AAPD Responds to Kellogg Foundation Report on Dental Therapists

April 10, 2012 11:10 AM
CHICAGO – April 10th, 2012 — The American Academy of Pediatric Dentistry (AAPD)[i] commends the Kellogg Foundation for undertaking the monumental task of documenting dental therapists and their work in various countries by conducting an extensive review of the literature. The report, A Review of the Global Literature on Dental Therapists: In the Context of the Movement to Add Dental Therapists to the Oral Health Workforce in the United States, reviews the history and practice of dental therapists in 54 countries ranging from the United States to the United Kingdom to Malaysia, and makes broad-based conclusions regarding safety and effectiveness . However, the mid-level programs in these 54 countries differ so dramatically in scope of practice, populations served and degree of dentist supervision that it is difficult to make a genuine evaluation of the fit of dental therapy in the U.S. mainstream dental care system. Further, the AAPD is concerned that much of the literature cited is based on opinions rather than data, and further makes no conclusion as to the effect of these programs on the oral health of the targeted population. More specifically:

·         The report includes about 1,056 citations, the majority of which are commentaries, opinion pieces and news releases. The AAPD encourages the Kellogg Foundation to base such reports on evidence and current data rather than opinions and commentaries.

·         An estimated 44 of the citations provided include actual data on dental therapists, but the majority of those examine therapist knowledge, acceptance and technical performance. None examine effectiveness and impact on oral health status.

·         None of the studies compare any improvements in oral health among targeted populations to the potential outcomes had the same resources been directed to providing these patients with care from dentists.

AAPD President Dr. Rhea Haugseth provided an accurate assessment of the AAPD’s evaluation of the report when she said:

"As the recognized leader in children’s dental and oral health, the AAPD is strongly committed to improving the oral health status of America’s children, through a variety of advocacy, service and public education initiatives. Therefore, the AAPD wants to ensure that the best interests of children come first and foremost in any strategies that address access to oral health care. The majority of AAPD member dentists are Medicaid providers, demonstrating on a daily basis that pediatric dentists care deeply about access to care. Although we are pleased that a compendium of literature related to the use of non-dentist providers that offer dental services throughout the world has been compiled, we remain unconvinced of the potential effectiveness of this type of model in the United States. The AAPD remains dedicated to the concept of a dental home as the best way to support the oral health of ALL children through the provision of the full range of dental services within the context of a relationship with the dentist."

The Kellogg report would lead the reader to believe that school-aged children in New Zealand are in excellent oral health due to the dental therapist program.  However, reports published by the New Zealand (NZ) Ministry of Health establish that some NZ children face significant access issues and that oral health inequalities are evident across cultural and economic lines. 

The Kellogg report details comparisons between the cost of specific dental services in other countries and in the United States without taking into account the overall cost of managing the program.  The report also compares salaries of dental therapists and dentists, but does not account for the variances in cost of living and average salaries between countries.  Moreover, the report does not take into account the costs associated with supervision of the dental therapists.   There is, therefore, dubious utility in making these comparisons.

A recent economic feasibility study published in the California Dental Association Journal (Jan 2012, pp. 49-64) concluded that Dental Health Aid Therapist programs are sustainable only with direct subsidy. Further, the study by Holt and colleagues (2004) cited in the paper concluded that, in an examination of four private dental offices that employed therapists, "the gross fees and patient charges generated by the dental therapist in all four practices fail to cover the cost of the salary of the dental therapist, dental nurse and associated overheads borne by the practice." This is an economically unviable option for the private sector oral health care in the U.S.

