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4 Current Demographics and Future Trends of the Oral Health Workforce Two panels of experts discussed the demographics and trends of the oral health workforce, including the relevant numbers, distribution, train- ing, and specialization. The first panel examined the members of the dental workforce directly involved in the delivery of oral health servicesâdentists, dental hygienists, and dental assistants. The second panel considered other members of the health care workforce who may provide oral health services including physicians and nurses, and how they interact with traditional dental professionals. The Dental Workforce Dentists Richard W. Valachovic, D.M.D., M.P.H. American Dental Education Association A variety of data sources can be used to describe the dental workforce, and those data vary depending on variables such as the year and source of collection. There are over 179,000 professionally active dentists in the United States (ADA Survey Center, 2008). Professionally active dentists are predominantly male, white, in private practice, practicing general den- tistry (as opposed to a specialty), and over age 45 (ADA Survey Center, 2008). Some of these demographics are beginning to change, however. For example, women account for 39.6 percent of all dentists graduating since 1997 and 43 percent of current graduates (ADA Survey Center, 2008). 23
24 THE U.S. ORAL HEALTH WORKFORCE A Â dditionally, while the number of applicants from underrepresented minor- ity groups has been on the rise in recent years, these numbers remain too low to have an immediate impact. There are several ways in which to consider the appropriate number of dentists. The Health Resources and Services Administration (HRSA) defines dental health professional shortage areas (HPSAs) according to several factors related to access; this definition roughly approximates when the dentist-to-population ratio rises to 1 to 5,000 (HRSA, 2009a). In the early 2000s, there were less than 2,000 dental HPSAs. By 2008, this num- ber climbed to over 4,000 dental HPSAs, representing 49 million residents (HRSA, 2009b). Another data point is the number of professionally active dentists per 100,000 population, which has been decreasing for several years and is expected to continue to decrease (see Figure 4-1). However, this may be attributable in part to the increased use of technology or other oral health professionals. 61 Actual 59 Projected 57 55 53 51 49 47 45 1976 1982 1987 1992 1994 2000 2005 2010 2015 2020 Year FIGURE 4-1â Number of professionally active dentists per 100,000 U.S. population, 1976â2020. NOTE: Data for the years 2010â20204-1 projected. Figure are SOURCE: Personal communication, W. Wendling, ADA. May 5, 2009. R01521 redrawn Fully editable vectors
CURRENT DEMOGRAPHICS AND FUTURE TRENDS 25 Finally, there are the trends seen at schools of dentistry. Recently there has been an upturn in the number of applicants, with about three Âapplicants for every available slot. While the number of available slots has been variable over the past few decades, the current number of slots will be insufficient to replace the cohort of retiring dentists. Since 1982, seven schools closed, four opened, and eight are seeking accreditation or are under consideration. Dental Hygienists Ann Battrell, M.S.D.H., RDH American Dental Hygienistsâ Association The oral and general health needs of the population are growing. Health care practice and education need to evolve to meet those needs, health care delivery needs to become more integrated, and health care stake- holders need to work cooperatively to identify and remove the barriers that restrict the publicâs access to oral health care services. Currently there are 312 entry-level dental hygiene programs, with at least one program in every state. Fifty-nine programs are at the baccalaureate level and 18 are masterâs level (ADHA, 2009c). Enrollment trends are up, and new programs are arising regularly. The sustainability of these programs may be problematic as positions are being cut back or eliminated altogether. However, while traditional positions may be on the wane, the demand for hygiene services in alternative settings is on the rise. For Âexample, the Bureau of Labor Statistics (BLS) predicts a 30 percent growth in the employment of dental hygienists by the year 2016; at the same time, they predict only a 9 percent growth in the employment of dentists (BLS, 2007b,c). To obtain licensure in dental hygiene, 49 states require graduation from an accredited program. All states require national written exams and either state or regional clinical exams. Some states require completion of jurisÂprudence exams, and 49 states require continuing education. Dental hygiene is a predominantly a profession of white females. On average, dental hygienists are in their mid-forties with just under 20 years of experience. Most dental hygienists are in private practice. AccordÂing to data collected by the American Dental Hygienistsâ Association (ADHA), one-quarter of dental hygienists hold licenses in more than one state, and almost one-third work in multiple sites, indicative of a trend toward the use of part-time hygienists, which becomes an issue due to the loss of full- time benefits. â âEntry-level programs offer degrees or certificates that allow for entry into the practice of dental hygiene.
