The Push to Integrate Mid-Level Providers into Dentistry

Are dentists risking losing their relevance?

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.

RESPONSE TO COMMENTARY

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."

The authors describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general and pediatric dentistry residency programs in the United States. They first briefly review the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. The authors then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, the authors call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general and pediatric dentistry. In doing so, the Title VII program can more effectively address current and future challenges in dental education, dentist workforce, and disparities in oral health and access to care.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

A chronic shortage of dentists, the importance of oral health, and the lack of access to care led to the introduction of a new oral health practitioner in Minnesota, the dental therapist. Dental therapy graduates from the University of Minnesota have been in practice since 2012. To date, there has been no formal study of how they have been incorporated into dental practice. The purpose of this study was to obtain baseline knowledge of dental therapists' practice patterns in Minnesota and determine if dentists' patterns of work changed after a dental therapist was employed. Four dental practices were sampled purposefully to obtain various practice types and geographic locations within Minnesota. Secondary data were collected from practice management software databases in each practice between January-March, 2015. Data were used to describe the work undertaken by dental therapists, the types of patients seen and payer mix. Additionally, data from 6 months before and after employment of the dental therapist were collected to determine whether dentists' practice patterns changed after a dental therapist was employed. Dental therapists were employed full-time, seeing an average of 6.8 patients per day. No distinct pattern emerged with regard to ages of patients seen by dental therapists. Dental therapists saw up to 90% of uninsured patients or patients on public assistance. Restorative services across practices comprised an average of 68% of work undertaken by dental therapists. Dentists delegated a full range of procedures within the dental therapy scope of practice indicating trust and acceptance of dental therapists. Dentists in two practices began to take on more complex dental procedures after a dental therapist joined the practice. Dental therapists are treating a high number of uninsured and underinsured patients, suggesting that they are expanding access to dental care in rural and metropolitan areas of Minnesota. Dentists appear to have an adequate workload for dental therapists and are delegating a full range of procedures within their scope of practice. Dentists performed fewer restorative and preventive procedures after a DT was hired.

Gap in Dental Care Can Lead to Diabetes, Other Disease Conditions

To perform an online survey and follow-up interviews to assess the current level, nature and attitude of dental hygienists and dental therapists to the provision of treatment under Direct Access. Method In November 2022 an online survey was sent to all members of the British Society of Dental Hygiene and Therapy together with an information sheet. Completed questionnaires were returned via Google Docs and analysed. Participants for the follow-on interviews were recruited from survey participants who had consented to being contacted. The survey was given ethics approval by the University of Kent Global and Lifelong Learning Ethics Committee. Results The response rate to the survey was 16% (n=419). Eleven follow-up interviews added a richness to the quantitative survey data. The vast majority of participants were female (96% n=403): 64% (n=268) reported their scope of practice as a dental hygienist and 36% (n=151) as a dental therapist. Two-thirds (n=281) of the treatment carried out by participants was on a private basis. Eighty-one percent of participants (n=340) reported their clinical work to be mainly dental hygiene, with 3% (n=11) carrying out mainly dental therapy and 16% (n=66) carrying out an equal mixture of both dental hygiene and dental therapy. Almost a fifth (19% n=80) of participants reported to never providing treatment under Direct Access. A large majority (71% n=299) worked under Direct Access some of the time and 9% (n=39) worked under Direct Access all of the time. Conclusion This study has established the level and extent of the provision of Direct Access amongst members of the British Society of Dental Hygiene and Therapy. Within the limitations of this mixed method study, dental hygienists and dental therapists are confident in providing care under Direct Access within their scope of practice, although there are contractual and other barriers leading to their underutilisation in the NHS.

