ALTERNATIVE DENTAL PROVIDER MODELS
Background
An alternative dental provider model is a model of oral healthcare delivery that utilizes a non-dentist, acting outside the direct supervision of a non-dentist, as a primary care provider of dental care.
While various alternative dental provider models have been proposed in different states, all models promote the position that the creation and incorporation of new, non-dentist dental providers within state rules, regulations or statutes, is essential to improving access to oral health and improving the oral health status of Americans.
Proponents of Alternative Dental Provider Models
Three sectors of the dental marketplace are driving the movement for alternative dental providers: public health, dental educators, and mid-level professional organizations.
These segments also promote faulty presumptions regarding the challenges to improving oral health and the role that new non-dental providers will play. These presumptions are discussed below.
Proponents of alternative dental provider models who have voiced support for alternate dental provider models and may advocate for these models in your state include the Pew Center on the States, W.K. Kellogg Foundation, the American Association of Public Health Dentistry
(AAPHD), the American Dental Education Association (ADEA) and the Institute of Medicine (IOM).
Alternative Dental Provider Models
The two leading alternative dental provider models that are likely to be proposed in your state are the dental therapist and the Advanced Dental Hygiene Practitioner (ADHP). Additionally, the American Dental Association (ADA) has presented an alternative to dental therapists or the ADHP in the Community Dental Health Coordinator (CDHC).
Dental Therapists
Dental therapists (Dental Health Aide Therapist (DHAT) and variations thereof) are favored by the Pew Center on the States and the W.K. Kellogg Foundation, and are at the forefront of the race for new non-dentist providers.
Minnesota’s dental therapist models provide the blueprint for most alternative proposals in the contiguous states.
In 2009, Minnesota passed legislation creating two types of providers: the dental therapist who works within a practice under the indirect or direct supervision of a dentist, and the advanced (master’s level) dental therapist who works remotely under the general supervision of a dentist. Both may perform irreversible dental procedures.
It should be noted that Minnesota is the only state in which midlevel providers can practice independently upon the general population, rather than being limited to treating Native American populations only. The Minnesota practitioners were modeled after New Zealand, Great Britain, and Canadian midlevel providers.
ADHP
The ADHP, created by the American Dental Hygienist Association (ADHA), may diagnose and treat patients, including the restoration and extraction of teeth, under general or no supervision of a dentist.
The Pew Center on the States has cast some doubt upon the ADHP. In its 2009 report, Help Wanted: A Policy Maker’s Guide to New Dental Providers (Pew Report), Pew voiced concern that independent hygienists may not be able to afford to practice in underserved areas. In another publication, Pew commented that the requirement that the ADHP complete a two-year master’s program after completing a hygiene program constituted a disincentive in comparison to many dental therapist programs which only require two years of training without completion of a prior degree.
CDHC
The ADA’s CDHC primarily provides education and prevention under general, indirect or direct supervision, but leaves the door ajar for some treatment, including scaling and excavation, under indirect or direct supervision. The CDHC model that allows for them to provide irreversible procedures has failed to gain significant traction and is unlikely to be proposed in your state. However, the model in which the CDHC practitioner acts only as a "patient navigator" is still being proposed in several states. The AGD has been a strong proponent of the patient navigator concept.
Faulty Presumptions Presented by Proponents of Alternative Models
A fundamental presumption relied upon by advocates of new providers is that there will be a shortage of dentists.
The American Dental Education Association (ADEA) presented this presumption as fact in 2007; as support, ADEA cited Dr. Jackson Brown’s ADA article, Selling your practice at
retirement: are there problems ahead (2000), to assert that, in the coming years, only one dentist will graduate for every two dentists who retire.
However, with numerous new dental schools opening, and many dentists with empty chairs, the truth is that there is not a shortage of dentists but only an uneven distribution of dentists.
Pew and other proponents also assert that dentists simply do not want to practice in underserved areas or accept Medicaid patients. Pew has repeatedly gone on the record as saying that the rate of dentists accepting Medicaid is lower than that of physicians. However, Pew fails to make any mention of the differences in Medicaid coverage and reimbursement rates between medicine and dentistry. While W.K. Kellogg echoes Pew’s characterization of dentist unwillingness as a challenge, ADEA has not yet broached this subject.
A third presumption shared by the proponents of midlevel providers is that an area can be deemed to be underserved solely by examining the dentist-to-patient population ratio, without consideration of practice capacity. Dentist-to-patient ratios used by proponents are outdated and fail to consider technological advances and the increase in capacity produced by the use of existing midlevel providers – dental assistants, hygienists, and expanded function dental assistants (EFDAs) – within the dental team under the supervision of a dentist.
Additionally, proponents of alternative models have promoted the following faulty presumptions, which you may see argued in your state:
1. The new providers will practice in underserved areas.
2. The new providers are not truly independent practitioners, but collaborative practitioners. 3. The new providers are still a part of the dental team, and will preserve and expand the
prevention aspect.
4. The new providers fit into the dental home concept by bringing the dental home to where the underserved reside.
5. The new provider models provide safe care (Note: although Kellogg alleged that the Alaska DHAT had proven to be safe, the Kellogg study was very limited in scope and did not prove that the new provider models were in fact safe)
6. The new provider models have successfully improved oral health status in other countries and will therefore work in the United States.
