THERAPISTS & ADVOCACY
Presented By
Carter Brown, DMD, FAGD, FACD, FICD, FPFA
Vice President, Academy of General Dentistry
Why the Interest?
What the Policy Makers See
82 million with limited care
The Governmental Efforts
& Safety Nets
• Populations underutilizing available services
• Up to a third of the population do not get care from the Private
Market
• Depends on a set of uncoordinated programs and policies:
– Systems: FQHCs, VA, HIS
– Policies: Medicaid, CHIP
– Other: Volunteer Pro Bono Care, Free Clinics, Dental Schools,
Corporate Medicaid practices, other community and public health
programs
• Limited capacity and overall has not addressed the underutilization
in substantive way
Policy Makers Are Looking
at the Wrong Things
They Don’t Understand, You
Can Never Get 100%
DENTAL VISITS IN THE LAST YEAR
Source: National Healthcare Disparities Report 2005, Department of DHHS
1996 MEPS
< FPL
100 < 200%
200 < 400%
400% +
Total
2004 MEPS
< FPL
100 < 200%
200 < 400%
400% +
Total
Visit
4,320,000
4,650,000
12,750,000
10,170,000
31,890,000
No visit
9,210,000
10,250,000
10,530,000
5,540,000
35,530,000
Total
13,530,000
14,900,000
23,280,000
15,710,000
67,420,000
4,410,000
5,700,000
11,860,000
13,620,000
35,590,000
7,910,000
9,120,000
10,990,000
6,140,000
34,160,000
12,320,000
14,820,000
22,850,000
19,760,000
69,750,000
Source: IADR March 2007, Medical Expenditure Panel Survey
DHHS Responses:
• OIG Report on EPSDT Dental Service Utilization (1996) –
< 1-in-5 getting any dental services
• HCFA/HRSA Oral Health Initiative (1990s)
• Surgeon General’s Conference, Workshop and Report on Oral
Health (1999–2000)
• NGA Oral Health Policy Academies (2000–2001)
Congressional Responses:
• GAO Reports, Midlevel trials proposed
• Legislation
• Hearings (Deamonte Driver)
WHO
• Alaska ANTHC
• Minnesota Legislature, University of Minnesota, Metropolitan
State Normandale
• Renewed CMS attention/new administration
• Prominent foundation involvement:
– PEW
– Kellogg
• HRSA / CA Health Foundation-funded Institute of Medicine
(IOM) studies
• Public Health Dentists, Small core group
• ADEA, interest expressed in the model
Access
No set definition, clouds the debate
• Access: AGD Making Dentistry Available
– Patient Education and Responsibility
– Affordability – Sufficient Medicaid/insurance coverage to
make healthcare affordable for patient
– Availability – Incentives/financial support to enable dentists to
serve in underserved/rural areas
History on Midlevels
• In 1917, ‘Dental Dressers’ were established in some
counties in England:
– The first dental therapists
– American hygienist with the addition of ‘filling those cavities
without pulpal involvement’ and ‘the extraction of ‘temporary
teeth in school clinics’
– Desperate shortage of school service dental officers
– First World War
– The Dental Act of 1956 there were enough dentists to work in
the service and the dresser’s duties were reduced to that of a
hygienist
History on Midlevels
• In 1920, New Zealand established a School Dental Service:
– Called Dental Nurses
– Were the first contact point for rural patients with an onward
referral to a dentist if necessary
History on Midlevels
• Back to the UK:
– In 1950, there was once again a desperate shortage of
dentists in the school services
– Following visits to New Zealand the Dentist Act of 1956 was
changed to allow the training of Dental Auxiliaries – however,
Dental Auxiliaries would be referred patients by the Dentist
History on Midlevels
• In 2002, British Association of Dental Therapists caused the
Dental Act to be amended
• Dental Therapists were allowed to work in general practice and
along with that the SOP finally changed and ‘extended duties’
were added
• In every country that has therapists, these associations
become a political force and SOP continually expand
Added Procedures in England
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Scaling and polishing
Apply materials to teeth such as fluoride and fissure sealants
Take dental radiographs
Provide dental health education on a one to one basis or in a group situation
Routine restorations in both deciduous and permanent teeth, on adults and
children, from Class 1-V cavity preparations
Can use all materials except pre cast or pinned placements
Treats adults as well as children
Extract deciduous teeth under local infiltration analgesia
Pulp therapy treatment of deciduous teeth
Placement of pre formed crowns on deciduous teeth
Administration of Inferior Dental Nerve Block analgesia
Emergency temporary replacement of crowns and fillings
Take impressions
Treat patients under conscious sedation provided the dentist remains in the
surgery throughout the treatment
Where Are They?
