NDA position paper on mid-level providers

Nov. 22, 2010
The National Dental Association comments on access to care and mid-level providers for underserved communities in a September 2010 position paper.

For over 95 years, the National Dental Association has been the voice and forum for African American Dentists, and has historically served as an advocate for minority and underserved patients whom our members have treated throughout the tenure of our organization. Our mission to improve access to oral healthcare is significant and unwavering and our experience has taught us that under-attention, under-funding and inappropriate measures will not solve the complex health issues that burden minority and poor communities. The National Dental Association recognizes that access to oral health care is a long-term problem and getting worse, however, it is our position that we are against the Mid Level Oral Health Care Provider except in Alaska which is geographically isolated.

The U.S. Surgeon General has concluded that oral health is an essential and integral component of health throughout life. No one can be truly healthy unless he or she is free from the burden of oral and craniofacial diseases and conditions.(1) Millions of people in the United States suffer from the experience of having dental caries, periodontal diseases, oral cancer, and cleft lip and palate. The orofacial disorders result in needless pain and suffering; difficulty speaking, chewing and swallowing; increased costs of care; loss of self-esteem; decreased economic productivity through lost work and school days; and, in extreme cases, death.(2) Oral and pharyngeal cancers, which primarily affect adults over age 55 years, have resulted in significant illnesses and morbidity/disfigurement associated with treatment, substantial cost, and more than 8,000 deaths annually.(3)

Poor oral health and untreated oral diseases and conditions, especially periodontal disease, have been shown to impact the morbidity of diabetes(4), cardiovascular disease(5) and the incidence of premature or low birth weight babies.(6) There is also a high risk in the United States due to a number of genetic and environmental factors for development of very rare genetic disorders to more common chronic diseases such as cardiovascular disease and diabetes.(7) Dental caries is the single most common chronic disease of childhood, occurring five to eight times as frequently as asthma, the second most common chronic disease in children.(8)

Over the past 20 years, deaths from oral and pharyngeal cancers have declined by approximately 25%, and new cases have declined by 10%. However African American men have experienced increases in both death rates and new oral and pharyngeal cancer case rates.(9) The 5 year survival rate is lower for oral and pharyngeal cancers among African-Americans than Whites (34% versus 56%) due to late stage of detection.(10)

The disparity in health status between African Americans and non-hispanic whites is alarming. The need to focus specific attention on inherent systematic inequities in the institutions and structures of health care is overwhelming. Racial minorities are sicker than White Americans and are dying at significantly higher rates. These are undisputed facts. There are numerous examples of disparities between racial and ethnic groups and between men and women. Mortality rates are 2.5 times higher for African Americans (11) and 1.5 times higher for Native Americans than Whites.(12) The death rate from heart disease for African Americans is higher than for Whites(13); 50% of all AIDS cases are among minority populations(14) and African Americans are twice as likely to be diagnosed with diabetes as non- hispanic whites. Additionally, they are more likely to suffer complications from Diabetes, such as end-stage renal disease and lower extremity amputations. Although African Americans have the same or lower rate of high cholesterol as their Non-Hispanic counterparts, they are more likely to have hypertension.(15)

Yet with all these glaring disparities, there are many voices who propose that the answer to health equity is a two tier system of oral health care delivery with what is called Mid-Level Providers with minimal training; some with as little as 2 years post secondary education. These voices recommend the employment of mid level providers to care for the oral health needs of the underserved, economically challenged populations with challenges related to managing complications and compromised systemic health conditions. These are the patients that typically have more severe levels of dental disease and multiple co-morbidities that require a health care professional with advanced training, skill and experience. This seems an acceptable solution for the poor and underserved, while those well to do individuals in our society enjoy comprehensive oral health care from licensed dentists who have completed an average of eight or more years of post secondary, university, pre and post graduate school training.

Examples of Mid-Level Providers include the Dental Health Aid Therapist, (DHAT) and the Advanced Dental Hygiene Practitioner, (ADHP). These models are designed to work autonomously and/or under minimal/remote general supervision. The Mid Level Provider Models proposed are models that will be an addition to the previously established and accepted Expanded Function Dental Assistant (EFDA), an adjunct to the dental team usually working under the direct supervision of the dentist.

