AMERICAN ACADEMY OF PEDIATRIC DENTISTRY RESOURCE SECTION 329 Analysis and Policy Recommendations Concerning Mid-level Dental Providers

Access to oral health care for children is an important concern that has received considerable attention since publication of the US Surgeon General’s report, Oral Health in America: A Report of the Surgeon General, in 2000. The Surgeon General’s report concluded that for certain large groups of disadvantaged children there is a “silent epidemic” of dental disease, and that the US public health infrastructure for oral health is insufficient to address the needs of disadvantaged groups. That report also identified dental caries (tooth decay) as the most common chronic disease of children in the United States, noting that 80 percent of tooth decay is found in 20-25 percent of children, large portions of whom live in poverty or low-income households and lack access to an ongoing source of quality dental care (ie, a dental home). Addressing the disparities between these disadvantaged children and the tens of millions of US children who enjoy access to quality oral health care and unprecedented levels of oral health is a major focus of the advo cacy efforts of the American Academy of Pediatric Dentistry (AAPD). AAPD is a recognized leader in ad vancing policies and programs geared to ward achieving optimal oral health for all children. Notable activities in the area of policy include annual publication of oral health policies and clinical guidelines; support of Title VII authorization and funding by Congress to expand pediatric and general dentistry residency training programs; revision of the Centers for Medicare and Medicaid Services (CMS) Guide to Children’s Dental Care in Medicaid ; adoption (in 2001) and promotion of a formal oral health policy on the “dental home” for children; and ongoing federal and state advocacy efforts to improve the performance of public programs whose purpose is to provide access to dental services for disadvantaged children [eg, Medicaid, Children’s Health Insurance Program (CHIP)]. Prominent program-related activities include a major national initiative sup ported through an ongoing partnership with the Office of Head Start to provide quality dental homes for the roughly one million preschool children enrolled annually in Head Start and Early Head programs throughout the US. Additional activities include leadership in advancing oral health care for young children and children with special health care needs and sponsorship of various professional education programs aimed at increasing general dentists’ ability to provide quality dental care for children. Medicaid is a major federal program designed to provide access to care for children with the greatest need for diag nostic, prevention and treatment services. Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) provisions require that a broad range of dental services necessary for the diagno sis, prevention, and treatment of disease-related or developmental conditions be provided to eligible children on an ongoing periodic basis from birth through late adolescence. However, numerous studies – including several by the US Congress and Department of Health and Human Services – and recurring federal legal actions have documented that State Medicaid programs gener ally do not devote sufficient resources to provide adequate access to dental care for Medicaid children. With few exceptions, Medicaid reimbursement rates for dental providers have remained appallingly low, below market-based levels, and often less than the overhead costs of most private practices. This leads general and pedi atric dentists in many states to opt out of Medicaid, thereby restricting much-needed care for this sizeable segment of the population. AAPD recognizes that Medicaid programs generally have failed to provide adequate dental care for American children who are most in need of dental services, and that these pro grams must be improved to address the oral health care needs of America’s most vulnerable children. Growing concern and attention to access to care issues have prompted a variety of proposals that call for work force strategies involving greater use and, in some cases, the development of new so-called ‘mid-level providers.’ Examples include various types of dental therapists, an advanced dental hygiene practitioner, and a community dental health coordina tor. These examples are in addition to the more established expanded function dental auxiliary/assistant (EFDA) mid-level model currently employed in many states and govern mentsponsored programs throughout the US. In light of these circumstances, the AAPD created a Task Force on Work force Issues in 2008 to examine various midlevel dental provider models. This Position Statement builds on the Task Force’s findings and offers AAPD’s policy recommendations regarding the use of mid-level providers in dental care for children.