26 THE U.S. ORAL HEALTH WORKFORCE Dental hygienists can help overcome many patientsâ hurdles to access- ing oral health care services. While the heart of dental hygiene is in preven- tion, many patients are in need of both prevention and treatment services. To change the ability of dental hygienists to provide needed services, many stakeholders need to be engaged, including the dental examiners. In addi- tion, we need to use a common nomenclature. For example, the term direct access should be used instead of unsupervised practice. Much activity has occurred at the state level reflecting the increasing recognition and use of dental hygienists. The ADHA defines direct access as meaning that the dental hygienist can initiate treatment based on his or her assessment of patientâs needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and can maintain a provider- patient relationship. (ADHA, 2009b) Since 1995, the number of states allowing direct access to a dental hy- gienist outside of the dental office rose from 5 to 29. Figure 4-2 shows the status of direct access by state as of January 2009. In addition, 15 states currently recognize and directly reimburse dental hygienists as Medicaid providers (ADHA, 2009d). FIGURE 4-2â States that allow direct access to dental hygienists in some settings outside of the dental office, January 2009. NOTE: States in dark shading allow direct access. SOURCE: ADHA, 2009a. Figure 4-2, text is editable, map is not
CURRENT DEMOGRAPHICS AND FUTURE TRENDS 27 There are many opportunities to increase the use of dental hygienists. Dental hygienists are often trained to provide services beyond what they are allowed to do, and changes in legislation would enable them to prac- tice to the extent of this education. Options for practice settings should be increased to shift the paradigm from supervision to collaboration. Finally, new types of practitioners should be considered, such as the ADHA model for the Advanced Dental Hygiene Practitioner, which builds upon the exist- ing workforce. Many changes are needed to improve access to oral health services for many different populations. As new roles are considered, oral health professionals must be able to work within the system, know how to use research, know how to make informed decisions, and practice in an evidence-based capacity. Dental Assistants Cathy J. Roberts, CDA, EFDA, COA, CDPMA, MADAA American Dental Assistants Association At about 280,000 persons, dental assistants make up the largest part of the dental workforce (BLS, 2007a). Dental assistants primarily work in a clinical capacity. Other roles include front-office positions, practice man- agement, and education. Most dental assistants work in private practices and as assistants to general dentists, but many dental assistants work in specialty practices such as orthodontic and pediatric practices. Currently, there are more than 30 different job titles for dental assistants across the country in different states. While the dental assisting profession used to be regarded as a transient profession, many more dental assistants are now making it a long-term career. For example, according to the American Dental Assistants Association (ADAA), the average number of years of employment of a dental assistant in any one practice is about 11 years. The BLS expects employment for dental assistants to grow about 29 percent between 2006 and 2016, putting it among the fastest growing professions during that period of time (BLS, 2007a). As dentistsâ workloads increase, they may turn to dental assistants to perform more routine tasks. With proper education and training, expanded function dental assistants can perform many procedures such as applica- tion of topical fluoride or anesthetic, application of sealants, and coronal polishing. However, the laws regulating the practice of dental assistants vary by state. State variation in laws also affects educational requirements. Current programs vary widely from weekend courses in a dentistâs office with no set curricula to ADA-accredited programs with defined curricula. Some assistants receive on-the-job training, but this often does not prepare assistants for positions in other offices or does not allow them to carry
28 THE U.S. ORAL HEALTH WORKFORCE their credentials to other states. As with other professions, a standard- ized and mandatory national credential would allow more flexibility and s Â tability in the profession. For example, many dental assistants serve in the armed forces and acquire significant experience, but are unable to meet state-based educational requirements when returning to the United States. State variation in education and credentialing is also confusing because requirements also vary among states for individual tasks, such as taking an X-ray. ADAA and the Dental Assisting National Board (DANB) have com- piled minimum core competencies for dental assistants for each advanced level of duty. DANB offers two national certification exams (e.g., for the certified dental assistant) and two exams for stand-alone national certifi- cates of competency (e.g., radiation health and safety). The certified dental assistant credential is recognized in 29 states, and 38 states recognize at least one DANB exam (DANB, 2009). This certification leads to higher wages and a higher likelihood the individual stays in the profession. As the education and credentialing of dental assistants becomes more standard- ized, they may be one source to increase access to oral health services for many populations for some basic oral health care needs. The nondental ORAL health workforce Integration with Nondental Health Care Professionals Irene V. Hilton, D.D.S., M.P.H. San Francisco Department of Public Health Aside from traditional dental practitioners in the United Statesâ d Â entists, dental hygienists, and dental assistantsâmany more individuals can be involved in the delivery of oral health services, including physi- cians, nurses, and other health care workers. To integrate the dental and nondental workforces, more consideration is needed for what services the nonÂdental workforce can provide. Within the medical model, tasks may include the assessment for oral disease risk and the presence of oral dis- ease, the initiation and promotion of prevention strategies, the initiation and management of nonsurgical interventions, and the proper referral of patients. In addition, consideration is needed to determine which popula- tions these professionals can best serve. Currently most members of the nondental workforce involved in the provision of oral health services a Â ddress the needs of pediatric populations. Other special populations that â âThe nondental health care workforce includes health care professionals aside from dentists, dental hygienists, and dental assistants.
