ISSUE
               
Access to Care
Advanced Dental Hygiene Practitioner (ADHP): Background and Forecast
- Ms. Ann Battrell


Ann Battrell, RDH, MSDH

Executive Director, American Dental Hygienists' Association




The House of Delegates of the American Dental Hygienists' Association (ADHA), in a visionary effort to address the severe oral health disparities plaguing millions across the United States, at its 81st annual session in 2004, adopted three key resolutions designed to impact the oral health of the public. Among these resolutions was a call for the creation of an Advanced Dental Hygiene Practitioner (ADHP).

ADHA's vision for the ADHP is a master's-level educated, licensed oral healthcare provider who will leverage the existing dental hygiene workforce to have an even greater impact on the delivery of oral health care to those in need.

In the medical field, healthcare providers such as nurse practitioners and physician assistants have proven effective and successful in working with physicians to expand medical care in a multitude of healthcare settings. The concept of mid-level providers in oral health is not new. Currently, more than 40 countries including Canada, New Zealand, Australia, and the United Kingdom allow mid-level practitioners to practice in oral health.

The ADHP is intended to serve in a capacity similar to that of the nurse practitioner—as a new member of the oral healthcare team who could provide an additional point of entry into the oral healthcare system for those who do not currently have access to routine dental care.

A 2007 survey conducted by the National Association of Community Health Centers found that restorative and preventive services were the top two needed oral health services as identified by the Federally Qualified Health Centers (FQHCs).1 The report also noted that among non-physicians, the dentists comprise the highest rate of provider vacancies in FQHCs. At the national level, a report by the Pew Center on the States proclaims that 49 million Americans live in areas federally-designated as having a shortage of providers.2

ADHPs will be educated in health promotion and disease prevention, provision of primary care, case and practice management, quality assurance, and ethics, a course of study which will provide a comprehensive approach to the delivery of oral healthcare services. ADHPs will bring increasing numbers of patients into the oral healthcare pipeline and make necessary referrals to dentists and other healthcare professionals, serving to strengthen the crucial link between the oral health, medical, and community networks.

ADHPs are anticipated to provide a full range of preventive services in addition to select restorative services with limited prescriptive authority to meet identified patient needs.

As envisioned, the ADHP will be a licensed dental hygienist educated at the master's degree level, the general academic standard for other advanced practice healthcare providers.

ADHPs will provide care in a variety of public health settings—schools, clinics, and long-term care facilities among others—to a diverse patient population. ADHPs will be well-placed to work collaboratively with dentists and other members of the oral health team through the use of teledentistry (the use of information technology and telecommunications for dental consultation, education, and public awareness) and other technology. The ADHP model has been acknowledged as a meaningful and substantive response to the call of the US Surgeon General to increase access to oral healthcare services for the nation's underserved.3

Recent Developments and Current ADHP Status

In March 2008, the Board of Trustees of ADHA adopted the Competencies for the Advanced Dental Hygiene Practitioner. The adoption of ADHP policies by the ADHA House of Delegates and ADHP Competencies by the ADHA Board of Trustees were the first steps in establishing the framework for advanced practice dental hygiene. Concurrently, the first advanced practice dental hygiene educational program began to be developed by Metropolitan State University in Minnesota, based, in part, upon ADHA's approved ADHP Competencies.

In 2009, Minnesota was the first state to pass legislation into law to create two new types of dental healthcare providers. This groundbreaking legislation was introduced by the Minnesota Safety Net Coalition and was supported by more than 60 stakeholder groups including the Minnesota Dental Hygienists' Association and the Minnesota State Colleges and Universities (MnSCU). The MnSCU system includes Metropolitan State University.

The outcome of the Minnesota legislation was the establishment of two new oral healthcare providers: a Dental Therapist (DT) and an Advanced Dental Therapist (ADT). The Dental Therapist language essentially outlines practice for a provider whose scope of practice would include some basic preventive services, limited restorative services, and extractions of primary teeth. Most services offered by Dental Therapists will require the presence of a dentist. In order to become licensed, Dental Therapists will have to graduate from an approved bachelor's or master's degree program.

The other new provider, the Advanced Dental Therapist, is a master's-level educated provider who will be licensed to practice under a more advanced scope of practice. Advanced Dental Therapists will evaluate, assess and treatment plan, perform nonsurgical extractions of permanent teeth, and administer all the services of a Dental Therapist. ADTs will also be able to provide, dispense, and administer analgesics, anti-inflammatory agents and antibiotics. Like Dental Therapists, Advanced Dental Therapists will work with a supervising dentist; however, ADTs will not require onsite supervision because they will administer care via a collaborative management agreement that sets forth standing orders for the administration of care.4

Metropolitan State University requires that enrollees in its master's program already be licensed to practice as dental hygienists. Graduates from the Metropolitan State University program will have dual licensure as an ADT and a dental hygienist and will be able to administer a wide range of preventive and restorative services. The first class of Advanced Dental Therapists is set to graduate from the Metropolitan State University System in June 2011. At this time eight state legislatures are currently investigating similar advanced practice dental hygiene or combined Dental Hygiene/Dental Therapy providers.

