Kim S. Krust, RDH, MS; Lynn Schuchman, RDH, MA
Out-of-office dentistry: an alternative delivery system ~
Access to care continues to be a barrier in meeting the dental needs of a growing elderly population as well as other special patient care groups. One nontraditional delivery system reported and used by some practitioners is the mobile dental clinic. A dual purpose written survey was designed to: collect descriptive information about the operation of mobile and portable dental clinics and examine the attitudes and beliefs of dentists practicing out-of-ofnce dentistry. This survey showed out-of-office dental clinics deliver dental services to a variety of patient populations. Portable dental clinics appear to be suited for care delivery to nursing home patients. There also appears to be a significant correlation between portable clinics and the delivery of denture service (P < .05).
espite the progress made in the prevention of dental diseases, providing care to underserved communities and special patient care groups continues to be a problem.*-3 Overcoming the barriers to providing dental services in rural communities, to the mentally and physically handicapped, to the elderly and nonambulatory groups is a great challenge. The traditional private practice does not provide the access to care needed by these special care group^.^-'^ A variety of delivery care systems have been investigated for the provision of dental services in nontraditional settings. One delivery system reported in the literature and used by some practitioners is mobile dentistry. A review of the literature indicates that mobile dental care can generally be categorized according to equipment type: portable or mobile. The term mobile dentistry, for the purpose of this paper, will be used to describe delivery systems with intact, primarily independent, functional dental operatories and equipment contained in a transportation vehicle such as a van or mobile trailer. Portable dentistry, on the other hand, is used to describe equipment that can be conveniently transported to and set u p for dental services at various nontraditional locations. To refer collectively to both clinic types, the term “out-of-office” dentistry has been adopted in this paper. The use of mobile and/or portable equipment may require on-site provisions to obtain complete operation. In addition to the instruments, small equipment and supplies found in conventional dental offices, out-of-office clinics also must provide suitable pa-
tient and operator chairs, a light source, and a system to operate a dental handpiece and evacuation ~ y s t e m . ~ Moore recommends units which incorporate a compressor to improve accessibility and decrease set-up time.5 Standard dental office equipment can also be specially adapted for out-of-office use. Lejeume describes one method for modifying an ultrasonic scaler for portable use.h There are advantages and disadvantages associated with both mobile and portable equipment. Portable equipment is generally less expensive, more accessible and perhaps easier to maintain. It may, however, be incapable of delivering the range of services provided by mobile equipment. Mobile equipment, on the other hand, is more costly, may be unable to service restricted populations and is generally more susceptible to mechanical difficulties. The decision for selecting one type of equipment over another should be made with consideration for the population of patients served, variety of services needed, individual preferences and functional considerations of each.5 Several articles appear in the literature describing various out-of-office clinics operated throughout the United States and Canada. They are generally operated in association with a university, a health agency, or by independent practitioner^.^.'^ A wide variety of services can be offered and provided by out-of-office dental clinics. The University of Toronto’s Mobile Dental Clinic for the disabled, serving four communities, provides predominately exams, restorative, extractions and periodontal or preventive services. Endodontics and fixed and removal
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prosthodontics are also provided on a less frequent basis.'" The University of Alberta's grant-supported mobile clinic services three underserviced areas. Services provided are similar to those provided by Toronto's program. Restorations, extractions and prophylaxis comprise the majority of treatment services. To a lesser extent dentures, denture repair and endodontics are also p r ~ v i d e d . ~ The National Foundation of Dentistry for the Handicapped operates mobile dental clinics in New Jersey, Colorado, and Illinois. Both programs provide diagnostic and preventive services as well as restorations, extractions, denture related services, periodontal surgery, and endodontic therapy.14Out-of-office clinics have also been established to provide health education, administer preventive sealant programs, and serve specific special care populations such as nursing homes and disabled children.15,16 As previously mentioned, a majority of the existing literature pertaining to out-of-office dentistry is available in individual case descriptions. Little information is available describing staff, patient pools, productivity, and administrative considerations. Additionally, no comprehensive survey was found comparing the specific aspects of each clinic. Therefore, this survey had two purposes: to collect descriptive information regarding equipment, function, services, patient populations, and staffing out-of-office dental clinics to make comparisons between mobile and portable clinics; and to examine the attitudes and beliefs of dentists practicing out-of-office dentistry.
