| We must work together to ensure a constructive responsiveness to concerns about access to and availability of quality oral health care. |
In this month's letter, Dr. Rick Valachovic, Executive Director of the American Dental Education Association, reports on addressing access to dental care with new models for the allied dental workforce.
Learning Lessons and Lessons Learned from Alaska
You get there by small plane or boat or snowmobile, because there are no roads in the bush country of rural Alaska. Some 85,000 Alaska Natives live there in isolated communities of 300 to 400 people. Community isolation creates problems in the access and availability of health and oral health care.
In the best of times, public health dentists visit each community once or twice a year for a week or two. Occasionally a volunteer dentist shows up. The rate of dental caries in the communities is two and a half times the rate for the rest of the United States. One third of the kids have missed school because of dental pain.
The Alaska Native Tribal Health Consortium, in 2003, implemented a Dental Health Aide Therapist (DHAT) program, modeled after the New Zealand dental nurse program. The DHAT program is part of the Community Health Aide Program Certification Board established by the United States Congress in the early 1990s to create an integrated system of community-based primary health care providers, linked with the Alaska Native Medical Center in Anchorage, Alaska. Currently, there are more than 200 community-based, locally educated health care providers in the system. The DHAT program is designed to provide basic emergency, restorative, and preventive dental care for remote and isolated Alaska Native communities. Eight DHATs have completed the dental nurse program conducted at the University of Otago School of Dentistry in New Zealand and have been assigned to remote Alaska Native communities, functioning as part of the integrated system of community-based primary health care providers. Other Alaska Native DHAT students are also now participating in this program. More than 40 countries have implemented DHAT type programs to expand the capacity of their oral health care systems and improve the access to and availability of oral health care.
The Dental Health Aide Therapists are selected from indigenous residents of isolated Alaska Native communities. The first selected DHATs have been and are being educated in the New Zealand based program because there is no equivalent program in the United States. However, the W.K. Kellogg Foundation has recently granted the University of Washington $2.8 million to establish an education program so that future Alaska Native DHATs will not have to travel to New Zealand. Called the Alaska DentEX program, the program will be a joint curriculum under the auspices of both the University of Washington's physician assistant program, MEDEX Northwest, and the Community Health Aide Program Certification Board, which has the authority to grant federal certification to the Alaska Native DHATs.
I find a lot of food for thought in the DHAT story. Some salient points:
DHATs are only one of several new models for the allied dental workforce. The American Dental Association’s 2006 House of Delegates introduced the certified Community Dental Health Coordinator (CDHC). This category of individual would work under a dentist's supervision as an adjunct to the existing dental team to help improve access to oral health care for underserved communities and populations. Among other competencies, the CDHC would be prepared to develop and implement community-based oral health prevention and promotion services, provide individual preventive services, and temporize dental cavities for restoration by a dentist.
The ADA also has advanced the concept of the certified Oral Preventive Assistant, who would provide a range of preventive services for relatively uncomplicated patients. It is expected that the education programs for both of these new categories of allied dental professionals will be accredited by the Commission on Dental Accreditation.
The American Dental Hygienists' Association (ADHA) has proposed the Advanced Dental Hygiene Practitioner (ADHP), who would be educated in a master's level program to extend the delivery of primary dental care in partnership with practicing dentists. The model is focused on collaboration within the health care system, care coordination, and establishment of referral networks for patients. An ADHA task force is developing competencies for the advanced dental hygiene practitioner, such as periodontal therapies, administration of anesthetic agents, primary restorative services (currently being defined), and extractions.
I would not be surprised to see still more models proposed. Access to oral health care in this country encompasses many differing populations and settings, with varying situations and unique circumstances. No single solution will suffice.
As the Surgeon General's report on oral health in America told us seven years ago, there are "profound and consequential oral health disparities within the population," particularly among its diverse segments, "including racial and ethnic minorities, rural populations, individuals with disabilities, the homeless, immigrants, migrant workers, the very young, and the frail elderly." There now are more than 3,300 designated dental health profession shortage areas, in which 46.3 million people live. It is doubtful how many of these areas can financially support a dentist or attract a dentist by virtue of their infrastructure or location. But the issue remains. There are unserved and underserved communities and populations, as well as a growing desire in society to have equitable access to health care for all. The challenge to dentistry is not only to expand the capacity of the dental workforce; it must also improve its distribution and access to oral health care. Incidentally, we know that pediatricians in several states are receiving insurance reimbursements for treating their patients' teeth with fluoride varnishes. We are also hearing about school nurses applying the varnishes for children with limited access to care.
ADEA policy supports the extended employment of allied dental professionals as one way to increase the efficiency of oral health care delivery and the availability of oral health care. But it is not ADEA’s role to develop new practice workforce models. However, ADEA must anticipate and prepare for changes to the curriculum that new workforce models would require as states modified their practice acts to create a more flexible dental workforce. ADEA policy also endorses formal education of allied dental professionals through accredited academic programs. To ensure the competence of allied dental professionals, the academic dental education community must continue to support accredited programs. It must also continue to support the recognition of national certification of dental assistants and laboratory technicians and the licensure of dental hygienists. As the scopes of work for allied dental professionals are expanded and the levels of supervision are modified, the education community must ensure that the allied dental professionals have the functional, critical thinking, and decision-making skills essential to fulfill these new roles and responsibilities competently. Whatever name or position description they might have, whatever scope of practice and level of supervision, the evolving roles of allied dental professionals underscore the need for quality education and the recognition of professional competence through certification and licensure.
We held an "ADEA Summit on Allied Dental Education" last summer at which many of these issues related to the education of new workforce models were discussed. The ADEA Council of Allied Dental Program Directors will be deliberating the proceedings of that Summit when we meet at the ADEA Annual Session in New Orleans.
It may be relatively easy to envision an allied dental workforce model. The challenge is a design that has the support of all communities of interest, is flexible in structure and content, and can be accommodated and employed to meet the needs and circumstances of varying types of practices, settings, and population groups. Increasing technology and adding procedures, roles, and responsibilities of increasing complexity require formal education. A primary concern during this time of evolving roles, designs, and transition is that the education and credentialing requirements keep pace with the changing requirements of practice.
While the dental community continues to propose and debate new models for the allied dental workforce, I would like us to have a certain underlying sense of urgency about access to dental care. It is not an overstatement to say that such access can be a matter of life and death.
Those of us who read the Washington Post were reminded of that just last month. A 12-year-old boy with an abscessed tooth, part of an uninsured and sometimes homeless family whose Medicaid coverage had lapsed, went untreated. The boy's tooth infection spread to his brain. After two brain surgeries and six weeks in the hospital (and tens of thousands of dollars in medical expenses), the young boy died.
The dental and allied dental professions have a common goal: to improve the oral health status of all Americans. Working together, we must ensure a constructive responsiveness to concerns of access and availability of quality oral health care. Working together, we must increase the productivity and flexibility of the dental team. Working together, we must prepare dental and allied dental students to competently provide oral health services to diverse populations and communities. And working together, we can achieve change of our choosing, through design and transition.
