The oral health care workforce is a critical component of access to care for vulnerable and underserved populations in that access is dependent, in part, on the availability of a sufficient supply of competent oral health care professionals. The extent to which the different professionals interact with each other can vary greatly. In addition, the services that may be delivered by each professional often vary by state. These issues are not dissimilar to those which have been faced in other health care professions.
This chapter gives an overview of the oral health workforce including basic demographics, how professionals are educated, what kind of care they provide, and how they interact. The chapter continues with a discussion of the regulation of the health care workforce in general, and the dental workforce specifically. Finally the chapter concludes with descriptions of a variety of innovations in workforce education, training, and use to improve access and care for underserved and vulnerable populations. The capacity and efficiency of the oral health care system (including consideration of the adequacy of the workforce) is discussed in Chapter 4.
As with other health care professions, it can be difficult to definitively quantify the dental workforce for a variety of reasons including changes in employment status, differing measures (e.g., licensed vs. active professionals), the holding of more than one position per professional, and the presence of multiple and overlapping job titles. Aside from sheer numbers,
consideration is needed for geographic distribution and racial, ethnic, and gender diversity. This section provides a general overview of the basic demographics of the dental workforce.
Most professionally active dentists are general dentists (ADA, 2009d) (see Box 3-1 for types of dentists). Recognized specialties include orthodontics and dentofacial orthopedics, oral and maxillofacial surgery, pediatrics, periodontics, prosthodontics, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, and dental public health. Almost all professionally active dentists (92 percent) work in the private practice set-
Types of Dentists
A professionally active dentist is primarily or secondarily occupied in a private practice, dental school faculty/staff, armed forces, or other federal service (e.g., Veterans Administration, U.S. Public Health Service); or is a state or local government employee, hospital staff dentist, graduate student/intern/resident, or other health/dental organization staff member.
An active private practitioner is someone whose primary and/or secondary occupation is private practice.
A new dentist is anyone who has graduated from dental school within the last 10 years.
An independent dentist is a dentist running a sole proprietorship or one who is involved in a partnership.
A solo dentist is an independent dentist working alone in the practice he or she owns.
A nonowner dentist does not share in ownership of the practice.
An employed dentist works on a salary, commission, percentage, or associate basis.
An independent contractor contracts with owner(s) for use of space and equipment.
A nonsolo dentist works with at least one other dentist and can be an independent or nonowner dentist.
NOTE: Each of these types can be either general or specialty practitioners.
SOURCES: ADA, 2009b,d.
• Dental school faculty/staff member (1.7 percent)
• Armed forces (0.9 percent)
• Graduate student/intern/resident (1.3 percent)
• Hospital staff dentist (0.4 percent)
• State or local government employee (0.8 percent)
• Other federal service (0.8 percent)
• Other health/dental organization staff (1.0 percent)
In 2009, 48 percent of dental school graduates planned to enter private practice immediately while 30 percent planned to pursue advanced education, 10 percent planned to enter some form of government service, and less than one-half of 1 percent planned to enter the fields of teaching, research, or administration2 (Okwuje et al., 2010).
Dental hygienists are found in most settings where oral health services are provided, but they are mainly employed in private dental practices. They also work in educational institutions and in public health settings such as school-based clinics, prisons, long-term care, and other institutional care facilities (ADHA, 2009b; Mertz and Glassman, 2011). In private dental practice, the work of dental hygienists is generally billed under the dentist’s contractual agreement with an insurance company using the supervising dentist’s provider number. However, as of June 2010, 15 states allowed their state Medicaid departments to directly reimburse dental hygienists for their services (ADHA, 2010c).
Dental assistants primarily work in a clinical capacity, but other roles include front-office positions, practice management, and education (McDonough, 2007). Most dental assistants work in private practices and as assistants to general dentists, but many dental assistants work in specialty practices. Currently, there are multiple job titles for dental assistants across the country in different states (ADAA/DANB Alliance, 2005; DANB, 2007). These titles are generally grouped into four categories: entry level (e.g., trainees), dental assistants, certified or registered dental assistants, and expanded functions dental assistants (EFDAs) (DANB, 2007). Each of these categories includes multiple titles, depending on the state. For example, while the title of EFDA is commonly used to describe all dental assistants who can perform extended duties, there are many other titles used (e.g., expanded duties dental assistant, advanced dental assistant, registered restorative assistant in extended functions), and many states permit dental
1 Does not total 100 percent due to rounding.
2 The remaining graduates reported “other/undecided” for their future plans.
assistants to perform specific extended functions (e.g., coronal polishing, administration or monitoring of sedation, pit and fissure sealants) (DANB, 2007). In fact, some states permit certified dental assistants to act at the level of an EFDA, even though titles such as certified dental assistant or registered dental assistant are used (DANB, 2007). As stated by the Dental Assistant National Board, “Without a single, nationally accepted set of guidelines that govern the practice of dental assisting in the country, it is difficult to execute a concise overview” of the profession (DANB, 2007). (EFDAs are discussed further later in this chapter.)
Dental laboratory technicians (also known as dental technicians) create bridges, dentures, and other dental prosthetics. Dental technicians work in a variety of settings including dentists’ offices, their own private businesses, or small privately owned offices (BLS, 2010e). While dental technicians create devices based on the prescription of a dentist, denturists are trained and licensed in some states to work independently in taking impressions and making, fitting, and repairing dentures. Denturists were first recognized as a profession in Oregon, where licensure began in 1980 (Oregon State Denturist Association, 2011). Seven states currently regulate denturists (National Denturist Association, 2011). Denturists are not typically considered part of the traditional dental team.
Current Numbers and Future Demand
As mentioned previously, determining the exact number of professionals can be difficult because of differences in terminology, differing measures, and employment characteristics. According to the Bureau of Labor Statistics (BLS), dentists held approximately 141,900 jobs in 2008, with about 85 percent of those practitioners being general dentists (see Table 3-1). In that same year, an American Dental Association (ADA) survey found that there were 181,725 professionally active dentists, of which 79 percent were general dentists and 21 percent were new dentists (graduated within the previous 10 years) (ADA, 2009d). Similarly, it can be difficult to estimate the dental hygiene workforce. As shown in Table 3-1, dental hygienists held just over 174,000 jobs in 2008, but this is likely an overestimate, since many dental hygienists hold more than one job. A 2007 survey commissioned by the American Dental Hygienists’ Association (ADHA) found that there were about 152,000 licensed dental hygienists in the United States and that 130,000 were actively practicing (ADHA, 2009b). About half of all dental hygienists work part time (ADHA, 2009b; BLS, 2010c).
Table 3-1 also shows the BLS estimates of numbers of jobs held by and increases in growth of all dental professions. The BLS predicts a 36 percent growth in the employment of both dental hygienists and dental assistants
Employment of Dental Professions and Occupations, 2008 and Projected 2018
|Projected Increase in
Growth (%), 2008-2018
SOURCES: BLS, 2010b,c,d,e.
between 2008 and 2018, ranking them among the fastest growing of all occupations.
The BLS reports a mean annual wage of almost $143,000 for salaried general dentists (BLS, 2010d). This is similar to the ADA estimate of the average net income (from the primary private practice) for employed dentists of $132,000 (ADA, 2009c); however, as noted above, employed dentists account for only a small portion of all dentists. Dentists’ income can vary depending on setting and type of employment (see Table 3-2). Incomes also vary slightly depending on whether the practice is incorporated or unincorporated, the age of practitioner, the number of years since graduation, and the number of hours worked per year. In comparison, a survey of executive directors of health centers reported an average salary for the highest-paid dentist on staff of $125,000; the average budgeted salary for a dentist with 10 or more years of experience was $145,000 (Bolin, 2010).
In 2008, dental hygienists had a median annual wage of about $66,500 and dental assistants had a median annual wage of about $32,000 (BLS, 2010b, 2010c). Nearly 30 percent of dental hygienists do not receive any benefits (ADHA, 2009b). In 2008, dental technicians had a median annual wage of about $34,000 (BLS, 2010e).
The ADA estimates that 35 percent of all professionally active dentists are age 55 and older, with an average age of 49.6 years (ADA, 2009d). Among independent dentists in private practice, 43 percent are age 55 or
Private Practice Dentists’ Net Income by Type of Employment, 2007
|Practitioner||Net Income from
|All independent dentists||234,000||237,000|
|Independent general practitioners||206,000||208,000|
|Independent nonsolo general practitioners||232,000||237,000|
|Independent nonsolo specialists||392,000||405,000|
|Solo general practitioners||195,000||196,000|
|Employed dentists (weighted)||132,000||n/aa|
|Employed general practitioners||122,000||n/a|
|New employed dentists||114,000||n/a|
|Independent contractors (weighted)||114,000||n/a|
aN/A = not available.
SOURCE: ADA, 2009c.
older, with an average age of 52.3 years (ADA, 2009b). This may add to the burden of need for dentists as these practitioners near retirement. The mean age of dental hygienists is about 44 years of age (ADHA, 2009b), which, like dentists, may lead to concerns about the numbers nearing retirement.
About 79 percent of all professionally active dentists are male (ADA, 2009d). However, the gender gap is slowly closing; 63 percent of new professionally active dentists are male, and only 56 percent of first-year dental students in the 2008-2009 academic year were male (ADA, 2009d, 2010a). Overall, dental hygienists and dental assistants are virtually all female (ADHA, 2009b; McDonough, 2007). This is not likely to change drastically in the near future; among all students enrolled in accredited programs in 2008-2009, 97 percent of dental hygiene students and 95 percent of dentalassisting students were female (ADA, 2009a).
Racial and Ethnic Diversity
The racial and ethnic profile of the dental workforce is not representative of the overall population (see Table 3-3). While diversity among the dental professions students has increased in the previous decade (see Table 3-4), the numbers still are not significantly changed.
Evidence shows that a diverse health professions workforce (including race and ethnicity, gender, and geographic distribution) leads to improved access for underserved populations, greater patient satisfaction, and better
Dental Professions by Percentage of Race and Hispanic Ethnicity, 2000
|Black or African
aCategory excludes Hispanic origin.
SOURCES: U.S. Census Bureau, 2000, 2002.
Percentage of Dental Professions School and Program Enrollment by Race and Hispanic Ethnicity, 2000-2001 and 2008-2009
aIncludes only dental assistant students enrolled in CODA-approved programs.
Racial and ethnic diversity of entire dental assistant workforce may be different.
SOURCES: ADA, 2002, 2009a, 2010a.
communication (HRSA, 2006; IOM, 2004). The Agency for Healthcare Research and Quality 2010 National Healthcare Disparities Report (AHRQ, 2010) stated:
Workforce diversity increases the opportunities for race- and language-concordant health care visits. It also can improve cultural competency at the system, organization, and provider levels in several ways. These include appropriate program design and policies, organizational commitment to culturally competent care, and cross-cultural education of colleagues [Nickens, 1992]. As such, diversity is an important element of a patient-centered health care encounter.
Health care professionals from underrepresented minority (URM) populations, in part due to patient preference, often account for a disproportionate amount of the services provided to URM and low-income populations (Brown et al., 2000; HRSA, 2006; IOM, 2003; Mitchell and Lassiter, 2006). For example, a 1996 survey by the ADA revealed that nearly 77 percent of white dentists’ patients were white, while 62 percent of African American dentists’ patients were African American and only 27 percent were white (ADA, 1998; Brown et al., 2000). More recently, among dental students graduating in 2008, 80 percent of African American students and 75 percent of Hispanic students expected at least one-quarter of their patients would be from underserved racial and ethnic populations; nearly 37 percent of the African American students and 27 percent of the Hispanic students expected at least half their practice would come from these populations (Okwuje et al., 2009). In comparison, only 43.5 percent of white students expected at least one quarter of their patients to come from underserved racial and ethnic populations, and only 6.5 percent expected at least half of their practice to comprise these populations (Okwuje et al., 2009). It is important to note that the recruitment of low-income students (regardless of race or ethnicity) may also be important for the care of vulnerable and underserved patients (Andersen et al., 2010). A 2011 study of dental students found that students who were female, from URM populations, or had low socioeconomic status expressed greater attitudes of altruism than other students (Carreon et al., 2011).
Several factors complicate recruitment of URM students including lack of exposure to and knowledge of the dental profession, minimal opportunities for mentorship from dental professionals, and competition from other health professions for underrepresented minority students who are academically qualified (Haden et al., 2003). Other barriers may include lack of financial resources or knowledge of available financial aid.
