In a national report entitled Oral Health in America, the Surgeon General reviewed the profound disparities among specific population groups in oral health status and access to dental care.² Dental disease is a chronic problem among low-income populations.³ Federal agencies and state governments are addressing these gaps in access to oral health care through legislation and policy development. Examples of some actions created through these processes are shown in the Guiding Principles box.^3,4 At the 2009 Access to Dental Care Summit, the American Dental Association (ADA) listed expansion and distribution of a well trained workforce with nationwide evaluation, standards, and regulations as a long-term strategy in improving access to dental care for underserved populations. Under this heading, the mid-level provider in dentistry was discussed and models are being developed and reviewed.⁵ Summits and conferences on access such as this and the follow-up strategies and action plans will very likely increase the demand for dental hygienists working in community oral health practice.

Alternative Practice Settings

Public health settings are categorized as alternative practice settings (i.e., providing oral hygiene services outside the private office in a “nontraditional” setting). Examples of the setting might be a community clinic, a mobile van, a school, a hospital, or a nursing home (Figures 2-1 and 2-2). The delivery of dental services offered in private practice does not reflect the need for services for those without means or without the capability of accessing care. In an alternative setting, dental care can be brought to people in need. Dental hygienists can provide preventive services in these settings, reaching large numbers of people who might not otherwise receive care.

Figure 2-1 A dental hygienist provides oral hygiene care to a resident of a nursing home.

Figure 2-2 A, A mobile dental van is used as an alternative practice setting. B, Inside treatment area of a mobile dental van.

Preventive services, or primary prevention, are more effective, less costly, and involve less technology than secondary or tertiary prevention (Box 2-1). Methods such as fluoride varnish or sealant programs, nutritional counseling, dental health education to community groups, and oral hygiene services and instruction are at the primary level. Often primary prevention strategies do not require a dentist.⁶ Therefore, with less restrictive supervision, the dental hygienist can perform functions at this level and reach underserved populations.

BOX 2-1 Levels of Prevention

• Primary prevention prevents the disease before it occurs. This level includes health education, disease prevention, and health protection. (Dental prophylaxis, sealants, and water fluoridation are examples.)

• Secondary prevention eliminates or reduces diseases in the early stages. (Restorations such as amalgams or composites are examples. This level requires more technology and is more costly than primary prevention.)

• Tertiary prevention limits disability from disease in later stages and requires rehabilitation and surgical procedures. (Dentures, implants, and bridge work are examples. This level is most costly and requires highly trained professionals to treat the disease.)

Public Health Supervision

Regulatory Changes

Because of the need for services in places such as schools, nursing homes, and migrant health centers, dental hygienists are initiating oral health programs in these alternative settings. They are also filling positions beyond those connected with public health agencies. To create such positions, dental hygiene regulatory changes are being discussed and are under way throughout the United States. As a solution to the access problem, many states have changed restrictive dental practice acts that prevent the dental hygienist from practicing without the supervision of a dentist and that prevent dental hygienists from receiving direct reimbursement form third-party payers such as Medicaid or private dental insurers. To view which states allow direct access to care without the need for a dentist to examine or authorize the dental hygiene services see the map in Figure 2-3. To determine supervision levels for specific dental hygiene services by state, view the website www.adha.org/governmental_affairs/practice_issues.htm. Examples of changes in state regulations around the scope of practice for dental hygienists include New Mexico, where dental hygienists are allowed to practice in certain settings without the oversight of a dentist through a collaborative practice agreement with a dentist or group of consulting dentists, and Washington state, where dental hygienists may practice unsupervised in hospitals, nursing homes, home health agencies, group homes, state institutions, and public health facilities provided the hygienists refers to the dentist for treatment and meets a requirement of clinical experience. Colorado is one of the states that allows dental hygienists to practice without supervision in all settings and allows licensed dental hygienists to own a dental hygiene practice. In a 2001 ADHA Access to Care Position Paper, the ADHA confirmed its position that dental hygienists who are graduates from an accredited dental hygiene program can be fully used in all public and private practice settings to deliver preventive and therapeutic oral health care safely and effectively. “Licensed dental hygienists, by virtue of their comprehensive education and clinical preparation, are well prepared to deliver preventive oral health care services to the public, safely and effectively, independent of dental supervision.”⁷

