Socioeconomic health and the scope of dental practice

INTRODUCTION

Data were compiled from multiple sources to determine whether the socioeconomic health of U.S. states affected their policies on the practice of dentistry in coexistence with medical doctors who have been granted the highest level of authority in medicine and prescriptive power. Several data have been compiled about the expansion of dentistry during times of natural disaster. An example of this includes the Illinois Healthcare Professional Emergency Volunteer Program, which has Dental Emergency Responders (DERs) who are deployed by the state.^[1] Another example is the State of Nevada. In Nevada, dentists can do triage, immunizations, general clinical care, COVID-19 testing, general emergencies, local anesthesia, airway maintenance, surgery drug dispensing, and general symptom/syndrome surveillance.^[2] However, now, it is necessary to study this on a national level, since dental regulation varies by state. There are many confounding factors such as healthcare worker shortages, public health emergencies, and abundance of dentists per area that come into play when dental practice acts are designed. A bill has also been introduced in the United States Congress to expand the role of dentists in emergency response situations on the federal level (DER Act of 2011, H.R. 112–24, 112^th Cong. (2011).).^[3]

To further understand the aforementioned confounding factors that play a role in the expansion or restriction of dental practice, it is important to study how and to what extent these factors play a role in the authority of dentists beyond their field. The data presents research only in mass epidemics such as SARS-COV-2 (COVID-19), but not times of natural disaster or peace.^[4,5]

MATERIALS AND METHODS

Sources were compiled to assess the economic effects on the practice scope of dentistry. In total, two factors (Practice of Teledentistry, and Dental Hygienists with Direct Access) were used to address an expansion or restriction of dental practice. To compile a feasible and navigable data set, data were only compiled for the top and bottom-most 11 states based on their poverty rate. Further, data were compiled for the ratio of rural/urban land in a state. Data for the urban/rural settings in the United States were also compared with specialized data about urban-rural differences in dental care. The top and bottom-most ten states were used for these data sets. This comparison will help to see whether a dental health disparity is apparent in the urban/rural setting.^[6] Any skewed data below or above the lower first quartile and higher third quartile was removed due to outliers caused by natural disasters in the COVID-19 emergency. In lieu of the removal, standard statistical tests were performed to keep data unbiased.^[7,8]

RESULTS

Figure 1 shows the poverty rate in percent form from March of 2020 in accordance with the state that it represents. Figure 2^[9,10] (in accordance with Figure 1) shows the number of factors met out of the two presented in the methods. The graph shows that there is a linear trend, with an R-squared value of 0.267. Figure 3^[11] shows the GDP growth in the past 5 years from 2018 to 2022 versus the name of the U.S. state (R² = 0.956). Figure 4^[9,10], which complements Figure 3 shows that a negative linear trend is present between the number of factors met and the GDP growth of 5 years, R-squared = 0.435.

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Figure 1:

Poverty rate (%) versus state name. 10% error bars present. Top and bottom 11 states used for the data set (n = 22). Wash. D.C.: Washington D.C. n is a standard statistical term which refers to the size (number) of data (points).

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Figure 2:

Number of factors met out of two provided versus poverty rate (%). 10% error bars present. The top and bottom ten states were used for data (n = 20). 1 and 2: The two methods are practice of Teledentistry and RDH’s with direct access. n is a standard statistical term which refers to the size (number) of data (points). 0 means that no factors have been met.^[9,10]

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Figure 3:

Relationship between gross domestic product growth over 2019–2022 and State. 10% error bars with top and bottom 10 states (n = 20). USD: US Dollar, GDP: Growth domestic product. n is a standard statistical term which refers to the size (number) of data (points). 0 means that no factors have been met.^[11]

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Figure 4:

Number of factors out of two met versus gross domestic product growth from 2019 to 2022. 10% error bars, n = 20 (top/ bottom 10 states). USD: US Dollar, GDP: Growth domestic product. 1 and 2: The two methods are practice of Teledentistry and RDH’s with direct access. n is a standard statistical term which refers to the size (number) of data (points). 0 means that no factors have been met.^[9-11]

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Figure 5^[12,13] shows the urbanization index in regard to the states with the best and worst overall dental health. The top and the bottom ten states are used for this graph. There is also a negative linear trend present in this set of data (R² = 0.353).

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Figure 5:

Relationship between urbanization index and states with best/worst dental health in order. 10% error bars, (n = 20). Wash. D.C.: Washington D.C. n is a standard statistical term which refers to the size (number) of data (points).^[12,13]

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DISCUSSION

Morlang (1996)^[14] first described the general idea of DERs and the expansion of dentistry. Although Morlang does not explicitly use the term DER, he suggests that civilians must have a Military Dental Officer Style training program. Morlang advocates that this training program will help dentists who provide excellent care at a time of an event where large amounts of injuries or casualties have occurred. This idea was again brought to life at the beginning of the COVID-19 pandemic,^[5] and continued worldwide as the Public Health Emergency expired.^[4] After disaster proclamations expired, both the general public and dentists were left confused about where their scope of practice lies.^[15] For example, as dentists helped the NHS (National Health Service [England]) deliver babies during a pandemic, they questioned whether the expanded scope of practice would continue in the future.^[16] The trend of DERs also holds true in other countries, for example, China. After the 2008 Wenchuan Earthquake, around 40% of people had suffered some form of a maxillofacial injury. The study also suggested that a specialized dental response team must be created to counter emergencies such as this one in the future.^[17]

In the first part of the research [Figures 1 and 2], a positive linear trend was seen between meeting the two factors of expansion of practice and poverty rate. The positive linear trend suggests that dental practice was expanded as the poverty rates went up for the respective states. This can also suggest that with an R-squared value of 0.267, the findings were significant since only two factors were used to calculate this value. Figures 3 and 4 show a negative linear trend with another significant R-squared value. The negative linear trend suggests that states that have had the largest amount of GDP growth over the past 5 years overwhelmingly expanded the practice of dentistry. Figure 5 shows that states which have urbanized the post has better overall dental health. The data from Figure 5 also affirms the claim that as family income and urban urbanicity city increase, the percentage of preventative dental visits increases as well.^[18]

CONCLUSION

The agreement between these figures and ideas strongly suggests that the practice of dentistry is expanded at times when dentists are needed for their skill and knowledge. The strong association can be seen during times of natural disaster, public health emergencies, increasing poverty rates, and a widening gap in healthcare in rural settings, etc. Overall, as socioeconomic health has declined, the scope of dental practice has expanded linearly.