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

1. Bobbie Brown, CDA, RDH, MSDH
Diann Bomkamp, RDH, BSDH

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.  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

6.  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, 2004
by Houghton Mifflin Company. Published by Houghton Mifflin
Company. All rights reserved.

7.  The medical model for
a mid-level provider
includes advanced
education
 Frequently a Master‟s
level

8.  Providers who may
perform intermediate
restorative
services, such as
drilling and filling
teeth, under remote
supervision of a dentist
GAO. Efforts under way to improve children's access to dental services, but sustained attention needed to
address ongoing concerns. Washington D.C. November 2010.

9.  Educationrequirements for proposed dental
mid-level providers vary greatly
 ADHPis most closely modeled after the
medical mid-level
 Master‟s Degree education

10.  Dentist
 Various Specialties
 Dental Assistant
 Expanded Function DA
 Dental Hygienist
 RDHAP
 Extended Care Permit
 RDH LAP
 DentalLaboratory
Technician

11.  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

12. 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

13. • 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

14. • 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_

15.  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 providers
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.

16.  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

17. 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.

18.  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

19.  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

20.  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

21.  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

22.  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

23.  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

24.  Advanced Dental Hygiene Practitioner
 ADHP
 Similareducational level as a nurse
practitioner
 Master‟s Degree required
 True „Mid-level provider‟
 Restorative services
www.ADHA.org

25.  “Workingwith partners across the country to
build awareness of oral health”

26.  PEW Charitable Trusts:
http://www.pewtrusts.org

27.  Fund oral health programs through grants

28.  Dental Therapist or Dental
Health Aid Therapist
 Community Dental Health
Coordinator (CDHC)
 Advanced Dental Hygiene
Practitioner (ADHP

29. http://www.rdhmag.com/index/display/articledisplay.5327511813.arti
cles.rdh.volume-30.issue-5.columns.mid-level-providers.html
Accessed January 10, 2012
Author: Christine Nathe

30.  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

31.  Fones intended dental
hygiene to focus on
public health not
exclusively in private
practice
 Prevention based
 School based

32.  Fones traveled extensively to promote the
new profession to state dental associations
 He found opposition even at that early date
Nathe CN. Dental public health & research: contemporary practice for the dental
hygienist. Third ed. Upper Saddle River, New Jersey: Pearson Education, Inc.;
2011.

33.  “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 dental
hygienist. Third ed. Upper Saddle River, New Jersey: Pearson Education, Inc.; 2011.

34.  It‟sbeen done…Multiple
times!!
 Howard University
 The Forsyth Experiments
 University of Kentucky
 University of Iowa
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, Berman KB, Chaisson LB, Karelas HA, Nolan LF. The forsythe experiment in training of advanced
skills hygienists. J Dent Educ. 1974;38(7):369-379.

35.  Forsyth Dental Center
 1949
 Funded by a USPHS grant
 Abandoned under pressure
from organized dentistry

36.  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 students
Lobene, Ralph and Alix Kerr. The Forsythe Experiment: An Alternative System for Dental Care.
Cambridge: Harvard University Press, 1979

37.  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. Kellogg
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, Berman KB, Chaisson LB, Karelas HA, Nolan LF. The forsythe experiment in training of advanced skills hygienists. J
Dent Educ. 1974;38(7):369-379.

38.  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

39.  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

40.  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

41.  “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 forsythe
experiment in training of advanced skills hygienists. J Dent Educ. 1974;38(7):369-
379.
Nash DA. Expanding dental hygiene to include dental therapy: improving access
to care for children. J Dent Hyg. Winter 2009;83(1):36-44.

45.  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

46.  New Zealand Dental Therapists
 History
 Current status
 NZ Dental Therapists around the world

47.  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 1980s
Nash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Int Dent J. Apr
2008;58(2):61-70.

48.  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 earnest
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.

49.  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
Netherlands
Nash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Int Dent J. Apr
2008;58(2):61-70.

50.  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
dentist
Nash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Int
Dent J. Apr 2008;58(2):61-70.

51.  DT‟s practice in >53
countries
 >14,000 exist worldwide
 Both developed and
developing countries
 Countries with high and
low dentist to population
ratios
Nash DA, Friedman JW, Kardos TB, et al. Dental
therapists: a global perspective. Int Dent J. Apr
2008;58(2):61-70.

52.  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

53.  Background of the Alaska Native use of DHATs
 Lawsuit by the ADA
 Current status

54.  “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 2001
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.

55.  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 available
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.

56.  New Zealand‟s well-established history in
utilizing and training Dental Therapists
 Willingness of the training program to accept
Alaska Native students

57.  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

58.  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

59.  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

60.  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

61.  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 Alaska
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.

62.  Dentists who developed the DHAT program in
Alaska were speaking…along with one of the
therapists
 Things I learned…

63.  “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

64.  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 children's 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.

65.  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.