In determining the necessity of regulatory changes, one must consider many factors such as the following:

1. The ratio of dentists to people

2. The number of dentists and dental hygienists in the state

3. The number of low-income adults and children who need dental care

These factors contribute to defining dental health professional shortage areas. Statistics compiled from Synopsis of State and Territorial Dental Health Programs provide information necessary in determining the available workforce of dental professionals and of community health departments and clinics.⁸ The workforce numbers, compared with population size, are useful in determining professional shortage areas and the need for community oral health programs. Inadequate access to health care caused by professional shortages and geographic and financial barriers prevents people from attaining improved health status and improved quality of life. The dental profession, in realizing the need for reaching these underserved populations, is initiating preventive programs conducted by dental hygienists in many states.

It is interesting that some dental hygienists, initially volunteers, have found creative ways to be reimbursed for working in alternative settings. Writing grants, seeking school board funds, collecting Medicaid payments through an accepted provider, or contracting with a facility in states that allow it are a few of the innovative reimbursement plans currently being used. With less restrictive dental hygiene supervision and an increased number of dental hygienists seeking public health work, funding changes in the way of direct payment may be further explored in the future.

Mid-Level Provider

In the medical field, a mid-level provider is the term for a clinical medical professional who provides patient care under the supervision of a physician. Examples of mid-level providers include the nurse practitioner and the physician assistant. These professionals have advanced medical training but not on the level of the physician. It has been reported that physician assistants and nurse practitioners provide a majority of physician services for a much lower cost than the physician, thereby addressing the unmet need for medical services by providing quality care to more people at a lower cost. This concept applied to dentistry also addresses the problems of access to oral health care for underserved populations. Various models of workforce delivery are being developed to serve the populations who cannot easily access dental services as the result of problems of geographic location, poor financial resources, no dental insurance, and a lack of understanding about disease prevention measures. A shortage of dentists to meet the needs of the population and low dentist participation in Medicaid programs also affects access. The burden of oral disease is spread unevenly throughout the population (see Chapter 6), with minority children from low income families and the elderly population being most vulnerable. Models of delivery are provided in the next section, including the advanced dental hygiene practitioner (ADHP) defined in Chapter 1. Dental hygienists should develop an understanding of the necessity for new provider types in the existing health care system.

Dental Therapist

More than 50 countries worldwide have developed dental therapist programs to meet the dental needs of the people in their countries.⁹ In 1921, a dental therapist program was first introduced in New Zealand. At that time, the dental therapist was called the dental nurse.

Services provided by the dental therapist vary by country, although most include basic restorative procedures, emergency treatment and preventive measures. The dental therapist in Alaska, called the dental health aide therapist (DHAT), completes 2 years of training and works under the general supervision of a dentist to provide preventive procedures, emergency care, and basic restorative procedures. DHATs provide services to the most isolated rural regions of Alaska in which little to no care was previously provided.

Community Dental Health Coordinator

In 2006, the ADA proposed the development of the community dental health coordinator (CDHC) to support the existing dental workforce in reaching out to underserved communities.⁹ The CDHC works under the supervision of the dentist to promote oral health for communities and to assist patients in navigating through the health care system to establish a dental home. They would complete a 12-month training program and 6-month internship.

Advanced Dental Hygiene Practitioner

In June 2004, the ADHA House of Delegates, addressing the problem of access to health care, approved the creation of the ADHP credential. As stated in Chapter 1, this credential allows dental hygienists to provide diagnostic, preventive, restorative, and therapeutic services directly to the public.⁹ Dental hygienists who receive the ADHP credential have graduated from an accredited dental hygiene program and also have completed an ADHA-approved advanced educational curriculum. This credential is designed to improve and enhance the oral health care delivery system. Because dental hygienists with the ADHP credential do not have to be supervised by a dentist, the door will open for them to work in school systems and nursing homes, as well as with underserved populations throughout the country.

