Dental Therapists as New Oral Health Practitioners - Journal of Dental

Dental Therapists as New Oral Health Practitioners: Increasing Access for Underserved Populations Colleen M. Brickle, RDH, EdD; Karl D. Self, DDS, MBA Abstract: The development of dental therapy in the U.S. grew from a desire to find a workforce solution for increasing access to oral health care. Worldwide, the research that supports the value of dental therapy is considerable. Introduction of educational programs in the U.S. drew on the experiences of programs in New Zealand, Australia, Canada, and the United Kingdom, with Alaska tribal communities introducing dental health aide therapists in 2003 and Minnesota authorizing dental therapy in 2009. Currently, two additional states have authorized dental therapy, and two additional tribal communities are pursuing the use of dental therapists. In all cases, the care provided by dental therapists is focused on communities and populations who experience oral health care disparities and have historically had difficulties in accessing care. This article examines the development and implementation of the dental therapy profession in the U.S. An in-depth look at dental therapy programs in Minnesota and the practice of dental therapy in Minnesota provides insight into the early implementation of this emerging profession. Initial results indicate that the addition of dental therapists to the oral health care team is increasing access to quality oral health care for underserved populations. As evidence of dental therapy’s success continues to grow, mid-level dental workforce legislation is likely to be introduced by oral health advocates in other states. This article was written as part of the project “Advancing Dental Education in the 21st Century.” Dr. Brickle is Dean of Health Sciences, Normandale Community College and Faculty and Liaison, Metropolitan State Dental Hygiene Department; Dr. Self is Associate Professor and Director, Division of Dental Therapy, Department of Primary Dental Care, School of Dentistry, University of Minnesota. Direct correspondence to Dr. Colleen Brickle, Normandale Community College, 9700 France Ave. S., Bloomington, MN 55431; 952-358-8158; [email protected]. Keywords: allied dentistry, allied dental education, dental therapy, intraprofessional dental team member, oral health practitioner Submitted for publication 1/13/17; accepted 2/17/17 doi: 10.21815/JDE.017.036

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ental therapists are primary care professionals who are new members of the oral health care team. They engage in oral health promotion programs as well as provide evaluative, preventive, restorative, and minor surgical dental care. These new intraprofessional dental team members are educated to the same standard of care as a dentist for their defined scope of practice and currently provide care under the supervision of a licensed dentist through a collaborative management agreement and/or standing orders. This article examines the development and implementation of the dental therapy profession historically, globally, and in the U.S. and provides an in-depth look at dental therapy programs in Minnesota. This article was written as part of the project “Advancing Dental Education in the 21st Century.”

Historical and Global Perspective In 2000, in the first U.S. surgeon general’s report on oral health, Surgeon General Satcher

alerted Americans to the importance of oral health, the connection between oral health and systemic health, and the challenges to providing oral health care to all Americans.1 This report addressed the many barriers to access to oral health care and the oral health disparities of our most vulnerable citizens: poor children, the elderly, medically compromised individuals, and many members of minority racial and ethnic groups. A follow-up report was released in 2003 by Surgeon General Carbona as A National Call to Action to Promote Oral Health.2 This report reinforced the 2000 surgeon general’s report and named specific actions to be taken regarding oral health workforce capacity. The report identified a lack of progress in providing dental professionals to many rural and urban areas with low-income and racial and ethnic minority populations. One action recommended was expanding the current workforce capacity to provide oral health care in these areas. Millions of Americans simply cannot afford dental care, and 54 million people live in federally designated shortage areas where there are not enough dentists.3 To serve those populations in shortage areas, the Bureau of Health Workforce estimated in

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June 2017 that 8,636 new dental practitioners would be needed. The concept of social justice is important regarding access to care because it stands for everyone receiving the same high-quality, affordable oral health care regardless of socioeconomic status, ethnicity, education, or ability to pay.4 A bridge needs to be developed between people in need and access to care, with a new approach to streamline access and provide an additional entry point to oral health care. These needs motivated an interest in dental therapists—an allied oral health professional already established in many other parts of the world. In 1921, New Zealand began training school dental nurses, later called dental therapists, to provide basic dental care for children.5 Today, dental therapists are providing care in more than 50 countries around the world including New Zealand, Australia, the Netherlands, and Great Britain where dental therapy is integrated with dental hygiene education and training.5,6 Around the globe, dental therapists are valued members of the dental team, improving access to care and reducing oral health disparities.7 Contrary to other parts of the world, development of dental therapy in the U.S. has been a challenging foray into the statutory and political arena. The concept of dental therapy continues to experience national scrutiny with much debate over the merits of these newest members of the dental profession.