Several Title VII grants are specifically targeted to increase the diversity of the health care workforce. Dental schools with significant enrollment of URM students are eligible for Centers of Excellence grants to improve
recruitment and training of URM students.3 Health Careers Opportunity Program grants are available to dental and dental hygiene schools to establish or extend programs to identify, recruit, and support students from disadvantaged backgrounds.4 Scholarships for Disadvantaged Students grants provide funding to dental and dental hygiene schools for financial aid to disadvantaged students.5 Experiences with bridge and pipeline programs to recruit students from URM, low-income, and rural populations are discussed later in this chapter.
Distribution of the Dental Workforce
The distribution of the dental workforce, both in geographic dispersion as well as specialization, is a long-recognized challenge (Brown, 2001; Hart-Hester and Thomas, 2003; Mertz and Grumbach, 2001; Saman et al., 2010). In 1957, Dr. Wesley Young stated, “A recurrent problem in dental manpower is the tendency of dentists to concentrate in urban areas, leaving sparsely settled sections of the state understaffed” (Young, 1958). In 2001, Brown noted that while the workforce may be adequate at the national level, there are imbalances at the regional level (Brown, 2001). Part of the reason for maldistribution has to do with the ability of a dentist to support private practices in rural areas because of population size or income (Allison and Manski, 2007; Wall and Brown, 2007; Wendling, 2010). These same issues may affect the development of independent dental hygiene practices (Brown et al., 2005). One way to estimate geographic distribution is to look at the ratio of dentists per population. In 2007, there was an average of about 59 professionally active dentists per 100,000 population, ranging from about 40 dentists per 100,000 population in Mississippi and Arkansas to about 102 dentists per 100,000 population in the District of Columbia (ADA, 2009d; U.S. Census Bureau, 2010). The lowest ratios occur across the southernmost states in the United States (Kaiser Family Foundation, 2011).
Within these numbers, there are variations in the types of dentists available in each region and across the country. For example, there are 0.7 professionally active periodontists per 100,000 adult population (age 18 and above), or more than 144,000 adults per professionally active periodontist. In contrast, there are about nine pediatric dentists per 100,000 population of children aged 17 and under, translating to more than 11,000 patients per pediatric dentist (about 3,200 children under age 5 for each pediatric dentist). But this varies even more when looking at individual states. For ex-
3 42 U.S.C. §293.
4 42 U.S.C. §293c.
5 42 U.S.C. §293a.
ample, Massachusetts has one pediatric dentist for every 6,000 children age 17 and under (one for every 1,600 children under age 5), but West Virginia has only about one pediatric dentist for every 23,000 children age 17 and under (one for every 6,200 children under age 5). Similarly, Massachusetts has one periodontist for every 18,500 adults, while West Virginia has one periodontist for every 84,000 adults.
Concurrently, the dental hygiene workforce may also be experiencing challenges owing to the maldistribution of dentists and the downturn in the economy. For example, a 2009 survey of dental hygienists showed that 68 percent of respondents reported finding sufficient employment was somewhat or very difficult in their geographic area, and of these, 80 percent felt that there were too many hygienists living in the area (ADHA, 2009a). Based on the number of providers per population, another way to measure the distribution of the dental workforce is to examine the designation of Health Professional Shortage Areas (HPSAs). By regulation, the secretary of the Department of Health and Human Services (HHS) has the responsibility of defining HPSAs.
Health Professional(s) Shortage Area means any of the following that the Secretary determines has a shortage of health professional(s): (1) An urban or rural area (which need not conform to the geographic boundaries of a political subdivision and which is a rational area for the delivery of health services); (2) a population group; or (3) a public or nonprofit private medical facility.6
Box 3-2 delineates the specific requirements for designation of a dental HPSA.
As of March 13, 2011, there were 4,639 dental HPSAs with 33.3 million unserved individuals; it is estimated that 9,933 new dentists would be needed to achieve the target ratio for these populations to be adequately served, defined as 1 dentist per 3,000 individuals (HRSA, 2011b). The number of dental HPSAs and need for dentists is on the rise; in 2009, there were 4,230 dental HPSAs and a need for 9,642 new dentists to meet unserved needs (HRSA, 2010c). Two-thirds of current dental HPSAs are in nonmetropolitan areas (HRSA, 2011b). Among all dental HPSAs, 17 percent are designated by geographic area, 34 percent are designated by population group, and 49 percent are designated by facility (HRSA, 2011b). Figure 3-1 shows the array of dental HPSAs across the country for both geographic areas (including areas in which the entire county is a dental HPSA) and population groups.
As discussed in Chapter 1, making estimates of underservice and unmet
Requirements for Dental HPSA Designation
Geographic areas must meet these requirements:
• Be rational areas for the delivery of dental services.
• Meet one of the following conditions:
￮ Have a population to full-time equivalent (FTE) dentist ratio of at least 5,000:1, or
￮ Have a population to FTE dentist ratio of less than 5,000:1 but greater than 4,000:1 and unusually high needs for dental services or insufficient capacity.
• Dental professionals in contiguous areas must be overutilized, excessively distant, or inaccessible to the population.
Population groups must meet these requirements:
• Reside in a rational service area for the delivery of dental care services,
• Have access barriers that prevent the population group from use of the area’s dental providers,
• Have a ratio of the number of persons in the population group to the number of dentists practicing in the area and serving the population group of at least 4,000:1, and
• Members of certain federally recognized American Indian tribes are automatically designated. Other American Indian or Alaska Native groups may be designated if the meet the basic criteria described above.
Facilities must meet these requirements:
• Be either federal and/or state correctional institutions or public and/or nonprofit medical facilities, and meet specific criteria.
• Federal or state correctional facilities must:
￮ have at least 250 inmates, and
￮ have a ratio of the number of internees per year to the number of FTE dentists serving the institution of at least 1,500:1.
• Public and/or nonprofit private dental facilities must:
￮ provide general dental care services to an area or population group designated as having a dental HPSA, and
￮ have insufficient capacity to meet the dental care needs of that area or population group.
SOURCE: HRSA, 2011a.
Dental Health Professional Shortage Areas designated by geographic area and population group.
SOURCE: HRSA, 2011c.
need are complicated. The committee recognizes that ratios of provider per population and designation of HPSAs alone do not fully depict access issues and do not on their own determine the availability of or utilization of care. For example, an increase in the number of providers per population does not necessarily translate into improved access to care. In addition, shortcomings in the current criteria and methodologies used to make HPSA designations have been identified (GAO, 2006; Orlans et al., 2002). However, until improved methodologies and criteria are developed, these measures serve as some of the only resources to help inform discussions about the availability of services, and serve as the basis for many policy decisions.
Over time, the education of dental professionals has largely evolved from apprenticeships to formalized programs in a variety of locations including dental schools, 4-year colleges and universities, community colleges,
and technical schools (Haden et al., 2003). The U.S. Department of Education recognizes the Commission on Dental Accreditation (CODA) as the accrediting agency for predoctoral dental education programs; programs for dental hygienists, dental assistants, and dental laboratory technicians; and advanced dental educational programs (e.g., residencies) (U.S. Department of Education, 2010). Federal support for dental education allowed dental schools to expand dramatically between 1960 and 1980, but this support has lagged in recent years (HRSA, 2005). Title VII training grants for dentistry currently take two forms: grants to increase the workforce that is prepared to care for vulnerable populations and grants to diversify the workforce, though the public policy goals of the Title VII grants have varied over time (HRSA, 2005; Reynolds, 2008).
Most U.S. dental schools offer a 4-year curriculum, after which graduates are awarded a degree as either a Doctor of Dental Medicine (D.M.D.), or a Doctor of Dental Surgery (D.D.S.) (ADA, 2010a). The number of dental schools in the United States is increasing, and more dentists are being produced. As of 2011, there were 61 predoctoral dental education programs in the United States and Puerto Rico, up from 57 schools in 2009 (ADA, 2010a; ADEA, 2011b). About 4,800 new dentists graduated in 2008, up from 4,095 in 1999 (ADA, 2010a). The number of dental schools is currently on the rise. (See Chapter 4 for further discussion.)
Cost of Education
The cost of dental education is a barrier to entry, especially for lowincome and URM students (IOM, 2004; Pyle et al., 2006; Sullivan Commission, 2004; Walker et al., 2008). In 2008-2009, the average annual tuition for dental schools was $27,961 for state residents and $41,561 for nonresidents (ADA, 2010a); the difference is significant considering many states do not have a single dental school. As this problem exists for several professions, the Western Interstate Commission for Higher Education created the Professional Student Exchange Program in which students from certain states may receive assistance to attend health professional schools (including dental schools) in other states (WICHE, 2011).
In 2009, average dental education debt was $164,000, ranging from $141,000 for graduates of public schools to $195,000 for graduates of private schools (Okwuje et al., 2010). Overall, 77 percent of graduates had at least $100,000 in debt, and 62 percent had at least $150,000 in debt (Okwuje et al., 2010). The average educational debt for all medical school graduates in 2010 was comparable; debt for medical students was approxi-
mately $158,000, with 78 percent of graduates having at least $100,000 in debt and 42 percent having at least $150,000 in debt (AMA, 2011b). However, these groups may not be exactly comparable, as medical students typically spend several years after graduation in internship, residency, and fellowship programs that may add to their subsequent accumulated debt.
Debt varies greatly among dental graduates and may affect future career choices. Twenty percent of graduates report having little to no debt (almost 10 percent had no debt); at the other end of the spectrum, another 20 percent report graduating with more than $250,000 in debt (Okwuje et al., 2010). Even within these numbers, there are variations; for example, 38 percent of graduates from private schools had more than $250,000 in debt, compared to 6.5 percent of graduates from public schools (Okwuje et al., 2010). Among graduates with no debt, 40 percent planned to enter private practice compared to 56 percent of those with $250,000 or more of debt; additionally, 33 percent of those with no debt planned to pursue advanced education compared to only 24 percent of those with $250,000 or more of debt (Okwuje et al., 2010). However, among all graduates, only 33 percent said that their educational debt had “much” or “very much” influence on their plans upon graduation (Okwuje et al., 2010).
One strategy that has been used to ameliorate the burden of student debt is the provision of financial incentives to care for vulnerable and underserved populations. The National Health Service Corps, developed in the 1970s, offers both scholarships and loan repayment to clinicians, including dentists and dental hygienists, who agree to serve for 2 to 4 years in an HPSA (HRSA, 2010b). In FY 2009, 464 dentists and 66 dental hygienists served in the National Health Service Corps (Anderson, 2010).
Traditionally, dental schools own and operate their own patient care clinics, where students receive most of their clinical training. These clinics operate as teaching laboratories in that their primary goal is to educate students; the care that patients receive is a secondary outcome and the patients served in those clinics may not be representative of a broad populations. (See Chapter 4 for more on dental school clinics as a site of care.) For both educational and financial reasons, many dental schools are now moving from the traditional clinical education model to community-based education where students rotate through off-site locations to provide care to vulnerable and underserved populations (Bailit et al., 2007; Ballweg et al., 2011; Berg et al., 2010; Formicola et al., 2008; Hood, 2009; Walker et al., 2008).
Community-based education is associated with greater confidence in performing procedures and caring for underserved and vulnerable popula-
tions (Bailit, 1999; McQuistan et al., 2010). These experiences have also been associated with smoother transition into professional practice; improved clinical skills; greater appreciation for social, ethical, and cultural issues; and increased willingness to care for vulnerable and underserved populations (Atchison et al., 2009; Baumeister et al., 2007; Berg et al., 2010; DeCastro et al., 2005; Holtzman and Seirawan, 2009; Johnson et al., 2007; McAndrew, 2010; Strauss et al., 2010). Community-based dental education has also been shown to have financial benefits for both the dental schools and the community settings (Bailit, 2010). However, a survey of dental students graduating in 2009 showed a varied response as to whether these experiences would affect their choice in practice location as well as their interest in treating URM patients (Okwuje et al., 2010).
Community surveys of graduating dental students show that the cumulative time students spend in extramural clinics has been steadily increasing; between 2003 and 2008, the percentage of students providing 4 or more weeks of care on extramural clinical rotations (cumulatively over the 4 years of dental school) increased from 47 percent to 62 percent (Okwuje et al., 2009). However, the survey of 2009 graduating dental students asked about the time spent in these sites on an annual basis (rather than cumulative time over the 4 years of school). The majority of students reported spending little time in extramural clinical rotations, with most of it occurring in the last year of school (see Table 3-5).
Support for community-based education is growing. In 2001, the ADA said “Dental schools should develop programs in which students, residents, and faculty provide care for members of the underserved populations in community clinics and practices” (ADA, 2001). In January 2010, the Advisory Committee on Training in Primary Care Medicine and Dentistry
Percentage of Time Spent in Extramural Clinics for Each Year in Dental School Reported by 2009 Dental School Graduates
SOURCE: Okwuje et al., 2010.
