Bridging the Gap
Under pressure to mitigate the spread of SARS-CoV-2, health care providers changed the way they practiced in 2020. Limiting hours and services, adding infection control protocols, and incorporating telehealth were key to these adjustments. This rapid change in patient care may be only short term or may continue to be the standard through 2021. It's possible that the relationship between health care providers and patients will continue to experience a shift, as the population reassesses everything "normal" after the disruption of COVID-19.
Access to care has long been a concern for oral and public health systems. Populations with less access include those who are low-income, uninsured, minority, immigrant, or rural residents.1 In this environment, with rising unemployment, even more people have lost access. Efforts to increase access continue, with proposals to "integrate oral health and primary health care, incorporate interventions at multiple levels to improve access to and quality of services, and create health care teams that provide patient-centered care in both safety net clinics and community settings."1 One option for creating new health care teams that is being studied extensively is the mid-level provider or dental therapist.
A Long, Steep Climb
The American Dental Hygienists' Association (ADHA) defines a mid-level oral health practitioner as "a licensed dental hygienist who has graduated from an accredited dental hygiene program and who provides primary oral health care directly to patients to promote and restore oral health through assessment, diagnosis, treatment, evaluation and referral services. The mid-level oral health practitioner has met the educational requirements to provide services within an expanded scope of care, and practices under regulations set forth by the appropriate licensing agency."2
As with other dental professions, dental therapists' scope of practice is regulated state-by-state. Dental therapists began providing care in Alaska in 2005, then in Minnesota in 2011.3 The Alaska Dental Therapy Educational Program (ADTEP) requires 2 years of education, followed by a preceptorship with a supervising dentist, prior to certification by the Alaska Community Health Aide Program Certification Board. They are then certified to work offsite under general supervision, consulting with dentists electronically, and referring treatment outside their scope to dentists.4 In Minnesota, the dental therapist is limited to practicing primarily in settings that serve low-income, uninsured and underserved patients, or in a dental Health Professional Shortage Area. Additionally, the law defines specific services they can perform åunder the direction of a Minnesota licensed dentist through a collaborative management agreement.5 In 2015, the Commission on Dental Accreditation guidelines for dental therapy training programs were published. Since then, other states and tribal communities have gradually instituted programs; however, they are still in the minority, as legislation makes its way through each state individually.3
As states consider licensing mid-level providers, opponents argue that this model is unnecessary and potentially unsafe. Studies to determine the efficacy of this function have mostly concluded that appropriately trained mid-level providers are capable of providing satisfactory care. However, as stated in the Journal of the American Dental Association (JADA): "What is less clear is whether midlevel providers can provide these services in a cost-effective manner and whether incorporation of these providers into the workforce will result in improvement in the population's oral health."6
Moreover, the American Dental Association (ADA) has argued that access to care is not a result of dentist workforce size, but rather the location of practices, which can be solved by other measures. Allowing non-dentists to perform irreversible surgical or restorative procedures, with little or no direct supervision by fully trained dentists, is not acceptable to the ADA. Even though there are many successful mid-level programs in other countries, the organization states, applying these ideas here is misleading, as their systems differ dramatically from the United States.7
The Wider Landscape
While the ADA and state dental boards continue to weigh the need for dental therapists, other organizations and stakeholders have been providing resources and information to advocate for this model, including the Pew Charitable Trusts and the W.K. Kellogg Foundation. In a 2018 report from concerned US government agencies, Reforming America's Healthcare System Through Choice and Competition, the authors affirmed the need for more caregiver models with less stringent oversight: "Emerging healthcare occupations, such as dental therapy, can increase access and drive down costs for consumers, while still ensuring safe care. States should be particularly wary of undue statutory and regulatory impediments to the development of such new occupations."8
Naturally, the ADHA is committed to supporting new dental hygiene-based models, stating that: "1) The dental hygiene workforce is ready and available; there are currently 185,000+ licensed dental hygienists in the United States; 2) The educational infrastructure is developed; there are over 300 entry-level dental hygiene programs; and 3) The public will benefit from providers with a broad range of skills sets which include preventive and specific restorative services."2
Prior to 2020, progress toward dental therapists and expansion of access to care was being made amid a number of significant changes in oral health care. Variations in Medicaid, private and public insurance, the trend toward group practices and dental service organizations, emerging and important research on oral-systemic health, and even the rapid increase in dental technologies have been shifting the ground for years. Now, in a system that was already in flux, the impact of this year is even more likely to accelerate changes in workforce models.
"Between candidate scarcity and increased operating costs due to the pandemic, it's difficult for practices in large cities to service patient load right now," explains Tonya Lanthier, CEO and founder of DentalPost, an online job board. "That means it's even harder for rural and underserved areas to receive the dental care they need. The good news for these communities and for those who are considering becoming mid-level practitioners is that the pandemic is pushing many young people out of bigger, dense cities in pursuit of homeownership and a different lifestyle. If that trend continues, we could see a surge in demand for dental therapists/mid-level professionals and see it become more mainstream."
The next stages in oral hygiene professional opportunities are predicted to be extensive, more independent, and collaborative, with roles that are still being developed and may even be self-defined. Fortunately, in the end, these changes may improve the potential for better care for our underserved populations.
1. Northridge ME, Kumar A, Kaur R. Disparities in access to oral health care.Annu Rev Public Health. 2020;41:513-535.
2. American Dental Hygienists' Association. Expanding Access to Care through Dental Therapy. July 2019. https://www.adha.org/resources-docs/Expanding_Access_to_Dental_Therapy.pdf. Accessed August 26, 2020.
3. The Pew Charitable Trusts. Dental Therapy Timeline 2020. April 28, 2020. https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2020/dental-therapy-timeline-2020. Accessed August 30, 2020.
4. Lenaker D. The dental health aide therapist program in Alaska: an example for the 21st century. Am J Public Health. 2017;107(Suppl 1):S24-S25.
5. Minnesota Department of Health. Dental Therapist (DT) and Advanced Dental Therapists (ADT). https://www.health.state.mn.us/facilities/ruralhealth/emerging/dt/index.html#scope. Accessed August 31, 2020.
6. Wright JT. Do midlevel providers improve the population's oral health? JADA. 2013;144(1):92-94,
7. American Dental Association. Dental Crisis in America: The Need to Expand Access. February 29, 2012. https://www.ada.org/~/media/ADA/Publications/ADA%20News/Files/statement_120227_expandaccess.pdf. Accessed August 29, 2020.
8. U.S. Department of Health and Human Services; U.S. Department oftThe Treasury; U.S. Department of Labor. Reforming America's Healthcare System Through Choice and Competition. December 3, 2018. https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf. Accessed August 29, 2020.