Introducing Dental Therapists in the U.S. In the U.S., dental therapists are currently providing oral health services in Minnesota and Alaska.8,9 In 2014, Maine passed legislation authorizing a dental hygiene therapist, and in 2016, dental therapy legislation was passed in Vermont.10 While no dental therapy educational program has currently been developed in Maine, curriculum planning is under way in Vermont. Advocates in a number of other states are pursuing changes to recognize and enable these types of professionals to provide care due to pressure to lower costs, rising demands for oral care, and a shortage of dentists. The majority of new oral health workforce models being proposed are dental hygienebased, which means that applicants receive advanced standing for holding a dental hygiene license. Yet the Commission on Dental Accreditation (CODA) standards for dental therapy programs, implemented in 2015, do not require dental hygiene education but

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do allow for advanced standing for dental hygienists and dental assistants.11 Another operational model, the Alaska dental health aide therapist (DHAT), does not mandate a dental hygiene education.9

Alaska Dental Health Aide Therapists In 2003, the first native Alaskan traveled to New Zealand to receive education and training as a dental therapist.7 In 2005, after completing a two-year course of study, DHATs became new allied dental providers in the United States.9 The DHAT program is modeled on the dental therapy program in New Zealand introduced in 1921.9 After completing coursework and a preceptorship, DHATs moved into remote Alaskan villages to provide year-round dental care to communities. This care is within their scope of practice and under the general supervision of a dentist. For years, there had been a lack of dentists willing to work in these communities. Therefore, most of these DHATs were recruited from and placed back into their home villages. The DHAT model has been found to be successful in this environment.12

Minnesota’s Dental Therapists and Advanced Dental Therapists The barriers and challenges for Minnesota’s most vulnerable populations in 2008 mirrored that of many other states. Social determinants of health created access problems for people. Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect health, functioning, and quality-of-life outcomes and risks.13 Other barriers faced by Minnesotans included the following: the average age of dentists was 53 years in urban areas and 57 years in rural areas;14 45% of dentists were expected to leave practice in ten years or less;15 there was a shortage of dentists in rural Minnesota serving public program enrollees;16 statewide, only 43% of children on a public program received dental care;17 and emergency room visits were being used as dental homes, increasing costs for a preventable disease.18 Due to these factors, the 2009 Minnesota legislature authorized new primary care oral health providers: the licensed dental therapist and the certified advanced dental therapist.8 The purpose of these new providers is to help address the access to dental care crisis. While they are not a panacea or the only

Journal of Dental Education ■ Volume 81, Number 9 Supplement

solution to the access problem, they have the potential to be one solution that can help underserved patients receive safe, high-quality dental care. There are two levels of dental therapy in Minnesota.8 The licensed dental therapist, the first level, must receive a bachelor’s degree. Dental therapists perform their work under a combination of general and indirect supervision through a collaborative management agreement with a dentist. In general, dental therapists provide preventive and non-invasive services under general supervision, while more invasive services such as restorative care and extractions of primary teeth are provided under indirect supervision. Eligibility for certified advanced dental therapist (ADT) status, the second level, requires a master’s degree.8 After 2,000 hours of practice as a licensed dental therapist, educationally eligible dental therapists may apply to take the ADT certification examination through the Board of Dentistry.19 Advanced dental therapists can perform their full scope of practice under general supervision through a written collaborative management agreement (CMA) with a dentist. In addition to performing the dental therapy scope of practice, advanced dental therapists are allowed to evaluate, assess, and develop treatment plans, as well as perform limited nonsurgical extractions of mobile permanent teeth. This scope of practice gives advanced dental therapists the flexibility to practice in rural areas and in nontraditional urban community settings, providing preventive and restorative care to patients utilizing established protocols agreed to in a CMA. The Minnesota statute does not require a dental hygiene background for either the dental therapist or the advanced dental therapist.19 Those dental therapy providers who also are licensed dental hygienists are described as dual-licensed. As the dental therapy scope of practice does not include scaling or prophylaxis, the dual-licensed providers bring flexibility to offices that cannot incorporate both kinds of providers.

Dental Therapy Educational Programs On February 6, 2015, CODA voted to adopt educational standards for dental therapy in the U.S.11 On August 7, 2015, CODA authorized the establishment of an accreditation process for dental therapy educational programs. It is anticipated that

this process will lead to consistency in educational requirements for states contemplating dental therapy legislation.

