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
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