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ADEA Takes Note of Allied Dental Changes

In this month's letter, Dr. Rick Valachovic, Executive Director of the American Dental Education Association, looks at developments that are changing the face of allied dental education.

Positioning Allied Dental Education for "Disruptive" Change

Less than a week ago, 200 allied dental program directors gathered in the mountain resort of Coeur d'Alene, Idaho, to focus on the theme of this year's ADEA Allied Dental Program Directors' Conference, "Transitions in Allied Dental Education." I was a participant in the Conference, and like the others who were there, I arrived ready to contemplate the opportunities that lie ahead and to gain concrete skills that we all can use in our work.

The Conference offered a rich and varied program, including a session called "Working Effectively with Conflict." We knew that evaluations from previous conferences revealed that this is a major concern, not just for administrators, but for faculty and students as well. Given the wave of change forecast at the conference, skills acquired in this session should prove extremely useful.

Two significant developments are simultaneously under way in allied dental education. One is a movement to create more graduate programs in dental hygiene. For a long time, there were only eight Master in Dental Hygiene programs in the United States, with most of these focused on preparing graduates to enter academic positions. The inability of most dental hygienists to pick up and move to one of these campuses traditionally limited enrollment in these programs. But in the last five years, we've seen a welcome expansion in opportunities for advanced dental hygiene education. Now more than twelve Master in Dental Hygiene programs are operating, with at least two more in the pipeline.

Secondly, and perhaps more significantly, advanced education in the allied dental professions is also being made more accessible by a shift in how education is delivered. New programs are using a mixed model that incorporates both on-campus and distance learning, and established programs are beginning to offer distance learning opportunities as well. These changes should help to alleviate the faculty shortage in allied dental education, but these programs are not solely aimed at producing educators. They are also seeking to prepare dental hygienists to play a major role in expanding access to dental care.

There's no question that greater independence for the practice of dental hygiene is the wave of the future. A bill passed in Maryland this spring will allow hygienists, beginning this fall, to provide preventive services in public health settings without a dentist's prior authorization or direct supervision. In some states, hygienists can establish their own practices. In others, under certain circumstances they can perform restorative functions. Most of us are well aware of the significant initiative in Minnesota this past spring that provides for the creation of a new "Oral Health Practitioner." Given these trends, opportunities for advanced education in dental hygiene take on even greater importance.

At the Conference, four presenters who are at various points in the process of establishing graduate programs shared their experiences with attendees. Many in the audience were also considering ways to expand educational options at their campuses. Stephanie Harrison, Director of the Dental Hygiene Program at the Community College of Denver, found food for thought among the diverse approaches represented. "Whether they started with legislative support, articulation agreements, or putting the financing in place, they're all striving to reach the same end. The session gave me a lot of alternatives to consider as we seek to expand opportunities in Colorado."

The Conference also focused on the move toward accreditation of dental assisting programs. The ADEA Section on Dental Assisting Education is focusing its efforts on developing a strategic plan for a uniform educational and credentialing model for dental assisting. It's good to see the dental assisting com munity moving in this direction. It bodes well for quality assurance in an environment where dental assistants, like their colleagues in dental hygiene, are being called upon to take increased responsibility for patient care, especially in underserved communities. About a dozen states now allow dental assistants to apply dental sealants, and proposals to expand their scope of practice are on the table in additional states.
As we all know, the number of professionally active dentists is expected to decline in the next decade, yet some are predicting that the supply of dental services will increase due to enhanced productivity and an increase in the number of allied dental personnel. Indeed, the U.S. Bureau of Labor Statistics lists dental hygiene and dent al assisting among the ten top fastest growing occupations. These trends may prove beneficial as we strive to provide dental care to a greater portion of the population. As a 2001 ADA report titled The Future of Dentistry notes, "A more intensive and extensive employment of allied dental professionals can provide a more rapid, flexible, and cost-effective way of increasing workforce productivity, distribution, and availability."

That said, these transitions are sizable, and will disturb the status quo in ways that inspire and unsettle us in equal measure. Dr. Karl Haden, President of the Academy for Academic Leadership, said as much in his keynote address, "The Opportunities Ahead: Making the Most of Disruptive Change in Oral Health Care."

Karl gave his audience a thorough introduction to the concept of disruptive innovation. In a nutshell, a disruptive innovation overturns the status quo, increasing access to a product or service by enabling more people to acquire skills previously possessed only by specialists. By definition, the change is far reaching. Within the health professions, disruptive innovation can meet with resistance, yet it can be a fundamental driver of economic growth.

