A to Z of alternative workforce models in dentistry

By Natalia Sanchez, University of Connecticut School of Dental Medicine, ’12

CDHC, DHAT, ADHP ... the list goes on. These and other acronyms are part of a growing list of mid-level provider models in dentistry that are the subject of much debate across the country. At the local, state, and national levels, dentists and component societies, as well as organizations such as the American Dental Association (ADA) and American Dental Hygienists’ Association (ADHA), are tackling the issue of mid-level providers. As legislation related to alternative workforce models in dentistry is introduced across the country, dentists counter by defending the status quo or offering opposing legislation.

The primary mid-level provider model supported by the ADA is the Community Dental Health Coordinator (CDHC). Three 18-month pilot programs currently exist at UCLA, the University of Oklahoma, and most recently, Temple University. With the goal of improving access to dental care and overcoming cultural, linguistic, educational, and socioeconomic barriers, a CDHC serves the community as a conduit for dental care. According to Dr. W. Ken Rich, ADA sixth trustee and Board liaison for the pilot project, the CDHC “is a member of the dental team that focuses on prevention, education, and advocacy.” The scope of screening and preventive services delivered by a CDHC ranges from fluoride application and sealants to basic cleanings and temporary fillings. According to Jon Holtzee, Director of State Government Affairs at the ADA, “The CDHC’s focus is on reducing oral health disparities by targeting social determinants of oral disease.” CDHCs work in public health settings such as schools, churches, and community health centers, and their position serves as a dental parallel to the community health worker.

Similar to CDHC, the Dental Health Aide Therapist (DHAT) model recruits high school graduates for a 24-month training program that focuses on prevention and community access. However, the DHAT model is unique to Alaska, where geographical barriers and health disparities for Alaskan Natives challenge the success of health delivery. “American Indian and Alaska Native children between the ages of two and four have the highest rate of decay in the U.S. — fives times the national average.” (Nash 2005)

DHATs are either employees of the Indian Health Service or members of a tribal health program, and they are charged with providing culturally competent education and basic dental care to patients in rural Alaska. The model also attempts to direct services to at-risk populations that include children, pregnant women, and minorities. A DHAT’s scope of practice may include diagnosis, restorations, prophylaxis, simple extractions, pulpotomies, and crowns. This is seemingly more extensive than the scope of practice of CDHCs, perhaps due to the geographic expansiveness of rural Alaska. Compared to the rest of the United States, where there is a dentist to population ratio of 1:1,500, Alaska has a ratio of 1:2,800. DHATs are under general supervision by a supervising dentist who is authorized to assess their skills, sometimes using a telehealth network to supervise DHATs in more remote villages.

The American Dental Hygiene Practitioner (ADHP) model is the brainchild of the ADHA and is one of the most highly politicized models. Based on the platform of access to care, this two-year master’s level hygiene program seeks to provide cost-effective dental care to underserved communities. The model has been likened to the nurse practitioner model in medicine. The extent of practice by ADHPs includes the full scope of hygiene in addition to restorations, extractions, pulpotomies, pulp capping, diagnosis, and prescription writing for analgesics. According to legislation passed in Minnesota in 2008, ADHPs must enter into a written “collaborative management agreement” with a licensed dentist in order to work in out-of-office settings.

Finally, the implementation of the dental therapist (DT) model in Minnesota has received a lot of coverage. Based on the dental therapy model in Alaska, the University of Minnesota program offers two educational tracts — the basic DT and the advanced DT, which requires two years beyond a bachelor’s degree. The Minnesota Dental Society and the ADA were successful in narrowing the scope of practice from the traditional Alaskan DHAT model. In addition to writing scripts, performing primary extractions, pulpotomies, pulp capping, limited diagnosis, and atraumatic restorative treatment, advanced DTs may perform permanent extractions with mobility 3+ or 4+, but a dentist must authorize any surgical procedures the DT performs. Unlike the Alaskan DHAT, DTs in Minnesota must work under the direct supervision of a dentist and are considered to be a core member of the dental team focused on increasing access to care for the underserved.

Not only is it important for dentists to be aware of the ongoing debate surrounding these models, it is also helpful to know some basic differences between them. There are many opportunities for dentists who are engaged in and knowledgeable about the debate to get involved politically with their local or state dental associations to help support or oppose relevant legislation.

Bibliography: Nash DA, Nagel RJ. Confronting oral health disparities among American Indian/Alaska Native children: the pediatric oral health therapist. Am J Public Health. 2005;95(8):1325-1329