Dental hygiene is cha cha-changing

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Powerpoint of continuing education program on mid-level providers in dentistry. Focus on the training of advanced skills hygienists both in terms of ADHP and prior projects in the United States for training dental hygienists to perform skills traditionally reserved for dentists

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  • What is a mid-level? How does ‘collaborative practice’ fit in? Who is proposing new providers and why?
  • LAP = Limited Access Permit: Allows RDH to provide all sA hygienist who holds a Limited Access Permit may render dental hygiene services without the supervision of a dentist to patients or residents of facilities who, due to age, infirmity or disability, are unable to receive regular dental hygiene treatment. In other words, unsupervised, independent practice in limited access settings. This is a unique permit to the state of Oregon.
  • Surgeon General David Satcher
  • American Association of Public Health DentistryLots of groups are interested in issues related to oral health and access to care. These professional associations and foundations have an interest in alternative workforce models. This is by no means an exhaustive list of groups interested in oral healthcare.
  • Mid-level is not hygiene-based…No scaling competencies included. Also created pathway for a RDH interested in DT practice.AAPHD is supportive of ideas to expand “Access to Care” and that includes expanded workforce models that are demonstrated and evaluated.    Formally, AAPHD membership adopted a resolution in 2005 to support innovative demonstration projects (click here to see the formal position in its entirety).  This includes supporting the ADA and ADHA models for workforce expansion.  Regardless of the model adopted, AAPHD wants there to be a consistency in training and that training programs be accredited. Because of the interest surrounding dental therapists, AAPHD took on the project to develop a model curriculum for training.
  • More than 30 years ago, studies conducted at the University of Minnesota School of Dentistry demonstrated that dental productivity could be increased through the appropriate delegation of expanded functions, including placing, carving, and polishing amalgam restorations.5-6 In 1973, a study showed that younger Minnesota dentists were more receptive than their older counterparts to having trained dental auxiliaries place restorations.7 During that same time, the "TEAM" project (Training in Expanded Auxiliary Management) looked at the importance of training dentists to successfully incorporate enhanced delegation into their practices.8 However, the dental workforce pendulum swung from a shortage of dentists in the 1970s to a dentist "busyness problem" in the 1980s. Plans to advance restorative expanded duties for allied dental personnel in Minnesota all but vanished until recently.
  • Organized Dentistry was not made aware of the purposes or intent of the programThey planned the program in such a way as to integrate the new competencies concurrent with the existing dental hygiene program. This caused concern that graduates of the program would not meet existing requirements as dental hygienists.
  • Note the dates and the players. Many years of involvement with this issue…Not just since 2000. And this isn’t all…Howard University in Washington DC 1969
  • Curriculum was an aggregate of that of dental students, traditional dental therapy programs and dental hygiene education
  • Blind studies showed that their quality was essentially the sameTime frame to train was projected at 47 weeks but it only took 25 weeksParticipants in Forsyth were all licensed RDH’s with 7 months clinical experience
  • Dental hygienists are relatively new in New Zealand.
  • Dentists initially skepticalKelso said that the two things changed with the addition of the DHATs….One was that when he visited the remote villages where Aurora (Johnson) practiced he could concentrate on the dentistry that really required his expertise. Before the DHAT all he could do was try to make progress against the massive amounts of decay present in the patient population and deal with current emergencies. After Aurora all that decay was under control so he could do crowns, bridges, partials, endo…all the things that really required advanced skills. The other change was that with Aurora’s presence in the village patients were being referred for needed care. Dr. Kelso and his colleagues were BUSIER than they had previously been because of Aurora’s work!
  • Dental hygiene is cha cha-changing

    1. 1. Bobbie Brown, CDA, RDH, MSDH Diann Bomkamp, RDH, BSDH
    2. 2.  Toprovide the participant with an enhanced understanding of the changes occurring nationally, internationally and here in our own backyard related to mid-level providers and their role in access to care.
    3. 3.  Define „mid-level provider‟ Describe the history of the mid-level provider movement Distinguish between various types of workforce models currently being proposed Discuss the role that „access to care‟ plays in the continuing discussion about mid-level providers and expanded workforce models
    4. 4.  mid·lev·elprovider (mdlvl)n.A medical provider who is not a physician but is licensed to diagnose and treat patients under the supervision of a physician.The American Heritage® Medical Dictionary Copyright © 2007, 2004by Houghton Mifflin Company. Published by Houghton MifflinCompany. All rights reserved.