The National Dental Association, relying on its members’ historical experience of providing care for the underserved and at risk populations, created a task force in 2009 to assemble and share in the formulation of a position paper with the information we have gleaned through the years. This position paper is not a supposition, but an observation and assessment of clinical, scientific and cultural evidence defining the clinically relevant question of how best to increase access and provide quality, comprehensive, and appropriate care. Through this process we have examined and will present the proposed options to the Mid Level Provider Concept and contrast them with proposals based on the existing frame work of comprehensive care delivery that is directly related to and compatible with the oral and medical condition, history and culture of our target population. Mid Level Provider Addendum is attached.

Summary of Proposed Mid-Level Models

All of the described mid-level models differ greatly from the current existing model of care delivery, which admittedly varies from state to state. The ADHP Model proposes to create a new independent practitioner with substantially less education and training than is presently required for the practice of dentistry. The Alaska and Minnesota Dental Therapist Models are being developed along the lines of other Dental Health Aid Therapist Models, with a base line for training of two years post high school. Expanded Function Dental Assistants, EFDA have been utilized in the United States and have been permitted under numerous Dental Practice Acts since the 1970’s. EFDAs are also used by the armed forces and programs sponsored by several other federal agencies and have a long history in Europe and Canada. Educational programs for training EFDA’s vary from state to state. Numerous studies have demonstrated that EFDA’s enhance dental practice productivity and efficiency without compromising technical quality of care.

National Dental Association Values and Principles Concerning Oral Health

The NDA believes that all citizens are entitled to equal protection and healthcare under the law. Since early in American history the racial dilemma that affected America, also distorted relationships and institutions. There has been active relegation of minorities to an under funded, overcrowded and inferior public health care system, excluding the input of minority dentists in the formulation of policy for the populations they have served and been a part of for generations.

Minority communities have been the victims of flawed assessments and social medical experiments dating from the Flexner Report to the Tuskegee Project. The National Dental Association believes that the deployment of mid-level providers to underserved communities would also be a disincentive for comprehensively trained, minority dentists to locate in health shortage areas among a host of experimental models adding additional layers of care and disrupting the establishment of dental homes that would offer comprehensive, appropriate, timely, continuous, coordinated family centered care by or under the direct supervision of a licensed dentist.

A report of the Journal of Dental Education found that African American Dentists treat a higher percentage of African American Patients and a higher percentage of economically disadvantaged patients than their White counterparts. In addition, ADEA Senior Survey Data for 2002(16) reported that Black/African American Students planned practice locations where the major portion of patients will be from inner-city or underserved populations in a higher percentage than that of White Students. The percentage for Black/African American Students was 68.7 percent, while that of White Students was 20 percent.

There is more general evidence, beyond dentistry, as well. The 2004 Institute of Medicine Report, “In the Nation’s Compelling Interest”, (17) concurred with the decision of the Supreme Court on the Grutter vs. Bollinger et al. case that there is substantial evidence that the quality of the educational experience in a university that has achieved a “critical mass” of diversity is significantly greater than what is experienced without it.

The Hopwood (Texas) and Proposition 209 (California) challenges to affirmative action in 1995 caused stagnation in efforts to address diversity objectives during the late 1990s. The 2003 decision of the Supreme Court with regard to the Michigan affirmative action challenge, however, concluded that diversity is a compelling national interest. This decision established both a challenge to the nation and set in motion the parameters for more inclusive admissions practices to achieve diversity and consideration of race-neutral alternatives to achieve diversity.

ADEA’s long-held position is that, without minority practitioners, access to care will be limited or absent in minority communities throughout the nation. (18) The Dental Practice Data from both the ADA and ADEA support this position. In fact, the ADA Survey Report 2000 (19) documented the practice characteristics of U.S. Dentists. Black Patients are the only racial/ethnic group that is treated primarily by Black Dentists. Continued vigilance and activities must be sustained and documented to ensure a critical mass of diversity within United States Dental Schools and within the dental profession. (20) The NDA is willing to accept the utilization of Mid Level Oral Health Care Providers, solely in Alaska (only as a temporary measure) because of its unique geographical and isolated care environment, while no other current viable options exist.