CURRENT DEMOGRAPHICS AND FUTURE TRENDS 29 might be served by the nondental professions include the perinatal popu- lation, special needs populations, adults with complex medical needs, and geriatric patients. Challenges and Opportunities for Increased Integration Members of the nondental workforce need increased training and e Â xposure to oral health care. For physicians, residency appears to be the most opportune place to teach oral health content due to residentsâ engage- ment, increased time allotment (as compared to medical school curricula), and the ability to impart both clinical and didactic experiences. Currently, family medicine is the only area of medicine that has developed standard- ized competencies for oral health in residency programs. Finally, if oral health services are provided by nondental professionals, consideration is needed for how to assess the clinical quality of those services. In truth, there are not many evidence-based standardized clinical guidelines for oral health care in general. For example, it is known that fluoride varnish reduces caries incidence, but there is no consensus as to the best frequency of application. Several barriers challenge the true integration of dental professionals and other health care professionals. First, dental professionals are less likely than nondental professionals to be familiar with participating in a referral network with other types of practitioners. Second, while academically based training programs may be easier to implement since many medical train- ing institutions are associated with a dental school, physicians and other professionals may lack a community referral network of dentists once they are out in practice. This requires an infrastructure that may not exist for many professionals, such as referral forms, electronic recordkeeping, and case management follow-up procedures. Conclusions As the use of nondental professionals increases, consideration is needed for the effects on the oral health workforce overall. The more training these professionals receive to recognize oral disease, the more unmet need will be identified, especially for surgical restorative services in the short term. However, with the implementation of successful prevention strategies, there may eventually be a long-term decrease in the demand for surgical services. Additionally, integration with the nondental workforce allows for evolution toward true oral health, with dental professionals being an integral part of maintaining the systemic health of their patients.
30 THE U.S. ORAL HEALTH WORKFORCE Pediatrics David M. Krol, M.D., M.P.H., FAAP University of Toledo Physicians may receive oral health education at many levels including during medical school, during residency training, and in continuing educa- tion programs. A 2006 survey found that two-thirds of graduating residents thought they should be performing oral health assessments on their patients (Caspary et al., 2008). However, only about one-third of pediatrics resi- dents receive any oral health training during their residencies and of those that do, two-thirds get less than 3 hours of training. Only about 14 percent had clinical observation time with a dentist. The majority of pediatrics residents want more oral health training. In addition, in a recent survey of recently trained general pediatricians, more than half of respondents expressed the need for additional residency training in oral health (Freed et al., 2009). In fact, this need was second only to mental health in terms of areas in need of increased training. Increasing Recognition of Oral Health The pediatrics profession has taken many steps to ensure better training of residents in oral health care. The Academic Pediatrics Association, the society for general academic pediatrics, has explicit educational guidelines for oral health training in pediatric residency. In addition, the pediatric board exam has questions about oral health. However, the residency review committee for pediatrics has not yet identified oral health as a required topic for pediatric residencies. While the topic is not required in residency, many curricula have been developed to educate and train pediatricians in oral health care. The pediatrics profession has increasingly recognized the importance of oral health in recent years via policy statements, publications, and meet- ings. In May 2003, the American Academy of Pediatrics (AAP) delivered its first policy statement on oral health, covering basic topics such as dental caries, risk assessment, and the dental home (Section on Pediatric Dentistry, 2003). In December 2008, a second policy statement addressed support for medical-dental collaboration and the inclusion of oral health in well child care (Section on Pediatric Dentistry, 2008). In addition, AAPâs agenda has included oral health for the last few years and pediatric dentists have been members of the AAP since 1999. Bright Futures provides prevention and treatment guidelines on well child visits to pediatricians, including a specific subset of guidelines specific to oral health. In the most recent edition, oral health was one of the 10 major themes and was identified as a component
