modification of existing workflows, with staff buy-in, to foster a smooth transition towards MDI in primary care. Finally, the presence of local leadership to spearhead transformative change, and geographic proximity or the co-location of oral health care services emerged as practical considerations.¹¹

Dynamic Roles for Dental Hygienists in MDI Care Models

The various facilitators identified by Harnagea et al. collectively constitute the ideal criteria needed for MDI care models to be successful in primary care. Many of these criteria can be satisfied by the employment of dental hygienists in primary care teams.^12-14 For example, by encouraging the employment of dental hygienists as members of pediatric and prenatal care teams, the Wisconsin Medical-Dental Integration program (WI-MDI) has increased access to preventive oral health care services for children and pregnant women across multiple sites. Since 2019, the WI-MDI program has provided access to oral health care services in more than 15,000 patient visits to a pediatric or prenatal care provider.¹² At the macro level, this program was made possible by supportive policies that allowed dental hygienists to become certified Medicaid providers, which significantly expanded direct access to non-traditional settings, including medical offices, without requiring the authorization and supervision of a dentist.^11-12 Direct access is “the ability of a dental hygienist to initiate treatment based on their assessment of a patient’s needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship.”¹⁵ At the meso and micro levels, the WI-MDI program leveraged appropriate case management (e.g. well-visits for pediatric and prenatal patients) and effective collaborative practice as dental hygienists became an integral part of the pediatric and prenatal care teams. Furthermore, there were incremental modifications of the existing workflow where the dental hygienist would typically provide care after the medical provider’s portion of the well-visit appointment.^11-12 Each dental hygienist visit would take approximately 10 minutes and may consist of a caries risk assessment, the application of fluoride varnish and/or silver diamine fluoride as indicated, the provision of anticipatory guidance, and care coordination, such as referral to a dental home. This typical visit structure also leveraged the principle of local leadership and the co-location of oral health care services, as dental hygienists can focus on oral health promotion, oral hygiene, and preventive oral health care, while also facilitating care coordination for restorative dental care as indicated.^11-12

The dental hygienists who participated in the WI-MDI program between 2019 and 2023 identified limited referral options to a restorative dentist as a significant barrier. Similarly, Braun et al. found that facilitating access to restorative dental care was a barrier in their MDI care model in the state of Colorado, despite otherwise positive results that showed the potential of integrating dental hygienists with primary care teams may have on oral health outcomes.^12-13 Leveraging telehealth may help the expansion of MDI care models. For example, in the SMILES (Spanning Miles in Linking Everyone to Services) Dental Home Model, telehealth was utilized to facilitate collaborative practice between a dental hygienist and a dentist. The dental hygienist would collect pertinent information needed to formulate a treatment plan, including clinical examination findings, intraoral x-rays, in addition to intraoral clinical photographs. This data was securely shared with a collaborating dentist at a “dental hub” to formulate a treatment plan. When a treatment plan was decided on, the dental hygienist could implement the plan in a non-traditional dental setting, or they could facilitate care coordination to a treating dentist.⁶

Policy Advocacy and Stakeholder Education

If dental hygienists are allowed to work at the top of their license and increase access to oral health care through innovative care models that promote MDI, effective policy supporting direct access should be a priority for all stakeholders in the broader health care system. Since the release of the Surgeon General’s report in 2000, the proportion of states with some form of direct access has increased from 18% to 84%.³ However, numerous state dental practice acts continue to present barriers to dental hygienists providing oral health care in non- traditional settings, therefore the majority of dental hygienists continue to work in dental offices.^{3-4, 8} Dentists typically practice in isolation from other members the health care team,¹⁶ thus limiting the capacity of dental hygienists to support MDI care models in non-traditional settings. As national accreditation standards for dental hygiene education are uniform across all states, differences should be minimal when it comes to the practice of dental hygiene as it applies to direct access. However, there is much inconsistency in the scope of practice permitted, including supervision requirements, limitations on choice of work setting and eligibility for direct reimbursement.^{3, 15}

The Dental Hygiene Professional Practice Index (DHPII), a numerical tool designed to measure the state-level professional practice environment for dental hygienists, has been used in several studies to examine the relationship between the scope of practice of dental hygienists and access to oral health care and related costs.¹⁷ In 2005, one study showed that an increased scope of practice led to increased utilization of basic oral health care.¹⁸ Other studies have shown that when a restrictive scope of practice is imposed on dental hygienists, the cost for oral health care services has increased.^19-20 Indeed, results from one study showed that the costs associated with providing basic oral health care services were increased by 12% when dental hygienists were restricted from providing those preventive oral health care services.²⁰ Furthermore, it has been shown that when dental hygienists are reimbursed for the provision of oral health care services directly, the utilization of basic oral health care services increases by three to four percentage points.²⁰ However, only 38% of states permit direct reimbursement from Medicaid to dental hygienists who provide oral health care services for Medicaid-insured patients. ²¹ Supportive policies, especially those emphasizing reimbursement, are crucial to facilitating MDI in primary care.¹¹ Thus, policy advocacy and stakeholder education on the benefits of less restrictive licensure policies to increase access to preventive oral health care are critical for advancing oral health equity.^{3-4, 8}