Alaska Programs The Alaska Native Tribal Health Consortium (ANTHC) initiated the dental health aide therapist (DHAT) program. The DHAT program consists of a two-year curriculum that provides students with the education and training necessary to become oral health care providers in rural and remote areas of Alaska.20 ANTHC works in partnership with the University of Washington MEDEX program, a regional physician assistant training program, to administer the first year of the DHAT educational program. In year two, students begin a 12-month clinical component. Students also continue to receive didactic training, but attention is focused primarily on clinical implementation of didactic material. Students gain clinical experience in the DHAT scope of practice and engage in a year-long community outreach program. Upon completion of the program and a required preceptorship, a DHAT can apply for certification from the Alaska Community Health Aide Program Certification Board.21 After receiving their certification, DHATs can provide culturally appropriate oral health education and routine dental services in Alaska Native communities. DHATs have the ability to implement preventive programs, provide for continuity of care, and provide culturally appropriate care under the general supervision of a dentist. Written standing orders define the scope of practice that a DHAT can perform.22

Minnesota Programs Minnesota law established the requirements for licensure of dental therapists and certification of advanced dental therapists, but left it to educational institutions to determine what admission requirements should be and how to structure their programs.19 Thus, different educational institutions may establish different types of programs, as long as the programs appropriately educate and train students to the necessary level of competence. University of Minnesota School of Dentistry. This dental school developed a dental therapy education program with the intention of creating a diverse student body with a demonstrated history of community service and a commitment to improving access to care for underserved populations.8 This dental therapy program, which is directed by the


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second author (KDS), draws upon the experiences of related dental therapy training efforts in other countries—most notably, New Zealand, Canada, and the United Kingdom. The curriculum of the dental therapy program focuses on four key areas: general education, biomedical foundations, dental sciences, and dental therapy science. The program confers a Master of Dental Therapy degree and is designed to educate dental therapy students alongside dental and dental hygiene students in a team environment. As such, where the dental therapist’s scope of practice aligns with procedures traditionally performed by a dentist, the dental therapy students take courses with the dental students. Where their practice more closely aligns with the work of a dental hygienist, they take courses with the dental hygiene students. This emphasis on team-based education and care was designed to ensure collaboration within the profession, a single standard of care for patients, and a smooth transition from education into professional employment after graduation. While the University of Minnesota program initially educated only to the licensed dental therapy standards, it currently educates to both the licensed dental therapy and the certified advanced dental therapy standards. Metropolitan State University and Normandale Community College Partnership Program. The Master of Science in Advanced Dental Therapy (MSADT) program is the result of a partnership between Metropolitan State University and Normandale Community College, where the first author (CMB) is dean of health sciences. The mission of the program is to educate students to improve the oral health of underserved populations by providing highquality, patient-centered care. The program is dental hygiene-based with admissions criteria that include current dental hygiene licensure, completion of a baccalaureate degree, a minimum cumulative GPA of 3.0, a professional portfolio presentation and goals essay, and a professional interview. These applicants already have a foundation and are proficient in many competencies that must be taught in models that do not begin with a licensed dental hygienist. This partnership established a master’s program that integrates both the basic level of dental therapist education and the additional education needed to be an advanced dental therapist. Students in this program are eligible to become licensed as a basic dental therapist as part of the longer curriculum that will lead to advanced practice certification as well. The MSADT curriculum is built on scholarly

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principles and practices as well as academic excellence and service. The program is committed to improving the general well-being of underserved community members. While the program is based on the foundation of baccalaureate dental hygiene education, the breadth and depth of the curriculum prepare graduates with the critical thinking and problem-solving skills necessary for advanced dental therapy practice and judgment in collaboration with dentists and other health care professionals.

Practice Settings and Impact An evaluation of the dental health aide therapist in Alaska was completed in 2010 by the Research Triangle Institute.20 To evaluate these therapists, that study used examination standards to assess clinical competence for board certification of U.S. dental school graduates. Key findings of the evaluation were that DHATs were technically competent to perform the procedures within their scope of work and were doing so safely and appropriately; were consistently working under the general supervision of a dentist; were successfully treating decay and relieving pain for people who often had to wait months for travel hours to receive care; and were well accepted with high patient satisfaction in tribal villages. In Minnesota, a dental therapist or advanced dental therapist is limited to primarily practicing in settings that serve low-income, uninsured, and underserved patients or in a dental health professional shortage area. One of the criteria to meet this limitation is for the patient base served by a dental therapist or advanced dental therapist to be comprised of at least 50% low-income, uninsured, and/ or underserved populations.19 As of November 2016, there were a total of 63 licensed dental therapists in Minnesota, 30 of whom have achieved ADT certification, and 22 of whom are dual-licensed dental hygienists-dental therapists.23 Those numbers will continue to grow with 14 students projected to graduate in 2017. Graduates of Minnesota educational programs are actively practicing in over 20 counties throughout the state. They work in both rural and urban areas of the state. While these new providers have found opportunities to provide care in Federally Qualified Health Centers (FQHCs), public hospitals, and public or community health settings, private practice settings have become the largest employers