(established by law and supported by HRSA’s Bureau of Health Professions) recommended that Congress and the Centers for Medicare and Medicaid Services (CMS) “should revise funding policies for Graduate Medical Education and other educational programs to foster and support the use of community-based (nonhospital) sites for primary care training for physicians, dentists, and physician assistants” (Advisory Committee on Training in Primary Care Medicine and Dentistry, 2010). In addition, they recommended the provision of training grants to support and recruit communitybased clinician educators for health care trainees, including dentists.
In August 2010, CODA adopted a new resolution that includes a requirement for schools to make service learning and/or community-based learning opportunities available and encourage students to participate in these opportunities (ADA, 2010c; ADEA, 2011a). The stated intent of this requirement is
Service learning experiences and/or community-based learning experiences are essential to the development of a culturally competent oral health care workforce. The interaction and treatment of diverse populations in a community-based clinical environment adds a special dimension to clinical learning experience and engenders a life-long appreciation for the value of community service. (ADA, 2010c)
Over 90 percent of dental schools now offer community-based rotations for dental students (Haden et al., 2010). However, the breadth and depth of these experiences remains unknown. Additionally, many considerations are needed when establishing community-based dental programs such as the best time in the academic schedule to participate, transportation and housing issues, cultural competence of the students to work with diverse populations, legal liability, and developing partnerships with community sites (Mascarenhas and Henshaw, 2010). An additional challenge, as discussed in general previously, is the recruitment of experienced and available faculty in these settings, or the development of academic skills for those willing to become community educators (Hood, 2009; Mascarenhas and Henshaw, 2010; McAndrew, 2010).
Experiences with Specific Populations
Associated with community-based dental education, dental students’ exposure to specific vulnerable and underserved populations and students’ perception of the quality of the education they receive regarding those populations affects their confidence in caring for those populations (Baumeister et al., 2007; McQuistan et al., 2010; Vainio et al., 2011; Weil and Inglehart, 2010). For example, hands-on experiences with caring for children with special health care needs (Casamassimo et al., 2004), homeless populations
(Habibian et al., 2010), and patients with autism (Weil and Inglehart, 2010) has been associated with improvement in perceptions of those populations, increased confidence in caring for them, and greater likelihood to care for special populations in the future. However, among dental students graduating in 2008, 23 percent felt less than prepared to care for older adults and almost 31 percent felt less than prepared to care for patients with disabilities (Okwuje et al., 2009).
CODA’s accreditation standards state “graduates must be competent in assessing the treatment needs of patients with special needs” but does not require specific education or clinical experiences with caring for these populations (ADA, 2010c). The standards clarify the intent of the above requirement as
appropriate patient pool should be available to provide experiences that may include patients who’s [sic] medical, physical, psychological, or social situations make it necessary to consider a wide range of assessment and care options. The assessment should emphasize the importance of nondental considerations. These individuals include, but are not limited to, people with developmental disabilities, cognitive impairment, complex medical problems, significant physical limitations, and the vulnerable elderly. Clinical instruction and experience with the patients with special needs should include instruction in proper communication techniques and assessing the treatment needs compatible with the special need. (ADA, 2010c)
Training in the care of specific populations may affect dentists’ practice patterns. For example, one study of general dentists in Michigan and pediatric dentists across the country showed that only 41 percent of the general dentists reported performing infant oral health examinations compared to more than 80 percent of pediatric dentists, and that the general dentists were less engaged in prevention activities than the pediatric dentists (Ananaba et al., 2010). Other studies show examples of both pediatric dentists and general dentists not routinely encouraging or performing dental examinations or treatments before the age of one (Brickhouse et al., 2008; Malcheff et al., 2009; Salama and Kebriaei, 2010), which could indicate a need for improvements in dental education regarding the care of infants. One study from 2001 showed that the education of dental students in caring for infants varied widely among dental schools (McWhorter et al., 2001).
Upon completion of dental school, students may have had few opportunities to integrate their skills and knowledge with practical hands-on
experience and may not feel adequately prepared for independent practice, especially to care for underserved and vulnerable populations. Dental residencies provide further training in general dentistry or specialization in one of the nine recognized dental specialty areas. In 2008-2009, there were 5,864 total dentists enrolled in 723 advanced dental education programs in the United States (3,009 in first-year enrollments), including dental residencies and fellowship programs (ADA, 2010b). About half of these programs were sponsored by dental schools (ADA, 2010b). Among enrollees, 61 percent were male, and the racial and ethnic diversity mirrored their proportion in dental schools (see Table 3-4) (ADA, 2010b). Currently, two states require a residency as a requirement for licensure: New York and Delaware.7
In the 1995 IOM report Dental Education at the Crossroads (Crossroads) report, noting the lack of time in the curricula of undergraduate programs to develop critical skills, the committee concluded that “all graduates of U.S. dental schools should have the opportunity to round out and refine their predoctoral work through a supervised and accredited postgraduate experience,” leading to a formal recommendation for the development of postdoctoral educational programs to be made available for every graduate (IOM, 1995). A survey of deans of dental schools performed for that report found that three-quarters of the deans agreed that building or sustaining a strong postdoctoral general dentistry program was a priority, and slightly more than 60 percent agreed that a year of postgraduate training should be required within 10 years.
Additional training has been attributed to the better preparation of dentists to care for underserved and vulnerable populations (IOM, 1995). Postgraduate dental education in particular is seen as an opportunity to address these needs (Garrison, 1991; Glassman and Meyerowitz, 1999; Lefever et al., 2003; Morris et al., 1982). Dentists who have completed general dentistry residency programs report feeling more comfortable caring for underserved patients and patients with complex health care needs, and care for those patients more often, even after completing residency (Atchison et al., 2002; Dixon et al., 2002; Gatlin et al., 1993; Lam et al., 2009; Tejani et al., 2002).
The advantages and disadvantages of dental residency have been debated for decades. Advantages of dental residency include enhanced status of the profession and the opportunity to address both dissatisfaction with the breadth of undergraduate education and lack of student confidence in preparedness for practice (Hillenbrand, 1981; Lefever et al., 2003). In particular, many have noted that given the advances in science and technology,
7 Del. Code. Ann. tit. 24, s. 1122 (2011); N.Y. Comp. Codes R. & Regs. tit.8, s. 61.18 (2010).
the nation’s changing demographics, and the rising challenges in caring for vulnerable and underserved populations, the 4-year undergraduate education is inadequate to fully prepare students not only with sufficient knowledge, but with the skills to integrate this knowledge into practice (Atchison et al., 2002; Glassman and Meyerowitz, 1999; Hillenbrand, 1981; Kennedy and Tedesco, 1999; Lefever et al., 2003; Thierer and Meyerowitz, 2005; Yeager, 2001). Disadvantages of dental residency include the increased cost of education and the opportunity costs related to the delay of professional practice (Atchison et al., 2002; Hillenbrand, 1981; IOM, 1995; Lefever et al., 2003).
A survey of several cohorts of dentists showed that the respondents were evenly split regarding support of a mandatory fifth year of training (Lefever et al., 2003). Those who supported the extra year were more likely to have completed a residency themselves or to work in a setting such as a hospital or nursing home. Those who did not support the year argued that alternatively, curricular reform of dental school education would be preferable; they also cited autonomy—that is was the right of each dentist to decide if he or she needed additional training (Lefever et al., 2003). Both groups agreed that the extra year needed to be a practical, real-world experience rather than an extension of the undergraduate education program.
Barriers to expanding residency opportunities include the fact that funding sources, especially for the creation of new programs, may be tenuous, availability of training sites and faculty may be lacking, and adequate supportive staff is needed (Hillenbrand, 1981; IOM, 1995; Lam et al., 2009; Ng et al., 2008; Thierer and Meyerowitz, 2005). The 1995 Crossroads report found that “creating appropriately structured, stipend-paying residency positions demands a substantial investment of administrative and faculty time—and favorable local conditions” (IOM, 1995). Also, in 1981, Hilllenbrand expressed concern for the basis of such programs in the hospital setting, noting that “too much emphasis may be placed on the hospital aspects of the program at the risk of producing less than a comprehensively trained general practitioner” (Hillenbrand, 1981).
In comparison, other doctoral-level health care professions (e.g., allopathic medicine, osteopathic medicine, podiatric medicine) have requirements for residency training. The Crossroads report noted
[I]n contrast to medicine, substantial numbers of dental students do not pursue residency training after graduation. Yet, the emphasis in most dental schools on preparing students to be competent, entry-level general practitioners upon graduation puts a considerable burden on both schools and students. (IOM, 1995)
Students of allopathic and osteopathic medicine both complete 4 years of general graduate education. After this, these physicians complete be-
tween 3 and 8 years of internship and residency training (AMA, 2011a; AOA, 2011; BLS, 2009c). Further, some physicians receive additional fellowship training in a subspecialty (e.g., child and adolescent psychiatry as a subspecialty of psychiatry) (AMA, 2011a). Like dental students, students of podiatric medicine complete 4 years of graduate education geared toward their disciplines. However, after this, podiatrists then complete 2 or more years of postgraduate education in residency programs (APMA, 2011). Most states require at least 2 years of postgraduate training as a prerequisite for licensure in podiatric medicine (BLS, 2009d).
The role of dental residency programs in providing direct care for vulnerable and underserved populations is discussed further in Chapter 4.
HHS Financial Support of Dental Residency Programs
Title VII has been successful at expanding residencies in general and pediatric dentistry, which were, until recently, the only dental disciplines for which the grants were available (Ng et al., 2008). Title VII-funded dental residencies have been successful at recruiting and training URM students, and graduates of Title VII-funded medical residencies are more likely to provide care to underserved communities and populations, and are more prepared to provide culturally competent care (Edelstein et al., 2003; Green et al., 2008; HHS, 2003; Ng et al., 2008). A review of the impact of Title VII-funded dental residency programs found that
Title VII grantees have been instrumental in promoting community-based training to increase access to oral health services to underserved and vulnerable populations in the medically and dentally underserved communities where they reside. (Ng et al., 2008)
Title VII-funded programs have also been credited with developing curricula regarding the oral health needs of many vulnerable and underserved populations and developing interprofessional training approaches (Ng et al., 2008).
The Patient Protection and Affordable Care Act (ACA) significantly expanded the number of grants available for dental training, including funds for residencies in general, pediatric, and public health dentistry, as well as technical assistance to pediatric dentistry training programs. In addition to Title VII funds, several individual HHS divisions provide support for residency training (CDC, 2011; HRSA, 2010a).
Graduate Medical Education (GME) payments are also available to help train dental residents.8 Direct Graduate Medical Education (DGME)
8 Code of Federal Regulations, Centers for Medicare and Medicaid Services, Department of Health and Human Services, title 42, sec. 413.75 (2009).
payments cover a portion of the cost of resident stipends and expenses, and indirect medical education (IME) payments cover the additional costs associated with training (Iglehart, 2010). When dental residencies are located in a hospital setting, the hospital receives both DGME and IME payments from CMS. Dental school-based residencies are much more limited in their ability to receive GME funds. In 2003, CMS issued a regulation clarifying its policy on GME payments for residents trained outside the hospital: CMS would no longer provide any GME payments for residents whose training had historically been paid for by dental schools.9 As a result of this rule, 26 dental schools lost funding for most or all of their residency programs (Bresch, 2010).
In the 2008-2009 academic year, there were 301 CODA-accredited dental hygiene education programs (ADA, 2009a). Most of these programs award associate degrees (82 percent), but others award bachelor degrees, diplomas, and certificates. In 2008, there were 6,723 dental hygiene graduates (up from 5,345 in 1999) (ADA, 2009a). In the early years of the profession, dental hygiene education programs were often co-located with dental education programs in schools of dentistry (Haden et al., 2003). Today, about two-thirds of dental hygiene education programs are located in community, junior, and technical colleges (ADHA, 2006), which may decrease the amount of interaction between dentists and dental hygienists during their training, and therefore not prepare them to work as a team. Annual tuition can vary widely. For example, community colleges have an average annual tuition of $3,145 while the average annual tuition for programs co-located with dentals schools is $12,659 (ADA, 2009a). While the educational admissions requirements for dental hygiene education programs vary widely, more than 80 percent of first-year students have completed at least 2 years of college (ADA, 2009a). Faculty in dental hygiene education programs are mostly dental hygienists (76 percent) and dentists (21 percent) (ADA, 2009a). Recently, the ACA extended Title VII grant funding to dental hygiene programs in general, pediatric, and public health dentistry.