Rebutting the Myth of the Alternative Provider Solution
In 2008, the AGD adopted its White Paper on Access to and Utilization of Oral Health Care Services (White Paper), taking a position against the advances of ‘independent midlevel providers’ as obstacles that detract from the funding and effort to further more than 30 proven solutions.
Since then, arguments presented in various states by proponents of midlevel provider models have grown increasingly more sophisticated. Notably, these entities do not always claim a move toward independent practice nor do they claim to offer an alternative to the traditional dental team model.
Independence from dentists has been rephrased as an opportunity for expanded collaborations with dentists. Proponents tout the Minnesota therapist models that market advanced dental therapists as off-site practitioners who work in collaboration with dentists, not as independent practitioners.
Said Suzanne Beatty, DDS, a dentist and curriculum coordinator for the advanced dental therapist master’s program at Metropolitan State University in Minnesota, “There are so many people who are underserved. This [the advanced dental therapist] would free up the dentist to do more complex procedures. It’s not an independent practice. It’s part of a collaboration.”
Therefore, refocus your response on detailing the nature of specific procedures that are likely to trigger the need for a dentist to be readily available on-site (direct supervision), rather than to take a defense approach that seeks to dismiss independent practice.
The proponents’ re-characterizations compel the AGD and other organizations that stand for the preservation of the oral health of the public to concentrate on the most fundamental elements that generate concern about patient health and safety. Simply echoing or restating terms such as “independent midlevel provider” may not be effective much longer.
Instead, explain that the minimal level of ‘collaboration’ that is necessary to ensure the safety of the patient is the direct supervision by a licensed dentist.
Further, rather than offering an alternative model of oral healthcare delivery, proponents of the new practitioners claim an enhancement of the “dental team concept.” Advances in technology have also allowed these entities to claim that teledentistry, historically a term indicating
consultation between a generalist and specialist, for example, allows for an expansion of supervision.
Proponents of new providers argue that the dental team concept is enriched by the addition of a non-dentist who can remotely collaborate with the dentist without his or her direct supervision. It may be beneficial to focus your response on the fact that expansion of the dental team to include non-dentists who treat patients without the direct supervision of a dentist
undermines the most fundamental tenet of the dental team concept – patient safety through the supervision of a licensed and educated dentist - which has proven to be the beacon of success of the prevention model.
The traditional dental team draws analogies to an auto racing pit crew. The cohesive and
concurrent acts of practitioners of different levels of education and expertise, under the direction of a captain trained for that purpose, create the symbiosis needed to ensure the integrity of each patient’s health.
Intentionally splintering the dental home constitutes poor parenting of the oral health of the public and is mere steps from possible neglect.
The divided dental team concept proposed by new provider proponents creates too many opportunities for lapses in patient diagnosis, planning and treatment: the insufficient training of the first point of contact (a non-dentist without direct supervision) will create a burden on the next point of contact and the entire system, all the way down the line, from the general dentist who must correct the midlevel provider’s errors stemming from a lack of training, all the way to the specialist to whom the general dentist may refer when the patient’s disease state is especially critical or advanced, with each level adding to the cost of care.
With a midlevel practitioner passing the baton to the dentist, the midlevel providers’ version of a dental team functions as a relay team rather than a pit crew, which is not in the best interest of the patient.
Further, it’s notable that none of the guidelines, articles and other documents produced by proponents of alternative providers appears to challenge what the Commission on Dental
Accreditation (CODA) has set out as minimal competencies for graduating practitioners who can competently practice dentistry.
Failure to meet CODA’s minimum educational standards for a dentist renders any alternative dental provider model unsafe to provide those service currently relegated to dentists without a dentist’s direct supervision.
We should also note that proponents of midlevel providers have historically found dentists who will testify that they would have no reservation about having lesser-educated non-dentists
perform dental treatment on themselves and their families. However, those dentists, who understand the importance of regular checkups and are not likely to have major oral health issues, are probably not a good example of the kind of patients that midlevel providers would be targeted to treat—underserved populations who may not have been to a dentist for several years and may have underlying oral health problems.
Alternative provider models target those patients in rural communities and of low socio-economic status. These populations exhibit the greatest rate of medical complications and therefore need healthcare providers with the greatest of expertise.
Last but not least, proponents of alternative providers have not disagreed with our focus on oral health literacy and patient utilization. Studies to develop benchmarks and data on current and desired patient utilization, both in private and public markets, may place the AGD in a
significantly stronger position to promote its long-standing and proven solutions over these new provider proposals that may actually jeopardize patients’ wellbeing.
There has been no research that has shown that dental therapists in Minnesota are practicing in rural areas, as predicted by the legislation. In fact, in a December 2013 webinar by the National Conference of State Legislatures and Pew, Minnesota state representative Kim Norton
commented that the new dental therapists are not moving to the rural areas of the state, as had been predicted when the legislation was enacted in 2009. Additionally, a 2005 ADA study1 revealed that, when provided the opportunity to practice in underserved areas without the physical presence of dentists, alternative non-dentist providers nonetheless prefer wealthier neighborhoods, driven by the inability to cover overhead costs in other areas.
Remind your state of the proven solutions presented in the AGD’s White Paper, and the wisdom in funding solutions that work rather than experiments that may not work.
1 Brown, L.J., House, D.R., & Nash, K.D. The Economic Aspects of Private Unsupervised Hygiene Practice and Its