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Alaska
Australia
New Zealand
Canada
Great Britain
Various other smaller projects
Alaska DHAT
Per the DHAT Website
• DHAT:
– 10 practicing DHATs trained in NZ
– Since 2003, only one has stopped practice in AK
– First training center in the US, partnership with UW
• MEDEX
– 9 graduates, 13 in training
– Predict: 32 DHATs in AK by 2012
– PDHA -11 cert (22)
– EFDHA -12 cert (23)
– DHAH - 0 cert
– Role models for younger
Alaska DHAT
• Alaska DHAT training
program information:
– First year: 40 weeks
– Second year: 39 weeks
– Total: 79 weeks (3,160 hours)
• Curriculum breakdown,
first year:
– Biological Science: 30%
– Social Science: 10%
– Pre-Clinic: 40% (623 hours)
– Clinic: 20% (316 hours)
• Curriculum breakdown,
second year:
– Biological Science: 15%
– Social Science: 7%
– Pre-Clinic: 0%
– Clinic: 78% (1,215 hours)
• Curriculum breakdown,
two years combined:
– Biological Science: 22.5%
– Social Science: 8.5%
– Pre-Clinic: 20% (632 hours)
– Clinic: 49% (1,548 hours)
Alaska DHAT
• After graduation, 400 hours preceptorship
• Standards and procedures:
–Standing orders
–Renewal every two years
Australia
• Dental therapists have practiced in Victoria since 1975.
• Since 2000, movement of dental therapists into new work
settings such as private, community, and hospital practices.
• Prior to 2000, dental therapists were limited to children
attending school.
• Now provide up to eighteen years and, upon the prescription of
a dentist, from nineteen to twenty-five years.
• In orthodontic practices, care prescribed by an orthodontist or
dentist may now be provided by dental therapists to clients of
all ages.
This Year, a New Oversight
Group in Australia:
National Oral Health Alliance
• Did not recommend enhanced Therapists, instead they
recommended what the AGD has been saying for 5 years,
namely:
– Phasing in a dental residency (foundation) year over 5–10
years as policy, infrastructure, professional mentoring, and
support develop (initially $20m pa for operations and $60m pa
for infrastructure)
– Introducing regional, rural, and remote incentives to improve
the distribution of the workforce (initially $10m pa)
New Zealand
• Now, dental therapists train for three years at university or a
polytechnic and are registered with the Dental Council of
New Zealand
• The majority of dental therapists are employed by District
Health Boards in schools, though a small numbers work in
private practice alongside a dentist
• While dental therapists work independently, they will have a
professional link to a dentist and refer your child to a dentist
when more specialized care is required
New Zealand
• Treatments that can be carried out by a dental therapist
include:
– Advice on oral health and cleaning practices for children and adults
– Cleaning the teeth
– Diagnosis of decay (cavities) in baby (deciduous) or permanent (adult)
teeth – this may include using x-rays
– Restoration of decayed adult and baby teeth using fillings
– Extraction of baby teeth
– Preventive therapies to keep teeth healthy – for example using special
sealants or topical fluoride
– Referrals to other oral health practitioners for assessment and treatment
– Keep records of dental treatment
New Zealand
• Therapists don’t stay long, not cost effective
• High career satisfaction but much less satisfied with
remuneration
• Done in 10 years with dental therapy
• Younger DTs were more interested in moving to private
practice
• A mean of 6.5 years in career
Source: Ayers, K.M., et al. The working practices and career satisfaction of
dental therapists in New Zealand. Comm Dent Heal 2007; 24:257-63.