As with dental students, dental hygiene students need to be prepared to care for special populations and work in the community setting, but little is known about the extent of the education and training of dental hygienists for a variety of such populations (e.g., infants, diverse populations, older adults). A recent survey of dental hygiene programs revealed that nearly all programs (98 percent) present information on special needs
9 Code of Federal Regulations, Centers for Medicare and Medicaid Services, Department of Health and Human Services, title 42, sec. 413.75 (2009).
Competencies for Entry into the Professions of Dental Hygiene and Dental Assisting: Community Involvement (CM)
CM.1 Assess the oral health needs and services of the community to determine action plans and availability of resources to meet the health care needs.
CM.2 (Hygienists) Provide screening, referral, and educational services that allow patients to access the resources of the health care system.
CM.2 (Assistants) Provide educational services that allow patients to access the resources of the health care system.
CM.3 Provide community oral health services in a variety of settings.
CM.4 Facilitate patient access to oral health services by influencing individuals or organizations for the provision of oral health care.
CM.5 Evaluate reimbursement mechanisms and their impact on the patient’s access to oral health care.
CM.6 Evaluate the outcomes of community-based programs, and plan for future activities.
CM.7 Advocate for effective oral health care for underserved populations.
SOURCE: ADEA, 2010.
populations through lectures, but only 42 percent require related clinical experiences (Dehaitem et al., 2008). Most cited challenges with space in curricula, but nearly 30 percent expressed support for increasing these clinical experiences, and accreditation standards now require competence in assessing the needs of these populations. Dental hygiene programs are also embracing community-based education. In 2010, the American Dental Education Association House of Delegates redefined competencies for entry into the allied dental professions. Box 3-3 lists the competencies that focus on community involvement.
As will be discussed later in this chapter, some dental hygienists perform expanded duties in various sites of care and under different levels of supervision. As these duties expand, further consideration will be needed for the adequacy of dental hygiene education to practice in these settings, or if advanced training will be needed.
Dental assistants are trained on the job or in formal education programs. Education programs in dental assisting may be located in post-
secondary institutions (that may or may not be accredited by CODA), high schools, vocational programs, and technical schools (ADAA/DANB Alliance, 2005). Dental assistants may also be trained on the job by their employers. Considering the numerous educational pathways and the fact that most states do not license dental assistants, it is difficult to generalize a description of the workforce as a whole or to assess the impact of the various training alternatives (ADAA/DANB Alliance, 2005; Neumann, 2004). Little is known about the wide variety of programs that are not accredited by CODA.
In 2008-2009, there were 273 CODA-accredited dental assisting programs, almost all of which (87 percent) were in public institutions (ADA, 2009a). Average cost for tuition and fees of these programs for in-district students was $6,791 (ADA, 2009a). In 2008, there were about 6,100 graduates from CODA-accredited programs (ADA, 2009a). Virtually all CODA-accredited programs (88 percent) require a high school diploma for admission, and 9 percent require even more (ADA, 2009a). Most CODAaccredited programs are 1 year in length leading to a certificate or diploma. However, a few have a 2-year curriculum resulting in an associate degree. About 14 percent of faculty10 in CODA-accredited programs are dentists, 70 percent are dental assistants, and 28 percent are dental hygienists (ADA, 2009a).
Dental Laboratory Technicians
There are no formal education or training requirements for dental technicians, and most learn required skills through on-the-job training; however, some formal programs exist in universities, community and junior colleges, vocational schools, and in the military (BLS, 2010e). In the 2008-2009 academic year, there were 20 CODA-accredited programs (ADA, 2009a). Most accredited programs last 2 years, and 13 confer an associate’s degree. In the last 5 years, applications to these programs decreased by nearly 13 percent (ADA, 2009a). Average total tuition and fees range from $7,838 for in-district students to $18,214 for out-of-state students (ADA, 2009a). In 2008, there were 234 total graduates from accredited programs (ADA, 2009a).
As oral health has become recognized as integral to overall health, nondental health care professionals have become increasingly involved in the prevention, diagnosis, and treatment of oral diseases. Training primary
10 Some faculty members reported more than one discipline, so thesenumbers do not total 100 percent.
care clinicians in oral health leads to their increased ability to recognize oral disease and may help to increase their referrals to dentists (Dela Cruz et al., 2004; Pierce et al., 2002). In addition, practice changes resulting from this training can lead to increased access to preventive services and decreased dental disease (Chu et al., 2007; Kressin et al., 2009; Rozier et al., 2010). This section considers the education, training, and potential role of several nondental health care professions in the oral health care of the nation. The specific role of nondental health care professionals in the delivery of preventive services is discussed later in this chapter.
The need for physicians to learn about oral health has been recognized for nearly a century. In 1926, Gies stated
[A] policy of health service … which ignores oral hygiene, or neglects dental maladies … cannot be expected to commend itself to enlightened public opinion. Fortunately this disregard in the medical profession is gradually being replaced by serious attention to oral conditions, especially among the physicians who are engaged in public health services, and among … public-health nurses and teachers acting in their behalf. … This desirable movement promises to attain its logical development among practitioners of medicine in general when medical schools give to their students suitable instruction in oral hygiene, and in the correlations between clinical medicine and clinical dentistry. (Gies, 1926)
By the mid-20th century, this had become even more widely recognized (Ast, 1952; Bender and Seltzer, 1963; Bigler, 1951). In 1940, Dunning stated “It is amazing, at times, to realize how little many excellent physicians know about dental pathology and the modern treatment of dental lesions” (Dunning, 1941). Today, many physicians still do not receive education or training in oral health either during medical school, during residency training, or in continuing education programs (Krol, 2010; Mouradian et al., 2003). In addition, the breadth and depth of existing education and training efforts is highly variable (Douglass et al., 2009a; Ferullo et al., 2011).
Evidence on the ability of physicians to deliver oral health care is mixed. Even though many physicians recognize the importance of oral health, they often do not feel prepared to provide oral health care. Other barriers to the incorporation of oral health care into medical care include the ability to be reimbursed for services, availability of time in the practice schedule, and difficulty in making dental referrals (Close et al., 2010; Lewis et al., 2009). The following sections describe the education and training in oral health and the delivery of oral health care by several medical specialties.
Few medical schools include curriculum on oral health, despite the presence of oral health topics on medical licensing exams (Ferullo et al., 2011; Krol, 2004; Mouradian et al., 2005; USMLE, 2010a,b). Almost 70 percent of medical schools include 4 hours or less of oral health in their curricula, and more than 10 percent have no oral health education at all (Ferullo et al., 2011). Fewer than 50 percent of schools that teach oral health cover the risks of dental caries (Ferullo et al., 2011). In 2004, the Josiah Macy, Jr. Foundation funded a 3-year grant to examine oral health education (Formicola et al., 2005; Machen, 2008). One of the project’s reports emphasized the role for physicians in the identification and referral of patients with oral health needs (Mouradian et al., 2008). Subsequently, the American Association of Medical Colleges published learning objectives for oral health (AAMC, 2008). Courses that incorporate these objectives result in significantly increased student knowledge of oral health topics, even after 6 months (Silk et al., 2009). Efforts of the University of Washington to improve the oral health education of medical students are discussed later in this chapter.
A 2000 national survey of pediatricians found that more than 90 percent believed they had an important role in the recognition of oral diseases and the provision of counseling regarding the prevention of caries, and three-quarters expressed interest in the application of fluoride varnish in their practices (Lewis et al., 2000). However, half reported no oral health training in either medical school or residency. In spite of efforts to improve upon this, little has changed in the last decade. A recent survey of pediatricians on the care of children age 0-3 showed that more than 90 percent agreed they should examine these patients’ teeth but only 54 percent reported actually doing so (Lewis et al., 2009). In addition, 41 percent of respondents cited a lack of training as a barrier to incorporating oral health care into their practices. A 2006 survey found that two-thirds of graduating pediatrics residents thought they should be performing oral health assessments on their patients, but only about one-third received any oral health training during their residencies, and of those that did, two-thirds got less than 3 hours of training (Caspary et al., 2008). Only about 14 percent had clinical observation time with a dentist.
The American Academy of Pediatrics, the professional society for pediatricians, has developed explicit educational guidelines for oral health training in pediatric residency and the Accreditation Council for Graduate Medical Education (ACGME) requires that all residents must be able to
“implement age-appropriate screening, including oral health” (AAP, 2011c; ACGME, 2007b). In addition, the pediatric board exam has questions about oral health (ABP, 2009).
Family Medicine Physicians
In 2006, the residency review committee for family medicine residencies added oral health as a requirement (ACGME, 2007a; STFM, 2011b). Yet, a recent survey showed only three-quarters of the residency directors knew of this requirement, and only about two-thirds of the programs were actually including oral health content, with the most common training time being 2 hours per year (Douglass et al., 2009a). The development of an oral health curriculum for family medicine residency programs is discussed later in this chapter.
Internal Medicine Physicians
Oral health education is not a requirement for internal medicine residencies, although the geriatrics subspecialty requires education in oral health prevention, and the sleep medicine subspecialty requires residents to have experience receiving consults from oral maxillofacial surgeons (ACGME, 2008b, 2009a,b). In a survey of internal medicine trainees, 90 percent reported receiving no training on periodontal disease during medical school, and 23 percent said they never referred patients to dentists (Quijano et al., 2010).
Little is known about advanced education and training in oral health for obstetrician-gynecologists and oral health education is not a requirement for residencies in obstetrics and gynecology (ACGME, 2008a). There is some limited evidence that while obstetrician-gynecologists recognize the importance of good oral health during pregnancy, they may not incorporate it fully into their practice patterns (Morgan et al., 2009; Strafford et al., 2008; Wilder et al., 2007). For example, a national survey of obstetriciangynecologists showed that while 84 percent of respondents agreed that routine dental care is important during pregnancy, 69 percent do not routinely provide oral care information to their pregnant patients, 77 percent do not advise pregnant patients to get routine dental care, and only 54 percent reported performing an oral examination as part of their prenatal care (Morgan et al., 2009). In this same survey, 85 percent of respondents said “the quality of their training in oral health issues was inadequate to nonexistent” (Morgan et al., 2009).
The nursing workforce is composed of 3.1 million nurses including over 140,000 nurse practitioners (NPs) (ANA, 2011a,b). Basic professional nursing education includes mouth care and nurses could be educated to do oral health assessments as part of routine basic care for patients across the life span. However, in general, nurses have not placed a high priority on oral health (Clemmens and Kerr, 2008), and the training of nurses in oral health and hygiene is highly variable and often inadequate (Jablonski, 2010). Criteria set by the National Task Force on Quality Nurse Practitioner Education do not delineate any specific competencies for oral health (National Task Force on Quality Nurse Practitioner Education, 2008).
NPs in particular may have an important role to play in oral health care as a recent study found “substantial parallels” in the education and practice of dentists and nurses (Spielman et al., 2005). NPs have been defined as primary care providers (IOM, 1996) and can see patients independently and perform histories and physicals, perform lab tests, and diagnose and treat both acute and chronic conditions. NPs emphasize health promotion and disease prevention and especially focus on the health of individuals in the context of their families and communities. NPs commonly practice in rural areas and HPSAs, and the growth of the profession, in part, is due to their role in caring for underserved populations (Everett et al., 2009; Grumbach et al., 2003; Harper and Johnson, 1998). As such, they may serve as a frontline screening source for oral health disease. NPs have been shown to provide high-quality care (as compared with physicians), be cost effective, have high levels of patient satisfaction with their care, and contribute to increased productivity (Hooker and Berlin, 2002; Hooker et al., 2005; Lenz et al., 2004; Mezey et al., 2005; Mundinger et al., 2000; Sox Jr., 1979; Todd et al., 2004; Wilson et al., 2005).
In addition to NPs, there are over 3 million assistive personnel (e.g., nurse aides) who work in places where dental professionals generally do not (e.g., assisted living facilities, home health agencies) (PHI, 2010). In nursing home settings, certified nursing assistants often provide oral hygiene care for residents, but they may be unprepared for this task, having inadequate knowledge, and thus may make it a low priority (Chalmers, 1996; Coleman and Watson, 2006; Jablonski et al., 2009). For example, one survey of nursing assistants in nursing homes found they generally regarded tooth loss as “a natural consequence of aging” (Jablonski et al., 2009).