    5. 5.  The medical model for a mid-level provider includes advanced education Frequently a Master‟s level
    6. 6.  Providers who may perform intermediate restorative services, such as drilling and filling teeth, under remote supervision of a dentistGAO. Efforts under way to improve childrens access to dental services, but sustained attention needed toaddress ongoing concerns. Washington D.C. November 2010.
    7. 7.  Educationrequirements for proposed dental mid-level providers vary greatly ADHPis most closely modeled after the medical mid-level  Master‟s Degree education
    8. 8.  Dentist  Various Specialties Dental Assistant  Expanded Function DA Dental Hygienist  RDHAP  Extended Care Permit  RDH LAP DentalLaboratory Technician
    9. 9.  The concept is tightly interwoven with not only the mid-level provider movement, but with dental hygiene in general An agreement that authorizes the dental hygienist (or a mid-level) to establish a cooperative working relationship with other health care providers in the provision of patient care. This is a formal, written agreement
    10. 10. A protocol governing the circumstances in which the hygienist can initiate treatment A description of services The responsibilities of the dental hygienist to provide information to the dentist and referral procedures The responsibilities of the collaborating dentist concerning consultation with the hygienist
    11. 11. • Five states actually call it Collaborative Practice. – Arkansas (Collaborative Practice Permit) – Alaska – Minnesota • Advanced Dental Therapist (dual licensure as a RDH and DT) – New Mexico – South Dakota
    12. 12. • Variations of Collaborative Practice – Arizona (Affiliated Practice) – Iowa (Public Health Dental Hygienist) – Kansas (Extended Care Permit) – Massachusetts (Public Health Dental Hygienist) – Michigan (PA 161) – Ohio (Oral Health Access Supervision Permit Program) – Vermont (General Supervision Agreement) – Virginia (Remote Supervision) Pilot Program – Washington (Off-site Supervision) for nursing homes – West Virginia (Public Health Dental Hygienist) (June 2011_
    13. 13.  Major reports  Oral Health in America: A Report of the Surgeon General  Healthy People 2010 Oral health tied to general health Disparities existed along ethnic and socio- economic boundaries Began the discussion about „Access to Care‟  Numbers and shortages of dental providersUS Department of Health and Human Services. Oral Health in America: A Report of the SurgeonGeneral-- Executive Summary . Rockville, MD: US Department of Health and HumanServices, National Institute of Dental and Craniofacial Research, National Institutes ofHealth, 2000.
    14. 14.  AAPHD  Support the use of Dental Therapists  Created standard curriculum guidelines ADA  Community Dental Health Coordinator (CDHC)  Oral Preventive Assistant (OPA) ADHA  Advanced Dental Hygiene Practitioner (ADHP) Interested Foundations
    15. 15. Evans C, Jr., Mascarenhas AK, Formicola AJ, Campbell DG. Workforce development in dentistry: addressing access to care. Guesteditorial--introduction to the special issue. J Public Health Dent. Spring 2011;71 Suppl 2:S1-2.