New Zealand
• The dental health of young children continues to be among the
worst in the developed world, figures reveal
• Forty-four per cent of 5-year-olds have at least one decayed,
missing or filled tooth, a school dental services report has
found
• The Government has spent $417 million on the problem since
2007 but the figures have shown little improvement
• In 2000, 48 per cent of 5-year-olds had cavities, and the figure
has not dropped below 43 per cent since
• New Zealand rates are worse than the UK, US, and
Australia
Source: Gillis, Abby. NZ children's dental health still among worst. New
Zealand Herald, March 2011.
Canada
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Large country
Many rural, isolated populations
Transportation challenges
Dentists concentrated in population centers
Access to dental care limited
Canada
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Fillings on primary and permanent teeth
Vital pulpotomies on primary teeth
Stainless steel crowns on primary teeth
Extractions of primary teeth (Prov & Fed)
Extractions of permanent teeth (Fed)
Sealants
Cleanings
Fluoride
Radiographs
Education
Canada
• Too many dental staff for the amount of dental work that
needed to be done
• Large provincial deficit, conservative government
• Government scrapped the program in 1987, except for
the northern program
• Expanded dental hygiene schools
Dental Team Concept
• Prevention, prevention, prevention!
• Expanded Auxiliaries within the practice can play key role in
prevention
• Establishment of Dental Home*
• Dental benefits designs to support establishment of dental
home from childhood**
• Cost savings for patients & carriers!
*Advisory Committee on Training in Primary Care Medicine & Dentistry’s (ACTPCMD) 8th
Congressional Report (2010) recommends expansion of dental home to medicine as key
to prevention and cost-savings
**See the American Academy of Pediatric Dentistry’s (AAPD) Policy on Model Dental
Benefits for Infants, Children, Adolescents, and Individuals with Special Health Care
Needs (2008)
Midlevel Providers
• Examples: hygienists/dental assistants/expanded function dental
assistants (EFDA) within the dental team model, Dental Health
Aide Therapist (DHAT)*(AK), Registered Dental Hygienist in
Alternative Practice (RDHAP) (CA), Dental Therapist/Advanced
Dental Therapist (MN), independent practice of hygienists (CO,
ME), Advanced Dental Hygiene Practitioner (ADHP)(Not yet
implemented), limited access permits (OR), public health
hygiene endorsements (OR, ME), collaborative practice dental
hygienists(NM), Level III Hygienist (KS).
• Concern: Independent practice w/o direct
supervision of a dentist (a.k.a. “Alternative
model of oral healthcare delivery”)
Midlevel Providers
In the Affordable Care Act:
• SEC. 5304. ALTERNATIVE DENTAL HEALTH CARE
PROVIDERS DEMONSTRATION PROJECT
• Subpart X of part D of title III of the Public Health Service
Act (42 U.S.C. 256f et seq.) is amended by adding
at the end the following:
– “SEC. 340G–1. DEMONSTRATION PROGRAM
– “(a) IN GENERAL.—”(1) AUTHORIZATION.—The Secretary is
authorized to award grants to 15 eligible entities to enable
such entities to establish a demonstration program to establish
training programs to train, or to employ, alternative dental health care
providers in order to increase access to dental health care services in
rural and other underserved communities.
Midlevel Providers
In the Affordable Care Act:
• “(2) DEFINITION.—The term ‘alternative dental health care
providers’ includes community dental health coordinators,
advance practice dental hygienists, independent dental
hygienists, supervised dental hygienists, primary care
physicians, dental therapists, dental health aides, and any
other health professional that the Secretary determines
appropriate.