In 2005, a group of faculty from the Arizona School of Health Sciences and the Arizona School of Dentistry and Oral Health developed a set of eight general oral health competencies for NPs and physician assistants (PAs) (see Box 3-4). While these competencies have not been approved by any professional body, they reflect a combination of the evidence base
General Oral Health Competencies for Physician Assistants and Nurse Practitioners
1. Have the ability to do a thorough and competent oral examination
2. Be able to discern between normal and abnormal structures
3. Be able to discern obvious pathology and conditions of the oral cavity (e.g., oral cancers, fungal infections, traumatic conditions, dental diseases, congenital conditions)
4. Be able to inform adults and parents of young children what to expect in eruption patterns of primary and permanent teeth
5. Be able to recognize symptoms and manifestations of common diseases of the oral cavity
6. Be able to recognize oral symptoms of systemic diseases (e.g., anemia, syphilis, tuberculosis, thyroid dysfunction, Sjogren’s disease, xerostomia)
7. Understand what various dental specialties can do for your patients
8. Improve PA/NP-dental interface and referrals
SOURCE: Danielsen et al., 2006.
as well as the knowledge and skills that dentists think these professionals should have.
A survey of NPs regarding these proposed competencies showed that the majority do not feel prepared for basic competencies such as performing a thorough oral exam (58 percent), recognizing oral symptoms of systemic disease (78 percent), or discerning obvious oral pathology (60 percent) (Danielsen et al., 2006). In the same survey, PAs and NPs (answering together) thought they should have competence in performing the exam (77 percent), recognizing oral symptoms of systemic disease (79 percent), and discerning obvious pathology (88 percent). Further, in a different survey of NPs, only 19 percent thought their knowledge of oral cancers was current (Siriphant et al., 2001).
As health care professionals in community settings, pharmacists are often involved in health promotion and disease prevention activities such as public health education, health screenings, and the provision of vaccines. In 2008, pharmacists held almost 270,000 jobs; about 65 percent worked in retail settings and 22 percent worked in hospitals (BLS, 2009a). The BLS
notes a likely increase in the need for pharmacists to provide services in settings such as doctors’ offices and nursing facilities as well as to increasingly offer patient care services, such as the administration of vaccines (BLS, 2009a).
In regards to oral health specifically, customers may approach pharmacists regarding the treatment of oral health conditions such as mouth ulcers, cold sores, and persistent pain (Cohen et al., 2009; Macleod et al., 2003 Sowter and Raynor, 1997; Weinberg and Maloney, 2007). Pharmacists can have an important role in the management and treatment of oral disease such as through education on selection and use of daily oral hygiene products as well as referrals to dentists. No formal assessment has been done to evaluate the extent and depth of education and instruction that pharmacy students receive regarding oral health.
As primary care providers, PAs also have great opportunities and responsibilities to be involved in oral health care (Berg and Coniglio, 2006; Danielsen et al., 2006). PAs work under the supervision of a physician, but they can often work apart from the physician’s direct presence and can prescribe medications and bill for health care services. The BLS projects the PA profession to be the seventh fastest growing occupation between 2008 and 2018 (BLS, 2010a). In 2008, PAs held about 74,800 jobs (BLS, 2009b). More than half of these jobs were located in physicians’ offices, and about one-quarter were in hospitals.
About half of PAs work in family medicine or general medicine (Brugna et al., 2007; Hooker and Berlin, 2002). Like NPs, PAs are an especially important source of care for rural communities, low-income and minority populations, and in HPSAs (Everett et al., 2009; Grumbach et al., 2003) and have been shown to produce cost-effective care with quality of care comparable with physicians (Ackermann and Kemle, 1998; Brugna et al., 2007; Jones and Cawley, 1994; Sox, 1979; Wilson et al., 2005).
Most PA programs follow the traditional curricula of medical schools (Hooker and Berlin, 2002), and while some PAs receive advanced training, the bulk of the advanced programs focus on surgical and emergency care (APPAP, 2008). Very little is known about the extent of oral health education in the PA curricula. As in nurse practitioner programs, standards set by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) do not delineate any specific competencies for oral health (ARC-PA, 2010). A survey of PA program directors found “over 74 [percent] believed that dental disease prevention should be addressed in PA education, yet only 21 [percent] of programs actually did so” (Jacques et
al., 2010). The number of curriculum hours dedicated to oral health ranged from 0 to 14 hours, with an average of 3.6 hours.
In the previously mentioned survey regarding proposed competencies (see Box 3-4), only 53 percent of PAs indicated they were competent at performing an oral exam, 63 percent could “discern obvious pathology and conditions of the oral cavity,” and 34 percent could “recognize oral symptoms of systemic diseases” (Danielsen et al., 2006). Interestingly, 10 percent of PAs did not think it was important for them to understand what the various dental specialties could do for their patients (compared to 2 percent of NPs) (Danielsen et al., 2006).
The PA profession has started to address its lack of attention to oral health care. For example, the Duke University Physician Assistant Program has developed two online modules for oral health (Duke University, 2011). Further, as part of its 2010-2012 strategic plan, the American Academy of Physician Assistants (AAPA) cited one of its goals as being to “improve access to preventive health services by increasing the proportion of PAs in all specialties who are delivering oral health care” (AAPA, 2010). In addition, in 2010 the AAPA held a Physician Assistant Leadership Oral Health Summit that included leaders from the physician assistant profession as well as from dentistry and family medicine (Statler, 2010). A second summit will be held in July 2011.11
Public health workers include many of the professions previously mentioned, including both dental and nondental health care professionals. Public health generally refers to efforts to promote health and prevent disease for populations. As with other segments of the health care workforce, the public health workforce is difficult to enumerate due to the variety of professions involved, lack of a common taxonomy for job titles and duties, and a lack of a single comprehensive licensure or certification process for public health (HRSA, 2000). Little is known about the extent of training in oral health among schools of public health. A 2001 survey of schools of public health showed that 60 percent of schools had no faculty with a degree in dentistry or dental hygiene (Tomar, 2006). In addition, only 15 percent of schools offered a master of public health degree with a concentration in dental public health.
The predecessor to the present-day American Association of Public Health Dentistry was established in 1937, and represents a variety of public health professionals involved in oral health care (AAPHD, 2004). In 1948, the Association of State and Territorial Dental Directors was established to
11 Personal communication, C. Evans, University of Illinois, Chicago, February 9, 2011.
represent the directors and staff of state dental public health programs and is currently an affiliate of the Association of State and Territorial Health Officials (ASTDD, 2011). In 1951, the ADA recognized dental public health as a specialty of dentistry (AAPHD, 2004). In 2005, estimates of the number of public health dentists ranged from 153 (the number of diplomats of the American Board of Public Health Dentistry) to 498 (the number of dentist members of the American Association of Public Health Dentistry) to 543 (the number of members in the ADA directory reporting a specialty of dental public health) (Tomar, 2005). The role of state and local health departments is discussed further in Chapter 4.
Members of the community themselves also contribute to health improvement through the efforts of individuals who become part of the public health workforce. For example, in communities across the United States, community health workers (known as promotoras in the Hispanic community) link community members to systems of care, help to mobilize communities to change the conditions for health, and conduct health education. Community workers seem to be most effective when they are selected from among individuals who are respected and trusted by their communities. In addition to their knowledge of the community’s needs, their formal participation in the public health enterprise may also reassure community groups that are wary of government systems or health care providers for political, economic, or other reasons. In general health care, the use of community health workers has been shown to increase utilization of health care services and improve outcomes (Babamoto et al., 2009; Brownstein et al., 2005; Lewin et al., 2010; O’Brien et al., 2010; Rosenthal et al., 2010; Viswanathan et al., 2010; Whitley et al., 2006).
The importance of the interaction between dentists and other health care professionals has been recognized for nearly a century (Dunning, 1958; Rauh, 1917). More recently, in 2001, the ADA stated that “A formal dialogue among all health care professions should be established to develop a plan for greater cooperation and integration of knowledge in medical and dental predoctoral education, hospital settings, continuing education programs, and research facilities” (ADA, 2001). Still, health care professionals are typically trained separately by discipline. As a result, professionals may gain little understanding of or appreciation for the expertise of other professionals or the skills needed to effectively participate on a team, including how and when to refer patients to each other and how to best communicate with each other.
The Value of Interprofessional Care
The value of interprofessional care, especially to care for patients with complex care needs, and the importance of interprofessional education and training has been increasingly acknowledged (Baum and Axtell, 2005; Blue et al., 2010; Buelow et al., 2008; Dodds et al., 2010; Dyer, 2003; Fulmer et al., 2005; Hall and Weaver, 2001; Howe and Sherman, 2006; Lerner et al., 2009; Misra et al., 2009; O’Leary et al., 2010; Wilder et al., 2008; Williams et al., 2006). In particular, evidence is growing that interprofessional care leads to better care coordination, and, ultimately, better patient outcomes, improved satisfaction, and cost savings (Hammick et al., 2007; HHS, 2010; McKinnon and Jorgenson, 2009; Reeves et al., 2008, 2010; Snyder et al., 2010). While more professionals are gaining experience in interprofessional training, little evidence exists to determine which methods are best for imparting the knowledge and skills necessary to work as a team member, how such training affects patterns of practice, or how it affects patient outcomes (Cooper et al., 2001; Hall and Weaver, 2001; Remington et al., 2006; Thistlethwaite and Moran, 2010).
HHS supports interprofessional education and training through such vehicles as the Title VII interdisciplinary, community-based grant programs that are designed to promote interdisciplinary care and increase access to care for underserved populations and in underserved areas. In January 2010, the Advisory Committee on Training in Primary Care Medicine and Dentistry recommended that “training grants should provide funds to develop, implement, and evaluate training programs that promote interprofessional practice in the Patient-Centered Medical-Dental Home model of care” (HHS, 2010). They also stated that “funding should support clinical sites that prepare trainees for inter-professional practice by educating medical, dental, physician assistant, and other trainees together on health care teams.”
Interprofessional Care in Oral Health
Within oral health, two levels of team care may exist—first among dental professionals and second among various health care professionals. The federal government has a history of training dental professionals to work together more effectively. For example, in the 1960s, the predecessor to the modern-day HHS was actively involved in promoting workforce innovations such as dental auxiliary utilization, otherwise known as four-handed dentistry, and dental school-based training in expanded auxiliary management programs (Gladstone and Garcia, 2007; Johnson, 1969). These educational initiatives were designed to spur the adoption of team care in dentistry with each member of the dental team working up to the capac
ity of his or her training, in order to provide more care at less cost. More research will be needed for understanding the dynamics of the dental team as new types of dental professionals emerge. For example, a recent study of registered dental hygienists in alternative practice (RDHAP) in independent practice in California showed that nearly 48 percent found it “difficult” or “somewhat difficult” to find a dentist willing to accept their referrals (Mertz and Glassman, 2011).
Little research exists on the education and training of dental professionals and nondental professionals together in caring for mutual patients who have complex oral health needs. One exemplar is the creation of craniofacial teams. In 1962, the predecessor to the National Institute of Dental and Craniofacial Research funded the first multidisciplinary study of cleft palate, at the University of Pittsburgh Health Center (NIH, 2010), a teambased approach spearheaded since the 1930s by Dr. Herbert K. Cooper, an orthodontist in Lancaster, Pennsylvania (Long, 2009). Such an approach is now the standard of care for the management of children with cleft palate. However, there are no robust data on the impact of interprofessional training leading to interprofessional practice or on improving oral health outcomes.
Regulation of the health care workforce occurs at several levels. The primary role of the federal government is to protect consumers and promote fair competition. The bulk of activity to regulate the health professions occurs at the state level. In spite of national standards for education, each state develops its own statute for each health care profession, which establishes requirements for who may enter a profession, what competency requirements must be satisfied for licensure, and what services the professional may provide. Finally, the private sector can be involved in the healthcare workforce in that they often offer voluntary certification that may be required to practice in some states. For professions and occupations without licensure requirements, certification is one source of information and assurance of quality for consumers.
The Role of the Federal Government
The Federal Trade Commission (FTC) is charged by Congress to prevent “unfair methods of competition in or affecting commerce, and unfair or deceptive acts or practices in or affecting commerce,”12 including the enforcement of antitrust laws and other basic consumer protection laws.
12 15 U.S.C. §45.
The FTC and the Department of Justice (DOJ) advocate against the actions of professions that limit or prevent competition for the delivery of health care services by another profession (e.g., scope of practice laws or licensure restrictions) without providing countervailing consumer benefit (Chiarello, 2009).
As the FTC often does not have institutional expertise in specific professions, it provides guidance but leaves ultimate decision making to legislators and others to determine proper constraints on competition. The FTC suggests a four-part test for legislators to use in assessing their regulations (Chiarello, 2009). First is whether the regulation restricts competition. This often applies in the health care professions, since scope of practice laws by definition limit who can perform a particular service. Second is whether the restriction benefits consumers in a way that would not exist without the regulation. This often relates to consumer safety in that the restriction might prevent incompetent individuals from providing services. Third is consideration of the costs versus benefits to the consumer. That is, would the consumer gain more if restrictions were removed, such as through increased provider access. Finally, is the consideration of whether there is a less restrictive way to achieve the same goal. For example, is foreclosing competition to a certain group of professionals less or more restrictive than changing the competency requirements of that profession?
