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Is the ADHA midlevel provider model fair to hygienists?
By Jay W. Friedman, DDS, MPH

April 6, 2012 -- The introduction of midlevel dental practitioners -- also known as dental therapists -- in the U.S. has begun: first in Alaska with the implementation of the dental health aide therapist for Native Alaskans, and then in Minnesota, where the first class of oral health practitioners graduated in 2011 and is now being deployed in facilities serving underserved populations.

In addition, under consideration in some states, and already adopted in Minnesota, is the advanced dental hygienist practitioner (ADHP) advocated by the American Dental Hygienists' Association (ADHA). However, while the ADHA deserves much credit for stimulating interest in dental therapists, the ADHP model is not the best solution to the dental workforce shortage because of the extended length of training.

Jay W. Friedman, DDS, MPH
Jay W. Friedman, DDS, MPH

To enter the ADHP's two-year master's degree program, one must first have a four-year baccalaureate degree in dental hygiene. This extends the ADHP program to six academic years, compared to the proven success of training a dental therapist with a high school diploma in only two years. Furthermore, the associate-degree dental hygienists, who far outnumber baccalaureate hygienists, would be denied advancement for which they are well qualified should this model prevail.

A zero-sum game

Dental hygienists becoming dental therapists is like a zero-sum game. From the viewpoint of alleviating the dental workforce shortage, it is a wash. What is gained in dental therapy is lost in periodontal therapy. The periodontal needs of the adult population are great and much under-supplied. We need dental hygienists and dental therapists. Nonetheless, dental hygienists should have the same right to advance their skills as general practitioners who become specialists. But it was demonstrated long ago that they can acquire the competencies of dental therapists with no more than a year of additional training ("The Forsyth Experiment: An Alternative System For Dental Care," Lobene, R, Cambridge, Massachusetts: Harvard University Press, 1979).

There are nearly 300 dental hygiene programs in the U.S., most of which offer two-year RDH certification. Many could expand to include a two-year dental therapist curriculum (Journal of Public Health Dentistry, Spring 2011, Vol. 71:2, pp. S9-S19). The dental therapist students and the dental hygienist students could share the same basic science courses during the first year, even as they "track" into their separate disciplines in the second year. Existing dental hygienists could be allowed credit for the first year of training, enrolling in the second year to become certified dental therapists.

In the most extensive and successful programs, such as in New Zealand, Australia, and Malaysia, dental therapists have been dedicated to children's care in school-based programs. More recently, some countries, including New Zealand, Australia, and The Netherlands, are combining both disciplines in a three-year training program for oral health therapists who will practice collaboratively with a dentist, but not necessarily under direct supervision (Journal of the California Dental Association, January 2011, Vol. 39:1, pp. 23-29).

The prerequisite is not a dental hygiene degree but graduation from high school. They will provide basic preventive, restorative, and periodontal therapies, including sealants, fillings, simple extractions, scaling, and root planing.

In the U.S., these hybrid therapists will most likely be deployed in community health centers and public health facilities in rural and inner-city dentist-shortage areas, serving both children and adults within the restricted scope of their dual competencies.

Effective, efficient, safe

That there is a need to enlarge the dental workforce if our population is to receive adequate oral healthcare is inarguable. That dental therapists can provide effective, efficient, and safe care to children has been thoroughly documented. With proper training and supervision they should also be able to provide basic care to adults, allowing dentists to practice at a higher and more fulfilling level.

For dentists to oppose dental therapists is to deny themselves the opportunity for self-advancement and the poor and underserved population of essential oral health care.

Jay Friedman, DDS, MPH, has published more than 60 papers in professional journals and is author of An Intelligent Consumer's Complete Guide to Dental Health. He has more than 60 years of experience as a clinician, university researcher, consultant, dental insurance administrator, and director of large group dental practices.