Policy Recommendations

The NDA believes that with appropriate policy, legislation, provider and patient incentives, and support for recruitment of underrepresented minorities into dentistry, that the existing frame work of oral health care delivery can be improved to provide health equity for the underserved.

Therefore, the National Dental Association makes the following recommendations:

1. The NDA recommends funding Pipeline Initiatives to recruit underrepresented minorities into dentistry starting at the middle school level and provide preparatory courses to instill them with the skills and knowledge to perform well on the Dental Aptitude Examinations and successfully matriculate through dental school.

2. Medicaid rates should be increased minimally to the 65 percentile of usual customary and reasonable (UCR) fees. Streamlining Medicaid administrative processes making the system more ‘dentist friendly’ to providers. Having a single Medicaid benefits manager within a state translates into one set of program policies, one claims processor and one organization responsible for contract deliverables within a state. These measures have been proven to increase dentist participation in Medicaid networks. (21)

3. Provide investment tax credits for Dentists who locate in underserved communities, as an incentive to dentists to offset lower fees and investment risk in under developed communities.

4. Provide sustainable community grants to address the issue of dental healthcare desserts and promote investments in underserved communities to improve the quality of life.

5. The NDA supports greater use of Expanded Duty Dental Assistants and Hygienists, under the supervision of a licensed dentist as a measure to increase the efficiency and capacity of the dental care delivery team. Furthermore, the NDA recommends increased subsidized training opportunities to increase the numbers of underrepresented minority EFDA’s and EDDH’s in underserved populations.

6. The NDA recommends that underrepresented minority clinical dentists be part of all Institute of Medicine Panels and hearings to improve access to care. The NDA calls for the involvement of underrepresented minority clinical dentists in the recommendation and formulation of policy drawing upon our historic experience of providing care to underserved populations. After all, we have been the caregivers for many of these patients when no other provider would care for their oral health needs.

7. The NDA recommends further evaluation of the safety of Dental Therapist and Community Dental Health Coordinator (CDHC) models prior to policy decisions regarding their use.

8. More efficient use of uniformed Public Health Service (PHS) and Health Services Corps (HSC) Dentists for rotating deployment to areas of need. Promotions should be linked to efficiencies and capacity building.

9. Reconfigure placement of Indian Health Services Corps Dentists to remote areas to support but not compete with Native American Dentists. Increase the scope of practice to provide comprehensive care with salaries and promotions linked to efficiencies and capacity building.


The National Dental Association believes that all children and adults deserve access to quality dental care. We further believe that a two tier system which offers a premise that "something is better than nothing" is unacceptable. In the early history of our country would our forefathers have thought that a little freedom was better than no freedom? "We hold these truths to be self evident that all men are created equal and are endowed by their creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness". For a government to propose or allow a different standard of health care for the poor versus the privileged is un-American. The NDA believes that comprehensively trained dentists supervising properly trained auxiliaries in a reformed health care system with appropriate medical-dental interdisciplinary cooperation and communication is the standard of care for all Americans. Finally, the National Dental Association considers it critical that in meeting the needs of the underserved community that the highest quality and standards of care are always maintained. Therefore, it is our position that we are against Mid Level Oral Health Care Providers (DHAT, ADHP), except in Alaska which has a unique geographical and isolated access issue.

Task Force Members and Contributors:

Michael Battle, D.D.S., Darryl A. Chapman, Sr., D.M.D., Paula L. Coates, D.D.S., Katrina Y. Eagilen, D.D.S. Nathan L. Fletcher, D.D.S., Nellie Graves, C.D.A., D.O.M., R.P., William Hoskins, D.D.S., Dorita Newsome Dobbins, D.D.S., Walter R. Owens, D.D.S, Kim B. Perry, D.D.S., Madge Potts-Williams, D.D.S., Mfon Umoren, D.D.S., Edward H. Chappelle,Jr., D.D.S., F.A.G.D.


1) U.S. Department of Health and Human Services (HHS). Oral Health in America: A Report of the Surgeon General. Rockville, MD: HHS, National Institute of Dental and Craniofacial Research, 2000.

