RESPONSE TO COMMENTARY

ASSESSMENT OF TREATMENT PROVIDED BY DENTAL HEALTH AIDE THERAPISTS IN ALASKA

This paper examines the supervisory relationships between Alaska's dental health aide therapists (DHATs) and their supervising dentists to gain insight into how DHATs are being deployed and supervised to increase access while ensuring safety and quality. Telephone interviews were conducted with four DHATs, their supervising dentists, and the dental directors at three health corporations in geographically distinct areas of Alaska. Follow-up questions were submitted and responded to via e-mail. This article profiles three DHATs and their supervising dentists, and offers observations on how dentists supervise and work in a team format with DHATs. DHATs practice as part of a care team, with dentists providing direct, indirect, and general supervision. Both DHAT training, with its mandatory preceptorship, and the group practice model are designed to assure that DHATs provide safe, competent, and appropriate care within their limited scope of practice. The presence of DHATs allows dentists on the care team to play roles commensurate with the full extent of their training. Tribal health organizations in Alaska are deploying these providers safely and effectively in a variety of roles, according to regional needs and preferences. This suggests the model's potential adaptability to settings outside Alaska.

The use of midlevel dental providers (MLDPs) is being debated as a means of reducing oral health disparities and increasing access to care among underserved populations. Midlevel dental providers include the advanced dental hygiene practitioner, community dental health coordinator, dental health aide therapist, and dental therapist. While midlevel providers are new to the U.S. dental profession, medicine has utilized these positions for years. Medical literature has shown mixed results as to whether midlevel providers improve access to care and increased practice efficiency, however, it has demonstrated clearly that the quality of care outcomes of these providers have been comparable to those of physicians. Studies of MLDPs suggest potential practice and public health benefits. With appropriate training, licensure, supervision, and deployment to geographical areas of significant need, we believe MLDPs could increase access to care to underserved populations and help in the prevention of deaths attributable to untreated dental disease.

The Push to Integrate Mid-Level Providers into Dentistry

Dental Health Aide Therapists (DHATs) have been part of the dental workforce in Alaska's Yukon-Kuskokwim (YK) Delta since 2006. They are trained to provide preventive and restorative care such as filling and extractions. In this study, we evaluated community-level dental outcomes associated with DHATs. This was a secondary data analysis of Alaska Medicaid and electronic health record data for individuals in Alaska's YK Delta (2006-2015). The independent variable was the number of DHAT treatment days in each community. Child outcomes were preventive care, extractions, and general anesthesia. Adult outcomes were preventive care and extractions. We estimated Spearman partial correlation coefficients to test our hypotheses that increased DHAT treatment days would be associated with larger proportions utilizing preventive care and smaller proportions receiving extractions at the community-level. DHAT treatment days were positively associated with preventive care utilization and negatively associated with extractions for children and adults (P < 0.0001). DHAT treatment days were not associated with increased dental treatment under general anesthesia for children. Dental therapists are associated with more preventive care and fewer extractions. State-level policies should consider dental therapists as part of a comprehensive solution to meet the dental care needs of individuals in underserved communities and help achieve health equity and social justice.

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."

We appreciate the opportunity to respond to the criticisms of our article, “Improving the Oral Health of Alaska Natives,”1 by some members of the dental public health community. The American Dental Association (ADA) is fully supportive of the Dental Health Aide Program in Alaska, except for allowing non-dentists to perform irreversible surgical treatments. The ADA considers protecting the oral health and safety of the public as its obligation; allowing nondentists to provide irreversible surgical procedures jeopardizes both, particularly Alaska Natives, because of the extent and the severity of oral diseases they suffer. A dentist’s education involves considerably more than manual training, and that knowledge is critical for safely managing untoward events that can occur. Dental Health Aide Therapists (DHATs) operating in remote villages will not have the ready emergency support they need, unlike dental nurses working in New Zealand metropolitan schools. Alaska Natives are a most unlikely group as subjects in a high-risk experimental project of this nature. It is misleading to state that “there are some 42 countries with some variant of a dental therapist. . . .” Evaluation of the use of auxiliaries is difficult in some areas, because “dental nurse” and “dental therapist” do not have universally agreed upon definitions. Some would be classified as “dental assistants” in other countries. This we do know, however; today, almost 85 years after the introduction of this auxiliary, there is only 1 training program for “oral therapists” in the western hemisphere! This concept has been rejected in most countries. The ADA supports appropriate expansion of duties for dental team members. One letter states, “[The ADA has] a long record of preventing anyone except dentists from providing treatment, even to the underserved.” Were the words “unsupervised, irreversible surgical treatment” to be used, it would be an accurate statement and one of which the ADA would be proud. The “underserved” is not a subgroup of society for which treatment by lesser trained persons is all right and better than nothing, but rather a group that needs to be brought into the mainstream of dental care. It is interesting to note that two thirds of the signers of the letter from current and past leadership of the American Public Health Association Oral Health Section supporting DHATs are not dentists. James B. Bramson and Albert H. Guay present a more complete discussion of DHATs as Comments2 on David A Nash’s article on the pediatric oral health therapist in the Summer edition of the Journal of Public Health Dentistry.3

