The Future of Oral Health Care Delivery

When envisioning the future of the dental therapy profession, all of its moving parts need to be considered. Significant changes to the United States’ dental health care delivery system are on the horizon. The role of the dental therapist likely will be integrated into a variety of dynamic and fluid delivery systems. To assess how dental therapy will evolve, several factors merit attention: the directions in which health care and oral health care delivery systems will be moving; delivery models that will be prevalent in the future; how dental therapists may contribute to cost-effective delivery systems; health care providers with whom dental therapists will interact interprofessionally and intraprofessionally; influence of legislative change on the profession; and various types of educational models for dental therapists and the elements of curricular content that will be essential.

CHANGES IN DENTAL HEALTH CARE SYSTEM MODELS

Data reveal that the dental practice of yesteryear is slowly vanishing. Dental students are graduating with daunting debt, so the long-established tradition of opening a private practice is fading. As reported by the American Dental Association, the number of new graduates entering large group practices and/or dental service organizations (DSOs)—where they may be reimbursed through salary schedules based on outcomes data valuing quality of care and productivity—is rising.¹

Solo or small group practices are being replaced by more nontraditional models. DSOs, integrated medical/dental models, federally qualified health care facilities, and community-based delivery systems are examples of novel practice sites—environments that could offer employment for dental therapists. Trends indicate that the transition to the aforementioned nontraditional delivery systems will not be short-lived. These alternative models may even become more prevalent as more states move to managed care, and patients covered by Medicaid are required to seek care at practices that assume more financial risk.²

Student debt is not the only variable that is driving delivery system changes. Consumers need and want access to cost-effective oral health care. DSOs, in particular, are designed to manage the business aspects of a practice, enabling dentists to focus on direct delivery of dental services. DSOs’ primary focus is to treat lower- and middle-income patients on a fee-for-service basis. However, in the long-term, DSOs may look to treat publicly insured individuals and assume more financial risk. In this eventuality, dental therapists may be an ideal resource for providing cost-effective care that will offset loss and enhance the potential for profitability.

With the exception of 12 states, dentists must by law be the only individual to own a dental practice.³ However, as DSOs become more prominent, this number may grow, introducing more change to traditional dental practice.³

The mentality that oral and systemic health are married, and that a health home is all-inclusive, will drive an increase in integrated medical/dental models. Integrated medical/dental models, such as Health Partners, provide a cooperative arrangement where capitation fees are based on risk ratios. Utilizing dental therapists rather than dentists to provide routine dental care is more cost effective for this type of large, integrated group practice. Another model of import is the community-based delivery system. Oregon’s Advantage Dental Services is a large group practice company that provides care in schools and other community sites. Dental therapists could deliver low-cost accessible dental care to underserved children in this type of setting.

Other models afford opportunities for dental therapy and could enable collaboration between dental hygienists and dental therapists. Permitted by practice acts in several states, dental hygienists work directly with physicians, without a dentist present. Colorado dental hygienists are collaborating interprofessionally with physicians at rural clinics^4,5 and federally qualified health care facilities. Oregon’s dental practice act permits dental hygienists to deliver care in pediatric and obstetrics/gynecology medical practices. In each of these environments, dental therapists could work in tandem with dental hygienists and provide complementary dental services. For example, in a pediatric practice, dental hygienists could assess a patient’s hard tissue status and provide preventive education and prophylaxes while dental therapists could handle pediatric emergency needs on-site. Both providers could triage to help find dental homes for families and their children.

LEGISLATIVE INFLUENCES

The changing health care landscape will have legislative ramifications. Nondental organizations and nonprofit groups will advocate for more direct delivery models of care that provide cost-effective quality services. Leaders of DSOs and other progressive models may be the strongest voices in state capitals to advocate for more liberal state practice acts for dental therapy and for practice ownership by nondentists. DSOs and other nontraditional models will recognize the benefits of allowing nondentist oral health providers to work to the fullest extent of their scopes of practice and have the potential to be powerful allies in moving dental therapy forward. This advocacy bodes well for increased utilization of all nondental oral health care providers. For example, as expanded function dental assistants are delegated more responsibilities, the roles of dental therapists and dental hygienists will broaden.

Other legislative momentum that enhances the future of dental therapy is the increase in state practice acts that allow patients direct access to dental hygiene care. In 42 states, dental hygienists are now permitted some level of direct access.⁶ Most likely, direct access will support the utilization and sustainability of dental therapists.

EDUCATIONAL MODELS FOR DENTAL THERAPY

A continuing debate relates to the level of education that a dental therapist should obtain. Some argue that no maximum level is necessary, as 2 years of education have been shown effective. For example, the Alaskan model of the dental health aide therapist (DHAT) has been very successful in the indigenous tribal communities. DHAT education does not confer a degree and it requires 2 years of education. Others argue that dental therapists are providing irreversible dental procedures that demand more than technical expertise but require elevated clinical judgment, a strong grasp of the oral/systemic link, broad knowledge of the dental and medical sciences, and high-level learning and skill sets that 2 years of education may not provide. The University of Minnesota and the Metropolitan College/Normandale partnership in Minnesota, both offer dental therapy master’s level education. As with the DHAT, Minnesota’s dental therapists and advanced dental therapists have received positive evaluations. High ratings for both models indicate that each has a place in the dental therapy profession.⁷