Alternative Models
• Advanced Dental Hygiene Practitioner (ADHP)
• Community Dental Health Coordinator (CDHC)
• Dental Therapist (DHAT and numerous variations)
ADHP
• Created by ADHA
• Completion of hygiene program + 2 years of Master’s
study
• Diagnose and treat, including restorations and extractions
• General or No Supervision
• Pilot Study in CO indicated hygienists failed to practice in
underserved areas
• Not implemented in any state
New Data, Implications
of New Legislature
• Possible funding for the ALTERNATIVE DENTAL
HEALTHCARE PROVIDERS DEMONSTRATION PROJECT
• Expansion of National Health Service Corps to specifically include
dental therapists
• Create demonstration programs for training and employment of
alternative dental health care providers, including within the
Departments of Defense and Veteran Affairs, Federal Bureau of
Prisons and Indian Health Service
• Amend Medicaid reimbursement criteria to include services provided
by alternative dental providers.
CDHC
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Created by ADA
18 Months of training
Community, public health, and private practice settings
Provides education/case worker services under general
supervision
• Limited treatment with door open for modification of SOP
• New Mexico to implement
Dental Therapists
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Favored by Pew and W.K. Kellogg
Modeled after New Zealand, Great Britain, Canada
Two years or so of education
Diagnosis, restorations & extractions
General supervision
Implemented in AK (native) & MN
Benchmark for Proponents - Minnesota
Minnesota Model
• Dental Therapist (DT):
– Both indirect and general supervision
– Only 26 to 28 months of training
– 16 licensed so far
• Advanced Dental Therapist (ADT):
– 2,000 hours
– Prerequisite DT license
– General Supervision
• Practice Settings:
– Both DT and ADT are limited to primarily practicing (about 50%)
in settings that serve low-income, uninsured, and underserved
patients or in a dental health professional shortage area.
Other States
• W. K. Kellogg targeting 5 states for dental therapist pilot
programs: KS, NM, OH, VT, and WA
• Washington:
– Eastern Washington Univ. – ADHP Masters Program
– HB 1310 (Advanced Dental Therapist) Bill withdrawn (2011)
• Kansas:
– HB 2280 (Registered Dental Practitioner) defeated (2011)
– Does now have new Level III Hygienist
States with Mid-Level Provider Legislation
Legend:
Pending
Enacted
Failed
Nash Review of 1,100 Reports
• Released by W.K. Kellogg Foundation, April 2010
• Claims that dental therapists can provide “technically
competent, safe and effective” care
• Fails to measure true patient health outcomes
• More of position paper than a clinical research report (as
noted by title, A Review of the Global Literature on
Dental Therapists: In the Context of the Movement to
Add Dental Therapists to the Oral Health Workforce in
the United States)
ADA Systematic Review
• Sought to find the science to back up claims
• 7,700 articles reviewed
• Only 18 possibly useable, of which 12 were high bias, 5
were medium bias, and only 1 was low bias
• Found no improvement in the oral health of the
community by adding therapists
• Quality of data was poor and refutes the foundations
claims of hundreds of articles
California Study
• SB694 – A bill to study use of midlevel providers in CA
• No dentist shortage in CA
• Bill died in appropriations
• The sponsor has called for a special session of the
legislature to discuss the bill – will take place in Dec. ‘12
Jackson Brown Articles
• The Economic Aspects of Unsupervised Private Hygiene Practice and
Its Impact on Access to Care (2005)
• www.ada.org/sections/professionalResources/pdfs/report_hygiene.pdf
• “Unsupervised private dental hygiene practice has not had a notable
effect on access to care in Colorado”
• “They are located in areas served also by dental offices with traditional
dental hygienists”
• “The economic viability of the unsupervised hygienist business model