Results A total of 23 dental clinics (53%)returned the survey questionnaire. Seventy-four percent were classified as portable clinics, (n = 17) 9% were mobile clinics (n = 21, and 17%were equipped to function for both portable and mobile care delivery (n = 4). Only 13%of the respondents reported completely independent operation. Electrical outlets were necessary to operate 83% of the clinics. Additionally, respondents reported the need for onsite light sources (26%),compressors (13%),and telephones (13%)to achieve full operational capacity. No relationship was found in the Chi-square analysis between clinic type and the need for additional equipment.
A 35-item written questionnaire was mailed to a convenience sample of 43 mobile and portable dental clinics in the United States and Canada. No definitive known population of existing mobile and portable dental clinics was found during this investigation. Therefore, the sample consisted of those clinics identified by the American Dental Association, in dental journals, and by dental supply companies. Instructions asked that the primary care dentist associated with each clinic complete the questionnaire.
A summary of all services provided by portable or mobile and combined
Table 1. Percentage of patient populations served by all units (N ~
Materials and methods
Forty percent of the respondents reported current patient enrollments of more than 2,000 patients. Only 5% reported patient enrollments of 1,001 to 2,000. Twenty percent had between 501 to 1,000 patients enrolled in their out-of-office practice and 30% reported 500 or less patients. Chi-square analysis showed no significant relationship between clinic type and number of patients. The distribution of patient populations served by all clinics is shown in Table 1.Sixty-five percent (n = 15) of all out-of-office clinics identified nursing homes as their primary delivery site. Statistical significance ( P < .OC12) occurred in the comparison of primary delivery site to clinic type. Portable dental clinics contributed a greater portion of their care to nursing homes than mobile or combined clinics together. In fact, three of the 17 respondents (13%)operating portable clinics reported serving nursing home residents only. One clinic reported treatment of children only and one clinic reported caring for the homebound exclusively. Comparatively, the mentally and physically handicapped and children received no care from 61% to 75% of the clinics surveyed. The most common means of patient referral (70%) was made by the patient's primary care facility.
Before the initial mailing, a pilot study determined the clarity of the survey items. The survey was constructed as a two-part instrument. Part one was developed to collect descriptive information pertaining to the equipment, services provided, patient populations, and staffing. Part two used a 10-item Likert scale component to obtain dentists' attitudes on financial support, barriers to care, practice costs, and adequacy of their education for special care groups. A second mailing was used to increase the usable response rate to the survey. Descriptive statistics were used in the initial survey analysis. Additionally, cross tabulations (Chi-square) were compiled to make comparisons between portable and mobile clinics.
Patient population Nursing home residents Physically handicapped Mentally handicapped Children
190 Special Care in Dentistry, Vol 11No 5 1991
100% 99-75% 74-50%
4% s=l 0
N = l
N = l
N = 3
N = l
65% N = 15
N = l
6170 = 14
N = 23
~ = 2 3 N = 23
70% ~ = 2 3 s = 16 75% N =23 ~ = 1 7 30% N =23 N = 7
48% N = l l
~ = 2 3
clinics are shown in Table 2. Oral prophylaxis was performed by all clinics. In addition, all mobile clinics provided radiographs, simple restorative treatments, extractions, and fluoride treatments. Portable clinics provided fewer of these procedures.