Assessment of Treatment Provided by Dental Health Aide Therapists in Alaska: A Pilot Study

Access to adequate oral health care is deficient in many parts of the world. Many countries are now using dental therapists to increase access, particularly for children. To inform the discussion on dental therapists in the workforce, particularly in the United States, the W.K. Kellogg Foundation funded a review of the global literature to identify as many documents as possible related to the practice of dental therapists since the establishment of the School Dental Service in New Zealand in 1921. Consultants in each of the countries considered to have a substantive literature on dental therapists were asked to participate in the research; seventeen in total. In addition to identifying and reviewing published articles, a focus of the research was on identifying 'gray' documents. Standard databases were searched for key words associated with dental therapists. In addition, searches were conducted of the governmental and dental association websites of all countries known to have dental therapists in their oral health workforce. Fifty-four countries, both developing and developed, were identified where dental therapists are members of the workforce. Eleven hundred documents were identified from 26 of these countries, with over 2/3 of them cited in the published monograph. Reliable evidence from the related literature and verbal communication confirmed the utilization of dental therapists in an additional 28 countries. Thirty-three of the countries were members of the Commonwealth of Nations, suggesting a mechanism of spread from New Zealand. Variable lengths of training/education existed for dental therapists with the tradition being 2 years postsecondary. In a few countries, the training of therapists and hygienists is now being combined in a three academic year program. Historically, dental therapists have been employed by government agencies caring for children, typically in school-based programs. Initiatives in some countries allow limited care for adults by dental therapists with additional training. The evidence indicates that dental therapists provide effective, quality, and safe care for children in an economical manner and are generally accepted both by the public and where their use is established, by the dental profession.

The U.S. surgeon general defined the national oral health care crisis in 2001 in Oral Health in America: A Report of the Surgeon General. The report concluded that the public infrastructure for oral health is not sufficient to meet the needs of disadvantaged groups and is disproportionately available depending upon certain racial, ethnic, and socioeconomic factors within the U.S. population. Now, several new workforce models are emerging that attempt to address shortcomings in the oral health care workforce. Access to oral health care is the most critical issue driving these new workforce models. Currently, three midlevel dental workforce models dominate the debate. The purpose of this report is to describe these models and their stage of development to assist the dental education community in preparing for the education of these new providers. The models are 1) the advanced dental hygiene practitioner; 2) the community dental health coordinator; and 3) the dental health aide therapist.

BackgroundIn Sierra Leone (SL), a low-income country in West Africa, dental care is very limited, largely private, and with services focused in the capital Freetown. There is no formal dental education. Ten dentists supported by a similar number of dental care professionals (DCPs) serve a population of over 7.5 million people. The objective of this research was to estimate needs-led requirements for dental care and human resources for oral health to inform capacity building, based on a national survey of oral health in SL.MethodsA dedicated operational research (OR) decision tool was constructed in Microsoft Excel to support this project. First, total treatment needs were estimated from our national epidemiological survey data for three key ages (6, 12 and 15 years), collected using the ‘International Caries Classification and Management System (ICCMS)’ tool. Second, oral health needs were extrapolated to whole population levels for each year-group, based on census demographic data. Third, full time equivalent (FTE) workforce capacity needs were estimated for mid-level providers in the form of Dental Therapists (DTs) and non-dental personnel based on current oral disease management approaches and clinical timings for treatment procedures. Fourth, informed by an expert panel, three oral disease management scenarios were explored for the national population: (1) Conventional care (CC): comprising oral health promotion (including prevention), restorations and tooth extraction; (2) Surgical and Preventive care (S5&6P and S6P): comprising oral health promotion (inc. prevention) and tooth extraction (D5 and D6 together, & at D6 level only); and (3) Prevention only (P): consisting of oral health promotion (inc. prevention). Fifth, the findings were extrapolated to the whole population based on demography, assuming similar levels of treatment need.ResultsTo meet the needs of a single year-group of childrens’ needs, an average of 163 DTs (range: 133–188) would be required to deliver Conventional care (CC); 39 DTs (range: 30–45) to deliver basic Surgical and Preventive care (S6P); 54 DTs for more extended Surgical and Preventive care (S5&6P) (range 38–68); and 27 DTs (range: 25–32) to deliver Prevention only (P). When scaled up to the total population, an estimated 6,147 DTs (range: 5,565–6,870) would be required to deliver Conventional care (CC); 1,413 DTs (range: 1255–1438 DTs) to deliver basic Surgical and Preventive care (S6P); 2,000 DTs (range 1590–2236) for more extended Surgical and Preventive care (S5&6P) (range 1590–2236); and 1,028 DTs to deliver Prevention only (P) (range: 1016–1046). Furthermore, if oral health promotion activities, including individualised prevention, could be delivered by non-dental personnel, then the remaining surgical care could be delivered by 385 DTs (range: 251–488) for the S6P scenario which was deemed as the minimum basic baseline service involving extracting all teeth with extensive caries into dentine. More realistically, 972 DTs (range: 586–1179) would be needed for the S5&6P scenario in which all teeth with distinctive and extensive caries into dentine are extracted.ConclusionThe study demonstrates the huge dental workforce needs required to deliver even minimal oral health care to the Sierra Leone population. The gap between the current workforce and the oral health needs of the population is stark and requires urgent action. The study also demonstrates the potential for contemporary epidemiological tools to predict dental treatment needs and inform workforce capacity building in a low-income country, exploring a range of solutions involving mid-level providers and non-dental personnel.