2) Reisine, S., and Locker, D. Social, psychological, and economic impacts of oral conditions and treatment. In: Cohen, L.K., and Gift, H.C., (Eds.). Disease Prevention and Oral Health Promotion: Socio-Dental Sciences in Action. Copenhagen: Munksgaard and la Federation Dentaire Internationale, 1995, 33-71.

3) Landis, S.H.; Murray, T.; Bolden, S.; et al. Cancer Statistics, 1999.CA-A Cancer Journal for Clinicians 49:8-31, 1999. PubMed; PMID 10200775.

4) Saremi, A; Nelson, R.; Tulloch-Reid, M.; et al. Periodontal Disease and Mortality in Type 2 Diabetes, 1999. Diabetes Care, American Diabetes Association.

5) Friedewald, Vincent; Kornman, K.; Beck, J.; et al. American Journal of Cardiology and Journal of Periodontology Editor’s Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease. Journal of Periodontology, 2009.

6) Fardini, Y.; Chung, P.; Dumm, R.; Joshi, N.; Han, Y. Transmission of Diverse Oral Bacteria to Murine Placenta: Evidence for the Oral Microbiome as a Potential Source of Intrauterine Infection, 2010. Infection and Immunity: American Society for Microbiology, 2010. p. 1789-1996, vol. 78, no. 4.
7) White, B.A.; Weintraub, J.A.; Caplan, D.J.; et al. Toward improving the oral health of Americans; an overview of oral health status, resources, and care delivery. Public Health Reports 108:657-872, 1993.

8) National Center for Health Statistics (NCHS). National Health and Nutritional Examination Survey III, 1988-1994. Hyattsville, MD: Centers for Disease Control and Prevention (CDC), unpublished data.

9) Greenlee, R.T.; Bolden, S.; et al. Cancer statistics, 2000. CA- Cancer Journal for Clinicians 50:7-35, 2000. PubMed; PMID 10735013.

10) NIH. SEER Cancer Statistics Review 1973-1996. Bethesda, MD, 1999 National Cancer Institute, NIH. Http://www.seer.ims.nci.nih.gov/Publications/CSR1973_1996 June 15, 1999.

11) ADA, CDC, and NIH. Proceedings: national Strategic Planning Conference for the Prevention and Control of Oral and Pharyngeal Cancer. Atlanta, GA: CDC, 1997.

12) U.S. Department of Health and Human Services, Office of the Inspector General. Children’s Dental Services under Medicaid: Access and Utilization. Pub. No. OEI-09-93-00240. Washington, DC: the Agency, 1996.http://www.dhhs.gov/progorg/oei/reports/a10.pdf November 23, 1999.

13) Eklund, S.A., and Burt, B.A. Risk factors for total tooth loss in the United States: Longitudinal analysis of national data. Journal of Public Dentistry 54:5-14, 1994.PubMed; PMID 8164192.

14) Burt, B.A., and Eklund, S.A. Dentistry, Dental Practice, and the Community. 5th ed Philadelphia, PA: W.B. Saunders Co., 1999, 205-206.

15) CDC, 2009. Health United States, 2008. Table 54. http://www.cdc.gov/nchs/data/hus/hus08.pdf[PDF] 12.2MB]

16) National Minority Recruitment and Retention Conferences. ADEA 2002: pub The Journal of Dental Education (September 2003).

17, 18, 19) J Dent Educ. 68(10):1112-1118 2004 ADEA Sinkford, J.C. Valachovic, R.W., Harrison, S.G.

20) Lotzkar, S, Johnson DW, Thompson MB. Experimental program in expanded functions for dental assistants: phase 3 experiment with dental teams. JADA 1971; 82:1067

20b) Bentley LJ, Rosenblum FN. Two-Year evaluation of auxiliaries trained in expanded function.

20c) Kilpatrick KE, Mackenzie RS, Delaney AG. An evaluation of expanded function auxiliaries in general dentistry. IN: Proceedings of the 6th Conference on Winter Simulation (San Francisco, CA, January 17-19, 1973) J. Sussman, Ed. WSC’73. ACM, New York, NY, pp.160-171.

21) Borchgreveink, A., Snyder, A. Gehshan, S. The Effects of Medcaid Reimbursements Rates on Access to Dental Care. National Academy for State Health Policy 2008; March: 1-32.