The American Association of Public Health Dentistry (AAPHD) reviewed the recently released report of the American Dental Association (ADA); Study of Alternative Dental Providers Five State Comparison Summary Report.1AAPHD strongly supports the development and use of evidence in clinical practice, dental public health, and public policy.
Unfortunately, the ADA report has several limitations and methodological flaws and does little to advance our understanding of the actual economic impact of mid-level providers on practices or within a delivery system. The practice assumptions used in this report are unrealistic and illustrate the issue of low Medicaid rates – which most agree are problematic – but would not be a factor that would impact mid-levels any more than it would impact dental practices.
In addition, given that there are currently mid-level providers in the US dental care delivery system, AAPHD is disappointed that this report did not include such information. It is unclear why information from dental practices in both Minnesota and the Alaska Native Tribal Health Consortium that currently employ mid-level providers was not included in this report. Whenever possible, actual data rather than hypothetical assumptions should be used to frame public policy.
Moreover, although financial viability is an important outcome, it is not the only outcome and certainly not the most important outcome to evaluate. Furthermore, efficiency and effectiveness can only truly be assessed in areas where the mid-level providers are actually employed. The impact of mid-level providers on enhancing the dental safety net and improving access to dental care cannot be ignored. According to Dr. Edwin Allgair, a dentist in Bethel Alaska, “The access to care for the children in our villages is the positive result of having DHATs.”2
In Minnesota where dental therapists recently began practicing, the dental therapists are producing at a much higher rate than that projected in the ADA report. Another inaccuracy in the ADA report is the assertion that therapists in Minnesota must be supervised on-site or remotely using teledentistry technology. “It is true that Dental therapists in Minnesota must be supervised on-site; however Advanced Dental Therapists (ADT) can operate under General Supervision and are not required to be at the same location as the supervising dentist. Finally, the assumption using a single operatory setting is not realistic, nor is the one provider to one assistant ratio. Both scenarios demonstrate the least efficient model possible.”3
According to Sarah Wovcha, Executive Director of Children’s Dental Services in Minnesota, the only barrier faced in hiring more ADTs is that there are none available to hire since all graduates who are eligible to become dental therapists are currently employed.
• AAPHD supports research that expands the current workforce in the US including research on the impact of dental therapists.
• AAPHD believes that the most useful research into the use of midlevel providers will be that which shows the actual impact in dental or other health care practices.
• AAPHD supports demonstration projects that seek to develop new and innovative ways to deploy an entire dental team towards the goals of improved health, improved care and reduced costs (triple aim).
• The impact of demand for services and the changing demographic in the US population must be included in order to make accurate predictions about the introduction of any new workforce model.4,5The ADA report falls short in this regard.
• The ADA report, written from a hypothetical viewpoint, concludes that these alternative workforce models are not viable. This is not a just conclusion according to those who currently employ dental therapists in Alaska and Minnesota and who see the benefits of dental therapists firsthand.
• Since actual practice data are available these data should be evaluated to learn what works and to conduct demonstration projects to make all practices better.
• AAPHD supports a research agenda that develops the evidence for improved practices and accurately and objectively assesses the impact of various workforce models in order to demonstrate which models work and which do not work in addressing the access to care crisis and thus improving the oral health of the US population.
1.Study of Alternative Dental Providers Five State Comparison Summary Report, dated April 9, 2012, released July 2012. ECG Management Consultants, Seattle, WA.
2.Personal communication - Edwin Allgair DDS, DHAT Supervisor / Preceptor / Staff Dentist, Yukon Kuskokwim Health Corporation, Bethel, Alaska.
3.Personal Communication - Sarah Wovcha and Jeff Bartleson, Children’s Dental Services, Minnesota
4.White, B.A. Factors Influencing Demand for Dental Services: Population, Demographics, Disease, Insurance. 2012; Journal of Dental Education Volume 76, Number 8; 996-1007.
5.Bureau of Health Professions. The physician workforce: projections and research into current issues affecting supply and demand. Washington, DC: Health Resources and Services Administration, Department of Health and Human Services, 2008.
About the American Association Of Public Health Dentistry
Founded in 1937, the American Association of Public Health Dentistry (AAPHD) provides a focus for meeting the challenge to improve oral health. AAPHD membership is open to all individuals concerned with improving the oral health of the public. Its broad base of membership provides a fertile environment and numerous opportunities for the exchange of ideas and experiences. During the past decade, many enthusiastic persons have joined AAPHD, increasing its influence and effectiveness. Improvements in the oral health of the U.S. population have been much heralded in recent years. However, these gains have eluded many of the most vulnerable people - those for whom public health personnel often have special concern - in the U.S. and other countries. For such individuals, living with oral pain and disfigurement means a lack of health that interferes with the opportunity to learn and obtain meaningful employment.