of dental therapists in Minnesota. Private practice settings include solo practitioners and small-group and large-group practices. Regardless of practice type or location, the majority of patients seen by dental therapists are enrolled in medical assistance or some type of Minnesota Health Care Program. The 2009 Minnesota dental therapy law required the Minnesota Department of Health and the Minnesota Board of Dentistry to conduct an assessment of the impact of dental therapy and advanced dental therapy.19 The statute identified the following outcome measures to be assessed: number of new patients served, reduction in waiting times for needed services, decreased travel time for patients, impact on emergency room usage for dental care, and costs to the public health system. A report to the legislature of the assessment findings was submitted in January 2014.24 The research methodology used for the report included licensing data, patient surveys, clinic interviews, administrative data from clinics, and emergency room data. Even with the limitations of designing the research study before dental therapy practice began, the lack of public program data, and few numbers of dental therapists and advanced dental therapists in the field, the findings were consistent with a study of the impact of new dental providers in Alaska.25 The main findings in the Minnesota study were the following: the dental therapy workforce is increasing access by serving low-income, uninsured, and underserved patients; clinics with dental therapists report improved quality and no safety concerns; clinics with dental therapists are seeing more new patients, and most are underserved; dental therapists have made it possible to decrease travel time and wait times for many patients; benefits for clinics employing dental therapists include direct personnel costs savings, increased team productivity, lower patient fail rates, and improved patient satisfaction; and dental therapists have the potential to reduce unnecessary emergency room visits.24

Quality and Effectiveness The Research Triangle Institute evaluation of the Alaska program and the Minnesota Department of Health evaluations of dental therapy are just two of the reports that address the quality and efficacy aspects of dental therapy.21,24 Numerous other reports over the past decade have come to the same conclusions: dental therapists can provide safe and high-

quality dental care, and they are effective in helping to address access issues for underserved patients. A 2013 article in the Journal of the American Dental Association reported on a systematic review asking the following research question: “In populations where nondentists conduct diagnostic, treatment planning, and/or irreversible/surgical dental procedures, is there a change in disease increment, untreated dental disease, and/or cost-effectiveness of dental care?”26 The authors reported that the quality of the evidence related to the specific research question was poor. Nevertheless, they concluded that, “in select groups in which participants received irreversible dental treatment from teams that included mid-level providers, caries increment, caries severity, or both decreased across time; however, there was no difference in caries increment, caries severity, or both compared with those in populations in which dentists provided all irreversible treatment. In select groups in which participants had received irreversible dental treatment from teams that included mid-level providers, there was a decrease in untreated caries across time and a decrease in untreated caries compared with that in populations in which dentists provided all treatment.” One conclusion that can be drawn from this review is that dental therapists were as equally effective as dentists in providing care to patients. More recently, a study published in 2016 reviewed the literature and activities of the dental therapy movement “by the categories of research, education, and legislation/practice, as well as analytical essays and commentaries.”27 It concluded that “the U.S. movement to adapt the acclaimed work of the international dental therapist to the oral health workforce is still in its infancy. Yet, in spite of the aggressive opposition of organized dentistry, the movement is growing and expanding as individuals, activists, and policymakers understand the role that dental therapists can play in improving access to care, particularly for children.” In spite of opinion pieces raising concerns about the quality and effectiveness of dental therapists, no published research studies support those claims.

