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  • 1. Oral Health Initiative Fact Sheet: Experience with Mid-Level Dental Health Providers There is increasing concern about the large numbers of underserved people in the U.S. suffering high rates of severe oral health disease, mainly due to a lack of access to quality affordable oral health care. Factors contributing to a lack of access include a workforce shortage of dentists—especially in rural and low-income communities, and a limited number of people with dental insurance. This concern, plus research indicating that over a third (36.8 percent) of dental patients receive services that could be handled by a mid-level dental provider, has increased interest in establishing such mid-level positions to provide care to the underserved. Though several different mid-level dental provider models have been considered, the following are those that have gained most attention: Classification of Mid-Level Providers mid-level models—a college-level Bachelor’s Degree, which may be a barrier to minority or Most Americans are familiar with three dental low-income applicants. The BDT can also attain a positions: dentist (highest level of education and Master of Dental Therapy Degree. The BDT can skills), dental hygienist, and dental assistant. The main perform most services under indirect supervision difference between dental hygienists and mid-level of a dentist, but a dentist must be on-site for any dental therapist positions is that the latter can restorative or surgical procedures. perform irreversible procedures, like tooth extraction. “Mid-level” dental care models that have been utilized in other countries or states, or which have been • Community Dental Health Coordinator (CDHC): proposed in America, include: Proposed by the American Dental Association, the CDHC position, similar in some ways to a community health worker model, requires a high • Dental Health Aide Therapist (DHAT): Created in school diploma. A CDHC receives 12 months of 2003 as part of an Alaskan program to provide didactic training followed by a six-month oral health care to rural, underserved Alaskan internship to gain a certificate. CDHCs would work Native communities, the DHAT receives a two- in safety net facilities doing education, intra-oral year education (after high school) provided by the assessment, care coordination, and very limited University of Washington, with the last year intra-oral treatment. focused on clinical training. The DHAT also completes a three-month clinical preceptorship to the satisfaction of a supervising dentist. The • Advanced Dental Hygiene Practitioner (ADHP): DHAT, who can only provide services within the Proposed by the American Dental Hygienists’ Tribal Health System under general, indirect or Association, the ADHP would provide primary oral direct supervision of a dentist, performs oral health care, preventive, therapeutic and limited exams, cleanings/scaling, fluoride treatments, restorative services in a model similar to that of a sealants, x-rays, and restoration services. nurse practitioner. Depending on past experience, an ADHP may be a Bachelors’ level dental hygienist who is then educated at the Master’s • Minnesota Basic Dental Therapist (BDT) and level. Advanced Dental Therapist (ADT): The BDT requires more education than any of the other Con Alma factsheet_state experience_12-18-09 Page 1
  • 2. • Dental Therapist (DT): The DT is a model long used position would create “sub-level” care for children, successfully in many other countries (Canada, the state legislature rescinded the original legislation Great Britain, New Zealand and Australia). These in 1950. In 1970, the Forsyth Dental Center initiated countries are now changing their dental therapists another experiment to train dental hygienists in to “dental hygiene therapists,” (OHTs) and adding anesthesia and restorative therapy for children, but a third year of training—roughly the equivalent of was forced by the State Board of Dental Examiners to a Bachelor’s Degree. OHTs, but not dental close this project in 1974. However, the experiment therapists, will be able to clean teeth below the did objectively verify that those trained provided gum line. Most all dental therapists practice with quality, cost-effective and efficient dental care and more autonomy than DHATs in Alaska, though that patient acceptance was high. they are always affiliated with a supporting dentist. DTs’ work has been focused on children, but that is also changing, with more of them Washington, D.C. serving patients in a wider range of ages. A similar program to that of the Forsyth Dental Center Summary of Experience with Mid-Level Dental in Massachusetts was begun at Howard University in Providers 1969, but the graduates were prohibited by Washington, D.C. practice acts from providing services to the general public. New Zealand Begun in 1921, school dental nurses (now called California dental therapists) were trained to improve the oral health of school children by providing them with free comprehensive preventive and restorative care. The program has been exceptionally successful, as at the In 1972, the University of Southern California, School end of each school year, all of children’s decayed of Dentistry proposed training New Zealand-type teeth have been handled. New Zealand has changed dental therapists whose community work could the dental therapy program into a “dental hygienist improve caries prevalence among school children. The therapist” program. Thus, training, originally two governor established a committee to study the roles academic years after high school, is now a three-year of dental auxiliaries and make recommendations to program; two-thirds of the curriculum time is spent in the state legislature. The committee’s 1973 report did the clinic treating children. The program is valued note the positive results of New Zealand’s program, highly not only by the public, but also by the country’s but stated that the California public would not accept dentists. the model, seeing it as a second-class method of oral health care. Although the committee’s findings were widely criticized, they were accepted, and since the University did not receive funding for its training, the Massachusetts proposed project ended. In 1972, the state legislature established the Health Workforce Pilot Projects program to evaluate new health provider models In 1949, the legislature authorized the Forsyth Dental before the legislature made any changes in Infirmary for Children, as a research project, to professional practice laws. Under these auspices, the establish the first two-year training program—similar Registered Dental Hygienist in Alternative Practice to that of New Zealand—in the U.S. The program, (RDHAP) model was tested in underserved California which combined dental therapy and dental hygiene communities in 1980. Legislation to support these courses, was meant to train dental therapists to providers was passed in 1997; currently more than provide dental care for children. Under pressure from 200 RDHAPs practice in California. the state’s dentists, who claimed the mid-level Con Alma factsheet_state experience_12-18-09 Page 2
