by Heidi Emmerling, RDH, PhD
The dental hygiene profession has earned another legislative victory. Minnesota Governor Tim Pawlenty signed Senate File 2083, a bill establishing the Advanced Dental Therapist, into law on May 13, 2009. Minnesota is the first state to pass legislation allowing a mid-level oral health provider (dentistry’s version of a nurse practitioner). The Advanced Dental Therapist (ADT) is Minnesota’s version of ADHA’s Advanced Dental Hygiene Practitioner (ADHP) model. According to Colleen Brickle, RDH, EdD, Interim Dean of Health Sciences at Normandale Community College, “This is one step toward health reform that addresses those who need oral health care the most.” Dental hygienists everywhere are not only celebrating Minnesota’s victory, but there are a number of states that hope to follow Minnesota’s lead.
The Advanced Dental Hygiene Practitioner (ADHP) is ADHA’s educational model for a mid-level oral health care provider. Individual states are moving toward this model but the language and official title will vary by state. For example, in Minnesota alone, the ADHP was termed Oral Health Practitioner before finally being referred to as Advanced Dental Therapist. Additionally, different states will use the ADHP model to suit the state’s individual needs regarding duties and coursework. Diann Bomkamp, RDH, BSDH, who was the ADHA president during the legislative session, explains that the idea of a mid-level practitioner is a licensed oral health care provider who has graduated from an accredited institution and will provide care through direct access. Bomkamp emphasizes that a mid-level practitioner is one who is midway between a dentist and a registered dental hygienist, similar to a nurse practitioner being midway between a physician and a registered nurse. In contrast, the American Dental Association’s proposal of the Community Dental Health Coordinator (CDHC) would be an expanded functions dental assistant, providing care only under direct dental supervision. The CDHC is a lower level provider, not the definition of a mid-level provider needed to provide direct care to underserved populations.
ADHA has been exploring the idea of an ADHP for a number of years, and the concept was approved at the 2004 ADHA House of Delegates. In 2008, ADHA established educational competencies for the ADHP. The ADHP would provide preventive and limited minimally invasive restorative and limited prescription services. The idea is that an ADHP would arrest infection, alleviate pain, and get patients into a pipeline to see a dentist.
Congress passed the Children’s Health Insurance Program (CHIP) reauthorization legislation in 2009, which includes dental benefits to children of low income homes and directed the Government Administrative Office (GAO) to study the feasibility and appropriateness of using qualified mid-level providers. President Obama signed the CHIP legislation in February. The addition of the GAO study was requested by ADHA and could be used to study the effectiveness of an ADHP-model provider. The concept is for ADHPs to focus their practice on care for underserved populations in their respective states and will administer educational, preventive, palliative, therapeutic, and restorative services. Providers educated under the ADHP model will build on their dental hygiene skill set by learning additional clinical skills (including restorative) and managerial skills. They will become competent in functioning within the health care system, advocating for the underserved patients, and effectively managing their clinic or practice.
Hygienists who might hope to run out and get rich in this type of practice setting are bound to be disappointed. The clientele include underserved and indigent people who do not otherwise have access to oral health care. Brickle advises those who may be interested in becoming an ADT: “Stay focused on the access and the underserved, not the provider. Maintain your integrity by remaining transparent and authentic. You will hold true to your passion, values, and beliefs.”
A dental mid-level provider is not a new concept. There is a precedent of other countries utilizing this model. Bomkamp states that there are 52 other countries that utilize dental mid-level practitioners, such as Australia, Great Britain, New Zealand, the United Kingdom, and Canada. According to Maria Perno Goldie, RDH, MS, president elect of International Federation of Dental Hygienists and owner of Seminars for Women’s Health, the ADHP model came from New Zealand’s Dental Nurse, a professional who provides emergency care for children in the bush. Alaska’s program is based on this idea of a Dental Nurse. Alaska’s government program allows Dental Health Aide Therapists (DHATs) to provide emergency restorative procedures such as pulp caps, extractions, and emergency care to Native American populations who are not otherwise able to receive care from private dental practices.
Goldie said, “Dental hygiene is one of the fastest growing occupations in the country, and is surpassing the growth of the dental profession. In order to promote total health, the public needs comprehensive, preventive oral health care. In addition to dentists, whose numbers are diminishing, dental hygienists are the health care professionals with the knowledge and skills best suited to meet the oral health care needs of the future. Diseases like caries can be prevented and/or managed, and prevention saves valuable health care dollars. Dental hygienists are licensed health care professionals who support the health and well-being of the public through oral health promotion, education, prevention, and therapeutic services.”