Some suggest that dental therapists should first be dental hygienists. The current Commission on Dental Accreditation guidelines for dental therapy provide advanced standing for dental hygienists. This framework naturally leads to a dual degree. Existing or planned programs specifically are designed to graduate dental therapists who are dental hygienists. The University of Minnesota’s educational model combines the two professions, with graduates receiving their dental hygiene degree and a master’s in dental therapy. Vermont Technical College also plans to follow this educational framework.⁷

The dental hygienist/dental therapist combined track would create a provider with a pre-existing science and clinical background who uses that base to develop skill sets for delivering restorative dental care, pain management services, and other allowable dental therapy treatment. Given a student’s pre-existing clinical knowledge and acquired psychomotor skills gained in a dental hygiene program, combined degree programs might have available curricular time to focus on inter- and intraprofessional collaboration. A combined dental hygiene/dental therapy degree seems an ideal marriage. It essentially builds on pre-existing knowledge and expertise without requiring the creation of a wholly separate profession. Others are afraid that the dental hygiene profession will disappear if dual-degreed programs are created. This seems unlikely.

EDUCATIONAL CONTENT AREAS

Regardless of the program’s duration or degree conferred, several content areas, in addition to clinical education, are needed. One is interprofessional education. If the future of health care moves toward integrated medical-dental models, dental therapists will collaborate with medical professionals. They will need to know how to communicate with nurses and physicians, and have a firm grasp of systemic health. As hospital and long-term care facility directors begin to realize how costly poor oral health is to their patients’ well-being and to their institutions, dental therapists and dental hygienists may see more placement in these types of environments. Current research shows that long-term care facility directors recognize that oral health care is not being sufficiently provided to their residents and that staff lacks knowledge related to oral health.⁸ Other research examines how daily oral hygiene can enhance the well-being of patients vulnerable to ventilator-acquired pneumonia in intensive care units. In these studies, daily oral hygiene care increased benchmarks of systemic wellness.⁹

Another important curricular area for dental therapy is intraprofessional education. Given the newness of dental therapy, dentists may need to learn more about the profession and ways that dental therapists can successfully be integrated into clinical practice. Dental therapy programs could enhance intraprofessional education by building community externships or dental school rotations into their curricula. Dental therapy program graduates in the Normandale/Metropolitan model must practice a specified number of hours to fulfill their requirements to become advanced dental therapists.⁷ Advanced dental therapists then have additional time to focus on developing sound clinical judgement and competent clinical practice skills.

In my opinion, there needs to be some level of flexibility when discussing the different dental therapy educational models. Much depends on the practice environment and population served. As stated above, reports indicate that both DHATs and advanced dental therapists who matriculated through different educational programs are each highly regarded by the populations they serve.⁷ If dental therapists are practicing autonomously and serving patients with complex health histories and unique needs, a higher level of education may be needed. No restoration is simple, no extraction is easy. Any contingency can arise. Dentists know this. How many have begun an extraction and realized it was more complex than originally thought? Perhaps a root fractures or an impaction is more involved than anticipated. These turning points require professional thinking and seamless action. A strong knowledge base, clinical judgment, and critical thinking skills are means to deal with the unexpected. An educational program of 2 years may be inadequate for the development of these critical traits. Realistically, for dental therapists practicing in medical environments, degree level speaks to parity, accountability, and status.

CONCLUSION

In summary, predicting the future of dental therapy is complex. Many variables whose impact is unknown at this time may factor into the equation. It is exciting to consider where dental therapy is headed. Given the evolution of health care delivery in the United States, the growth of dental therapy programs and current and future legislative changes that potentially can propel dental therapy forward, the future appears rosy. Certain trends are occurring that enable some reasoned speculation. However, only time will tell.

ACKNOWLEDGEMENT

The author would like to thank her colleagues on the project Advancing Dental* Education: Gies in the 21st Century for their wisdom and comradery. *Dental in this context includes dental hygiene, dental assisting, restorative dental technology, and dental therapy.

REFERENCES

1. American Dental Association. A Profession in Transition: Key Forces Reshaping the Dental Landscape. Available at: ada.org/​escan. Accessed December 15, 2018.
2. Brown LJ. Future organization of oral health services delivery: from 2012-2042. J Dent Educ. 2017;81(9Suppl):eS11–20.
3. Bailit H. The oral health care delivery system in 2020: executive summary. J Dent Educ. 2017;81:1124–1129.
4. Braun P, Cusick A. Collaboration between medical providers and dental hygienists in pediatric care. J Evid Based Dent Pract. 2016;16:59–67.
5. Braun P, Flowerday C, Villagrana K. The Colorado medical-dental integration project. Dimensions of Dental Hygiene. 2018;16(3):12.
6. American Dental Hygienists’ Association. Direct Access. Available at: adha.org/​resources-docs/​7513_​Direct_​Access_​to_​Care_​from_​DH.pdf; Accessed December 15, 2018.
7. Brickle CM, Self KD. Dental therapists as new oral health practitioners: increasing access for underserved populations. J Dent Educ. 2017;81(9 Suppl):eS65–72.
8. Willumsen T, Karlsen L, Naess R, Bjørntvedt S. Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Gerodontology. 2012;29: e748–e755.
9. Prendergast V, Kleiman C. Interprofessional practice: translating evidence based oral care to hospital care. J Dent Hyg. 2015:89( Suppl 10):33–35.

From Dimensions of Dental Hygiene. January 2019;17(1):12–14.