dental hygiene is cha cha-changing
DESCRIPTION
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 dentistsTRANSCRIPT
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”
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.