practitioner, answered a classified adtent of these continuing education vertisement, or learned about it in a courses was not precisely identified in postdoctoral residency. The mean this survey. length of out-of-office practice was 6 to The out-of-office staff 10 years; however, the median time in practice was 1 to 5 years. Less than 5% Sixty-five percent of out-of-office of respondents have practiced out-ofpractices employed dental assistants office dentistry more than 20 and 30% employed dental hygienists. years. Other out-of-office employees inTable 2. Chi-square comparison of services provided The out-of-office practice cluded receptionists (39%),accounby mobile and portable clinics. was generally operated by tants (26%),and nurses (9%).While the No sigone dentist (56.5%). number of hours hygienists worked Mobile" Portable nificant associations were varied from practice to practice, a maDiagnostic services 83YG 94.1 % evident in the analysis bejority of dental assistants worked 32 to tween clinic type and num40 hours per week. When dentists Radiographs 100 58.8 were asked if the direct supervision of ber of dentists per practice. Sample restorative 00 83.4 dental auxiliaries was a barrier to care Many of the dentists reCrown and bridge 33.3 47.1 sponding to the survey also for nontraditional patients, the reDenture and fabrication 33.3 88.2t practiced in a solo private sponse was almost equal; 48% agreed practice (39961, a group prac- or strongly agreed and 43% disagreed Denture adjustment 50 88.2 tice (30%),or as a dental or strongly disagreed. Chi-square Endodoiitics 66.6 29.4 school faculty member analysis showed no relationship beExtractions 00 76.5 (35%).Only 30% reported tween auxiliaries' employment and reProphylaxis 100 100 dedicating between 32 to 40 sponse to the supervision-as-a-barrieror more hours to operating to-care question. Scaling and root planing 66.6 82.4 their mobile and/or porPeriodontal surgery 33.3 11.8 Financial support table practice. The majority Fluoride treatments 100 70.6 (43%)worked in their outOf the respondents, 70% reported Sea la nt s 83% 17.6% of-office practice less than 16 operating as self-supported, for-profit hours per week. business; 22% were funded by govern'Combines mobile and those clinics capable of delivering A summary of what the mental health agencies; and 17% were both mobile and portable care. responding dentists liked state funded. Most (65%)held a cont (I' 2.05) most about out-of-office tract for services provided with an aspractice is presented (Table sociated institution. Fifty-five percent Chi-square analysis, however, 3). Respondents wereasked to check agreed or strongly agreed that thirdshowed a significant difference in the all responses that applied from a list of party reimbursement was a barrier to availability of denture fabrication ( P 5 generated choices. Interpretation of care for special patient populations. ,051by portable clinics when comeach choice was made on an indiMost disagreed or strongly disagreed pared with mobile and combined clinvidual basis. Although many benefits (70%)that current institutional supics. A similar trend was shown in the were recognized, most respondents port is sufficient to provide dental care provision of dental sealants by por(91YO)indicated that delivering serfor residing patients. table units; however, statistical signifi- vices to patients who otherwise would Perceptions regarding barriers to cance was not achieved. Outside connot receive care was rewarding. patient care are summarized (Table 4). tracts were commonly reported by A majority (70%)of the responding No relationships were evident in the respondents $or the services provided dentists were members of by dental laboratories (65%),medical the American Dental AssoTable 3. Response to dentists' attitude concerning consultations (52%),and radiographic ciation and 26% belonged to out-of-office dental care. * services (30%). the Academy of General Delivery services to patients who really 91 % Dentistry. Fifty-six percent The dentist need them thought they were prepared A majority of the responding deninadequately to provide care Personally rewarding 65 tists working in out-of-office dentistry to special patient populaProfessionally rewarding 48 were either contacted by a care facility tions by their undergraduate Patient variety 44 to provide treatment to a specific padental school training. ConVariety of practice settings 35 tient population (35%)or learned tinuing education was reabout this alternative practice setting ported by 40% to assist them Flexible hours 35 in school (17%).Less than 10%of the in providing out-of-office Financially rewarding 26 %, survey respondents read about it in a care to the nontraditional journal, learned about it from another patient population. The con- * Respondents were asked to check all that applied. ~