Anecdotally, it is currently accepted that many dental hygienists and dental therapists in the UK do not work consistently, if at all, to their full scope of practice, as determined by the General Dental Council and in line with their pre-registration training and post-qualification continuing professional development. Consider the professional demographics of the BSDHT and investigate the types of clinical skills that are being utilised in a particular setting, in addition to the members' usual daily practice, how consistently they are employing them, and any potential barriers and facilitators for working consistently to a full scope of practice. BSDHT members (n = 2487) were invited to complete an online questionnaire and take part in an individual 30-min semi-structured online interview with the investigator. The quantitative data was collected on a master Excel spreadsheet, and qualitative data following the interviews were available as digital recordings and AI transcripts. The response rate was 12.5% (n = 312), of which 64% (n = 200) were dental hygienists and 36% (n = 112) dental therapists: 70% (n = 19) of the dental hygienists who work in an NHS practice never work to their full scope, in comparison to 48% (n = 9) of dental therapists. Of those that would like to work to their full scope, 51% (n = 103) were dental hygienists and 31% (n = 35) were dental therapists. Of the 312 members who responded to the questionnaire, 24.7% (n = 77) indicated that they would be willing to take part in the online semi-structured interviews. The skills of dental hygienists and dental therapists are often underutilised across all dental practice settings. However, dental therapists are more likely than dental hygienists to work to their full scope of practice in both NHS and mixed dental practice settings. Further studies are needed to investigate and understand the barriers that prevent all dental hygienists and dental therapists from working to their full scope of practice and identify possible facilitators that could offer greater opportunities.

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 evaluates the impact of introducing dental therapists (DTs) into Children's Dental Services (CDS), a large non-profit organization in Minnesota. The aim is to assess the effect of DTs in improving access and reducing dental care costs in Minnesota by analyzing the trends in dental care delivery and procedures performed by CDS dentists and therapists. Using 2009 to 2021 data from CDS, the study compares trends in patient volume, types of procedures, salary data and payments by dentists, DTs, and registered dental hygienists (RDH). Return on investment (ROI) trends are calculated using salary and revenues for each provider type. After introducing DTs at CDS and implementing mobile clinics, the number of patients served and volume increased steadily, demonstrating increased access. DTs provided an increasing proportion of fluorides, sealants, and extractions through 2020. Interestingly 2021, there was a decrease for DTs, possibly due to Covid related workforce shortages. ROI analysis showed that DTs' ROI dramatically rose, eventually surpassing dentists, while RDHs maintained a constant ROI. Dentists' ROI also initially increased after adopting DTs in the practice. Integrating DTs at CDS improved access by expanding mobile clinics, increasing patient volume, and redistributing procedures, while demonstrating a positive return on investment. Results suggest that adopting the DT model may be a promising practice for other organizations seeking to improve access to dental care, increase operational efficiency, and boost the dental care team's ROI.

EXISTING EVIDENCE FOR DENTAL HYGIENE AND DENTAL THERAPY INTERVENTIONS: A DETERMINATION OF DISTINCT PATIENT POPULATIONS.

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.

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.Introduction

Rather than fantasizing on whether dental therapists might be a disruptive innovation in the United States, one should look to those states and countries with a long history of successful implementation—particularly New Zealand, Australia, and Great Britain, and most recently Alaska—without any disruption of dental practice.1,2 To put the matter in perspective, was the practice of medicine disrupted by the innovative introduction of nurse practitioners and physician assistants? Was the practice of dentistry in the United States disrupted by the innovative introduction of dental hygienists? Of course not. In each instance, the mid-level providers extended health care more broadly to the public without any disruption to the professions. It is fallacious to counterpose health care with industrial production, as if mid-level providers compete with and, if successful, replace the top-level doctor-providers in a competitive free market. Innovation in health care cannot be compared with disruptive innovations in industries such as the effect of the Internet on newspapers, or the digital camera on film cameras and film manufacturing, or the automobile on the horse and buggy. In no instance has the introduction of mid-level providers disrupted the practice of medicine or dentistry or harmed the status or income of doctors. The only disruption has been in the politics of the professions that oppose the innovations. Mid-level professionals neither replace nor diminish doctors, but rather assist and enhance their practices. In the case of dental therapists, it is only in the minds of traditional dentists and their trade organizations, principally the American Dental Association, that there is disruption. Edelstein presents the views of both opponents and proponents of dental therapists, as though they have equal credence. But almost all the arguments in opposition are based on assertions that have been shown to be false. For example, opponents still say that dental therapists provide substandard care when their quality of care has been documented time and again in objective studies to be equal to that of dentists. They question if the public will accept or be satisfied with dental therapists when studies have confirmed a high level of acceptance and satisfaction.3 Giving equal space to false arguments can only have the effect of diluting the evidence that innovative health care providers such as nurse practitioners and dental therapists do not disrupt the professions, much to the benefit of the public.