Kellogg, like the Pew Foundation, has been a consistent advocate for a new model for the delivery of dental services. Much of their evaluation of the dental therapist concept hinges on the supposed "technical competence" of these providers. Studies addressing the technical quality of restorative procedures performed by non-dentist providers have found, in general, that within the scope of services and circumstances to which their practices are limited, the technical quality is comparable to that produced by dentists. Technical competence cannot be equated with long-term outcomes. There is no evidence to suggest that dental therapists deliver any expertise comparable to a dentist in the fields of diagnosis, pathology, trauma care, pharmacology, behavioral guidance, treatment plan development, and care of special needs patients. The literature indicates, therefore, that individuals know how to provide certain limited services, not that those providers have the knowledge and experience necessary to determine whether and when various procedures should be performed or to manage individuals’ comprehensive oral health care, especially with concurrent conditions that may complicate treatment or have implications for overall health.  The AAPD also notes that the concentration of early childhood caries (ECC) in very young and often difficult to manage patients makes the pediatric dentist critical to eradicate ECC and improve access.

A major component of AAPD’s advocacy efforts is development of oral health policies and evidence-based clinical practice guidelines that promote access to and delivery of safe, high quality comprehensive oral healthcare for all children, including those with special health care needs, within a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivery, in a comprehensive, continuously-accessible, coordinated, and family-centered way. Such care takes into consideration the patient’s age, developmental status, and psychosocial well-being and is appropriate to the needs of the child and family. Children who have a dental home are more likely to receive appropriate preventive and therapeutic oral healthcare.

The position of the AAPD on dental therapy is that at this time, inadequate evidence supports its benefits to children’s oral health in the U.S. and those resources should be directed to existing proven care methods. The AAPD strongly believes there should not be a two-tiered standard of care, with our nation’s most vulnerable children receiving services by providers with less education and experience, especially when evidence-based research to support the safety, efficiency, effectiveness, and sustainability of such delivery models is not available. According to AAPD Pediatric Oral Health Research and Policy Center Director Dr. Paul Casamassimo:

"AAPD has long been serious about addressing early childhood caries in this country, but an untried, virtual workforce solution that attempts to stem well-established dental infection in older children through restoration is misdirected and goes against the epidemiology of this disease and would take decades to have an effect. Early intervention by medical and dental professionals holds the most hope of stemming ECC. We have to move past the technical prowess debate and look at the systems effects of a 180-degree workforce turn and whether we wait decades for a critical mass of untried workers to develop and let the ER visits continue, the $10,000 hospital admissions continue, the weeks of suffering of poor and minority kids continue, or we look at more immediate ways to address this problem. "

As an alternative solution, The AAPD advocates the use of Expanded Function Dental Assistants (EFDAs) to increase the ability of the dental office to serve populations who have difficulties in accessing dental care. An EFDA is a dental assistant or dental hygienist who receives additional education to enable them to perform reversible, intraoral procedures, and additional tasks (expanded duties or extended duties), services or capacities, under the supervision of a licensed dentist. Since the EFDA practices under the supervision of a licensed dentist, within the dental home, children are ensured access to comprehensive care, including restorative services to eliminate pain and restore function.

According to a recent AAPD survey, over 70 percent of AAPD members are Medicaid providers. This is supported by a recent published survey which found that pediatric dentists devote close to 20 percent of private practice delivery to children qualifying for public assistance programs. AAPD member dentists demonstrate on a daily basis that pediatric dentists care deeply about access to care. The AAPD is strongly committed to improving the oral health status of America’s children, through a variety of advocacy, service, and public education initiatives. As such, the AAPD wants to ensure that the best interests of children come first and foremost in any strategies to address access to oral health care.

[i] Founded in 1947, the AAPD is a not-for-profit membership association representing the specialty of pediatric dentistry. The AAPD’s 8,000 members are primary oral health care providers who offer comprehensive specialty treatment for millions of infants, children, adolescents, and individuals with special health care needs. The AAPD also represents general dentists who treat a significant number of children in their practices. As advocates for children’s oral health, the AAPD develops and promotes evidence-based policies and guidelines; fosters research; contributes to scholarly work concerning pediatric oral health; and educates health care providers, policymakers, and the public on ways to improve children’s oral health.


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