CURRENT DEMOGRAPHICS AND FUTURE TRENDS 31 of every well child visit. The AAP has developed Pedialink, a resource for continuing education online (available to AAP members), which has a specific module on early childhood caries as well as audio CDs on oral health. Oral health has also received increased attention at local, state, and national conferences. In 2005, the Pediatric Academic Societies had a mini-course on oral health for the first time, and in 2008, the AAP annual meeting focused on oral health. Many programs and grants have also risen to spread oral health educa- tion to pediatricians. Preceptorship programs provide individualized train- ing. The Chapter Advocates Training in Oral Health program is attempting to identify an oral health advocate at each of the 66 AAP chapters in the United States. These individuals will serve as chapter oral health experts and have a dental partner to build collaborations at the state and local levels. Conclusions Oral health has to be integrated into every level of pediatrics train- ing. It has to be supported and instituted by the accreditation bodies and competence must be tested. While there are multiple curricula, the content and quality of the information must be consistent to both practitioners and parents. These curricula also need to be evaluated for their effectiveness in changing behaviors and their effects on both the oral health and overall health of patients. Finally, there needs to be more collaboration at every level of education and practice. Family Medicine Russell Maier, M.D. Central Washington Family Medicine Residency, and University of Washington School of Medicine Family physicians practice across a spectrum of care settings and care for a variety of populations. Family physicians are the largest primary-care specialty and are a major source of care for rural and underserved popula- tions. Without family physicians, almost the entire nation becomes a health professional shortage area. Family physicians often provide the medical home for both children and adults. Family medicine physicians typically receive little exposure to oral health in medical school or residency and perceive oral health as an area of knowledge deficit. In June 2006, the residency review committee for f Â amily medicine residencies added oral health as a requirement. However, the extent or content of the requirement is not explicitly defined. In a Ârecent
32 THE U.S. ORAL HEALTH WORKFORCE survey of directors of family medicine residencies, about three-fourths of the residency directors knew of the oral health requirement and about two- thirds of the programs actually included oral health content, with the most common training time being 2 hours per year (Douglass et al., 2009) Several academic groups have come together to develop Smiles for Life, a curriculum based on a blending of the nationâs best practices for teaching oral health to family medicine physicians. The curriculum has seven mod- ules and is being used by at least eight states. Other efforts are attempting to educate practicing physicians on oral health. More continuing medical education lectures and published journal articles have arisen. Family medi- cine board exams also include questions on oral health. In conclusion, to advance oral health education and training within family medicine, more needs to be done to expand this education and train- ing in both medical schools and residency programs. In addition, strategies that are the most effective in changing physician practice patterns must be identified. Finally, the health care system needs to become more fully integrated. Nursing Caroline Dorsen, M.S.N., FNP-BC New York University, College of Nursing Donna Shelley, M.D., M.P.H. New York University, College of Dentistry Nurse practitioners are registered nurses with additional education and training at the graduate level and have either a masterâs or doctoral degree. Nurse practitioners can see patients independently and perform histories and physicals, perform lab tests, and diagnose and treat both acute and chronic conditions. Nurse practitioners emphasize health promotion and disease prevention and especially focus on the health of individuals in the context of their families and communities. Nurse practitioners are credentialed and take a national licensing e Â xamination offered by one of three different organizations (depending on the area of specialty). Nurse practitioner scope of practice is defined at the state level by each stateâs nurse practice act. For example, in New York state, nurse practitioners can write prescriptions but are required to have a collaborative practice arrangement with a physician, meaning that there is a â âIn 2004, the American Association of Colleges of Nursing recommended the practice doc- torate to be the graduate degree for advanced practice nurses, including nurse practitioners (AACN, 2004).