  • 3. DHAT, which requires two years of full time training at a dental school. In 2003, the first six Alaskan students Kentucky began training as therapists at the University of Otago in New Zealand, financed by the ANTHC. Opposed to this initiative, the American Dental Association (ADA) Between 1972 and 1974, supported by a Robert Wood began a campaign to amend the Indian Health Care Johnson Foundation grant, the University of Kentucky Improvement Act—being reauthorized by Congress— trained dental hygienists in restorative dentistry with so that no dental health aide would be certified under the aim of having the graduates provide primary the program to handle dental caries, pulpotomies, or dental care to children. In a double-blind study tooth extraction. The ADA’s amendment was not comparing the graduates’ skills with those of fourth successful. The Alaska State Board of Dentistry has year dental students, no significant differences were challenged the legality of dental therapists practicing found in the quality of dental procedures in the tribal health care system, and the challenge is implemented by either group. However, as at Howard under review. (?? Check update) The DHATs, located University, state practice acts prohibited these dental in far-flung villages, provide oral health education, professionals from applying their skills. preventive services, diagnosis and treatment of dental caries, uncomplicated tooth extraction, and pulpotomies under the general supervision of, and in telephone contact with, a dentist, who is most Iowa probably located at a hub clinic. Currently, a two-year evaluation implemented by RTI International and funded by four foundations is considering the viability of the DHAT model. In a process similar to that of Kentucky, the University of Iowa, College of Dentistry, supported by the W.K. Kellogg Foundation (1971-1976), trained dental hygienists in expanded restorative dentistry and Minnesota periodontal therapy. Evaluation showed that the hygienists performed at a comparable quality level as dentists, but as in Kentucky, the state proscribed those trained from working with the public. Currently, Legislation introduced in 2008 to establish the Iowa is developing a strategy for recruiting and Advanced Dental Hygiene Practitioner (ADHP) retaining health professionals, including dental program was supported by the Minnesota Safety Net providers based on the recommendations of a state Coalition. A compromise agreement to establish the entity that researched overall health care workforce Oral Health Practitioner (OHP) was made, and a planning. workgroup set up to recommend education, licensure and supervision requirements for the new mid-level provider. In 2009, legislation based on the workgroup’s recommendations was introduced, but Alaska was not supported by the state’s dental association, which, instead, supported legislation establishing a dental therapist position. Although the OHP legislation would have created a provider with a wider range of Recognizing that large numbers of Alaskan Natives clinical services and who could practice without a living in rural, underserved parts of the state had little, dentist on site, the Dental Therapist bill prescribed a if any, oral health care, the Alaska Native Tribal Health provider with a more limited set of services who Consortium (ANTHC) began developing a program in would be supervised by a dentist on-site. Both bills 2001 to provide native dental health aides to tribal emphasized the mid-level provider would serve communities. As the tribes are sovereign, the ability to underserved communities. The OHP bill was train and install mid-level dental providers could be supported by more than 50 organizations representing implemented without state policy constraints. One patients and the public, as well as the American Public position created, as part of the Dental Health Aide Health Association, but the Minnesota Dental Program (an expansion of the Community Health Aide Association waged a strong opposition campaign. Program), was the dental health aide therapist, or Con Alma factsheet_state experience_12-18-09 Page 3
  • 4. access to dental care in underserved areas. The bill, though not passed, is being revised and will be After much negotiation, a legislative compromise in resubmitted during the 2010 legislative session. May, 2009, established a new, mid-level oral health provider set—a Basic Dental Therapist (BDT) and an Advanced Dental Therapist. The BDT will be a graduate of a Bachelor’s or Master’s degree program and administer certain preventive and limited restorative services without a supervising dentist on- site, but all restorative services and extractions will require a dentist’s presence. The Advanced Dental Therapist requires a Master’s level training and has a more advanced scope of practice without having a References: dentist for on-site supervision. However, both the basic and advanced dental therapist must have a 1. The Pew Center on the States, National Academy for State Health Policy, & W.K. Kellogg Foundation. (May 2009). Help Wanted: A collaborative management agreement with a dentist. Policy Maker’s Guide to New Dental Providers. The Metropolitan State University has developed the dental therapist educational program, and the first students entered the program in the fall of 2009. Colorado Through a 2008 executive order, the Governor of Colorado commissioned a study of the evidence for expanding dental hygienists’ scopes of practice, as well as those of other health professionals. The report of the Colorado Health Institute found that “unsupervised dental hygienists can ‘competently’ provide oral health care preventive services ‘within their scope of training, education and licensure’…and can do so with quality of care ‘at least comparable’ to that of dentists,” but that statutes prevent dental hygienists from—and payers won’t reimburse them for—doing anything outside their scope of practice.1 To promote use of dental hygienists in underserved areas, the report recommended reviewing reimbursement policy options in the state. New Mexico During the 2009 legislative session, Senate Bill 302 was introduced to amend sections of the Dental Health Care Act, expanding the scope of practice for certified expanded-function dental auxiliaries, amending dental licensure examination requirements, and allowing UNM dental residents to obtain temporary licensure—all with the goal of increasing Con Alma factsheet_state experience_12-18-09 Page 4
  • 5. Con Alma factsheet_state experience_12-18-09 Page 5

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