Recognizing that the national debate on new oral health workforce models will continue to evolve along with the multitude of other strategically important issues related to access to care, the ADHA is open to examining and discussing developing workforce models that can build upon the preventive and therapeutic knowledge and skill sets of dental hygienists.

How Will the ADHP and Similar Models Expand Access?

While new oral health workforce models are receiving a great deal of national attention, there are a multitude of strategies that will need to be in place in order to address the oral health access issues in the United States. Any new workforce model will require research evaluations and studies of the quality of practicing providers in the field. To date, only the dental health aide therapist (DHAT), a model based on dental therapy practicing in Alaskan tribal areas, has been formally evaluated.

In the fall of 2010, an evaluation on the use of DHATs in Alaska was released by the W.K. Kellogg Foundation. ADHA Leadership was encouraged that the Kellogg research indicated that the DHAT model is successful in bringing high-quality, cost-effective dental care to those in tribal Alaska. The evaluation also found that restorative services, which were previously administered only by dentists but are now offered under the scope of DHAT, can be successfully taught to mid-level providers.5

Clearly, additional evaluation will be necessary with any model that is implemented to determine effectiveness, but this process has been complicated by recent events in Washington. As a part of the Affordable Health Care Act signed into law in 2010, a federal grant program (the Alternative Dental HealthCare Provider Demonstration Grants) was designed and established to pilot-test emerging models of oral healthcare delivery. The grant program recognizes the need for innovations to be made in oral healthcare delivery to bring quality care to those who are currently underserved. The program would provide funding for up to 15 grantees testing new dental workforce models, including those that use entry-level dental hygienists, advanced practice dental hygienists, and dental therapists. In the recent budget negotiations, in spite of broad support from more than 60 stakeholder organizations, a provision was included to prohibit funding for the grants in fiscal year 2011. ADHA remains hopeful that these programs will be funded in future budgets.

Several factors are inherent in the design of an advanced practice dental hygiene model that would indicate a positive effect on access to care. Among these factors are:

  • A Ready Workforce to Implement the Model. The projected growth in the dental hygiene workforce remains robust. The Bureau of Labor Statistics forecasts 36 percent growth in the profession by 2018. With over 150,000 dental hygienists in the US, 325 entry-level dental hygiene education programs, 57 degree completion programs, and 20 master's degree programs, the dental hygiene profession is an ample workforce that is educationally prepared and licensed to meet the preventive needs of underserved populations.
  • Taking a Lesson from Medicine. The ADHP model as designed provides the public with a licensed provider who has received an accredited education at the master's level. Further, this model is based upon the nurse practitioner concept, which has been highly successful in medicine. The public, regulators, and legislators are all familiar and comfortable with this type of model, which will prove invaluable in bringing patients who lack care into the oral healthcare system and creating the legislation necessary to implement the model.
  • Economic Advantages. In a recent presentation at the Special Care Dentistry Association Annual Meeting, Michael Helgeson, DDS, made a presentation entitled "New Oral Health Workforce—Serving People with Special Needs.? Dr. Helgeson provided data from an analysis conducted by Apple Tree Dental in Minnesota, which looked at the cost impact of adding Minnesota's ADTs to their workforce. When Apple Tree estimated the salary of the new provider as midway between a dental hygienist and a dentist and looked at over 65,000 specific services based on ADA categories and codes, they found that each full-time ADT will result in savings of $50,000 per year.

ADHA readily acknowledges that with 50 states and 50 different practice acts, this issue is not a "one size fits all" proposition. ADHA, on behalf of the 150,000 dental hygienists in America, is dedicated to remaining open to collaboration and flexibility on this issue. Dental hygiene wants to do its part to ensure that no American ever need go without adequate oral health care.

1 Heath Centers' Role in Addressing the Oral Health Needs of the Medically Underserved, National Association of Community Health Centers, August 2007.

2 Shortage Designation: HPSAs, MUAs & MUPs, Health Resources and Services Administration, U.S. Department of Health and Human Services, http://bhpr.hrsa.gov/shortage (Accessed April 20, 2011).

3 American Dental Hygienists' Association. Advanced dental hygiene practitioner fact sheet January 2009. At: http://www.adha.org/downloads/ADHP_Fact_Sheet.pdf . Accessed: April 2011

4 American Dental Hygienists' Association. The History of Introducing a New Provider in Minnesota. At: http://www.adha.org/downloads/MN_Mid-Level_History_and_Timeline.pdf . Accessed: April 2011

5 Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska, W.K. Kellogg Foundation, October 2010