dental hygiene is cha cha-changing

DENTAL HYGIENE IS CHA-CHA-

CHANGINGBobbie Brown, CDA, RDH, MSDH

Diann Bomkamp, RDH, BSDH

COURSE OBJECTIVE:

To provide 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.

LEARNING OBJECTIVES…

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

ARE YOU CONFUSED???

DHAT CDHCOPA

ADHP

RDHAPADTOHP

LAYING THE GROUNDWORK

WHAT IS A ‘MID-LEVEL PROVIDER?’

mid·lev·el provider (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.

WHAT IS A ‘MID-LEVEL PROVIDER?’

The medical model for a mid-level provider includes advanced education

Frequently a Master’s level

DENTAL MID-LEVEL PROVIDER

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.

DENTAL MID-LEVEL PROVIDER

Education requirements for proposed dental mid-level providers vary greatly

ADHP is most closely modeled after the medical mid-levelMaster’s Degree education

TRADITIONAL DENTAL TEAM MEMBERS IN THE U.S… Dentist

Various Specialties Dental Assistant

Expanded Function DA

Dental Hygienist RDHAP Extended Care

Permit RDH LAP

Dental Laboratory Technician

COLLABORATIVE PRACTICE 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

COLLABORATIVE PRACTICE CONT’D 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

WHERE DOES IT EXIST?• 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

• 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_

DO WE NEED A NEW PROVIDER?

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.

INTERESTED GROUPS…

AAPHDSupport the use of Dental TherapistsCreated standard curriculum guidelines

ADACommunity Dental Health Coordinator

(CDHC)Oral Preventive Assistant (OPA)

ADHAAdvanced Dental Hygiene Practitioner

(ADHP) Interested Foundations

WWW.AAPHD.ORG

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.

ADA MODELS… ADA is opposed to anyone, other than

dentists, performing ‘irreversible surgical procedures’ i.e. cutting tooth structure

Propose two new workforce membersCDHCOPA

Neither is a true ‘mid-level’ provider

www.ada.org

ADA MODELS CDHC

Community Dental Health CoordinatorBased on the ‘Community Health Worker’

conceptDuties can include scaling skills

OPAOral Preventive AssistantProposed competencies similar to a

hygienist

COMMUNITY HEALTH WORKER 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

COMMUNITY DENTAL HEALTH COORDINATOR…

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

MORE ABOUT NEW MEXICO…

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

ORAL PREVENTIVE ASSISTANT…

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

ADHA MODEL… Advanced Dental Hygiene Practitioner

ADHP Similar educational level as a nurse

practitionerMaster’s Degree required

True ‘Mid-level provider’Restorative services

www.ADHA.org

W. K. KELLOGG FOUNDATION “Working with partners across the

country to build awareness of oral health”

OTHER FOUNDATIONS… PEW Charitable Trusts:

http://www.pewtrusts.org

THE ROBERT WOOD JOHNSON FOUNDATION Fund oral health programs through

grants

NEW PROVIDERS CURRENTLY UNDER CONSIDERATION:

Dental Therapist or Dental Health Aid Therapist

Community Dental Health Coordinator (CDHC)

Advanced Dental Hygiene Practitioner (ADHP

COMPARISON

http://www.rdhmag.com/index/display/articledisplay.5327511813.articles.rdh.volume-30.issue-5.columns.mid-level-providers.html

Accessed January 10, 2012Author: Christine Nathe

LET’S TAKE A LOOK BACK…

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

ALFRED C. FONES AND IRENE NEWMAN

Fones intended dental hygiene to focus on public health not exclusively in private practice

Prevention based School based

Fones traveled extensively to promote the new profession to state dental associationsHe 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.

“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.

IT’S IRONIC….

TRAINING HYGIENISTS TO DO RESTORATIVE TREATMENT

It’s been done…Multiple times!!Howard UniversityThe Forsyth ExperimentsUniversity of KentuckyUniversity 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.

THE FIRST ATTEMPT:

Forsyth Dental Center 1949 Funded by a USPHS

grant Abandoned under

pressure from organized dentistry

HOWARD UNIVERSITYWASHINGTON DC-- 1969

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

TRAINING HYGIENISTS TO DO RESTORATIVE TREATMENT The Forsyth

Experiment(s)1949 & 1970Robert Wood Johnson

1970 University of Kentucky

1972-74Robert Wood Johnson

University of Iowa1971-76W. 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.

2ND FORSYTH EXPERIMENT…

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

FORSYTH CONT’D…

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

FINDINGS… 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

FINDINGS…

“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.

BACKGROUND

FORSYTH ARTICLE:

Authored by Christel Koppel Autuori, RDH

http://findarticles.com/p/articles/mi_m1ANQ/is_9_21/ai_n25015054/?tag=content;col1

Unique perspective of a trainee in Forsyth’s program

LET’S TAKE A LOOK BACK…

New Zealand Dental TherapistsHistoryCurrent status

NZ Dental Therapists around the world

NEW ZEALAND… 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.

NEW ZEALAND HYGIENISTS… 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.

NEW ZEALAND CONT’D…

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.

NEW ZEALAND CONT’D…

Until recently 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.

DENTAL THERAPISTS WORLDWIDE

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.

MORE ABOUT DENTAL THERAPISTS… 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 teethWorldwide, many DT programs now

combine dental therapy with dental hygiene

WHAT HAPPENED IN ALASKA? Background of the Alaska Native use of

DHATs Lawsuit by the ADA Current status

THE ALASKA STORY… “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.

WHY ALASKA?

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.

WHY NEW ZEALAND DENTAL THERAPISTS? New Zealand’s well-established history

in utilizing and training Dental Therapists

Willingness of the training program to accept Alaska Native students

EARLY TIMELINE… 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 dentists3months or 400 hours—whichever is longerCulminates in supervising dentist deeming

the DHAT ‘competent’ and writing their standing orders

SUPERVISION 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

TELEDENTISTRY 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

ADA OPPOSES DHATS IN ALASKA

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

SETTLEMENT… 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 Workforce Models: Considerations for Academic Dental Institutions. J Dent Educ. November 1, 2007 2007;71(11):1476-1491.

ADEA MEETING 2009 Dentists who developed the DHAT

program in Alaska were speaking…along with one of the therapists

Things I learned…

“Unless you 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.”

Mark Kelso, D.D.S. Norton Sound Health Corporation, Nome Alaska

REFERENCES: 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.

REFERENCES CONT’D… 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.