Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011) / Chapter Skim
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3 The Oral Health Care Workforce
3 The Oral Health Care Workforce
Pages 83-156
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From page 83... ...
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.
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Almost all professionally active dentists (92 percent) work in the private practice set BOX 3-1 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.
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However, as of June 2010, 15 states allowed their state Medicaid departments to directly reimburse dental hygienists for their services (ADHA, 2010c)
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The BLS predicts a 36 percent growth in the employment of both dental hygienists and dental assistants
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. 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)
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. Overall, dental hygienists and dental assistants are virtually all female (ADHA, 2009b; McDonough, 2007)
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leads to improved access for underserved populations, greater patient satisfaction, and better TABLE 3-3 Dental Professions by Percentage of Race and Hispanic Ethnicity, 2000 General Dental Dental Population Dentists Hygienists Assistants Whitea 75.1 82.8 90.9 75.8 Black or African 12.3 3.3 2.3 5.6 Americana Asiana 3.6 8.8 2.0 3.6 Hispanic or 12.5 3.6 3.7 12.6 Latino Origin aCategory excludes Hispanic origin.
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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
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. These same issues may affect the development of independent dental hygiene practices (Brown et al., 2005)
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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)
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93 THE ORAL HEALTH CARE WORKFORCE BOX 3-2 Requirements for Dental HPSA Designation Geographic areas must meet these requirements: • e rational areas for the delivery of dental services. B • eet one of the following conditions: M o ave a population to full-time equivalent (FTE)
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EDUCATION AND TRAINING OF THE DENTAL WORKFORCE 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,
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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)
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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)
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. Community-based dental education has also been shown to have financial benefits for both the dental schools and the community settings (Bailit, 2010)
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. 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)
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, 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)
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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)
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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.
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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.
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. 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)
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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.
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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)
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The specific role of nondental health care professionals in the delivery of preventive services is discussed later in this chapter. Physicians The need for physicians to learn about oral health has been recognized for nearly a century.
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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
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. 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)
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. 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)
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. Pharmacists 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.
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No formal assessment has been done to evaluate the extent and depth of education and instruction that pharmacy students receive regarding oral health. Physician Assistants 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)
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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)
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. INTERPROFESSIONAL EDUCATION, TRAINING, AND CARE The importance of the interaction between dentists and other health care professionals has been recognized for nearly a century (Dunning, 1958; Rauh, 1917)
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. 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.
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However, there are no robust data on the impact of interprofessional training leading to interprofessional practice or on improving oral health outcomes. REGULATING THE DENTAL WORKFORCE Regulation of the health care workforce occurs at several levels.
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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)
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. 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.
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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.
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(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)
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. 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)
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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.
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. 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 associ ated 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.
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. 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.
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. 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.
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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)
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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)
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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 continued
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Can counsel pregnant patients about pregnancy gin givitis and the need for regular dental care Oral Cancer Has knowledge of oral Can screen for oral malignancy on exam cancer risk factors and can Can assess risk factors for malignancy screen for oral cancer and (smoking, tobacco/alcohol use) counsel patients Can counsel patients about prevention strategies (prevention/cessation of smoking, tobacco, and alcohol use)
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From page 129... ...
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)
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. 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)
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. 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.
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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.
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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.
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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?
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(authorized in 2009) Dental Hygienists' Association Association (1970s)
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After coordination, health 18 months of care, promotion, and behav- physician or dentist ioral change must provide written prescription for con tinued care, which is valid for 2 years Education and Master's degree 12 months of train- Bachelor's degree Master's degree In-person and distance Training (program available to ing and 6-month education programs those with bachelor's internship for dental hygienists degrees currently with baccalaureate de licensed in dental grees already licensed hygiene) in dental hygiene Certification or Licensed as a dental Envisioned to be Pass competency Licensed as DTs, have State licensure Licensure hygienist first certified; no formal and licensure exam a master's degree in licensure advanced dental ther Envisioned to be apy, complete 2,000 licensed and regulated of clinical practice, and at the state level 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.
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• Community-based training experiences with vulnerable and un derserved populations increase dental professionals' comfort and intent to care for these populations. • Overall, the nondental health care workforce (e.g., nurses, phar macists, physician assistants, physicians)
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2010b. 2008-2009 survey of advanced dental education.
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Chicago, IL: Dental Assisting National Board. ADEA (American Dental Education Association)
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Assessing recruitment of underrepresented minority and low-income dental students to increase access to dental care. Journal of Dental Education 74(6)
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program on dental students' clinical experience and cognitive skills, 1994-2006. Journal of Dental Education 74(4)
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Journal of Dental Education 65(12)
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Journal of Dental Education 69(12)
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2009. Physician assistants and nurse practitioners as a usual source of care.
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Journal of Dental Education 74(Supp.
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Journal of Dental Education 74(5)
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2005. Financing dental education: Public policy interests, issues and strategic consid erations.
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1999. The predoctoral curriculum in an era of required postgraduate dental education; or if only it were true.
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2009a. Evaluating the dental pipeline program: Recruiting minorities and promoting community-based dental education.
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2006. Access to care and the allied oral health care workforce in Kansas: Perceptions of Kansas dental hygienists and scaling dental assistants.
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2008. The impact of Title VII on general and pediatric dental education and training.
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Journal of Dental Education 70(9)
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Journal of Dental Education 67(8)
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2010. The impact of community-based dental education on students.
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2008. Re forming dental education: Faculty members' perceptions on the continuation of pipeline program changes.
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A case for interprofessional education. Journal of Dental Education 72(11)
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