is questionable because their prophylaxis fees, on average, are not
different from traditional dental practices, which have the advantage of
providing a full range of practice services”
Study of Alternate Dental
Providers, Five State Comparison
• Five states, three models, three payment systems
• Only in a couple of scenarios would using therapist be minimally
economically sustainable – they would have to be heavily subsidized
• “The current public payor and indigent reimbursement levels is not
economically feasible for providers with salaries at 50% of the
Dentists”
• “The limitations to greater access to dental care is that existing fee
schedules do not cover the cost of treating the patients”
• The addition of additional providers does nothing to address this issue
AAPD Answers Kellogg
• In addition to AGD and the ADA, the AAPD also
responded to the Nash/Kellogg Report
• Key points of AAPD:
– Report fails to account for variations between 54
countries
– Based on opinions, not data
– Fails to address economic viability
– Technical competence ≠ long-term patient outcomes
The Perth Meeting
• The Presidents of the American Dental Association, the
British Dental Association, the Australian Dental
Association, the Canadian Dental Association, and the
New Zealand Dental Association had a discussion on the
success or failure of the therapist programs
• In ALL of the countries utilizing therapists, there was no
improvement in Access and NO cost savings
ADEA and Public Health
• They claim that this workforce issue is being driven by:
– Access to care
– Oral health disparities
– Some believe that the DT could be an answer to these
problems
Dental Extenders at CHC’s
• WSDA introduces legislation to introduce AFDAs
(Advanced Function Dental Auxiliaries) for
community health centers approved by the
Dental Quality Assurance Commission (DQAC)
• Essentially, public health EFDA with added
surgical privileges under direct supervision
Prevention-Focused Care
• A fully trained dentist and a full oral health team (dental team
concept), CDA, EFDA, RDH
• The dentist utilizes the team to increase efficiency in order to
treat more patients but without decreasing the level of care
• Just adding more hole fillers doesn’t
increase the level of overall oral health
Prevention-Focused Care
From: Vibeke Bælum
Date: October 23, 2012
Subject: Re: Dental therapists in Denmark
No, fortunately, we don't have dental therapists here, just
dentists and dental hygienists.
We don't need more professionals that are licensed to drill
and fill. The high speed drill was never instrumental for oral
disease control.
Best regards,
Vibeke
Prevention-Focused Care
• “Oral Health Inequities will only be reduced through the
implementation of effective and appropriate oral health
promotion policy.”
– The State of Oral Health in Europe, Dr. Rena Patel, September 2012
• 40 years ago, Denmark embarked upon oral health
improvement, and by the end of the 1990’s, they have 99%
of the children with consistent preventative services and a
high national level of Oral Health Literacy
Number of Dentists –
NOT the Issue
• 1:2,000
• Health Resources and Services Administration (HRSA)
standard is 1:5,000 or lower in many locations
• Advancements in technology and increases in the education
and number of auxiliaries within the dental team show that
capacity is the key, not ratios!
2,263
2,246
2,500
134,492
136,717
2,256
2,260
2,274
2,248
2,249
2,274
2,261
2,273
2,257
2,239
2,267
160,000
2,254
Number of Active Private Practicing
General Practitioners, 1996–2009
2,000
1,500
80,000
1,000
60,000
Population to GP Ratio
133,688
132,118
130,054
130,335
129,096
126,546
126,097
124,151
123,625
123,197
100,000
119,493
Number of GPs
120,000
120,250
140,000
40,000
500
20,000
Number of GPs
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
0
1996
0
Population/GP
Source: Distribution of Dentists in the United States by Region and State, various years, 1996 to 2009; and U.S. Census Bureau.
