Pathway to Dental Therapy

Currently, there are two major educational pathways for dental therapy (DT) programs:  the direct pathway and dental hygiene-based models.

The direct pathway model was the first type of DT program implemented in the United States. Initiated by Alaska Native/American Indian leaders, it was developed to address a critical shortage of oral healthcare providers, and is often called the “tribal” or “community-based model.” It delivers a tailor-made, community need-driven program that builds a more representative workforce that shares the language and culture of the population receiving treatment.

Dental hygiene-based models provide education and training for midlevel dental practitioners. Originating from the American Dental Hygienists’ Association’s educational framework for the advanced dental hygiene practitioner, these models deliver a higher level of education to non-novice students.

Even with the creation of educational standards by the Commission on Dental Accreditation (CODA) in 2015, multiple delivery models have been necessary to satisfy differences between state laws, community needs and resources, and institutional and operational factors. To combat variations in state law and further promote standardization, advocates for DT convened a panel of experts to create the National Dental Therapy Model Act in 2019 with guiding principles focused on increasing oral health access, improving health equity through diversity in the workforce, providing safe, high-quality services, and controlling healthcare and education costs. Passing legislation that closely follows this model would help ensure licensure portability from state to state and greater flexibility for institutions planning on delivering dental therapy education.

Classic Direct Pathway Model

Direct pathway models are the most efficient models. They require 3 academic years to complete, do not require students to take courses unrelated to DT practice, and may save costs over the long term. They can be created at various institutions with the lowest tuition rates, including community colleges. Two programs that resemble this model are the first and second to become CODA accredited: the Alaskan Native Health Program at Iḷisaġvik College in Barrow, Alaska, and the dəxʷx̌ayəbus (dahf-hi-ya-buus) at Skagit Valley College in Mount Vernon, Washington. Instead of students taking traditional science coursework that may service other health profession programs or majors, every course is specifically designed to meet the needs of their communities and satisfy CODA standards for dental therapy. Although there are some differences between the Alaskan and Washington programs, both include approximately eight consecutive quarters over 27 months.

A drawback to this design is that coursework is so tailored that it may limit the transfer of credits into alternative career paths. Also, even though DT training is extensive, many community colleges are limited to granting no more than an associate degree, perpetuating the belief that these providers are inadequately trained and less competent than those with a higher degree.

Another potential problem is that dental therapists supervise dental hygienists in many states, and it is becoming more common to encounter dental hygienists with a baccalaureate degree. This may create challenges when a lower degree commands a more comprehensive scope of practice, increased autonomy, and potentially a higher salary.

Lastly, this type of program often results in high startup costs for didactic, pre-clinical, and clinical course creation and requires additional clinical space, equipment, materials, supplies, and personnel. To offset these costs and increase sustainability, programs partner with tribal and large community health networks. These community partnerships are a potential source of faculty, a rich source of interprofessional experiences, and offer an established diverse patient population.

Dental Hygiene-Based Models

Pre-CODA standards, there were two dental hygiene-based DT programs: one at the University of Minnesota and the other at Metropolitan State University both in the Minneapolis-St. Paul region. The University of Minnesota program offers a dual-degree Bachelor of Science in Dental Hygiene/Master of Dental Therapy. Metropolitan State grants a Master of Science in Advanced Dental Therapy (MSADT).

The program at the University of Minnesota received CODA accreditation in March 2023 and is the third DT program to be CODA accredited. The Metropolitan State University program and a similar model at Minnesota State University, Mankato, that confers a MSADT, are still working on the accreditation process.

The University of Minnesota houses the only dental school in the state and it has much of the coursework, faculty, equipment, and supplies necessary to offer a DT program already in place. This reduces startup costs, but also requires possible changes to existing oral health curricula to facilitate this new educational path.

Other concerns are that the extensive prerequisites (a year of eight prerequisites), the requirement for dual-track admission, and a 32-month program may intimidate some students. Also, what happens to students who need to take a break from their studies? Can they complete their dental hygiene training and return to complete their DT degree? Is there a pathway to grant advanced-standing dental hygiene students or even foreign-trained dental students?

Metropolitan State University’s DT program was created in partnership with Normandale Community College. It resembles a career-laddering model for the dental hygienist. A prerequisite to entry is graduation from a CODA-accredited dental hygiene program with a baccalaureate degree, and after six semesters and documented completion of 2,000 hours of dental therapy scope practice, students receive a MSADT. This pathway provides training that exceeds the minimum CODA requirements for a dental therapist (which is 27 months). However, the more efficient timeline of a career-laddering model limits the amount of time a provider must spend outside the workforce while allowing students to begin entry-level training within their community.

The Vermont Story

Vermont passed hygiene-based DT legislation in 2016. Vermont Technical College (VTC) offered the only dental hygiene program in the state and supported the legislation. After reviewing all national dental therapy programs, accounting for the legislative requirements, and utilizing VTC’s existing dental hygiene program, an initial DT curriculum model was designed.

At the time, it was thought that the most feasible curriculum with the advanced practice option was a training program for the dental hygienist similar to the model created by Colleen Brickle, EdD, RDH, at Normandale Community College. VTC set about creating an entry-level, 33 months (a minimum of eight consecutive terms) direct pathway curriculum. It utilized the existing dental hygiene curriculum and added dental therapy coursework to confer a Bachelor of Science in Oral Health Science and a Graduate Certificate in Dental Therapy. Alternatively, students desiring to complete the CODA-accredited dental hygiene program could enroll in VTC’s 36-month dual enrollment program for a Bachelor of Science in Dental Hygiene and a Master of Science in Dental Therapy.

Restructuring the dental hygiene program and running both programs year-round was key to achieving a 3-year dental therapy curriculum. Surprisingly, adding a dental therapy curriculum increased the efficiency of both programs and lowered the institution’s financial burden for the dental hygiene program. Initially, state legislation seemed like a barrier, but it ultimately led to a curriculum with multiple student-friendly pathways. The tuition required for this program was similar to Skagit Valley College’s program, indicating that two different educational models could have similar costs regardless of degree.

The VTC program was preparing to submit for CODA accreditation in spring 2022. Simultaneously, VTC began a process of merging with Castleton University and Northern Vermont University to become Vermont State University on July 1, 2023. The merger impacted the DT program’s funding and personnel, putting the program’s progress on hold.

New Program Development

It may be unreasonable to expect CODA to respond to every unique programmatical difference and guide a program through self-study. However, when it comes to a new profession with new educational standards, more transparency and informal guidance would save a developing program both time and money. For example, assistance in defining what prerequisites are required for students to pursue different educational pathways and the number of clinical hours specific to the increased DT scope would be helpful. Many other elements in the standards, such as institutional policies on diversity, should be aligned and any redundancies between programs should fall under the same standard. Without CODA guidance, programs might unnecessarily add an additional year of education or tack on requirements that go beyond the CODA standards for DT, making the hygiene-based curriculum more costly and less desirable.

Multiple educational models and pathways to DT are needed. We need diversity, flexibility, and an “all hands on deck” collaborative approach to provide training for students from different states. Dental therapy may not be a panacea, but innovation in educational design, utilization of existing infrastructure, and promotion of multiple models may provide more efficient, community-driven comprehensive care to fill in oral health access gaps.

From Dimensions in Dental Hygiene. November/December 2023; 21(10):20,22-23