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dental school. Dental assistants were more frequently Federal cutbacks 73.9% employed than dental hyInsufficient interest among dentists 73.9 gienists. Although few dental hygienists were working, 73.9 Lack of family knowledge and interest all clinics reported providing 69.5 Negative attitude of the patient prophylaxis. It is possible 43.5 Direct supervision of dental auxiliaries that prophylaxis, while pro13.0% vided by all clinics, is perLack of support staff /care givers formed on an infrequent ba* Respondents were asked to check all that applied. sis, therefore not justifying a dental hygiene position. This, however, was not directly asChi-square analysis between financial sessed in this survey. support type and opinions related to Dentists reported a wide variety of third-party reimbursement, institucontinuing education training from tional, or federal cutbacks. very few to many hours of participaDiscussion tion. While only 40% reported receiving continuing education to assist Out-of-officedentistry has been used to deliver dental care services to a them in providing services to their outof-office patients, a majority did not variety of nontraditional settings and think they were adequately prepared patient populations. The portable and by their dental school programs to mobile clinics responding to this surserve special patient care groups. Few vey provided predominately diagnosrespondents reported participation in tic, simple restorative, and preventive formal postgraduate programs to asservices. This finding is similar to sist them in their out-of-office practice. those reported by out-of-officeclinics Although the majority reported that operated by the University of Toronto predoctoral programs did not adand the National Foundation of Denequately prepare them for practice tistry for the Handicapped. Crowns with special patient populations and and partial dentures and endodontics recognized a need for additional eduwere less frequently provided, percation, few have pursued continuing haps because of the complexity and education. Perhaps relevant continutime these procedures require. ing education programs need to be deThe fabrication and adjustment of veloped, marketed, and accessible to partial and complete dentures were this group of practitioners. more often provided by the portable The actual financial success of outclinics responding to this survey. If all of-office dentistry was not directly acpatients receive an initial diagnosis, then partial and complete denture ser- cessed in this survey. A majority of respondents reported operating as vices are second only to oral prophyself-supported, for-profit businesses. laxis as the most frequently provided service by portable clinics. This finding Further research is necessary to determine if operation of an out-of-office agrees with the finding that nursing practice may supplement private prachomes accounted for a majority of primary delivery sites and category of pa- tice income for those practitioners experiencing a decline in productivity. tients served. The relationship beA great number of patients are retween portable clinics, nursing home ceiving out-of-office services. It is not care, and denture fabrication suggests known, however, if provided services that the availability of portable equipand the amount of compensation is ment in these settings is critical, concomparable to that achieved in private sidering the ambulatory status of practice. The inability of the served many of these special care patients. Access to care continues to be a barrier populations to pay for services is probably a contributing factor in the finanfor the nation’s growing elderly.I5 cial status of these clinics. Most denOut-of-office dental clinics are pretists agreed that third-party dominately staffed by one part-time reimbursements and cutbacks in feddentist who also practices as 3 private practitioner or as a faculty member at a eral and institutional support to health Table 4. Barriers to patient care.*
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programs were barriers to providing out-of-office care. The uncertain population of out-ofoffice clinics limits generalizing these results to all portable and mobile practices. No comprehensive reference or source for estimating the number of existing clinics was encountered during this investigation. Only a small segment of the entire population was surveyed as part of this investigation. In fact, the relatively small number of mobile clinics responding should be considered when examining the lack of significant correlations between unit type and other demographic characteristics. Perhaps operators of portable and mobile dental clinics would benefit by the organization of a society or association. Such an affiliation would facilitate promotion of this special dental practice, help solve problems, and provide a continuing education resource. Further work and research is necessary to promote the practice of out-of-office dentistry. The identification of target populations, productivity, continuing education, and general rewards need to be investigated and enhanced to attract practitioners to this alternative practice setting.
Conclusion Access to care continues to be a barrier in meeting the dental needs of a growing elderly population as well as other special patient care groups. Portable and mobile dental clinics, as evidenced by this survey, are capable of delivering dental services to these populations. Portable clinics are a valuable delivery system for denturerelated services and the care of nursing home patients. The authors thank Ms. Karen Gross for her editorial assistance and Dr. Phillip Feil for his help with the statistical analysis.
Ms. Krust is assistant professor, Division of Dental Hygiene, University of Missouri-Kansas City, School of Dentistry, 650 E 25th St, Kansas City, MO 64108-2795. Ms. Schuchman is a dental resource teacher for the Kansas City School District. Address requests for reprints to Ms. Krust.
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