While speaking for herself, not the IFDH, Goldie continues, “I personally support the creation of the ADHP. This will provide an additional point of entry into the oral health care system for those currently deprived of care, such as children, the working poor, and the elderly, and will be similar to the nurse practitioner model. Dental hygienists should be integrated more fully into the health care workforce to provide a broader array of services to meet the changing needs of the public.”
According to ADHA’s “The Advanced Dental Hygiene Practitioner (ADHP) and Access to Oral Health Care,” millions of Americans are not currently able to access oral health care services they need: “Tooth decay, while almost completely preventable, is the nation’s most common chronic disease among children — five times more common than asthma.” ADHA reports show that an estimated 6,000 dentists retire annually while only 4,000 dental school graduates enter the workforce each year. This is compounded by the fact that 130 million Americans lack dental insurance and over 2,000 “dental health professional shortage areas” have been identified by the Health Resources and Services Administration.
ADHA claims that mid-level health care providers have proven effective in medical fields. Since a recent survey by the National Association of Community Health Centers has found that restorative and preventive services were the top needed services, ADHPs could fill this void.
Cathy Draper, ADHA District XI Trustee, writes, “Dental hygiene needs to partner with other health care providers to meet the needs of children as well as adults who cannot get care. The fact that dental decay is the number one infectious disease among California’s children should be enough to position dental hygiene on the forefront of disease prevention efforts. If we don’t align ourselves with medicine, we will find our role being outsourced to nurses and medical assistants. We have a workforce of highly educated hygienists and we are often underutilized and tied to the private practice delivery model of care for compensation.”
ADHA’s vision of the ADHP is that the licensee will be a registered dental hygienist educated at the master’s degree level (similar to other mid-level practitioners). The ADHP will have additional education in health promotion, disease prevention, provision of primary care, case and practice management, quality assurance, and ethics. ADHPs will provide care in settings such as schools, clinics, and long-term care facilities. The ADHP will be more than a clinician and will work with a collaborative management agreement with a dentist. See Tables 1 and 2 provided by the PEW report for comparisons of the various proposed dental health care providers.
According to ADHA reports, 29 states allow direct access, meaning that the dental hygienist can initiate treatment based on his or her assessment of patients’ needs without the specific authorization of a dentist, can treat the patient without the presence of a dentist, and can maintain a provider-patient relationship (see map). Bomkamp asserts that in states that already have direct access, moving toward an ADHP is the next logical transition. The following are states that have, or are moving toward, the ADHP model:
• Minnesota — Minnesota has become the first state to pass legislation to allow a mid-level oral health provider, termed an Advanced Dental Therapist. Hygienists who have met admission requirements (including a bachelor’s degree and two years of private practice experience) will be entering the master’s program offered by Metropolitan State University in St. Paul. The first class of eight will graduate in 2011. Part of the curriculum will include collaborative and advanced dental hygiene practice, restorative functions, and management of oral health delivery. For more information, contact Colleen Brickle, RDH, EdD, interim dean of health sciences, Normandale Community College at [email protected].
• Connecticut — Several years ago, the Connecticut House and Senate passed bipartisan oral health legislation that was eventually signed into law. The law also received support from state associations representing dentists, dental hygienists, and dental assistants. The legislation sought to increase access to oral health care in Connecticut by allowing dental hygienists to administer local anesthesia, amending the definition of dentistry, writing the statutes for mandatory education for dentists, and enabling dentists to complete one year of postgraduate dental training in lieu of a practical exam. The law also mandated the development of an expanded function dental assistant and a mid-level dental hygiene professional.
• New Hampshire — Earlier this year, the New Hampshire General Court passed legislation establishing a task force to study access to dental care. The bill was requested by the study committee on advanced dental hygiene practitioners and access to oral health care established in 2008. The 15-member task force will be represented by various organizations, including the New Hampshire Dental Hygienists’ Association and New Hampshire Dental Society. Input will also be provided by representation from the New Hampshire Community College System, Delta Dental Plan of New Hampshire, New Hampshire Health Care Association, New Hampshire School Nurses Association, Bi-State Primary Care Association, New Hampshire Minority Health Coalition, New Hampshire Public Health Association, New Hampshire Medical Society, the House of Representatives, the Senate, and the Department of Health and Human Services. The following is a link to the full text of the bill, http://www.gencourt.state.nh.us/legislation/2009/HB0301.html.