    16. 16.  ADA is opposed to anyone, other than dentists, performing „irreversible surgical procedures‟ i.e. cutting tooth structure Propose two new workforce members  CDHC  OPA Neitheris a true „mid-level‟ provider www.ada.org
    17. 17.  CDHC  Community Dental Health Coordinator  Based on the „Community Health Worker‟ concept  Duties can include scaling skills OPA  Oral Preventive Assistant  Proposed competencies similar to a hygienist
    18. 18.  Model upon which the CDHC is based Lay Members of communities who work either for pay or as volunteers in association with the local health care system. Usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve Lay Health advocates Offer culturally appropriate health education and information Community Health Workers; Expanding the Scope of the Health Care Delivery System; National Conference of State Legislatures; April 2008
    19. 19.  ADA model is designed to be flexible for states Competencies for CDHC can include scaling Three pilot sites for this workforce model New Mexico the first state to authorize this provider through the state dental practice act
    20. 20.  Dentists and Hygienists worked together to defeat the therapist proposal  Scope of practice was too broad  Hygiene services were to be allowed without therapist being a hygienist or going to DH school  Only an 18 month program CDHC is included in the practice act  First state to authorize this provider  No scaling skills allowed  Practice act was amended to allow CDHC and some expanded functions related to packing and carving amalgams. Also hygienists may now place sealants w/o prior diagnosis by a dentist. Hygienists can order fluoride
    21. 21.  This provider is a type of „scaling assistant‟  Must be DANB-certified in order to become an OPA Competencies are similar to a dental hygienist  Treatment of patients with „plaque-induced gingivitis‟ Direct/indirect supervision for rendering patient care States to determine eligibility, training, certification and/or licensure requirements
    22. 22.  Advanced Dental Hygiene Practitioner  ADHP Similareducational level as a nurse practitioner  Master‟s Degree required True „Mid-level provider‟  Restorative services www.ADHA.org
    23. 23.  “Workingwith partners across the country to build awareness of oral health”
    24. 24.  PEW Charitable Trusts: http://www.pewtrusts.org
    25. 25.  Fund oral health programs through grants
    26. 26.  Dental Therapist or Dental Health Aid Therapist Community Dental Health Coordinator (CDHC) Advanced Dental Hygiene Practitioner (ADHP
    27. 27. http://www.rdhmag.com/index/display/articledisplay.5327511813.articles.rdh.volume-30.issue-5.columns.mid-level-providers.htmlAccessed January 10, 2012Author: Christine Nathe
    28. 28.  Knowing something about where we‟ve been can help to frame the discussion for where we‟re headed… You‟ve probably heard this before…  RDH  Dental Therapist
    29. 29.  Fones intended dental hygiene to focus on public health not exclusively in private practice Prevention based School based
    30. 30.  Fones traveled extensively to promote the new profession to state dental associations  He found opposition even at that early dateNathe CN. Dental public health & research: contemporary practice for the dentalhygienist. Third ed. Upper Saddle River, New Jersey: Pearson Education, Inc.;2011.
    31. 31.  “If Fones had introduced the new profession to school teachers, school administrators, hospital administrators, and other professional health care organizations instead of state dental associations, dental hygienists most likely would have been permitted to work in a variety of settings”Nathe CN. Dental public health & research: contemporary practice for the dentalhygienist. Third ed. Upper Saddle River, New Jersey: Pearson Education, Inc.; 2011.
    32. 32.  It‟sbeen done…Multiple times!!  Howard University  The Forsyth Experiments  University of Kentucky  University of IowaNash DA. Expanding dental hygiene to include dental therapy: improving access to care forchildren. J Dent Hyg. Winter 2009;83(1):36-44.Lobene RR, Berman KB, Chaisson LB, Karelas HA, Nolan LF. The forsythe experiment in training of advancedskills hygienists. J Dent Educ. 1974;38(7):369-379.
    33. 33.  Forsyth Dental Center 1949 Funded by a USPHS grant Abandoned under pressure from organized dentistry
    34. 34.  Four hours per week added to the dental hygiene curriculum Cavity preparation, restorative placement, local anesthesia Studied all the basic sciences taught to dental students, but in a condensed format No significant differences in performance levels when compared to dental studentsLobene, Ralph and Alix Kerr. The Forsythe Experiment: An Alternative System for Dental Care.Cambridge: Harvard University Press, 1979
    35. 35.  The Forsyth Experiment(s)  1949 & 1970  Robert Wood Johnson 1970  University of Kentucky  1972-74  Robert Wood Johnson  University of Iowa  1971-76  W. K. KelloggNash DA. Expanding dental hygiene to include dental therapy: improving access to care for children. J DentHyg. Winter 2009;83(1):36-44.Lobene RR, Berman KB, Chaisson LB, Karelas HA, Nolan LF. The forsythe experiment in training of advanced skills hygienists. JDent Educ. 1974;38(7):369-379.
