Kyara Fortes hadn’t been to a dentist for about a year. So, when the 3-year-old and her mother stopped in to the offices of Brockton Area Multi-Services Inc. recently, she visited a tiny back office just big enough for a desk, a filing cabinet, and a collapsible dental chair.
“Do all your teeth feel good? Can you eat all the foods that you like?” dental hygienist Carol Gilmore of Halifax asked, and the bright-eyed girl in pink nodded. “Go, ‘Ahhhh.’ ”
Gilmore inspected Kyara’s teeth with a small disposable mirror — “It tickles!,” the girl said — before cleaning them and painting on a coat of fluoride, while Kyara clutched Flossy, the stuffed dinosaur with a set of plastic teeth that Gilmore uses to demonstrate good brushing.
Gilmore is a public health hygienist, one of the first licensed under a program created in 2010 to improve access to dental care among low-income children and adults by giving experienced hygienists more authority to deliver preventive care without direct supervision from a dentist.
The state Medicaid program covers dental care for children. Yet, each year, about 200,000 children enrolled in the program do not receive any care from a dentist, said Dr. Brent Martin, dental director for MassHealth.
Thirty-one hygienists have been licensed through the program and have begun working in schools, WIC offices, and other offices that provide social services to low-income children. “We’re getting kids treated that otherwise wouldn’t have prevention done,” Martin said.
In the last state fiscal year, the hygienists served about 6,900 children. While that’s a help, he said, there’s plenty of room for the program to grow.
At the end of 2012, the US Health Resources and Services Administration estimated that 30.6 million people in the country were “unserved” by dental care, primarily because they live in an area with few providers or they have a low income. In Massachusetts, that figure is 348,040.
Increasingly, states have looked to hygienists as a lower-cost way to expand access and to connect more families to regular dental care, though the efforts have sometimes been met with opposition from dental associations concerned about transferring authority from dentists and adequate training among hygienists.
Including Massachusetts, 35 states have allowed hygienists to do more, according to the American Dental Hygienists’ Association. That may include making decisions about patient needs without a dentist checking their work and sometimes operating independent of a dentist. In Colorado, hygienists can have their own practice.
“We support allowing dental teams to do more, because we see that more needs to be done,” said Julie Stitzel, campaign manager for the PEW Children’s Dental Campaign, which in a recent report highlighted Massachusetts’s public health program as a success story.
The Massachusetts program allows hygienists to see MassHealth enrollees for dental screenings, cleanings, and application of sealants or fluoride, though they cannot fill cavities or perform other “restorative” procedures. To qualify, they must have at least three years of experience, train in a public health setting, and have a “collaborative agreement” with a dentist with whom they could consult on patient care. They can only bill MassHealth, not commercial insurers, for their work.
Many of the public health hygienists, like Gilmore, have built upon Massachusetts’s tradition of portable dentistry, started by Dr. Mark Doherty, a fifth-generation dentist (his son is the sixth) who began a program in 1979 to deliver dental care to children living in state facilities.
Today, Doherty’s Commonwealth Mobile Oral Health Service includes 10 dental teams — a dentist and an assistant — who regularly visit more than 200 sites in Massachusetts, including Head Start programs, preschools, elementary schools, and state-run facilities.
Doherty serves as a collaborating dentist for some public health hygienists, including Gilmore. The challenge in any portable dentistry program, and perhaps more so with the hygienist program, he said, is closing the loop — making sure that the children who have dental decay get the care they need.
The obstacles for low-income families are many. Parents may not be able to take time off work or have transportation (MassHealth may provide it for some), or they may be unfamiliar with dentists.
When a hygienist refers a patient to a dentist for treatment, that’s just the first step, Doherty said. “Having the appointment happen and having the treatment happen is the other part.” Without those elements, he said, “we’re actually abandoning the patient.”
Doherty’s program includes caseworkers who follow up with families. Gilmore, who began in the public health program with a $10,000 grant from the University of Massachusetts Medical School to help her and a business partner purchase the portable equipment they needed, refers the children she sees who have signs of decay or other problems to a dentist. Later, she can look back at MassHealth records to see if they actually visited one and talk with families who return to her about any obstacles.
Several other portable dental programs have grown up in Massachusetts since Doherty began. The ForsythKids program, part of the Forsyth Institute in Cambridge, began sending dentists and hygienists to schools in 2003. Hygienists and assistants affiliated with Tufts University School of Dental Medicine and its partners work at 240 schools and community sites.
Kathy Eklund, a hygienist and patient advocate for ForsythKids, said she expects that the growth of such programs and other changes — for example, physician assistants and other medical providers now can apply fluoride varnish — has improved dental care for Massachusetts children in recent years. Still, she said, “there is a lot of need.”
One major obstacle is that only 3 or 4 out of every 10 dentists practicing in the state serve people on MassHealth. The number has grown considerably since 2007, from 797 to 2,295 last year. The Massachusetts Dental Society has been campaigning to get more dentists enrolled. And after consumer advocacy group Health Care for All and its partners sued the state 12 years ago over poor access to dental care for low-income children, MassHealth increased payments to dentists and allowed them to limit the number of Medicaid patients they serve in order to persuade them to accept any.
One area of need mostly unaddressed in the public health program is among low-income adults. MassHealth covers adult cleanings but very few of the procedures needed to treat dental disease. Governor Deval Patrick’s proposed budget, released last week, would cover all dental needs for low-income adults, if approved.
Lawmakers in several nearby states could soon consider proposals to create a new licensed dental profession that advocates say would help provide more treatment. Sometimes called a “dental practitioner,” it could be similar to a nurse practitioner, allowing hygienists with additional training to do more of the basic restorative work now performed by dentists.
In New Hampshire such a measure was defeated last year, opposed by the state dental society, but advocates are considering proposing it again. Similar efforts are underway in Vermont and Maine. There are no plans for such a change in Massachusetts. Martin said there may not be a need for it.
“The public health dental hygienist program is still a new program and represents a new type of dental health provider,” he said. “We need to give it time to get established. I’m confident that we will see continued progress because of the work of these hygienists.”
By the numbers
Licensed public health hygienists working in Massachusetts
Estimated number of children served by public health hygienists last fiscal year