Some have argued that health care practice is not consistent with the economic principles of competition in which rivals compete to satisfy the demands of well-informed consumers (Feinstein, 2009; FTC and DOJ, 2004). There are several ways in which economic principles of market forces fail in health care. First, consumers are not particularly well informed—either as to the quality of care they receive or, in the case of insured individuals, to the true cost of services (FTC and DOJ, 2004). Also, health care professionals do not necessarily benefit financially for providing higher-quality care. Finally, market principles of competition do not help individuals who cannot pay for the demanded services (FTC and DOJ, 2004).
In the 1980s and 1990s, the FTC advocated on behalf of consumers in a number of states on legislation or regulation regarding scope of practice or supervision, advertising restrictions, or other anticompetitive behavior. In recent years, the FTC has been involved in two notable cases directly related to oral health. In 2000, the South Carolina legislature changed supervision requirements for dental hygienists to allow the delivery of preventive services in school settings without the direct presence of a dentist (FTC, 2010, 2011). The following year, the South Carolina Board of Dentistry enacted an emergency regulation to reinstate the supervision requirement, and in 2003, the legislature amended the law to reflect the regulation. The FTC subsequently brought an antitrust action against the board for reasons of unfair competition that would lead to the loss of preventive services for
thousands of children (Chiarello, 2009). More recently, the FTC became involved in actions surrounding in-school dental clinics. A 2009 state bill (HB 687) supported by the Louisiana Dental Association sought to make it illegal for anyone to provide school-based oral health care for a fee (FTC, 2009; Moller, 2010). In a May 2009 statement to the Louisiana house of representatives, the FTC noted the evidence base in favor of school-based dental programs and the lack of evidence for harm, and stated that “HB 687 restricts competition among dentists and does not appear to provide any countervailing benefits” (FTC, 2009).
The Role of States
Like other health care professions, dental professions are regulated on a state-by-state basis through statutes and regulation promulgated, interpreted, and enforced by boards of dentistry or dental examiners, or committees of those boards. A discussion by Safriet on scope of practice legislation and regulation for health professions describes the complexities of affecting change in the legislative arena to increase access to services (Safriet, 2002). At one level, she argues, laws and regulations are structured to protect the public, address patients’ rights, provide accountability, encourage quality, and promote equitable access. At another level, laws and regulations establish professional autonomy or professional control of another group and help to control competition, support market share, and preserve financial gain. In 2007, Dower and colleagues noted that decisions on scope of practice often lack robust evidence bases, and that strong lobbying groups play a significant role in shaping legislation (Dower et al., 2007). The authors noted that independent committees are increasingly being used to review proposed expansions in scope of practice.
Scope of Practice and the Health Care Professions
Professional battles and controversy over expanding a profession’s scope of practice are not new to the health care professions or unique to oral health care (Carson-Smith and Minarik, 2007; Daly, 2006; Huijbregts, 2007; RCHWS, 2003; Wing et al., 2004). The delegation of job responsibilites has been seen across the spectrum of the health care workforce as lesser trained workers take on increasingly complex duties. Nurse practitioners, for example, are largely seen as well-accepted members of the health care team, and there is a growing evidence base that attests to the quality of their care as compared to physicians (Lenz et al., 2004; Mundinger et al., 2000; Schulman et al., 1995; Sox, 1979; Wilson et al., 2005). In spite of this, their initial development was resisted, and extension of their scopes of practice remains a sensitive issue (Gardner, 2010; Hayes,
1985; Nelson, 2006; Office of Technology Assessment, 1986; Schachtel, 1978; Sharp, 1996; Sorrel, 2010; Sullivan and Rohlfsen, 2007). Professional tensions typically center around the quality of care (e.g., safety) provided by individuals with less training, but in many cases, evidence has not supported this. For example, advanced practice nurses are often involved in high-risk procedures such as childbirth and the administration of anesthesia, yet the evidence base continues to grow that the quality of their care is similar to that of physicians (Dulisse and Cromwell, 2010; MacDorman and Singh, 1998; Oakley et al., 1996; Rosenblatt et al., 1997). These examples may not track perfectly to serve as a comparison for some of the newer models of dental professionals (discussed later in this chapter) as PAs and NPs often have many more years of postsecondary education and training in comparison to some of these models (ADA, 2011a). However, they provide some insight for the development and use of multiple provider types. For decades, many have called for states to standardize entry-to-practice requirements (in part to improve the ability of professionals to move from state to state) and for state practice acts to be based on competence (Altschuler, 1994; Christian et al., 2007; Dower et al., 2007; Finocchio et al., 1995; Safriet, 1994). Several previous IOM reports have supported the idea of expanding scope of practice in alignment with professional competencies. In a 2008 IOM study of the health care workforce for older adults, the committee stated
health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence. (IOM, 2008)
In a 2010 IOM study of the nursing workforce, the committee recommended “Advanced practice registered nurses should be able to practice to the full extent of their education and training” (IOM, 2010). Specifically, that committee recommended that the FTC and the DOJ “Review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anticompetitive effects without contributing to the health and safety of the public” (IOM, 2010).
Structure of State Dental Boards
Dentists represent the overwhelming majority of members on state dental boards; it is common for the highest-level professional to be overrepresented on professional boards. Over 20 years ago, the IOM criticized the makeup of state health professions’ licensing boards, especially in regards to the allied health professions, stating
Licensing boards should draw at least half of their membership from outside the licensed occupation; members should be drawn from the public as well as from a variety of areas of expertise such as health administration, economics, consumer affairs, education, and health services research. (IOM, 1989)
Boards of dentistry typically regulate the dental hygiene profession, but as of August 2010, 17 states had either established dental hygiene advisory committees to the state dental board or enabled varying degrees of selfregulation for dental hygienists (ADHA, 2010a). This is similar to physician assistants; physician assistants are largely regulated by state boards of medicine, but several states have developed advisory committees or boards of physician assistants (AAPA, 2011). When one class of professionals is regulated by a different group of professionals, it is difficult to effect change in scope of practice to reflect the natural evolution of a profession (Dower et al., 2007; FTC and DOJ, 2004; Nolan et al., 2003). As a result of the current regulatory configurations in oral health, there is often tension between dentists and dental hygienists over requirements for practice in the profession (e.g., education, professional liability) and expansion in permissions or scope.
The primary purpose of a state dental board, like other health professional boards, is specifically to protect the interests of the public. However in a recent survey, 52 percent of dentists thought that the primary purpose of the state dental board was to protect the interest of dentists, and 32 percent thought they protected the interests of both dentists and the general public (Malcmacher, 2011).
Dental Scope of Practice, Supervision, and Ownership
Scope of practice laws and regulations in oral health generally distinguish between preventive and restorative procedures as proxies for the divide between services considered to be within the exclusive scope of dentists and those that are permitted or may be delegated to other dental professionals. While provision of preventive care and education by nondentists is generally accepted in the United States, some cite concerns for quality of care when considering permitting nondentists to provide restorative services (ADA, 2011a; AGD, 2008; GDA, 2010). Variations in permissible practice among the states are broad, especially for dental hygienists and dental assistants (ADAA/DANB Alliance, 2005; HRSA, 2004). Laws and rules governing dental professionals are often proscriptive describing explicit parameters on
• Particular tasks that can or cannot be performed,
• The exact settings in which particular services can be provided, and
• The conditions under which allied professionals may work (e.g., levels of requisite supervision, mandates for preauthorization by dentists).
State boards not only manage and interpret state dental practice acts, but they also promulgate rules to address practical issues including how many dental professionals may be supervised by a dentist, whether dental hygienists are permitted to supervise dental assistants, and who can own a dental practice or employ dental professionals (known as corporate practice rules). Both the ADA and the Academy of General Dentistry support legislation that restricts the ownership and operation of dental practices to dentists licensed in that state (ADA, 2010d; AGD, 2011). As in medicine, where physicians are given significant latitude to delegate to other health professions, in dentistry, dentists have the autonomy to delegate tasks at their professional discretion.
Impact on Access to Care
While restricting scope of practice is generally attributed to protecting consumers from unsafe or untrained professionals, data suggest that restrictive licensure laws in oral health are not tied to better health outcomes or supported by scientific evidence; in fact, stringent laws have been tied to increased consumer costs, which may restrict an individual’s ability to access care (IOM, 1989; Kleiner and Kudrle, 2000; Shepard, 1978). Licensure laws also affect wages and employment opportunities. Studies show that more restrictive laws lead to increased income for dentists, while less restriction leads to decreased income and employment growth for dentists and greater income and employment opportunities for dental hygienists (Kleiner and Kudrle, 2000; Kleiner and Park, 2010; Shepard, 1978; Wanchek, 2010).
The Role of the Private Sector
Certification is a voluntary process by which a private organization imposes a certain level of standards, either through testing or some other method, in order to become “certified.” Certification is often used as a measure of competence, especially in professions that do not have a formal licensure. The Dental Assisting National Board estimates that almost 12 percent of dental assistants in the United States are certified dental assistants (CDAs) (ADAA/DANB Alliance, 2005). The CDA credential is a nationally recognized credential offered by the Dental Assisting National
Board. Certification as a dental assistant requires passage of a three-part written examination in the areas of radiation health and safety, infection control, and general chairside assisting. More than 32,000 dental assistants have CDA certification (DANB, 2010). Currently 28 states recognize or require CDA certification to perform expanded duties, and a total of 37 states plus the District of Columbia recognize or require one or more components of the full CDA exam for particular expanded functions (e.g., Radiation Health and Safety Exam, Infection Control Exam) (DANB, 2010).
Dental technicians can voluntarily become certified dental technicians by the National Board for Certification in Dental Laboratory Technology, an independent board established by the National Association of Dental Laboratories (BLS, 2010e). Three states (Kentucky, South Carolina, and Texas) require this certification. Certification exists for the manufacture of crowns and bridges, ceramics, partial dentures, complete dentures, and orthodontic appliances. In Florida, dental laboratories must register with the state, and at least one technician must meet requirements for continuing education (18 hours every 2 years) (BLS, 2010e).
The following sections provide descriptions of an array of workforce innovations being used to improve access to oral health care. These examples include improving the diversity of the workforce, enhancing the education of health care professionals, encouraging the participation of nondental health care professionals, expanding the roles of existing dental professionals, and developing new types of dental professionals. In some cases, these innovations are too new to have robust outcomes data for impact on access to care or oral health status, especially in the long term, and therefore the committee does not intend to imply that it is recommending these approaches. In addition, these examples are not exhaustive of all of the strategies being used across the nation. Instead, they serve to illustrate the wide variety of ideas and opportunities for improving how the oral health care workforce is recruited, educated, trained, and used in order to improve access to care for vulnerable and underserved populations.
Innovations in Recruitment
Bridge and pipeline programs are two strategies used to promote awareness, increase enrollment, and foster retention of students from URM, lower-income, and rural populations into the oral health professions. In the literature, bridge and pipeline are sometimes used interchangeably. Technically, bridge programs are interventions that focus on prebaccalaureate (e.g., elementary school students through high school graduates), and
pipeline programs are interventions that focus on undergraduate and preprofessional program populations. Key features of both types of programs include outreach to URM, lower-income, and rural students (sometimes as early as elementary school), community-based education opportunities, mentoring, and financial aid.
Bridge programs have a long history in specific health professions (e.g., medicine, nursing, and dentistry) (Awé and Bauman, 2010; Brooks et al., 2002; Kim et al., 2009; Lewis, 1996). For example, through its Bridge to Dentistry program, the Baylor College of Dentistry collaborated with local school districts, colleges and universities, community organizations, dental clinics, and community dentists to provide outreach, enrichment, and mentoring opportunities. Enrollment of URM students increased by 325 percent and subsequently, the school retained 91 percent of its URM students (Brooks, 2005; Brooks et al., 2002). More recently, the University of Minnesota School of Dentistry initiated the Building Bridges program with funding from HRSA’s Health Careers Opportunity Program.13 In partnership with the local school district, the university, and community-based organizations, the school of dentistry recruits middle school, high school, and college students from URM communities to participate in weekend and summer enrichment programs with community-based education experiences and mentoring.