    36. 36.  Forsyth trustees approved the plan in 1965 Massachusetts Dental Society approved the research project Forsyth directors were very careful to gain dental society approval in hopes of avoiding conflict Hygienists from three separate programs were chosen
    37. 37.  They all had practiced as hygienists for 7 months prior to beginning restorative training Special clinic was designed for teaching and research Educational objectives were performance based Evaluation was done by clinical dentists
    38. 38.  Total time needed for acquisition of skills was 10 weeks (47 weeks had been estimated) 184 hours was estimated for lectures, demonstrations and lab exercises in restorative dentistry 129 hours actually were used Estimated manikin practice was 296 hours but only 172 were used. The remaining hours were used to teach extensive cavity preps, cusp reductions and pin placement
    39. 39.  “Hygienists could be effectively trained, in a relatively brief time period, to perform, at a comparable quality level, restorative procedures traditionally reserved for dentists.”Lobene RR, Berman KB, Chaisson LB, Karelas HA, Nolan LF. The forsytheexperiment in training of advanced skills hygienists. J Dent Educ. 1974;38(7):369-379.Nash DA. Expanding dental hygiene to include dental therapy: improving accessto care for children. J Dent Hyg. Winter 2009;83(1):36-44.
    40. 40.  Authored by Christel Koppel Autuori, RDH http://findarticles.com/p/articles/mi_m1AN Q/is_9_21/ai_n25015054/?tag=content;col1 Uniqueperspective of a trainee in Forsyth‟s program
    41. 41.  New Zealand Dental Therapists  History  Current status NZ Dental Therapists around the world
    42. 42.  School Dental Nurses began in 1921  Basic preventive and restorative care to children  Care provided during the school day at the school.  Name changed to „Dental Therapist‟ in the 1980sNash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Int Dent J. Apr2008;58(2):61-70.
    43. 43.  The New Zealand Army began training dental hygienists in 1974 in order to provide oral health care for it‟s personnel  Civilian dental hygienists were not authorized in New Zealand until 1988  It wasn‟t until 1994 that training of civilian dental hygienists really began in earnestCoates DE, Kardos TB, Moffat SM, Kardos RL. Dental Therapists and Dental HygienistsEducated for the New Zealand Environment. J Dent Educ. August 1, 20092009;73(8):1001-1008.
    44. 44.  Currently DT and DH training is integrated  3-year program culminating in a Bachelor of Oral Health degree  This educational model is also the standard in Great Britain, Australia and The NetherlandsNash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Int Dent J. Apr2008;58(2):61-70.
    45. 45.  Untilrecently New Zealand‟s DT‟s provided care only for children  Now, with additional training, they may provide care for adults  They may work in private practice  They may practice independently  Only with a consultative agreement with a dentistNash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. IntDent J. Apr 2008;58(2):61-70.
    46. 46.  DT‟s practice in >53 countries  >14,000 exist worldwide  Both developed and developing countries  Countries with high and low dentist to population ratiosNash DA, Friedman JW, Kardos TB, et al. Dentaltherapists: a global perspective. Int Dent J. Apr2008;58(2):61-70.
    47. 47.  DT‟s are true „mid-level providers‟ However, DT‟s don‟t fulfill the advanced education requirement that is considered a standard for medical mid-level providers in the U.S. Traditional DT education has not included dental hygiene training, although these providers do scale teeth  Worldwide, many DT programs now combine dental therapy with dental hygiene
    48. 48.  Background of the Alaska Native use of DHATs Lawsuit by the ADA Current status
    49. 49.  “The Alaska initiative came at a time in which a heightened public awareness of children‟s oral health issues existed as a consequence of the 2000 Surgeon General‟s Report” (Mathu-Muju)  Initial meetings of stakeholders began in November of 2000  Second meeting was at The Forsyth Institute in 2001Mathu-Muju KR. Chronicling the dental therapist movement in the United States. J Public Health Dent.2011;71:278-288.Nash DA, Nagel RJ. A brief history and current status of a dental therapy initiative in the United States.J Dent Educ. Aug 2005;69(8):857-859.
    50. 50.  Alaska Natives experience large disparities in oral health  The Tribes are sovereign…they govern themselves…so development of this provider was possible in that environment  Funding was availableMathu-Muju KR. Chronicling the dental therapist movement in theUnited States. J Public Health Dent. 2011;71:278-288.Nash DA, Nagel RJ. A brief history and current status of a dental therapyinitiative in the United States. J Dent Educ. Aug 2005;69(8):857-859.
