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Midlevel providers could help expand oral care access in South LA

In South L.A., access to dental care among the safety-net population is
In South L.A., access to dental care among the safety-net population is "extremely limited," says one expert, and for many of those patients, dental health often isn't a "grade-A priority."
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An estimated 1 in 4 U.S. children living in poverty had untreated cavities in 2010, according to federal data.

That same data also noted that the condition was found to be much less common among kids considered not living in poverty.

South Los Angeles is home to many children living with untreated oral conditions, said Maryjane Puffer, the executive director of the Los Angeles Trust for Children's Health. She said if access to dental care providers in L.A. County were to be mapped out, places in West L.A. and North Hollywood would be well-represented.

"But when you get down into East L.A., the San Fernando Valley, South Los Angeles, there isn't the same availability – especially for pediatric dentists," Puffer said.

The problem with access to dental care is similar to the one facing primary care: There aren't enough providers to meet the demand, especially in underserved areas and especially for uninsured or underinsured populations.

In some places, including some South L.A. clinics, midlevel providers like nurse practitioners and physician assistants are seeing increases in the scope of their practice – that is, an expansion of their duties – to help health centers keep up with patient demand. A CEO of a South L.A. clinic has said the "future of primary care" lies with midlevel providers.

Health professionals and advocates have been exploring a similar solution for dental care.

Widening the scope of practice for midlevel dental providers

A new report from Community Catalyst, an organization that advocates for expanded, affordable health care access, says midlevel dental providers "can be cost-effective members of dental teams and improve access to care, especially for traditionally hard to reach and underserved populations."

In other words, widening their scope of practice can help patients get seen and ease the patient load for dentists. Among those "hard to reach" populations are children and low-income adults, said the report's authors, who found that about one-third of the services provided by midlevel providers – in this case, dental therapists – was preventive (e.g. sealants, fluoride varnishes).

Puffer said this was "absolutely" a strategy that should be looked at to increase health care access.

"When we look at how health care reform is going to impact the state, the idea that we can keep people out of the hospitals, out of the clinics is a strategy we all have to embrace," she said.

That means focusing on preventive care.

"This era is about prevention and how to make communities healthier overall," she said. "Because I don't know that the (health care) system will have the capacity to take care of the chronic disease we see now in our middle-aged adults and even younger people. We have to get on a primary prevention track."

The dental landscape in South Los Angeles

Nina Vaccaro, the executive director of the Southside Coalition of Community Health Centers, echoed Puffer's analysis of dental care in L.A. County.

"I would say the state of access to dental care among the safety-net population is extremely limited," said Vaccaro, citing a lack of affordability and capacity. Of the eight clinics within the coalition, just three offer dental services, which aren't "traditionally covered by health coverage programs."

"That's actually one reason why the Care Harbor event is so tremendously popular with the community," she said, referring to an annual free clinic that's based in South L.A. "They are providing a lot of free dental care over those four days."

Looking back on her experience, Vaccaro noted that with many safety-net patients, there's a "lack of prioritization of oral health," in part because there's often a "disconnect" between a person's understanding of oral and physical health.

"It's really not considered a grade-A priority for people," she said. "I think people tend to neglect their oral health."

Puffer added that in South L.A. communities, one common mentality is the notion that "your baby teeth really don't matter because you're going to grow your adult teeth later."

"The low-level infection (that's found in children's teeth) is actually considered a chronic disease," she said. "This is a low-level state of bacteria and it affects all of the way a child is able to function."

School's a good example: A child may have to miss days because of pain, or sit through classes but not be able to concentrate. 

"If a child in South Los Angeles can't have access (to dental care) for three, four, five months, and they have an urgent care need, and there's not a dentist who can take them, we're risking children's lives by that," said Puffer.

It's important that children are "screened early," she said, and then pushed to develop "healthier habits."