CAPACITY,
Survey March 2011
CAPACITY,
Survey March 2011
• Of the 589 members who were seeing fewer patients than two
years ago, 47.5 percent indicated that they are seeing between
11 and 25 percent fewer patients; 36.3 percent are seeing 10
percent or less fewer patients; and 10.9 percent indicated that
they are seeing between 26 and 50 percent less patients
• Of the 328 members who were seeing more patients than two
years ago, 45 percent indicated that they are seeing between
11 and 25 percent more patients; 27.7 percent are seeing 10
percent or less more patients; and 13.4 percent indicated that
they are seeing between 26 and 50 percent less patients
• The Dental Economics Advisory Group states that, with the
new dental schools coming on line and the anticipated
workforce and technology enhancements, the supply of
dentists is not likely to be a problem
• “Capacity Utilization” problem: In Economics this means,
“Don’t create more until you use what you already have”
• PEW's “shortage of dentists” based their assumption on the
numbers who are willing to treat low-market or non-market
patients
• PEW refuses to understand that, “regardless of how many
DHATs they produce, they still can't address the dental needs
of the underserved dealing with social and cultural issues,
transportation and health literacy.” Dr. Ron Tankersley, ADA
Past President
• The Foundations and others don't seem to want to work on the
major aspects of the issue
• In a report to the National Oral Health Conference, a state
with 62% dentist involvement in Medicaid in a 5-year CDC
assessment done by DOH using ASTDD standards on 5,732
children in 73 schools in 2008 showed:
In the Untreated Caries Summary:
• The children in the Medicaid group showed “NO
DIFFERENCE” than any other category
• Their data was the same as insured patients
In the Treatment Urgency Summary:
• The children in the Medicaid group showed “NO
DIFFERENCE” than any other category
• Their data was the same as insured patients
• Some claim that Medicaid reimbursements don’t affect
participation, but a statewide school nurse survey showed the
opposite trend
• Increases in Medicaid rates had a direct correlation to the
numbers of dentists
• However, Parent Involvement and Transportation were the
biggest barriers, not dentists’ involvement
Fiscal Pressure on
Medicaid Programs
Breakdown of Total
Medicaid Spending, 2010
• “CMS sees Medicaid costs outpace
projections.”
• “Medicaid spending will increase
7.9% per year over the next 10 years.
That compares to a growth rate of
4.8% in the general economy.”
1.8%
• “We must act quickly to keep state
Medicaid programs fiscally sound.”
Source: CMS and HHS
• “20 states cut Medicaid payment rates
last year. At least 16 governors have
proposed rate reductions this year.”
98.2%
Source: Kaiser Family Foundation
Oral Health Services
All Other
• Oral health is affected by more factors than access to dental
care
• Because so many factors at the individual, environmental, and
delivery system levels affect oral health, interpreting the
findings from international studies is difficult
Source: Community Dentistry and Oral Epidemiology, 2006
• “Direct public expenditures constitute only 6% of total spending
for dental care in the US, just three-eighths of the proportion in
Australia, and almost all of it is limited to the care of children
• New Zealand’s program in the schools has been in place a
long time and, thus, it may be surprising to learn that Baltimore
adolescents had (among all countries in ICS I and ICS II) the
lowest number of DMF teeth and the second- or third-lowest
number of decayed teeth”
Source: Chen MS, Andersen RM, Barmes DE, Leclercq MH, Lyttle CS. Comparing oral
health systems: a second international collaborative study.
• “Financial barriers to access are significant in explaining how
much desired dental care is actually received in the US”
Source: Mueller CD, Schur CL, Paramore LC. Access to Dental Care in the United States.
• Workforce is but a very small part of oral health
improvement
• “The New Zealand oral health therapist program is touted as
the model for this country’s foray into a mid-level provider. In
2004, the DHBNZ (Ministry of Health) declared the School
Dental Service to be “in strategic crisis” and that inequities
continue to exist, notably with low income, minorities, and rural
populations. They further concluded that facilities were run
down, not suited to modern practice and non-compliant with
health and safety standards.”
Source: Dr. Crall, AAPD presentation.
• The AAPD suggests the burden of proof from studying such
models is to first show they actually work, versus trying to
implement nationwide programs based on “what harm can they
do? / something is better than nothing”
• “Something” that drains away resources and provides
less comprehensive care for children could in fact be
worse than doing nothing”
Source: Dr. Crall, AAPD presentation.
New Strategy
• The goal is Improved Oral Health
– Access is only a small part of Oral Health
– Workforce is only a small part of Access
• The REAL BARRIERS are Oral Health Literacy, Economic,
Transportation, Cultural, and Social Issues
• Don’t fight over what will not help Oral Health anyway
Get Involved
US Representative Jeff Duncan
THANK YOU!