Karl also sought to address concerns within the community of practicing dentists that forthcoming changes may compromise care. He pointed out that we have yet to establish a basic standard of care, and that patients will play a central role in setting such standards in the health care arena of the future. Inaccessible and expensive health care won't be considered high-quality care. Instead, where risk is low and procedures well defined, patients will rate the quality of health care according to its convenience and expense. When risk is high and the options not clear (for example, when deciding whether to obtain a dental implant), patients will define high quality health care according to its reliability and efficacy.

Where does this leave allied dental professionals? The community can best position itself to benefit from these transitions by focusing on what it does best—prevention—and by looking for ways to reach those people with the greatest burden of disease. Karl noted that state practice acts with undue supervisory requirements prohibit allied dental professionals from health care promotion and provision of preventive care. He stressed that oral health care should be a collaborative team effort, with the dentist as the team leader, and that students in the allied dental professions mu st bec ome critical thinkers committed to lifelong learning if they are to succeed in a healthcare environment affected by disruptive innovation.

Disruptive change within dentistry seems increasingly imminent. The question is, how will we respond? Will we let coming innovations plunge us into turmoil, then wait for the government to sort things out? Or will we work across our professions to design a smooth transition to new models of care delivery that assure access, affordability, and quality across the spectrum of needs? I think you can guess my answer, and if the discussions I overheard in Idaho are any guide, I think our members in the allied dental professions are also eager to start mapping our route down the road ahead.

In the meantime, let's start with some smaller changes as suggested by our colleagues on the ADEA Council of Allied Dental Program Directors' Task Force on Collaboration, Innovation, and Differentiation. Their letter to the editor in this month's edition of the Journal of Dental Education challenges us to clean up our language so that everyone on the oral health care team and the work they perform is referred to with respect. This could certainly go a long way to lowering the barriers to communication among the professions and help move future discussions about the scope of allied dental education and practice in a positive direction.

Richard W. Valachovic, D.M.D., M.P.H.
Executive Director

Legislative Updates

Updated 5.15.08

OHP Bill Passed by Governor Tim Pawlenty

It is with great pleasure we report that the Governor has passed the Higher Education Policy bill, SF 2942, into law on Monday May 12^th, 2008. The bill contains the creation of an Oral Health Practitioner (based on the ADHP model) in law, and the working group to implement the details.

This bill is the result of a lot of hard work since initial presentation in October and a recommendation by Senator Lynch's cost containment workgroup to proceed with the idea. Please be sure to thank the legislators and dental professionals that supported this bill, and continue to watch for updates as the working group moves forward with a position on enacting this.

A final copy of the bill is as follows:

19.10    Sec. 26. [150A.061] ORAL HEALTH PRACTITIONER.
19.11    Subdivision 1. Oral health practitioner requirements. The board shall authorize
19.12a person to practice as an oral health practitioner if that person is qualified under this
19.13section, works under the supervision of a Minnesota-licensed dentist pursuant to a
19.14written collaborative management agreement, is licensed by the board, and practices in
19.15compliance with this section and rules adopted by the board. No oral health practitioner
19.16shall be authorized to practice prior to January 1, 2011. To be qualified to practice under
19.17this section, the person must:
19.18    (1) be a graduate of an oral health practitioner education program that is accredited
19.19by a national accreditation organization to the extent required under subdivision 2 and
19.20approved by the board;
19.21    (2) pass a comprehensive, competency-based clinical examination that is approved
19.22by the board and administered independently of an institution providing oral health
19.23practitioner education; and
19.24    (3) satisfy the requirements established in this section and by the board.
19.25    Subd. 2. Education program approval. If a national accreditation program for
19.26midlevel practitioners is established by the Commission on Dental Accreditation or
19.27another national accreditation organization, the board shall require that an oral health
19.28practitioner be a graduate of an accredited education program.
19.29    Subd. 3. Requirement to practice in underserved areas. As a condition of
19.30being granted authority to practice as an oral health practitioner under this section,
19.31the practitioner must agree to practice in settings serving low-income, uninsured, and
19.32underserved patients or in a dental health professional shortage area as determined by the
19.33commissioner of health.
19.34    Subd. 4. Application of other laws. An oral health practitioner authorized
19.35to practice under this section is not in violation of section 150A.05 relating to the
20.1unauthorized practice of dentistry and chapter 151 relating to authority to prescribe,
20.2dispense, or administer drugs.
20.3    Subd. 5. Rulemaking. The Board of Dentistry may adopt rules to implement this
20.4section.
20.5EFFECTIVE DATE.This section is effective July 1, 2009.