Minnesota Dental Therapist and Advanced Dental Therapist ¹⁰

The effort to establish a mid-level oral health provider went through a legislative process in Minnesota in 2008–2009. The result was the establishment of dental therapist (DT) and advanced dental therapist (ADT) programs. ADT trained at the University of Minnesota can provide basic preventive services, limited restorative services, extractions of primary teeth, and have limited prescriptive authority. A dentist is required to be present for the more complicated procedures, such as restorative procedures and extractions, but not required to be on site for preventive services. In the fall of 2009, the first dental hygienists entered a Master’s program at Metropolitan State University based on the ADHP competencies developed by the ADHA. Graduation from this program provides the dental hygienist with a master’s degree and the ADT title. The ADT will evaluate, assess, and plan treatment; perform nonsurgical extractions of permanent teeth; and administer all services of a DT without the requirement of onsite supervision. An ADT can also work in a collaborative management agreement with the dentist. The ADHA website (www.adha.org/governmental_affairs) posts the most current state legislative news on the ADHP and the DT and ADT programs, as well as other related legislative processes.

Table 2-1 describes the oral health current and proposed providers. See Additional Resources for more information on the oral health care workforce.

Table 2-1

Oral Health Care Workforce—Current and Proposed Providers

	Advanced Dental Hygiene Practitioner (ADHP)	Alaskan Dental Health Aide Therapist (DHAT)	Minnesota Dental Therapist/Advanced Dental Therapist (DT/ADT)	Community Dental Health Coordinator (CDHC)
Developed by	American Dental Hygienists’ Association www.adha.org/adhp	Alaska Native Tribal Health Consortium (ANTHC) – Community Health Aide Program www.anthc.org	Minnesota State Statute and Rules www.dentalboard.state.mn.us	American Dental Association www.ada.org
Stage of Development	ADHP educational competencies were finalized in 2008. The first educational program based on ADHP competencies began in Fall 2009.	DHAT practice began in Alaska in 2004. The first graduates from the US-based DENTEX program began practice in 2008.	Educational programs for the DT (at the University of Minnesota School of Dentistry) and ADT (at Metropolitan State University) began in Fall 2009.	Curriculum complete and initial educational pilot program began in Winter 2009.
Education/Training	Master’s level education at accredited institution; open to individuals currently licensed as dental hygienists who have a bachelor’s degree	24 month program administered by ANTHC in partnership with the University of Washington DENTEX program	DT—minimum Baccalaureate degree ADT—Master’s degree	Completion of 18 months of training.
Regulation/Licensure	Providers are already state licensed dental hygienists. ADHP is envisioned to be state licensed and regulated.	Providers are certified and regulated by Indian Health Service’s Community Health Aide Program	Providers required to hold state license; can be dually licensed as a dental hygienist and administer dental hygiene scope.	Providers envisioned to be certificated; no formal state licensure
Proposed Setting	Community and public health settings, possibly private practice	Remote Alaskan villages	Settings that serve low-income and underserved patients, or are located in designated dental health professional shortage areas.	Community and public health settings
Proposed Supervision	Collaborative arrangement envisioned with strong communication and referral networks; presence of a dentist not required; use of teledentistry.	Remote/general supervision of a dentist; presence of a dentist not required; use of teledentistry	DT—General or indirect supervision depending on service ADT—Collaborative management agreement with dentist, presence of a dentist not required for most services	On site or general supervision, depending on service
Preventive Scope	— Oral health and nutrition education — Full range of dental hygiene preventive services, including complete prophylaxis, sealant placement, fluoride treatments, caries risk assessment, oral cancer screenings — Expose radiographs — Advanced disease prevention and management therapies (e.g. chemotherapeutics)