CURRENT DEMOGRAPHICS AND FUTURE TRENDS 33 formal written agreement by the physician to be available to the nurse prac- titioner for questions or to help with quality assurance. These indiÂviduals commonly practice in areas where there are fewer health professionals. As such, they may serve as a frontline screening source for oral health and may need increased training and expanded scopes of practice. Nurse practitioners who specialize in pediatrics have much better edu- cation in oral health than nurse practitioners specializing in adult medicine or geriatrics, likely due to the emphasis on preventive care. Instead, these other tracks discuss oral health only in the context of reflecting disease states. Except in pediatrics, most nurse practitioner certification examina- tions do not include oral health. New York University Model In the 2001 report Crossing the Quality Chasm (IOM, 2001), the InstiÂ tute of Medicine called for the facilitation of interprofessional collabora- tion. As a result, the New York University (NYU) College of Nursing and College of Dentistry worked together to identify similarities, differences, and areas of potential improvement. NYU conceptualized and put into operation a model of multidisciplinary practice between these two colleges. This model has two goals: (1) to develop and evaluate new interdisciplin- ary practice and education models, and (2) to support interdisciplinary translational research. The first step was to have visiting professors from one discipline lec- ture to students of the other discipline. For example, nurses have talked to dental students about health promotion and disease prevention while dental faculty members have taught nursing students about performing oral assessments. A more creative approach has been to have nurse practitioner students and dental students receive side-by-side clinical training. Finally, nurse practitioner students and dental students work together on other activities, such as health fairs and international health care missions. This collaboration between the two colleges has also led to a fair amount of new research and practice. For example, smoking cessation relates to both professions in terms of oral cancers and smoking preven- tion. Other areas of shared interest include salivary HIV testing, diabetes screening and early intervention for periodontal disease, and elder abuse screening. Finally, the College of Nursing Family Practice was developed to provide primary care services by nurse practitioners to patients who are accessing dental services at the College of Dentistry clinics. About one-third of the patients coming through those clinics do not have a primary care provider. Previously, practitioners in the dental clinic did not routinely ask patients if they had a primary care physician. These data are now part of
34 THE U.S. ORAL HEALTH WORKFORCE the charting system so that these patients are flagged and can be identified as individuals who might need a visit. Conclusions As an oral health curriculum is developed, more needs to be done to coordinate with other disciplines to define the competencies and create a core curriculum that goes across the life span. Also, more models are needed for the interdisciplinary education and training of health professions students. Policies need to come into alignment with practice, such as the development and implementation of clinical practice guidelines. Finally, a research agenda is needed to follow the clinical agenda in order to track which interventions are most effective in changing practice patterns. reaction and DISCUSSION Moderator: Elizabeth Mertz, M.A. Center for the Health Professions, University of California, San Francisco Moderator: Daniel Derksen, M.D. University of New Mexico Open discussions followed the panelistsâ presentations. For these ses- sions, workshop participants were asked to submit cards with comments and questions for the panelists. The following sections summarize the dis- cussion sessions. (See Appendix E for a broader sampling of the submitted questions and comments.) Workforce Planning Several specific questions were posed regarding the workforce of d Â entists. In response to a question regarding the accreditation of foreign dental schools, Valachovic said that unlike international medical graduates, dental graduates must currently graduate from an American dental school to be eligible for licensure in nearly all states. He said there is some slow movement to consider the accreditation of foreign dental schools so that graduates would be eligible for licensure upon graduation (assuming im- migration status). In regards to a question on the effect of the increasing number of women in dentistry, Valachovic said male dentists tend to work many hours early in their careers and then start to diminish the number of hours they work later in their careers while women tend to take time off early in their careers for family-related issues, but then increase their
CURRENT DEMOGRAPHICS AND FUTURE TRENDS 35 number of hours later in their careers. In fact, he stated, the total number of hours worked by women during the lifetime of their careers may actually exceed the total number of hours worked by men. He added that female dentists may also have the opportunity to consider a variety of practice settings since, on average, spouses of female dentists tend to have higher incomes than spouses of male dentists. In response to a question regard- ing how to recruit more underrepresented minority students into dentistry, Valachovic said the numbers of applicants are increasing, but still not sufficient. He remarked that the American Dental Education Association (ADEA) has over $30 million invested in projects to increase the number of qualified underrepresented minority applicants. For example, he noted a collaborative effort with the Association of American Medical Colleges to hold a 6-week summer program in the basic sciences for first- and second- year college students with interest in medical and dental careers. One participant posed a question regarding the status of updated sup- ply requirement models or analysis of the oral health workforce. Mertz said that individual professions often project these needs and that HRSA has funded this type of research, but that many models may be limited since projections are often based on current trends instead of considering any new models of care. Valachovic said the