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Hospital-based dental care: increase in individuals seeking care outside of private offices presents new opportunities for dental assistants.

In the United States, dental services have traditionally been delivered through private dental offices. That may be changing. Visits to private dental offices declined by 9 percent during the period 2006-2012, while adults have increasingly sought care at health centers, including hospital-based dental clinics (up 74%) and emergency rooms (up 20%). A study by the Kaiser Family Foundation found that in 2013, 49 percent of adults with private health-care coverage had a dental visit in the last year, while only 20 percent of adults insured by Medicaid and 17 percent of uninsured adults saw a dentist (1).

The increase in the number of individuals using a hospital-based dental clinic is due in part to the fact that adults report they face financial barriers to dental care. Dental benefits for adults receiving Medicaid is far less comprehensive than for children. These factors make a hospital-based dental clinic more appealing (2).

The Centers for Medicare and Medicaid Services (CMS) recently proposed new standards to improve the quality of care and advance health equity in our nation's hospitals (applies to the 6,228 hospitals and critical care centers that participate in Medicaid and Medicare3). This proposal gives more funding to hospital-based dental clinics to purchase state-of-the-art equipment to improve the quality of patient care.

Additionally, the U.S. Bureau of Labor Statistics (BLS) expects employment for dental assisting to grow 18 percent through 2024--better than the overall average for other occupations. The BLS predicts 58,000 dental assisting jobs will be added between 2014 and 2024 (4). Dental assistants will be in high demand in a hospital-based dental clinic. Their presence will greatly increase the efficiency of the dentist in the delivery of quality oral health care. Dental assistants are an indispensable and integral member of the dental team, according to the American Dental Association (5).

Medically Fragile Patients

The concept of providing dental services in a hospital dates back to the late 1700s in New York City where it was introduced as a means of treating the poor. The primary role of a hospital-based dentist was to treat patients who were in pain. Today, however, the majority of dental care rendered in many modern hospitals is focused on the diagnosis and treatment necessary to support the recovery of medically compromised patients admitted for serious head and neck diseases, infection, or trauma.

The role of a hospital-based clinic is to address access-to-care issues by serving medically fragile patients who cannot be treated in a private practice (6). Hospital-based dental clinics are close to emergency departments and can manage patient conditions that would prevent them from being treated in a private dental office (7). Conditions that may warrant an emergency room visit include dental caries, periapical lesion gingival or periodontal conditions, abscess, or mouth cellulitis. Untreated dental conditions may progress to lesions that are severe enough to necessitate emergency visit and hospital admission (8).

To support the need for dental personnel training, teaching hospitals include training programs for graduate dental students, and rotate them through a dental department and other appropriate departments such as emergency medicine, internal medicine, and anesthesiology (9).

The dental assistant in a hospital-based dental clinic holds a unique position in the healthcare system. Many hospitals provide a great portion of their primary care through outpatient services, including dental care. This is especially true in neighborhoods with high poverty rates and a large number of uninsured individuals, whose general health is often poorer than that of middle and upper-class groups, due to poverty, inadequate diet, lack of education, and lack of knowledge of health care (10). These patients may also be impacted by low health literacy, which is defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions," according to the U.S. Department of Health and Human Services (11). Patients with low health literacy may find themselves in a dilemma with regard to post-operative instructions, pre-medication regimen, or even appointment scheduling (12). A dental assistant can be an important asset for this patient population.

Special Skills Required

To be successful in a hospital environment, a dental assistant must be highly organized and detail-oriented. For example, the documentation and infection control requirements in a hospital are far more stringent than a private office. Hospitals mandate in-house training for new staff members regarding these topics.

Additionally, many of the patients treated in a hospital-based dental clinic may have special needs or be medically compromised. Patients who are developmentally disabled, physically challenged, and who have survived cancer, to name a few, are perhaps best treated in a hospital-based dental clinic. They may need assistance transferring from a wheelchair to the dental chair, and patients with disabilities will need a longer appointment time. In fact, it's not uncommon for patients with disabilities or special needs to be placed under general anesthesia to perform various dental procedures. A dental assistant may need further training in assisting dentists who are treating patients under general anesthesia.

Because patients' primary care physicians are usually located within the same hospital, it's convenient not just for the patient and their caregiver, should they have one, but also for the doctors and the dental providers, who often need to consult on a patient's overall care regimen. Many patients have received emergency dental care, but few have received adequate instruction in home-based preventive care. The patients are usually very satisfied and appreciative after receiving theses services.

Also consider that many dental patients in a hospital-based dental clinic may be economically disadvantaged, and a hospital-based dental clinic is their only source for health care. It makes the business of working in a hospital dental clinic more rewarding. The hospital dental clinic setting also provides the dental assistant the advantage of working alongside a team of oral surgeons, dentists, dental hygienists, nurses, and medical doctors.