    51. 51.  New Zealand‟s well-established history in utilizing and training Dental Therapists Willingness of the training program to accept Alaska Native students
    52. 52.  February 2003 six Alaska Native students traveled to New Zealand February 2004 six more students went to New Zealand December 2004 four of the initial six completed the program and began preceptorships with their supervising dentists  3months or 400 hours—whichever is longer  Culminates in supervising dentist deeming the DHAT „competent‟ and writing their standing orders
    53. 53.  Dentists write standing orders for those procedures that he/she deems the DHAT „competent‟ DHAT cannot practice without current „standing orders‟ Dentists and the DHAT maintain communications (and supervision) via teledentistry
    54. 54.  Allows for long-distance supervision of dental extenders Requires internet connection Laptop computer, intra-oral camera, and digital radiography equipment Use is becoming more wide- spread….especially in rural areas
    55. 55.  ADA Resolutions were passed in 2004 against the new therapists doing any irreversible procedures or doing any type of diagnosis ADA attempted to change the Indian Health Care Improvement Act Ultimately the ADA and the Alaska Dental Society filed a lawsuit to stop the DHATs from providing care to Alaska Natives The lawsuit was ultimately settled
    56. 56.  Federal Indian Health Care Improvement Act pre-empted state laws regarding provision of oral care to Native Alaskans DHATs not to be used in any of the other 48 states Alaska to support a pilot for CDHC model Support long-term research for dental workforce models ADA was to look into new ways to introduce more dentists into AlaskaMcKinnon M, Luke G, Bresch J, Moss M, Valachovic RW. Emerging Allied Dental WorkforceModels: Considerations for Academic Dental Institutions. J Dent Educ. November 1, 20072007;71(11):1476-1491.
    57. 57.  Dentists who developed the DHAT program in Alaska were speaking…along with one of the therapists Things I learned…
    58. 58.  “Unlessyou have worked and lived in the Alaska bush, you cannot conceive of the level of need we confront on a daily basis, and the amount of resources that are required to provide even the most basic kinds of care.” MarkKelso, D.D.S. Norton Sound Health Corporation, Nome Alaska
    59. 59.  US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General-- Executive Summary . Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. GAO. Efforts under way to improve childrens access to dental services, but sustained attention needed to address ongoing concerns. Washington D.C. November 2010. Nathe CN. Dental public health & research: contemporary practice for the dental hygienist. Third ed. Upper Saddle River, New Jersey: Pearson Education, Inc.; 2011. Nash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Int Dent J. Apr 2008;58(2):61-70. Nash DA. Expanding dental hygiene to include dental therapy: improving access to care for children. J Dent Hyg. Winter 2009;83(1):36-44. Lobene RR BK, Chaisson LB, Karelas HA, Nolan LF. The forsythe experiment in training of advanced skills hygienists. J Dent Educ. 1974;38(7):369-379. Nathe CN. Dental public health & research: contemporary practice for the dental hygienist. Third ed. Upper Saddle River, New Jersey: Pearson Education, Inc.; 2011.
    60. 60.  DHHS. Oral health in America: a report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institues of Health; 2000. Evans C, Jr., Mascarenhas AK, Formicola AJ, Campbell DG. Workforce development in dentistry: addressing access to care. Guest editorial-- introduction to the special issue. J Public Health Dent. Spring 2011;71 Suppl 2:S1-2. Coates DE, Kardos TB, Moffat SM, Kardos RL. Dental Therapists and Dental Hygienists Educated for the New Zealand Environment. J Dent Educ. August 1, 2009 2009;73(8):1001-1008. Mathu-Muju KR. Chronicling the dental therapist movement in the United States. J Public Health Dent. 2011;71:278-288. Nash DA, Nagel RJ. A brief history and current status of a dental therapy initiative in the United States. J Dent Educ. Aug 2005;69(8):857-859. McKinnon M, Luke G, Bresch J, Moss M, Valachovic RW. Emerging Allied Dental Workforce Models: Considerations for Academic Dental Institutions. J Dent Educ. November 1, 2007 2007;71(11):1476-1491.

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