Integration into the Workforce As these new providers are graduating and joining the workforce, questions about how to introduce and integrate them into dental practices have been


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raised. In our experience, dentists who have been the early adopters are ambassadors for employing dental therapists and advanced dental therapists. Incorporating these new providers into the dental team is continuing to evolve, and more interest continues to build as the dental community learns of the positive outcomes for patients and practices. Introducing and integrating these new providers into the dental team may be challenging as dentistry in the U.S. has not experienced new dental team providers since the dental hygienist. Over 50 years have passed since the introduction of mid-level providers in medicine, and in recent years, medicine has further expanded its workforce, and most Americans are routinely receiving care from a variety of health care professionals in addition to physicians.28 The medical community has been working with midlevel providers (nurse practitioners and physician assistants) since the 1960s. Dentistry may be able to incorporate new dental providers more easily by following the medical community’s lead. Although these mid-level medical providers are now generally accepted and understood by patients, the medical community still takes measures to ensure these providers are appropriately introduced to patients and fellow employees, thus ensuring a smoother integration into their offices. In 2006, Tina Maluso-Boltan, an oncology nurse practitioner, identified seven common features that allow practices to successfully integrate new non-physician practitioners.29 These were 1) a clear, articulated job description, 2) a committed mentor, 3) physician and administrative support, 4) patient and coworker support, 5) feelings of acceptance of the new practitioner as a valued colleague by all concerned, 6) an atmosphere that supports growth, and 7) physician willingness to delegate. Dentistry can learn from these strategies in medicine to introduce and integrate dental therapists and advanced dental therapists into their dental offices. Comparing new dental therapists and advanced dental therapists to these medical models can also aid in patient understanding and acceptance. At this time, early experimentation is aimed at integrating dental therapists into other types of settings as dental therapists are finding opportunities to improve health in school-based settings, hospital settings, and mobile clinics. Other anticipated non-traditional opportunities include interprofessional care in senior housing centers and medical clinics. Additional efforts will be needed to educate dentists and other health care providers regarding creative ways in which dental

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therapists can be utilized to improve patient and community health. Ideally, in 20 years these new dental providers will be as common and as accepted in both medicine and dentistry as other primary care providers are in medicine. It is encouraging that a study by Self et al. found that, after four years of experience with the dental therapy program at the University of Minnesota, dental faculty members demonstrated greater acceptance of dental therapists and viewed the role of dental therapy more favorably than when the program was first introduced.30

Future Projections Demographic trends show that the U.S. population is changing and will continue to become more diverse each year with an increase in underserved patients and demographic groups that are underrepresented.1 This growth demonstrates that oral health disparities will continue to plague our country, increasing the demand for dental services. In addition, implementation of the Affordable Care Act is shifting the health insurance landscape and will lead to additional demand for children’s dental services. Nearly 24% of adults aged 20-64 in 2012 suffered from untreated dental caries.31 Growth in the size of aging population creates yet another demand. Combined, these issues speak to the need for the adoption of dental therapy to assist in meeting Americans’ oral health care needs. From 2012 to 2025, national and state-level projected increases in demand for dentists will not meet future oral health care needs, intensifying already existing shortages.32,33 With the average educational debt for dental graduates in 2015 of $255,567, a barrier for new graduates who desire to practice in low-income or rural communities where earning potential is lower has been created.34 This barrier to practicing in underserved areas does not exist for dental therapists. In Minnesota, many factors reduce this barrier. First, the total cost of education and estimated educational debt for dental therapists and advanced dental therapists in our programs is nearly one-fifth that of dentists. Also, the total compensation for dental therapists and advanced dental therapists is greater than that for dental hygienists and over 50% that of an associate dentist. In addition, loan forgiveness programs are available to dental therapists and advanced dental therapists who practice in Health Professional Shortage Areas. Thus, the confluence of continuing unmet demand for access to dental care


and a looming shortfall of dentists due to retirement can be ameliorated through incorporation of a new member of the oral health care team. The dental workforce has expanded and continues to grow in Minnesota and Alaska. The primary focus for creation of a new dental team member was to address the access to dental care crisis that exists in the nation. As additional states explore the feasibility of incorporating new team members, legislative initiatives will continue to increase each year. Other states can learn from the lessons learned in Minnesota when considering policies for creating new dental practitioners. It is also critical to continue conducting research to ascertain the impact of these new dental team members on access to oral health services for the underserved. It is incumbent upon the dental community to act on its convictions in order to meet the unmet oral health care needs of all Americans.

Acknowledgment

The authors thank Dr. Frank A. Catalanotto, University of Florida College of Dentistry, for contributing information to the quality and effectiveness section of this article.

Editor’s Disclosure

This article is published in an online-only supplement to the Journal of Dental Education as part of a special project that was conducted independently of the American Dental Education Association (ADEA). Manuscripts for this supplement were reviewed by the project’s directors and the coordinators of the project’s sections and were assessed for general content and formatting by the editorial staff. Any opinions expressed are those of the authors and do not necessarily represent the Journal of Dental Education or ADEA.

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