Increasing Access to Dental Care through the Use of New Midlevel Providers

GIH Access to Care Audioconference Series

Speakers:              
Dr. Burton L. Edelstein, Columbia University and the Children’s Dental Health Project                                               
Dr. Albert K. Yee, The W.K. Kellogg Foundation  

Summary and Materials:             

Dr. Burton L. Edelstein
Background 

• Oral is related to overall bodily health, and evidence of oral-systemic connections continues to grow.  Oral health problems can reduce quality of life, cause chronic pain, and contribute to low self-esteem. 
• There are significant oral health disparities between socially advantaged and disadvantaged populations. In addition, caries and periodontal disease are progressive over the lifetime, so older Americans face more oral health problems.
• More than half the U.S. population does not visit the dentist over the course of a year.  This is in part due to lack of coverage, as more than a third of the U.S. population is not covered by dental insurance. The Commonwealth Fund 2001 Health Insurance Survey found one in four U.S. adults experienced delayed dental care because of cost, and one in ten U.S. adults reported missing work because of dental problems.
• The Children’s Dental Health Project has identified the following five interlocking “buckets” to cover virtually every policy opportunity to address inequities in oral health:

-Financing: Includes private coverage, public coverage (Medicaid and CHIP), and healthcare reform. Financing has been a focus during healthcare reform, but so far Congress has only paid attention to children’s oral health.

-Workforce: Includes composition, numbers, distribution (ex: rural areas are underserved), competencies, and coordination. While we traditionally think of dentists, hygienists, and assistants, other countries have taken other approaches.

-Safety Net: Includes size, availability, and stability. Financial and workforce stability are of special concern.

-Prevention and Disease Management: Includes risk management and the best use of science.  This “bucket” is extremely important.

-Surveillance: Along with evaluation, necessary to track what is working and what is not.

 
Report: Training New Dental Health Providers in the U.S.  

• Training New Dental Health Providers in the U.S. was written by Dr. Edelstein with support from the W.K. Kellogg Foundation.  In addition to the full report, an Executive Summary and Policy Brief are available (see below).
• Workforce options are one of the approaches that can be taken to improve oral health, but also one of the more controversial. The goal of this report was to provide an objective analysis of 11 types of midlevel dental providers so proponents and opponents of each model can argue from a common set of facts.
• Foundations, government, dental professionals, advocates, educators, and industry all have an interest in what happens with midlevel dental providers. In 2009, Congress and the state legislature in Minnesota were especially active in moving midlevel dental providers forward. Over the same period, dental professionals proposed their own models.
• The report begins with a description of the 11 types of providers considered, broken up into four categories: conventional, unconventional, proposed, and conventional non-U.S. Providers which do or would provide irreversible surgical dental services are identified.
• Providers are also examined based on the relationship between training and responsibility. Of the 11 programs, training times vary greatly. The dental therapist has about half as much clinical training as the dentist, but for the procedures performed, training is equal to or greater than what the dentist receives.  In addition, dental therapists complete two thirds as much biomedical training and nearly three times as much socio-behavioral training.
• There are legal, educational, and implementation issues which must be considered for each provider.  Legal issues include scope of practice, supervision, and placement, educational issues include training and accreditation, and implementation issues include advocacy and funding.
• Goals for implementing dental therapists include:

-Expanding available care;
-Increasing the number of attuned primary care providers, by nature of training or background;

-Establishing a career ladder for minorities, as people may enter dentistry through a lower level position;

-Improving cost effectiveness;

-Strengthening the role of the dental safety-net, which has weaknesses in workforce; and,

-Maximizing the roles of the dentist as they care for the most complex cases.

Role of Funders  

• As outlined by Dr. Edelstein, funders can play a number of roles when it comes to the dental workforce:

-Exploring and assessing: Includes collecting and synthesizing available information on your geographical area.

-Defining: Includes articulating issues, such as composition, numbers, distribution, competencies, and coordination.

-Engaging: Includes raising dental workforce issues as a concern and priority.

-Convening: Includes bringing together communities of interest with disparate viewpoints and needs.

-Facilitating: Includes seeking commonalities, resolving differences, advancing an agenda.

-Promoting/programming: Includes supporting innovations and their evaluations.

-Coordinating: Includes integrating public and private efforts into effective collaborations.

Dr. Al Yee, Consultant for the W.K. Kellogg Foundation

• Many native Alaskan villages have difficulty accessing dental care for children and families, especially in isolated areas. Traditional approaches such as recruiting dentists from other areas and bringing in temporary volunteer dentists have not been successful.
• The Alaska Native Tribal Consortium learned about the dental therapist model used in New Zealand, and decided to send local students to be trained there. Currently, ten New Zealand-trained dental therapists are practicing in Alaska.
• Over four years ago, the W.K. Kellogg Foundation received a proposal from the Alaska Native Tribal Health Consortium, asking Kellogg to help them develop a U.S. based training program for dental therapists. With support from Kellogg and other foundations, the Consortium and the University of Washington developed a training program. The program is now in it’s fourth cohort of students, and by the time they finish there will be 22-24 new dental therapists to join the original ten.  Federal funding has been approved for this program, providing sustainability.
• The Kellogg foundation is in the process of evaluating the dental therapist program. The evaluation is looking at access, quality of care, prevention indicators, and office processes.  Results will be available later in the year.
• Previous evaluations of the dental therapist model in other countries have found the quality of care provided by dental therapists is equal to the quality of care provided by dentists, because dental therapists are much more limited in their scope of practice and perform the same procedures over and over.
• A dental therapist program is also being established in Minnesota.  Dental therapists in Minnesota will need at least four years of training, which is longer than the training period which has successfully worked in other areas.  This program is still a positive development, as it will raise the visibility of dental therapists and their potential.

Related Information

	Training New Dental Health Providers Full Report (1522K) [download]
	Training New Dental Health Providers Executive Summary (556K) [download]
	Training New Dental Health Providers Policy Brief (503K) [download]
	Dental Health Aide Therapist Brochure (1219K) [download]
	CDHP Summary of Dental Provisions in Health Reform - House and Senate (199K) [description]    [download]