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Academy of General Dentistry Responds to JADA Review of Midlevel Providers

Posted on Wednesday, October 9, 2013


CHICAGO (Jan. 2, 2013) — The Journal of the American Dental Association (JADA) published an article on January 2 titled “A Systematic Review of Oral Health Outcomes Produced by Dental Teams Incorporating Mid-level Providers.” This review examined the existing studies that occurred during a large time frame and aimed to answer this research question: “In populations where nondentists conduct diagnostic, treatment planning, and/or irreversible/surgical dental procedures, is there a change in disease increment, untreated dental disease, and/or cost-effectiveness of dental care?”

According to the JADA review, “Of critical significance is the fact that the quality of the evidence identified in this systematic review was poor overall.” After examining more than 7,000 studies, the review could only recommend 18 studies that met the review criteria. Of those 18 studies, only one had a low risk of bias, while 12 had a high risk of bias. This is extremely important when considering the conclusions of this review.

“Nearly 40 percent of the studies were conducted before the 1980s, before today’s fluoride exposure and other preventive measures,” says Academy of General Dentistry (AGD) President Jeffrey M. Cole, DDS, MBA, FAGD. “Despite the best efforts to identify relevant data, the data is just not there to support any assertion that the use of nondentists produces positive patient health outcomes.”

The JADA review also explains that “the supervision of the midlevel providers in each workforce model varied between, and sometimes within, countries.” In addition, the review could not find any data on the cost-effectiveness of dental care provided by the midlevel providers in these countries. This was an essential component of the question and a crucial portion of the review.

“The reviewers did not answer the question. The focus of the review is on dental teams that incorporate midlevel providers, not on midlevel providers acting independently or without supervision,” says AGD Speaker of the House W. Mark Donald, DMD, MAGD. “So, the conclusions of the review speak to the effects of increasing the size of the dental team, not to the effects of replacing dentists with midlevel providers.”

The review concluded that there was a decrease in caries increment/severity over time, and that there was no difference in caries increment/severity when compared to populations receiving treatment by providers other than midlevel providers.

“These may seem confusing,” says AGD Vice President W. Carter Brown, DMD, FAGD, “but actually all this is saying is that filling more cavities mean that more cavities were filled, but that the introduction of nondentists into the mix did not improve the overall oral health of the population. It did not reduce the number of individuals experiencing caries.”

This speaks to the broader view that the midlevel provider treatment strategy will not achieve improved oral health outcomes. To achieve improved health, we must turn our attention and resources to prevention, oral health literacy issues, and better utilization of existing services. Other countries, such as Denmark, have improved community oral health through this strategy, rather than trying to drill their way to health.

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