The Alaska Native people in rural Alaska face serious challenges in obtaining dental care. Itinerant care models have failed to meet their needs for more than 50 years. The dental health aide therapist (DHAT) model, which entails training midlevel care providers to perform limited restorative, surgical, and preventive procedures, was adopted to address some of the limitations of the itinerant model. We used quantitative and qualitative methods to assess residents' satisfaction with the model and the role of DHATs in the cultural context in which they operate. Our findings suggest that the DHAT model can provide much-needed access to urgent care and is beneficial from a comprehensive cultural perspective.

This chapter will describe the role and evolution of the scope of clinical practice of dental hygienists, dental therapists and oral health therapists. These three groups of allied oral health professionals are playing an increasingly important role in the provision of oral health services and it is therefore important to understand how they are utilised as part of the dental team. Historically, the dental hygiene profession originated in the early 1900s in the US, followed by Norway, 1924; United Kingdom, 1943; Canada, 1947; Japan, 1948; and Australia, 1971 (Johnson, 2009). Dental hygienists predominantly provide health education, preventive, periodontal and orthodontic auxiliary services to people of all ages. Dental therapists were introduced in New Zealand in 1921 to provide basic preventive and restorative dental care for children in the School Dental Service. Currently more than 50 countries utilise dental therapists (Nash et al., 2008). In Australia and New Zealand, dental therapists have been responsible for examining, diagnosing, and developing plans for the oral health treatment they provide to children and adolescents, and referring patients with treatment needs beyond their scope of practice to dentists (Satur et al., 2009). Oral health therapists are a relatively new addition to the dental team. They have the combined education and training of both a dental therapist and a dental hygienist. Currently across Australia all oral health therapy education is provided through the tertiary education sector. An emerging oral health problem in many Western countries is access to dental services by disadvantaged groups, in particular public adult dental patients. Oral health disparities and socioeconomic disadvantage have led to a growing burden of disease amongst sections of the community who at the same time have difficulties accessing appropriate oral health services. There is currently debate in the United States and elsewhere about the need for an oral health practitioner with similar skills to a dental therapist to address the high levels of unmet restorative treatment needs and extend access to oral health care services for lower income groups. This is somewhat different to the situation in countries like Australia, where dental therapists have been long accepted as playing a role in the provision of oral health

This study assesses the viability of three alternative practitioner types for provision of dental care to the underserved. Key factors modeled include compensation, training and practice costs, productivity, and payer mix scenarios. Utilizing dental therapists or dental health aide therapists is cost-effective for enhancing access. However, to be sustainable, the practices will require a subsidy or a better reimbursement than modeled. Without tuition support, the debt burden will deter applicants mostlikely to treat the underserved.

Introduction Mental health and wellbeing of the dental team has been brought into sharp focus during the COVID-19 pandemic. Despite this renewed interest, there has been longstanding issues with poor mental health and wellbeing in the dental profession for some time. While there is some evidence that documents poor mental wellbeing amongst dentists, there appears to be a lack of evidence concerning dental care professionals.Aims To explore the level of mental wellbeing and stress amongst dental hygienists and therapists (DHTs) in South West England.Method An online survey was distributed to DHTs in South West England via two professional networks.Results A total of 129 surveys were completed. The mean levels of reported wellbeing were lower amongst DHTs than the general population and 45% of respondents reported high anxiety levels. Younger respondents reported lower levels of life satisfaction. Plus, 43.5% of dental therapists reported performing solely dental hygiene treatments, with those performing no dental therapy reporting lower happiness levels.Conclusion Low mental wellbeing amongst DHTs in the South West has been identified in this survey and this is likely to impact negatively on the morale and motivation of the workforce, leading to increased levels of absenteeism and ultimately, loss of colleagues from the dental workforce. The stress encountered by DHTs is largely workplace-related and therefore, there is an increased need for team- and organisation-delivered interventions to improve mental wellbeing for this group.