Pipeline Education Programs
The pipeline strategy has been used in a variety of health professions (e.g., medicine, nursing, and dentistry) (Brunson et al., 2010; Cantor et al., 1998; Formicola et al., 2010; Grumbach and Chen, 2006; Hesser et al., 1996; Rackley et al., 2003; Thomson et al., 2010). In 2009, HRSA’s Bureau of Health Professions and the Office of Minority Health conducted a review of studies and evaluations of diversity-oriented pipeline programs and concluded that
These studies consistently indicate that pipeline interventions are associated with positive outcomes for racial/ethnic minority and disadvantaged students on several meaningful metrics, including academic performance and the likelihood of enrolling in a health professions school. (HHS, 2009)
13 For more information, visit http://www.dentistry.umn.edu/programs_admissions/BuildingBridges/home.html.
Yet, there is scant research on which specific program components and approaches yield the greatest results and few studies that document the long-term effectiveness of pipeline programs (Thomson et al., 2010). As one recent study suggests, it may be necessary to track program participants for as many as 10 to 15 years to accurately assess the impact of pipeline programs (Winkleby, 2007).
The Dental Pipeline Program
Between 2001 and 2010, the Robert Wood Johnson Foundation (RWJF), in collaboration with the California Endowment and the W.K. Kellogg Foundation, supported the Pipeline, Profession, and Practice: Community-Based Dental Education initiative with two primary goals:
1. Increase the time that senior dental students spend in community clinics and private practices providing care to underserved populations.
2. Increase enrollment of low-income and URM students in dental school (Bailit and Formicola, 2010).
An initial round of funding provided an average of $1.3 million to 15 dental schools for program development and implementation (Chard et al., 2009). A second round of funding included 14 additional dental schools (Bailit and Formicola, 2010). Program profiles, including activities, accomplishments, and community partners, can be found on the RWJF project website.14 Two recent supplemental issues of the Journal of Dental Education were devoted to the dental pipeline program. The first included an extensive evaluation of the program (Leviton, 2009a, b). The second described specific strategies for successful implementation of pipeline programs (Lavizzo-Mourey, 2010). In addition to these journals, there is a substantial literature related to dental pipeline programs (Andersen et al., 2005; Markel et al., 2008; Price et al., 2007; Thind et al., 2008; Veal et al., 2004). The following are some key findings:
• There was a 54 percent increase in the first year enrollment of URM students in the first phase of the program (compared to 16 percent in nonpipeline schools during the same time period) (Andersen et al., 2009; Formicola et al., 2010).
• Over the course of the program, pipeline schools increased the time senior students spent in community sites from an average of 10 days to 50 days (Formicola et al., 2010).
• Based on the number of patients served by pipeline programs, one study estimated, “If all dental schools assigned senior students and pediatric and general dentistry residents to community clinics and private practices for 70 days per year, about 2 million more lowincome patients would receive care” (Formicola et al., 2009).
A review of effective outreach and recruitment programs found that a number of strategies appear to have been especially effective, including summer enrichment programs, mentoring, and regional/collaborative outreach efforts (Brunson et al., 2010). Partnerships with affiliated medical schools and scholarship or loan programs were also noted as important elements of effective programs (Brunson et al., 2010).
However, the successes of the pipeline program represent small gains in national enrollment among URM students, and results were variable across schools (Brunson et al., 2010). Moreover, it has yet to be determined whether these programs will have a long-term impact on increasing diversity in the dental profession. Evidence suggests that pipeline programs require both a sustained commitment by participating schools and sufficient resources to maintain momentum (Brunson et al., 2010; Thind et al., 2009).
Innovations in Dental Education
As discussed previously, most dental schools are now moving toward adding community-based education to their curricula for both educational and financial reasons. In particular, community-based dental education has been associated with students’ improved confidence and willingness to care for vulnerable and underserved populations. The Pipeline, Profession, and Practice program described above gives one example of an innovation to move dental education into community settings. Below, several schools of dentistry are highlighted as examples of other innovations in dental education.
The Arizona School of Dentistry & Oral Health
The Arizona School of Dentistry & Oral Health focuses on training dental students to become community-based educational leaders for populations in need. In that regard, the school officials look to recruit students with diverse backgrounds who show commitment to serving communities in need. For example, one of the main criteria of admission is the documented demonstration of previous community service (ASDOH, 2011). In their fourth year, students spend half of their time outside the school including sites such as community health settings and Indian Health Service clinics. About one-quarter of graduating classes went to work in community health
centers (Dillenberg, 2009; Hood, 2009). Finally, every student graduates with a certificate in public health, which is a requirement for graduation.
East Carolina University School of Dental Medicine
The East Carolina University School of Dental Medicine was developed with capital funding from the North Carolina general assembly in response to the state’s significant access disparities (Chadwick and Hupp, 2008). Scheduled to start admitting predoctoral students in 2011, the school seeks to build its educational program with a focus on primary care for rural and undeserved populations. To this end, the school will build up to 10 service learning centers in underserved and rural areas of North Carolina that will operate to train dental students and residents while acting as a safety net provider for underserved populations in the state. Senior dental students will spend up to 24 weeks in these centers providing care and learning how to work in a delivery system that functions more like a private practice than a traditional dental school clinic. The centers will include faculty, general and pediatric dentistry residents, dental hygienists, dental assistants, and senior dental students (Bailit and D’Adamo, 2010; Chadwick and Hupp, 2008). Features include
1. Senior students will treat at least six to seven patients per day;
2. Faculty will practice as they supervise residents and students;
3. Residents will have some responsibility for supervising students; and
4. Centers will be operated by a professional management team.
When fully operational, the centers are expected to average 150,000 or more visits annually (Bailit, 2010). It is important to emphasize that the clinical education strategy is feasible because of the availability of an enhanced Medicaid reimbursement rate (discussed further in Chapter 5).
West Virginia University School of Dentistry
The educational program at West Virginia University requires dental students to work in a rural practice for a 6-week rotation in their senior year. During these rotations, the dental students are housed with other health professions students and have formal interprofessional activities (Hood, 2009). In addition, students must perform 100 hours of approved community service over the 4 years of school. In 2007, 58 percent of graduates began practice in underserved areas of West Virginia (Hood, 2009).
Innovations in Nondental Education
Innovation in Medical School Education
The University of Washington Medical School created and has started to implement a comprehensive oral health curriculum for medical students; results show students have more confidence in identification of oral disease, and attitudes toward oral health care improved (Mouradian, 2010; Mouradian et al., 2005, 2006). The goals and competencies in oral health developed for this program are listed in Table 3-6.
Innovation in Graduate Medical Education
In 2005, the Society of Teachers of Family Medicine released Smiles for Life, a national oral health curriculum for improving the oral health training in family medicine residency programs (Douglass et al., 2007, 2009a; STFM, 2011b). This curriculum was developed with materials developed by dentists, physicians, and educators and within 2 years was adopted by most family medicine residency programs (STFM, 2011b). In 2008, a second edition was released in which the curriculum was expanded to reach all primary care providers, including physician assistants and nurse practitioners (STFM, 2011b). Finally, in June 2010, a third edition was released that added interactive, online learning modules for individual practitioners (STFM, 2011b). As of 2008, about two-thirds of family medicine residency directors reported using Smiles for Life materials in their residency programs (Douglass et al., 2009a).
The Smiles for Life curriculum consists of seven 45-minute modules and has been approved for continuing education credit by the American Academy of Family Physicians (STFM, 2011a). These modules address the nature, prevalence, and consequences of oral disease throughout the life cycle; the clinician role in preventing oral diseases and promoting oral health; basic risk assessment and examination; patient counseling; and the needs of special populations. Smiles for Life also provides online learning for primary care providers to apply fluoride varnish in their offices (STFM, 2011c). Completion of this module is required by many states as a prerequisite for reimbursement.
Innovation in Nursing Education
In 2005, New York University created a unique partnership in which a college of nursing was located within the college of dentistry. As part of the interdisciplinary educational model, pediatric nurse practitioner students work alongside dental students to provide care in school clinics and
Oral Health Goals and Competencies for Medical Students
|Goals for Student
|Has dental public health knowledge, believes oral health is important, and that physicians have a role in oral health||Can describe which patients are at increased risk for oral diseases (low socioeconomic status/minority status, patients with special needs/disabilities, living in rural or underserved areas)|
|Can describe barriers to access/utilization of dental services (lack of insurance or providers, cultural, geographic issues, etc.)|
|Can describe importance and safety of public water fluoridation|
|Can describe roles physicians can play in identification/prevention of oral disease|
|Has knowledge in caries prevention and can screen for caries and collaborate with dentists||Can describe caries process and sequelae|
|Can screen for caries on exam|
|Can assess risk factors for caries (i.e., socioeconomic status, diet, hygiene, lack of fluoride, caries in mother or siblings of children at risk, medicines with sugar or xerostomia, lack of access to dental care)|
|Can counsel about caries process and prevention including diet/feeding, fluoride, oral hygiene (especially brushing with fluoridated toothpaste)|
|Can counsel mothers about transmission of cariogenic bacteria to infants and need for maternal oral health care|
|Can recommend regular dental care; refer to dentists appropriately|
|Has knowledge in periodontal disease prevention and recognition, and can collaborate with dentists||Can describe periodontal disease, sequelae|
|Can screen for periodontal disease|
|Can counsel about periodontal disease prevention (smoking/tobacco, oral hygiene, including brushing and flossing, role of medications in treating, or promoting periodontal disease)|
|Can recommend regular dental care and refer to dentists appropriately|
|Can counsel patients about systemic importance of periodontal disease (e.g., can affect diabetic control; possible linkages with prematurity/low birth weight, heart disease)|
|Can counsel pregnant patients about pregnancy gingivitis and the need for regular dental care|
|Has knowledge of oral cancer risk factors and can screen for oral cancer and counsel patients||Can screen for oral malignancy on exam|
|Can assess risk factors for malignancy (smoking, tobacco/alcohol use)|
|Can counsel patients about prevention strategies (prevention/cessation of smoking, tobacco, and alcohol use)|
|Oral-Systemic Health Interactions|
|Has understanding of important oral-systemic interactions and can monitor for these||Can monitor impact of oral health on nutrition (especially in infants/elderly and special populations)|
|Can monitor oral impact of medications, including erosion, caries, and periodontal disease|
|Can assess/treat oral conditions associated with AIDS, chemotherapy|
SOURCE: Adapted from Mouradian et al., 2005.
Head Start programs (Garcia et al., 2010; Hallas and Shelley, 2009). This allows the pediatric nurse practitioner students to learn about caries risk assessment and how to apply fluoride varnish while the dental students can become more familiar with the role of the advanced practice nurse in oral health. Both sets of students also learn key skills in team-based care, including how to care for systemic oral health diseases.
Innovations That Enhance the Use of Nondental Professionals
One strategy for improving access to preventive services for oral health, especially for children, has been to expand the use of nondental health care professionals (Douglass et al., 2009b; Hallas, 2010; Hallas and Shelley, 2009; Okunseri et al., 2009). Nondental health care professionals can incorporate oral health into their routine exams and wellness visits with basic risk assessments, oral exams, anticipatory guidance, and the provision of basic preventive services (Cantrell, 2009; Morrow et al., 2008; Riter et al., 2008). For example, fluoride varnish is increasingly being applied by nondental health care professionals and in community-based settings (AAP, 2011b; ASTDD, 2007).
One barrier to engaging nondental health care professionals is their inability to be reimbursed for some services through traditional medical insurance. Health insurance plans do not routinely cover oral health care. State Medicaid programs do provide coverage under the Early and Periodic Screening and Diagnostic Treatment benefit for children and adolescents receiving routine oral health care, but in the past, state Medicaid programs often did not allow nondental health care professionals to be reimbursed for preventive care in oral health. However, this is changing. In 2008, 25 state Medicaid programs reimbursed primary care providers for preventive services in oral health (Cantrell, 2008). In 2009, 34 states did so, and as of 2011, 40 states reimbursed for this care (AAP, 2011a; Cantrell, 2009). The types of services typically reimbursed include oral examination, screening, and risk assessment; anticipatory guidance and caregiver education; and application of fluoride varnish (Cantrell, 2009). Other barriers to engaging nondental health care professionals in preventive care can include the lack of appreciation of the importance of oral health, lack of confidence in their skills, skepticism on the efficacy of preventive services, and inadequate time in the patient visit (Lewis et al., 2000; Rozier et al., 2003).
Several individual state-based initiatives have arisen to help improve nondental health care professionals’ involvement in providing basic preventive services for oral health. North Carolina’s Into the Mouths of Babes
program targets children from birth to age 3 (Rozier et al., 2003, 2010). The project aims to improve practitioners’ oral health knowledge, incorporate caregiver counseling and fluoride varnish application into primary care practices, and increase screenings and dental referrals for children with oral diseases or are at risk for diseases (Close et al., 2010). In 2009, the North Carolina Department of Health and Human Services reported a 10-fold increase in the number of preventive procedures since the inception of the program (NC Department of Health and Human Services, 2009).
