Impact of interprofessional oral health care

Dear editor

I read with enthusiasm the evaluation results of Colorado’s oral health education (OHE) initiative reported by Braun et al.¹ As the health care community attempts to address the problem of persistent early childhood caries, expanding service delivery to nontraditional environments and expanding the scope of practice to non-dental providers are both promising ideas. I applaud Colorado and the other states where they have tied Medicaid reimbursement for non-dental providers to completing an OHE training program. I further applaud the effort of Braun and her team to evaluate the policy initiative. As other states consider how to move forward, it should be helpful for them to read the results of the strategies tested in Colorado.

I did wonder if clarification on three points would improve the utility of the reported work for use by other states and public health professionals working in rural and remote areas. First, in the narrative about “effectiveness” the authors stated they compared participants’ pre-/post-training scores on key variables but in the results for “effectiveness,” it appears the comparison was between provider types instead. Did the authors perform chi-square tests to compare medical professionals’ change from baseline? Was the “pre” OHE score from participant recall and were items like “confidence” scored on a Likert-style scale? From a qualitative look at the data, it appears that dental professionals who were participating because of inexperience working with very young children benefitted from the program. A chi-square to compare the dental providers change in scores from baseline might add meaningful data as states consider whether to include dentists or only medical professionals in OHE training.

The second point of clarification is related to “implementation” as reported in Table 2. If I understand correctly, providers who performed each care item at a rate greater than 50% with eligible children were considered to have “adopted” the lessons from the OHE program. I think the assessment item for “implementation” is designed to capture repeated care of those same eligible children 12 months later (maintenance). Is it correct to read the 12-month column in Table 2 as the “adoption” data and the 24-month column as the “implementation/maintenance” data? It was noteworthy that after 24 months, the 2009 cohort had continued to increase the provision of every care item.

The third question for the research team is regarding the distinction between medical professionals and non-dental professionals from a professional scope-of-practice perspective. My assumption is that the providers of patient care whose responses are reflected in Table 2 included participants from the medical, dental, and nursing professions (n=71). The authors reported in their discussion that the barrier related to “lack of adequate reimbursement” may have been a result of public health professionals not being eligible for reimbursement. My question is if billing code D1206 can be delegated. When a non-dental professional eligible for reimbursement performs the care then the V20.2 code could be used. In cases where the individual is not reimbursable, are there opportunities for the task to be delegated to them by the supervising prescriber and billed simply as D1206? I also wondered about the role of nurse practitioners and physician assistants in the expansion of oral health care into well-child visits. More than 700 participants in the OHE were surveyed. Were any of them mid-level providers?

I would like to restate my appreciation of this work documenting the positive impact of the Colorado OHE program for increasing oral health care delivery in the non-dental setting. I thank the authors in advance for considering my questions.