Related Reading

More U.S. states consider expanding hygienists' duties, March 22, 2012

Midlevel providers face uphill battle for acceptance, March 22, 2012

Wash. lawmakers mull dental therapist bills, February 1, 2012

More states moving forward with midlevel providers, November 17, 2010

2-year study finds in favor of U.S. dental therapists, October 26, 2010


Copyright © 2012 DrBicuspid.com

Last Updated kk 4/9/2012 7:10:02 AM
Forum Comments
14 comments so far ...
4/9/2012 1:42:08 PM
glenp		 Why  use Socialist countries and third world regions as proof of something that doesn't exist in the USA?  I'd like someone to show me where there is a lack of access to dental care other than in some remote isolated areas that really don't use the services of dentistry in the first place.  Maybe we should stick all those MLP's in those remote outposts and see how much work they actually do or how long they are self supporting. This MLP argument is to condition us all into second rate care under the new world socialist regimes.  Is England using MLP's? If not why not? They need help badly. Or maybe it is MLP work I see in those nasty Brit mouths.  BTW  I have a great pic of DIANA RIGG a former Bond girl and "AVENGER" for proof of ugly Brit teeth.
4/9/2012 1:56:11 PM
bytegently		 Seriously, that's your  argument?  Right out of the play book of the Tea Party?  Very helpful.
4/9/2012 2:59:21 PM
Dr. Z		 While I agree wholeheartedly with the author's premise that dentistry in the US needs to embrace the recent workforce expansion to include dental therapists, there are some major problems with the author's knowledge of the issue (or at least what he wrote). First, to say that we shouldn't seek out alternative providers in the form of hygienists that can now realize a career ladder of sorts because it will reduce the pool of hygienists to provide periodontal services is off the mark.  Readers of this editorial must know that hygienists/therapists trained in Minnesota will be able to provide both perio and restorative services.  Later in his editorial there is mention of streamlining future hygienists that wish to be therapists as well, so what's the problem?  How many existing hygienists are going to completely exit their current roles when there are so few educational opportunities?  Isn't a future combined program going to alleviate the issue he raises for a time when there will be more programs (if such a time arises)?  I get frustrated by those who see such a limited range of possibilities on the topic of dental therapy.  We have the opportunity to create whole new approaches in the US, so why not keep our options open rather than worry about the possibilities that have only remote chances of occurring?
Second, the need for restorative services by no means exists only within the US population of children.  The fact that children's therapist programs are the ones with the most success is no indication whatsoever of the likelihood of success in treating non-children populations.  Further, limiting dental therapists work to only children is a very short-sighted view of the potential of dental therapists expounded largely by pedodontists.  (Do they want to gain economically by limited dental therapists' care to children in their practices?  Also, why have DTs treat kids when pedodontists routinely state that they, the pedodontists that have gone through post graduate training, are best suited to treat children?)  Don't limit the scope of care to any given population at this time, especially when it is based on the conditioning of a limited view of dental public health.  The current dental therapy training programs in Minnesota are, thankfully, based on serving the full range of dental patients.  I would suggest the writer (and pedodontists in general) take a much closer look at the IOM reports on oral health -- the needs of adult populations are likely far greater than children inasmuch as there are no dental benefits in Medicare (thanks a lot for lobbying them out of Medicare, ADA) nor, for the most part in state Medicaid programs.  And don't forget that children often aren't brought to the dental clinic because their parents are unable to obtain dental care.
Finally, the Forsyth experiment was conducted on a far less expansive scope of practice than that which the programs in Minnesota train.  Again, get the facts right if you're going to advocate for dental workforce expansion.  In fact programs now existing in NZ, Australia and (to some degree) in Great Britain combine dental therapy with dental hygiene.
We need to do a much better job of informing the dental community of what is happening in this nascent world of dental therapy in the US.  I urge the author and any other potential authors to do their homework first before editorializing since misinforming those who already have great apprehension about dental therapy will only be more empowered by misstatements like those in Dr. Friedman's editorial.
4/9/2012 10:47:07 PM
Dr A Smith		 Why not let MLP's experiment with their rudimentary training on the young, poor and disadvantaged in a few test states? Give the hygienists a chance too. It seems to be the American way. We're not taking care of those populations now and we won't without a market economy for dentistry that naturally adjusts fee to demand for service. What a coincidence that a consortium of monopolistic dental benefit companies and governments have instituted a pervasive price-fixing scheme. Price controls have never benefited the consumer. While they limit profits for providers by reducing maximum fees they also perniciously limit lowest fees. No one thinks about this. Many consumers are thus priced out of the dental market. Either way, it creates a scarcity of dental services. The contemporary term for this is "access to care".
Meanwhile, in the professional dental community we speak about the need for residencies or post-doctoral training for the most recent graduates of our dental schools to be minimally competent. Compare this to two years training after high school. Who's playing on what court? Who takes responsibility for this new experiment with MLP's or hygienists?
4/11/2012 12:34:26 PM
Jay W Friedman, DDS, MPH		  A more careful reading would show that nothing in my column suggests denying hygienists from advancing to dental therapy. Rather, I gave reasons as to why the ADHP is not the best model. Why should it be restricted to baccaluareate hygienists when there are relatively few compared to the large number of 2-year certificate/diploma hygienists who have essentially the same clinical capabilities? Furthermore, it is been demonstrated that a dental hygienst can acquire the skills of a dental therapist with one additional year of clinical training. In our just released W.K. Kellogg Foundation monograph, A Review of the Global LIterature on Dental Therapists, of which I was one of the three principle co-authors, the effectiveness and safety of dental therapists caring for children has been well documented. It has yet to be documented for adults, although my personal opinion is that with adequate training, dental therapists will also be able to care for adults, within the limits of their competency. But there are additional reaons for emphasizing care for children. First, children are essentially non-ambulatorary. They must either have the luxury of a caretaker (parent, usually) who can take them to the dentist, or the service must be brought to them. The most successful dental therapists programs have been elementary school-based. There is also the issue of social justice, which states that priority must be given to those who can least provide for themselves. Consider also how long it will take to develop sufficient numbers of dental therapist to make a dent in the overall acess/need equation. So, there is always the question as to where to begin. But that is a different issue than how to best train dental therapists to serve our needs.
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