Another state-based example is Washington’s Access to Baby and Child Dentistry (ABCD) program. Like Into the Mouths of Babes, ABCD is a collaborative effort to engage primary care providers in oral health care and includes training in oral health screening and fluoride varnish application, referral plans, and reimbursement for services rendered (Riter et al., 2008; Shirk, 2010). The University of Washington trains dentists to work with young children, local health departments enroll children and link them to dentists, case managers work with families to help them meet their appointments, and the state increased payment rates. Evaluations of the ABCD program show mixed results: the percentage of Medicaid children receiving dental care has increased and untreated dental decay has decreased among all children, but decay has increased among low-income children aged 3-5 (Shirk, 2010).
Innovations That Expand the Duties of Existing Professionals
Efforts to define scopes of practice for new and existing dental professionals have been plagued by a decades-long, contentious history (Dunning, 1958; Edelstein, 2010; Fales, 1958; Hammons and Jamison, 1967, 1968; Hammons et al., 1971; Nash, 2009; Nash and Willard, 2010). This section will look generally at expanding the functions of existing dental professionals. The creation of new types of dental professionals (either from existing professionals or de novo) is discussed subsequently.
As described earlier in this chapter, EFDAs may perform some limited restoration functions under the supervision of a dentist (Skillman et al., 2010). Studies of expanded functions for dental assistants in the United States began in the 1960s and showed that certain procedures could be effectively taught to dental assistants and that the quality of the procedures performed by the EFDAs was equivalent to that of dentists, as determined through measures of technical excellence (by the independent examination of dentists) (Abramowitz, 1972; Abramowitz and Berg, 1973). Both the U.S. Army Dental Command and the Indian Health Service (IHS) have programs
to train and employ EFDAs (IHS, 2011; Luciano et al., 2006). As discussed previously, many states have allowed dental assistants to perform expanded duties under a variety of titles. For example, the Kansas legislature enabled a new category of oral health worker called scaling dental assistants who are allowed to perform dental hygiene services, including coronal scaling and polishing, after 90 hours of training (Mitchell et al., 2006).
In the 1970s, several projects examined the effects of teaching both preventive and restorative procedures to dental hygienists. The Forsyth experiment (named for Massachusetts’ Forsyth Dental Center), conducted between 1972 and 1974, focused on training dental hygienists in restorative care (Lobene and Kerr, 1979). The demonstration project was curtailed in 1974 because of litigation by the state dental board contending that permitting dental hygienists to drill teeth was a violation of the state dental practice act. However, evaluation research during that time showed that the clinical services provided were comparable in quality to dentists (based on existing measures of quality) (Lobene and Kerr, 1979). Examination of independent dental hygienists in a demonstration project in the 1990s again showed the high quality and consumer satisfaction associated with their care (Freed et al., 1997). In this case, quality was determined by practice structure (e.g., availability of appointments within 15 working days, infection control); process (e.g., documentation of follow-up to significant findings); and technical excellence (e.g., periodontal evaluation, calculus removal, quality of X-rays).
As of 2007, 47 percent of dental hygienists had the ability to perform some form of expanded function (ADHA, 2009b). As of June 2010, 32 states permit some form of direct access to dental hygienists in some circumstances (ADHA, 2010b). This means dental hygienists may perform dental hygiene assessment and provide dental hygiene services without the prior authorization or presence of a dentist, and maintain a provider-patient relationship.
As noted earlier in this chapter, as of 2010, 15 states had enabled direct reimbursement to dental hygienists through state Medicaid programs (ADHA, 2010c). There is no guarantee that independent practice will result in these professionals primarily serving vulnerable and underserved populations, as they may face similar financial challenges to caring for these patients as dentists do. For example, a study of the 17 independent practices of 20 dental hygienists in Colorado found the practices were located in areas also served by dentists and prophylaxis fees were generally the same as neighboring dentists (Brown et al., 2005). The authors concluded that the practices had not had a notable effect on access to care in Colorado.
However, a study of the 287 registered dental hygienists in alternative practice (RDHAPs) in California showed that RDHAPs primarily provide care to vulnerable and underserved patients in a variety of nontraditional settings (Mertz and Glassman, 2011). Notably, 68 percent of the RDHAP patients in residential facilities, 82 percent of the homebound patients, and 79 percent of the nursing home patients reported having no other source of dental care. In addition, 69 percent of RDHAP patients are medically compromised, 52 percent are physically disabled, and only 11 percent of RDHAP patients have private dental coverage. Only 14 percent of RDHAPs have an independent office-based practice, and 82 percent report also working in a traditional dental hygiene position.
As the role of dental hygienists expands, further consideration will be needed for the educational preparation of these professionals. If dental hygienists take on additional duties, care for patients with more complex health care needs, or practice in nontraditional settings, consideration will be needed for whether the basic dental hygiene educational program is adequate, or if dental hygienists with expanded duties also need advanced education and training, perhaps in the form of postgraduate education. Also, consideration will be needed for legal liability.
Innovations in Developing New Dental Professionals
Several new types of dental professionals have been proposed by stakeholders, ranging from entry-level workers to more highly educated and clinically trained professionals. While many of these models are based on expanding the duties of existing dental professionals, they are distinguished from the previous examples in that they have separate pathways for education and licensure or certification. These efforts have been controversial with some arguing for their potential ability to increase access, especially for vulnerable and underserved populations, and others voicing concerns for the quality of care provided by these practitioners and the creation of a two-tiered oral health care system (ADA, 2007; AGD, 2008; Edelstein, 2010; National Dental Association, 2010; Pew Center on the States and National Academy for State Health Policy, 2009). However, due to quality measurement and assessment challenges in oral health (see Chapter 2), there is limited ability to assess the quality of care provided by any dental professionals, which therefore makes comparison of care even more challenging. Further, more research will be needed to determine how these new professionals could be reimbursed, as well as how career ladders might be developed from the existing professions. The ACA authorized the secretary to award grants for demonstration programs to train or employ alternative dental health care providers in order to increase access for rural and
underserved populations. However, Congress’ FY 2011 budget explicitly prohibited the funding of these programs (ADA, 2011b).
The Dental Health Aide Therapist (DHAT) in Alaska
Most of the attention regarding new dental professionals centers on the DHAT model. Since the early 20th century, New Zealand and Australia have used professionals called dental therapists or dental nurses. Since then, this model has spread to over 40 countries around the world (APHA, 2006; Nash et al., 2008). Recently, the IHS gained some experience in training and deploying dental therapists to deliver basic dental care in remote tribal areas (Bolin, 2008; Fiset, 2005; Wetterhall et al., 2010). In 2003, the Alaska Native Tribal Health Consortium, in collaboration with tribal health organizations, began to send students for training in the 2-year New Zealand program under the authority of the federal Community Health Aide Program for Alaska Natives (DENTEX, 2010; GAO, 2010; Wetterhall et al., 2010). After training, each therapist had to complete a clinical preceptorship under direct supervision of a dentist for 3 months or 400 hours (whichever was longer) (GAO, 2010). By 2010, 10 DHATs were practicing in Alaskan villages working under remote consultative supervision of a dentist (Wetterhall et al., 2010).
International evidence speaks to the safety and quality of care (based on available measures) provided by dental therapists as compared to dentists and about their acceptance by the populations served (Ambrose et al., 1976; Gallagher and Wright, 2003; Ministry of Health Malaysia, 2005; Nash et al., 2008; Riordan et al., 1991; Sun et al., 2010). While the models used around the world operate in different economic and social climates, they provide insight toward the development of other similar models. The American Association of Public Health has expressed its support of the DHAT program (APHA, 2006). While assessments to date of DHATs in Alaska have focused on only five sites, data show that DHATs are performing within their scope of practice, patients are satisfied with their care, and there is no significant difference between the quality of the treatment provided by the DHATs as compared with dentists (Bader et al., 2011; Bolin, 2008; Wetterhall et al., 2010). The authors of these recent assessments note that quality was evaluated based on available qualitative measures and quantitative measures, including direct observation of technical excellence; blinded evaluations of technical excellence; performance of oral hygiene instruction; consultation with supervising dentists; chart reviews for procedures performed and any resultant complications; and community surveys of satisfaction.
Other New Dental Professionals
Several other models of new professionals are in existence or fairly well-established in their development and testing. These efforts are described briefly in Table 3-7.
Existing Professionals vs. New Professionals
Proposals for new types of oral health professionals beg the questions of practicality and efficiency. Is creating a new class of oral health provider justified considering the concomitant need to then create and fund new education programs, establish certification and licensing structures, and enable payment mechanisms? Is it more expedient to expand the scope of practice for already existing oral health professionals or build upon their skills and knowledge through enhancement of existing education and accreditation mechanisms? Can the competencies of dental hygienists and dental assistants be expanded to safely meet the need for oral health services? Might new models of care provision rather than new classes of oral health care professionals be designed to address the pervasive access issues?
There is likely not a single definitive answer to any of these questions. Multiple professional models and different professional collaborations are needed to address the myriad needs of disparate demographics, depressed economies, distinct cultural backgrounds, and challenging geography, all of which affect the provision of oral health services and the engagement of the populations to be served. Retraining and repositioning existing personnel, producing new types or classes of oral health care professionals, reconfiguring provision of services using models of interprofessional care (including the use of nondental health care professionals), and creating new and multiple points of entry to oral health services would all help address concerns about emerging demand and the enduring need for oral health care.
The committee noted the following findings and conclusions:
• Most dentists practice in the traditional private practice setting.
• Diversity among dental professionals has not increased substantially and does not represent the diversity of the general population.
• Diversity of the workforce plays an important role in the care of underserved and vulnerable populations.
• Efforts to increase the diversity of the dental workforce have been successful but represent only small gains.
Selected Models of New Dental Professionals
|Developed by||American Dental
(authorized in 2009)
(authorized in 2009)
finalized in 2008:
began in 2009
Pilots began at
UCLA, the University
of Oklahoma Dental
School, and Temple
University in 2009
ADA plans evaluation
of Dentistry basic
DT training (bachelor’s
to enter workforce in
to enter workforce in
2011; as of June 2010,
had been finalized
West Los Angeles
College and the
University of the
Pacific Arthur A.
Dugoni School of
|Primary dental care
providers who assess
risk, educate, provide
preventive and basic
restorative care, and
refer patients for
complex care; works
under remote consultative
from the communities
they intend to serve)
to provide limited
preventive and palliative care
Focus is risk assessment,
promotion, and behavioral
|Performs a range of
preventive and basic
restorative care under
|Performs a range of
preventive and restorative
care (basic and
treatment plans with
authorization of consulting
|Practices in underserved
Provides all services
allowed by dental
hygiene license, but
have dentist of record
on file for referral,
emergency care. After
18 months of care,
physician or dentist
must provide written
prescription for continued
care, which is
valid for 2 years
|Education and Training||Master’s degree
(program available to
those with bachelor’s
licensed in dental
|12 months of training
|Bachelor’s degree||Master’s degree||In-person and distance
for dental hygienists
with baccalaureate degrees
in dental hygiene
|Licensed as a dental
Envisioned to be
licensed and regulated
at the state level
|Envisioned to be
certified; no formal
and licensure exam
|Licensed as DTs, have
a master’s degree in
advanced dental therapy,
of clinical practice, and
pass certification exam
for advanced practice
SOURCES: Edelstein, 2010; GAO, 2010; Mertz and Glassman, 2011; Pew Center on the States and National Academy for State Health Policy, 2009.
• Geographic maldistribution of the workforce occurs, in part, due to the inability to sustain practices in underserved communities.
• Cost of education may be a barrier for many students to either enter the dental professions or to pursue advanced education.
• Community-based training experiences with vulnerable and underserved populations increase dental professionals’ comfort and intent to care for these populations.
• Overall, the nondental health care workforce (e.g., nurses, pharmacists, physician assistants, physicians) does not receive adequate education and training in basic oral health issues.
• Many nondental health care professionals demonstrate a willingness to participate in oral health care.
• Oral health care needs to become an integrated part of primary health care.
• State boards of dentistry regulate the profession of dental hygiene.
• Regulation of dental professionals has been characterized by polarization of the professions over scope of practice issues.
• Data suggest that restrictive licensure laws in oral health are not tied to better health outcomes or supported by scientific evidence, and may drive up costs for the patient.
• Early experiences with new types of dental professionals do not raise concerns for the quality of care provided based on the available measures of quality.
• More research is needed on the effective and efficient utilization of the existing health care workforce.
• No single workforce model will likely serve the needs of all vulnerable and underserved populations.
• More research is needed on the impact of new workforce models on access to care.
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