• Idaho — According to Linda Boyd, RDH, RD, EdD, associate professor and director of graduate studies in dental hygiene at Idaho State University, there is nothing in the works legislatively to pilot an ADHP program. The ISU MSDH program has incorporated most of the ADHP competencies in their program for the Rural and Community Health Emphasis with the exception of some of the restorative/extraction/pulp cap competencies in Domain I. Idaho currently had an extended access dental hygiene licensure, which allows placing and finishing restorations in alternative settings. But the practice act is not as broad as that of Oregon and Washington.
Dentists recently revisited expanding this function to all settings; however, the current economic climate has affected support for putting forth this legislation. Boyd has also voiced some concern about offering an ADHP until there is some sort of plan for credentialing and board exams stating it may be seen as unethical to offer a program if the places ADHPs can practice are too severely restricted to make it possible to conduct business. There is also the issue of reimbursement such as Medicaid and insurance providers. Furthermore, the cost of conducting ADHP programs could be prohibitive, especially since state funding has dwindled in most every state and new programs in Idaho will have to be self-supporting, meaning large program fees would be necessary. Since an ADHP would not be likely to make a significant salary, Boyd suggests investigating loan forgiveness programs being made to an ADHP before it would be feasible for RDHs to complete a program.
• Washington — Rebecca Stolberg, RDH, MS, who is the department chair and an associate professor of dental hygiene at Eastern Washington University, indicates there is no legislative action yet. The university is hoping to pilot an ADHP project on a Native American reservation where they will not be subject to state laws. The curriculum is approved, but there are no funds to carry out the plans.
Stolberg said, “Eastern Washington University’s Department of Dental Hygiene is committed to addressing the silent epidemic of oral disease in America as identified in the 2000 Surgeon General’s report, Oral Health in America. It can achieve this through the establishment of a master’s level program to educate, train, and pilot test the advanced dental hygiene practitioner model designed to serve as the oral health equivalent of the nurse practitioner. EWU is also proud to work with the Kalispel Tribe in the training of the ADHP. The ADHP will work in collaboration with all members of the dental and health care teams to facilitate greater access to oral health care for the Native American populations currently unable to obtain service, significantly impacting the quality of life of Washingtonians.”
• Michigan — In February, the Michigan Dental Association announced it withdrew as a pilot site for the ADA proposed community dental health coordinator program due to the closure of a federally qualified health center dental clinic in Detroit where the study was to take place. The program would have established pilot sites to perform preventive services in conjunction with a dentist. The ADA in 2006 proposed its version of a mid-level practitioner that appears to require less formal education than that of a hygienist, and dental supervision.
“This is a great time to be a dental hygienist. Registered dental hygienists are moving toward legally being able to practice to the full extent of their education and more,” says Bomkamp. She reminds us that now more than ever there is a need for direct access to preventive care. With this recession, more Americans will be without oral health insurance. “Be proud of who you are and be open to the idea that there are opportunities beyond traditional private practice jobs, and know that you, as a dental hygienist, are a valued health professional making a difference in improving the oral health care of the public!”
About the Author
Heidi Emmerling, RDH, PhD, is a professor of dental hygiene at Sacramento City College. A former columnist and consulting editor for RDH Magazine, Dr. Emmerling is also owner of Writing Cures, a writing and editing service. Her Web site is www.writingcures.com.
The broader view
The PEW Charitable Trusts released an Issue Brief in May 2009 titled, “Help Wanted: A Policy Maker’s Guide to New Dental Providers.” The PEW Center on the States strives to provide “nonpartisan, pragmatic solutions for pressing problems affecting Americans.” According to PEW, the Issue Brief is “intended to provide policy makers with objective information and the tools they need as they consider developing new providers.” The Issue Brief examined dental therapists, the ADA’s community dental health coordinator, and the ADHA’s advanced dental hygiene practitioner, weighing the pros and cons of all the solutions being proposed.
The document can be read in its entirety at http://www.pewcenteronthestates.org.
On the downside, PEW comments about the ADHP included:
- “Trained to perform restorative procedures under general supervision, which is controversial among some members of organized dentisty.”
- “Training may be excessive and expensive, given the limited expansions gained in scope of practice.”
- “It may be difficult to persuade dentists to collaborate with and accept referrals for ADHPs.”
On the plus side, the PEW report noted:
- “The public is familiar with dental hygienists and might feel comfortable receving care from them.”
- “A higher education level may help gain the confidence of dentists that they (ADHPs) can perform restorative functions.”
- “ADHPs could perform case management for underserved patients and help staff safety net clinics, which lack sufficient dentists.”