Anyone considering a position as a dental assistant in a hospital-based dental clinic must keep in mind that the position requires a great deal of patience, ingenuity, and patient dedication. Many patients may be encountering preventive, restorative, or oral hygiene care for the first time in their lives. Due to the present economic climate, hospital dental care is now becoming an alternative for dental care, rather than the traditional private office setting. Most hospitals accept Medicaid and private insurance, and have sliding scale fees for the uninsured as payment for dental services.

The clinical duties of a dental assistant in a hospital based dental clinic are distinct from those in a private practice setting. General clinical duties include assisting the dentist during a variety of treatment procedures, taking and developing dental radiographs, reviewing medical histories, and taking vital signs for surgical proanesthesia. Dental assistants are often the first health-care professionals who review medical histories with patients. The dental assistant is a naturally caring and compassionate individual who can encourage patients to express their fears in a supportive environment. After reviewing the patient's medical history, the dental assistant can inquire if the patient is currently experiencing any type of pain (13).

It is imperative that the dental assistant be knowledgeable about the medications that a patient may be taking. They should have a good understanding of the basic categories of medications and recognize their implications for dental treatment. Dental assistants should be able to recognize side effects that may occur from certain medications and know contra-indications for prescribing medications even though dental assistants do not prescribe medications. A familiarity with medications can be valuable in alerting the dentist to situations that could affect the patient's overall health (14).

The dental assistant will also provide post-operative care instructions following tooth extractions and periodontal surgery, and appropriate home-care instruction for the prevention of diseases. Patients with special needs and medically compromised patients are usually treated under sedation in a hospital- based dental clinic. The specifics to extent of a dental assistants' duties are specified based on hospital accrediting guidelines.

Office management tasks will include scheduling patient appointments and referrals. The dental assistant may also be involved in the ordering of supplies via the hospital's purchasing department and outside vendors.

Dental assisting in a hospital is a very exciting and rewarding career. The constant changes keep one sharp and abreast of current trends in the field.

Julie Bencosme, RDH, MA, CHES is an associate professor in the Dental Hygiene Program at Eugenio Maria de Hostos Community College in Bronx, New York. She has worked in dental hygiene for more than 30 years. Bencosme's experience includes private practice, hospital, and academia. She serves on the planning board of the American Association for Community Dental Programs and is a member of the Hispanic Dental Association.

References

(1) Tan, Y.Z. "New Funding Seeks to Help Clinics Swamped by Demand for Dental Care." Kaiser Health News, July 20, 2016.

(2) Vujicic, M. "Where have all the dental care visits gone?" The Journal of the American Dental Association. June 2015.146 (6).

(3) Goodrich, K., CMS Proposes Rule to Improve Health Equity and Care. Centers for Medicare and Medicaid. June 13, 2016.

(4) Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2016-17 Edition. www.bis.gov/ooh/healthcare/dental-assistants.htm. Accessed September 12, 2016

(5) American Dental Association, www.ada.org/en/education-careers/careers-in-dentistry/dental-team-careers/ dental-assistant. Accessed July 25, 2016

(6) Harris, N.O., Garcia-Godoy, F. Primary Preventive Dentistry. Pearson Prentice Hall, 2004.

(7) Allareddy, V., Rampa, S., Lee, M.K., Allareddy, V., Naillah, R.P. "Hospital-based Emergency Department Visits Involving Dental Conditions." The Journal of the American Dental Association. April 2014. Vol.145, Issue 4, pp 331-337.

(8) Carr, M. "Dental Hygienist in a Hospital Setting." ACCESS Magazine. May/June 2016.14-188.

(9) Rodriguez-Bencosme, J. "Dental Hygiene in a Hospital Setting." Modern Hygienist, May 21, 2012.

(10) Caverny, M. "The Dental Hygienist in Hospital Practice." The Journal of the American Dental Hygienist Association. May 1976. Vol. 50. pp 205-209.

(11) U.S. Department of Health and Human Services, Quick Guide to Health Literacy Fact Sheet: Health Literacy Basics. Office of Disease Prevention and Health Promotion, www.health.gov/communication/literacy/quickguide/factsbasic.htm. Accessed September 3, 2016.

(12) Rodriguez-Bencosme, J. "A special need to know: Overcoming patient's low Health literacy." Modern Hygienist, August 2008, 34-35.

(13) Bencosme, J., Macri, D. "Pain Management in Dentistry." The Dental Assistant Journal, March/April 2016.

(14) Govino, M. Wynn, L. The Importance of Pharmacology in the Delivery of Quality Dental Care, Crest Oral B Continuing Education Course, November 14, 2012.
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Author:Bencosme, Julie
Publication:The Dental Assistant
Date:Jan 1, 2017
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