ADEA is trying to look at new models while taking into account newly emerging changes in the applicant pool as well as the number of new schools of dentistry and dental hygiene programs approved by the Commission on Dental Accreditation. Battrell noted that the ADHA has developed a dental hygiene master file to try to analyze the education and workforce trends. She noted that there are six times as many dental hygiene programs as schools of dentistry, but not every dental school has a hygiene program; even when they do, the programs are usually not integrated, so the students do not learn how to work together. Evidence Base Several questions were submitted regarding the evidence around direct access to dental hygienists including the effects on access and impact of financing challenges. Battrell said several models of advanced practice in dental hygiene are beginning to collect data, adding that all existing and emerging models should be uniformly examined. Battrell distinguished between being an independently practicing dental hygienist (i.e., owner of the business) and a dental hygienist who provides direct access. She stated that it can be difficult to collect data since due to political pressures, many independently practicing dental hygienists do not want to be publicly iden- tified. In that regard, Battrell advocated for providing safeguards for these professionals so that they can uniformly share their data without fear of retribution. Battrell noted that some evidence does exist on the positive use
36 THE U.S. ORAL HEALTH WORKFORCE of the Limited Access Permit legislation in Oregon for dental hygienists (Battrell et al., 2008). One participant asked about the scientific evidence base of various oral health curricula for medical residents. Maier said the main issue is that there is a dearth of such evidence in general, noting there are just a few items each in pediatrics and family medicine that rise to the level of the Cochrane Collaboration or the United States Preventive Task Force. Second, Maier said there is also little data on whether or how education (in general) produces behavior change. He said, therefore, more evidence is needed both on how to integrate health care as well as whether specific services actually affect health outcomes. Public Health Several participants raised questions about how to incorporate public health principles into the fragmented health care system. Hilton said the strength of public health practitioners is in planning, implementation, and evaluation, especially for new models of care including new types of prac- titioners or new ways to integrate medicine and dentistry. She said that public health workers should be involved in program planning to ensure a built-in evaluation component. Hilton advised that when considering new models, care should be taken to step back and consider a basic needs assess- ment and resource planning principles. Dorsen said the health system does not financially support strong public health or preventive health care. For example, she said that Chile spends much less on their health care systems than the United States, yet has similar outcomes in terms of morbidity and mortality. Dorsen noted that Chile focuses on prevention, with universal access to vaccines, formula or breast milk, and access to food for older adults. Therefore, Dorsen stated, incorporating public health principles will require a grassroots movement to consider what is important to Americans as human beings and that public health should be thought of as a solution to fixing our broken health care system. Medical Homes One participant questioned the need for a separate dental home in light of the existence of a medical home. Maier noted that the medical home model is not comprehensive because it does not include all major categories of health care. He said that community health centers might be the best example of a truly comprehensive health care home because of their provision of medical services, oral health services, and behavioral health services. Krol noted that this is another example of the importance of common nomenclature, and that the health care home is the true ideal.
CURRENT DEMOGRAPHICS AND FUTURE TRENDS 37 He stated that distinguishing the medical home from the dental home is a matter of semantics. Professional Roles One participant commented that a joint statement of several medical societies recently stated that the medical home must include a physician- d Â irected team. The participant questioned how and when these organiza- tions would collaborate with other types of professionals and recognize them as equal members of the team. Krol stated that many medical offices use other types of professionals, such as nurse practitioners and physician assistants, and recognize their knowledge and talent. Dorsen stated that professionals need to stop thinking in terms of hierarchies, and think of themselves as being in a circle surrounding the patient. Dorsen added that all types of professionals need to recognize when they have a knowledge deficit or limitation as well as the fact that individual patients may develop better relationships with other members of the team, which only contributes to better outcomes and more personal satisfaction. Another participant asked if dental hygienists should be able to work with other types of health care professionals, such as pediatricians and f Â amily physicians. Krol said that in the spirit of increased collaboration, they should be able to work together, but that state dental practice acts might prohibit such an arrangement. Another participant asked which health care professionals should be allowed to apply fluoride varnish. Krol stated that nondental professionals are already performing this service. Maier said that professions commonly battle over ownership of services, but that provision of services should be dictated by the competency of the individual and not the professional degree. He noted that the same should be true for who leads a health care team (as mentioned in the medical home model). Shelley said that in her program, as a result of homebound patients requesting oral health services, nurse practitioners reached out to the dental hygiene school to send dental hygiene students out with nurse practitioners to help screen and educate patients. She noted that the regulatory environment may inhibit some of these types of naturally occurring collaborations.