U.S. grapples with mobile dentistry pros and cons

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The last batter still isn't out. Foes in a Louisiana battle over school-based dentistry are dusting themselves off after tussling their way to compromise legislation last week. But even if Gov. Bobby Jindal signs the bill into law as expected, the question of what kind of mobile dentistry should be allowed is likely to flare up again -- if not in Louisiana, then elsewhere in the U.S.

Already dental boards and legislatures in Florida, South Carolina, and Mississippi have taken action to restrict mobile dentistry services. The problem, they say, is preventive-only services that visit schools to do exams, fluoride treatment, and sealants, collecting Medicaid reimbursement but not following up on diseases they discover. "Some of these outfits would come in and skim the cream," said Connie Lane, executive director of the Mississippi Dental Association.

The complaint gets some support from a new study published in the July 2009 Journal of the American Dental Association (JADA, Vol. 140:7). Researchers from the University of Michigan found that programs providing only preventive services may actually result in fewer children getting comprehensive dental care.

“We're very interested in more dentistry going on in schools.”
— Liz Snow, chief strategy officer,
     California Dental Association

"I'm not against mobile vans or preventive programs," said JADA study co-author Woosung Sohn, D.D.S., Ph.D., Dr.P.H., an assistant professor at the University of Michigan. "But preventive-only services can be a little irresponsible."

Once someone has billed for examining or x-raying a patient, Medicaid generally won't reimburse another dentist for doing these services for at least another six months. That may make some dentists -- most of whom are already reluctant to treat Medicaid patients -- even less inclined to take on these patients. As a result, some patients may be getting fluoride or sealants at the expense of having cavities filled.

The study identified dental providers in Wayne County, MI, who had only billed Medicaid for diagnostic or preventive services. At least 20% of children age 5 to12 who received dental services through Medicaid in 2002 were treated by this type of provider, the researchers found. Compared to conventional dentists, the children treated by the prevention-only services were 2.5 times less likely to get restorative or surgical treatments.

Cherry pickers or saints?

"Somebody specialized in preventive is not a bad thing," said Dr. Sohn, who stressed that his study wasn't focused on mobile or school-based dentistry per se. "It's a good thing. But so much of the treatment is left out."

The problem stems from the way the U.S. pays -- or fails to pay -- for dental care. Millions of people across the country can't get themselves to the dentist. They may work in jobs where it's not possible to leave during the day, or live in remote areas without transportation. Others are disabled. Children depend on guardians who are willing and able to help.

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Technological innovations, like this Nomad portable x-ray system by Aribex, have made mobile dentistry easier. Image courtesy of Aribex.
Ideally, full-service dentists might visit these patients in their homes, or at least in places where large numbers congregate. But many of these patients are struggling to pay for food and housing, with no money left for healthcare. And few dentists are willing to work for what Medicaid is willing to pay, let alone make house calls. That's left an opening for services that visit schools and provide at least minimal care. Often, these services rely on hygienists who are willing to work for less money than dentists but can legally only provide cleanings, exams, x-rays, fluoride treatments, sealants, and education.

Children's Dental Services, in business since 1960, has connected many Minnesota kids in urban areas to nearby dentists, but in many rural counties, it just hasn't been able to find any dentists willing to take referrals. "We've been working hard to bring dentists in," said Executive Director Sarah Wovcha, M.P.H. "We're doing what we can with the resources we have."

That's left the program with a choice of providing some preventive services or no services at all in some of the 200 schools it serves. "We think the reality is that it's better to do something rather than nothing," Wovcha said -- a position with which even Dr. Sohn agrees.

But some states have come down on the other side of the question, acting to restrict the scope of preventive dentistry. "To curb abuses of mobile dentistry in the past, Florida limited Medicaid reimbursements to dental vans closely affiliated to the Florida Department of Health, Federally Qualified Health Centers, and similar not-for-profit organizations," stated Florida Dental Association President Ted Haeussner, D.M.D., in an e-mail to DrBicuspid.com. "Prior to enacting such restrictions, patients found follow-up care difficult to obtain, and the vast majority of Medicaid patients served by mobile dental vans were not encouraged to establish a dental home."

'The optimal situation'

That was more or less the approach the Louisiana Dental Association tried to follow in crafting legislation in the state as well. But the Louisiana bill, as originally drafted, would have shut down for-profit mobile dentists who were caring for children that other dentists had shunned. After weeks of debate, the state Legislature decided instead to ask the state dental board to issue tighter regulations.

Whether that will end the controversy remains to be seen; mobile dentistry regulations from dental boards haven't always succeeded. In South Carolina in 2000, the legislature eliminated a law preventing hygienists from treating patients until the patients were examined by a dentist. That opened the door for a group of hygienists to offer their services -- sans dentist -- in South Carolina schools.

The state dental board responded by issuing regulations that once again required a dentist's examination prior to a hygienist's treatment. In 2007, the Federal Trade Commission overruled the regulation on the argument that it had harmed consumers by restricting competition.

Mississippi has taken a slightly different approach. The State Board of Dental Examiners there is requiring mobile dental services to provide the name and address of a dentist who agrees to take referrals. "We have had no reported problems of patients not being able to receive follow-up care," said Executive Director Leah Diane Howell. What's less clear is whether children don't get preventive care because of the requirement.

These experiences have left dental policy leaders in other states scratching their heads. "We're very interested in more dentistry going on in schools," said Liz Snow, chief strategy officer for the California Dental Association (CDA). "I think virtually all the studies related to access have shown that one of the significant barriers is transportation. So a strategy that brings care to them is worth considering."

The CDA has two committees working on recommendations, with the hope of issuing them in the fall. "Our desire is for the optimal situation," Snow said. If California can figure that out, a lot of other states will be eager to hear.

Copyright © 2009 DrBicuspid.com

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