Florida Oral Health Conference

August 2012

Ron Nagel DDS MPH

CAPT USPHS (ret)

Barriers to Access Geographic (distribution) Economic (capacity) Cultural (social)

Dental Therapists At least 52 countries utilize Dental Therapists

– IDJ (2008) 58, 01-70

Function as part of the dental team under the supervision of a dentist

New Zealand has 90 yrs experience and Canada has over 40

Exceptional safety record under general supervision for children and adults – Nash 2012

Dental Therapists - Scope

Clinic, Village, or School based Provide the spectrum of health education and

preventive services Restore teeth to function utilizing amalgam

and composite materials Provide SSCs and pulp treatment for primary

teeth Extract teeth and manage dental emergencies Screen for oral and peri-oral disease

Clinical Guidance

AFHCAN CartAlaska Federal Health Care Access Network

Wireless Networking Touchscreen Mobile – Customized

Consultation Patient education Provider education

WWW. AFHCAN.ORG

Oversight Educate and calibrate supervising dentists Dental therapists are assigned to a primary

supervising dentist Supervising dentists provide patient

consultations and program planning Monitor the referral process and the scope of

practice QA: chart reviews, patient satisfaction, direct

observation Standardization of treatment to improve

outcomes

“Finally, we have pointed out the lack of published data available to serve as valid sources for comparison to assess the technical competence and practice procedures of those in the DHAT program. We have very little information about these qualities and characteristics from the practice settings in which the majority of private dentists in this country currently operate.”

Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska, Final Report, October 2010, Pg. 5-9, prepared by Scott Wetterhall, MD, MPH, James D. Bader, DDS, MPH, Barri B. Burrus, PhD, Jessica Y. Lee, DDS, PhD, Daniel A. Shugars, DDS, PhD, MPH

Quality Assurance in the Alaska program Begins with a 400+ hour directly supervised

preceptorship DHAs must demonstrate the practical

professional competencies for their level of certification throughout their career

Every two years each DHA must provide evidence that they completed the CE requirements (24 hrs)

Dentists proactively monitor sentinel events and treatment outcomes

These administrative controls help to assure quality and that a single standard of care is met in tribal programs

Competency Based Credentialing

Frequent sampling of knowledge and skills over time – not a single event test

We look directly at the services that they provide day to day to achieve high predictive validity with this process

Each DHAs’ scope of practice is individually assigned based on competency through standing orders

A Federal board oversees the process

DENTEX Training Program University of Washington

MEDEX Northwest Two year program based on NZ,

Canadian, and other models Integration into community

based prevention programs throughout training

A new mix of skills that includes the behavioral and public health skills needed to affect change

The use of simulation and extensive patient contact to develop a high level of skill

Alaska DHAT training program information:First year: 40 weeks Second year: 39 weeksTotal: 79 weeks (3160 hours)

Curriculum Break-down first yearBiological Science: 30%Social Science: 10%Pre-clinic: 40%Clinic: 20%

Curriculum Break-down second yearBiological Science: 15%Social Science: 7%Pre-clinic: 0%Clinic: 78% (1215 hours)

Curriculum Break-down two years combined:Biological Science: 22.5%Social Science: 8.5%Pre-clinic: 20% (632 hours)Clinic: 49% (1548 hours)

2 year vs. 3 year combined RDH programs Cost Infrastructure Career opportunities Provider Demographics

The truth about motivation and changing behavior…

Motivatedby information

Not going to be motivated

right now

Motivated by how I interact with provider over time

10 % 10 %

Miller & Rollnick, Motivational Interviewing, 2002

80 %

Foundations for Great Primary CareEffective Relationships =

Empanelment + Access + Continuity

What should new providers look like?

Nash DA, Friedman JW, et al. Dental therapists: a global perspective. Int Dent J. 2008 Apr;58(2):61-70

McDermott, PT, Mayhall, JT, Leake, JL, Dental therapists and the delivery of dental care in Canada’s Northwest Territorties. Circumpolar Health 1990: 668-671,

Ambrose ER, Hord AB, Simpson, WJA. Quality evaluation of specific dental services

provided by the Saskatchewan dental plan: final report. Regina, Saskatchewan, Canada, 1976:19 pages

Friedman JW, Ingle JI. New Zealand dental nurses. J Am Dent Assoc 1973;8:1331

Barkley RF, Successful preventive dental practices 1972 English  Book 256 p. : ill. ; Macomb, Ill. : Preventive Dentistry Press

Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3(2):159-66.

Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of Care: a Multidisciplinary Review. BMJ. 2003;327(7425):1219-21

Nash DA, 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, Apr 2012.

"WHEN THE DENTAL HISTORY OF OUR TIME IS EVENTUALLY WRITTEN, I BELIEVE THE NEW ZEALAND DENTAL NURSE PROGRAM WILL BE CONSIDERED ONE OF THE LANDMARK DEVELOPMENTS IN THE PRACTICE OF DENTISTRY AND DENTAL PUBLIC HEALTH.“

HAROLD HILLENBRANDEXECUTIVE DIRECTORAMERICAN DENTAL ASSOCIATION, 1947-1969