23.33    Sec. 29. ORAL PRACTITIONER WORK GROUP.
24.1    Subdivision 1. Oral health practitioner work group. By August 1, 2008,
24.2the commissioner of health, or the commissioner's designee, in consultation with the
24.3Board of Dentistry, shall convene the first meeting of the work group appointed under
24.4subdivision 2 to develop recommendations and proposed legislation for the education
24.5and regulation of oral health practitioners. The work group's recommendations must
24.6include an implementation schedule that allows for enrollment of students in oral health
24.7practitioner educational programs by the fall of 2009. The work group shall provide
24.8recommendations and proposed legislation on the following issues:
24.9    (1) necessary education and competencies, including clinical training requirements,
24.10faculty expertise, and facilities;
24.11    (2) the appropriate program accreditation;
24.12    (3) scope of practice that reflects the education and training of the oral health
24.13practitioner and includes the following services: preventive, primary diagnostic,
24.14educational, palliative, therapeutic, and restorative oral health services, including
24.15preparation of cavities and restoration of primary and permanent teeth using direct
24.16placement of appropriate dental materials, temporary placement of crowns and restorations
24.17and placement of preformed crowns; pulpotomies on primary teeth; direct and indirect
24.18pulp capping in primary and permanent teeth; extractions of primary and permanent
24.19teeth; placing and removing sutures; and providing reparative services to patients with
24.20defective prosthetic appliances. In recommending scope of practice for the oral health
24.21practitioner, the work group may consider which services may be provided to children and
24.22which services may be more appropriately provided to adults;
24.23    (4) the level of supervision required by a licensed dentist, including any limitations,
24.24restrictions, or dentist supervision requirements the work group recommends that should
24.25be applied to any of the services or procedures listed in clause (3);
24.26    (5) the medications that may be prescribed, administered, and dispensed by an oral
24.27health practitioner if authorized by the supervising dentist in a collaborative agreement.
24.28These may be limited to medications for anti-infective therapies, nonnarcotic pain
24.29management, and prevention;
24.30    (6) extractions that may be performed by an oral health practitioner if authorized
24.31by the supervising dentist in a collaborative agreement and are within any limitations,
24.32restrictions, and level of supervision requirements recommended by the work group;
24.33    (7) criteria for determining in which practice settings oral health practitioners
24.34should be authorized to practice in order to improve access to dental care for low-income,
24.35uninsured, and underserved populations, including a definition of "underserved";
25.1    (8) an assessment of the economic impact of oral health practitioners to the provision
25.2of dental services and access to these services;
25.3    (9) an evaluation process that includes clearly defined outcomes and a process for
25.4assessing whether these outcomes were successfully met; and
25.5    (10) licensure and regulatory requirements, including licensing fees.
25.6    Subd. 2. Membership and operation of work group. (a) The work group shall
25.7consist of the following members:
25.8    (1) one dentist and one dental hygienist appointed by the University of Minnesota
25.9School of Dentistry;
25.10    (2) two persons appointed by the Minnesota State Colleges and Universities, at least
25.11one of whom must be a dentist;
25.12    (3) one representative, who must be a dentist, appointed by the Board of Dentistry;
25.13    (4) two dentists appointed by the Minnesota Dental Association;
25.14    (5) one dental hygienist appointed by the Minnesota Dental Hygienists Association;
25.15    (6) two persons representing safety net dental providers serving low-income and
25.16uninsured patients appointed by the Minnesota Safety Net Coalition at least one of whom
25.17must be a dentist;
25.18    (7) a pediatric dentist appointed by the Minnesota Association of Pediatric Dentists;
25.19    (8) a representative of the commissioner of health; and
25.20    (9) a representative of the commissioner of human services.
25.21    (b) The appointing authorities under paragraph (a) must complete their appointments
25.22no later than July 15, 2008. The work group must elect a chair from its membership at the
25.23first meeting. The commissioner shall provide staff support and meeting space for the work
25.24group. The members serve without compensation or reimbursement for any expenses.
25.25    Subd. 3. Research and recommendations. In developing its recommendations, the
25.26work group shall review existing midlevel dental practitioner programs in other countries
25.27and in Alaska and proposals for dental therapists, advanced practice dental hygienists,
25.28and other models. The work group shall review research on midlevel practitioners and, to
25.29the extent possible, base its recommendations on evidence-based strategies that are most
25.30likely to: (1) improve access to needed oral health services for low-income, uninsured, and
25.31underserved patients; (2) control the costs of education and dental services; (3) preserve
25.32quality of care; and (4) protect patients from harm. The work group shall complete its
25.33recommendations by December 15, 2008, and the commissioner and Board of Dentistry
25.34shall submit a report containing the work group's recommendations and draft legislation to
25.35the chairs and ranking minority members of the legislative committees with jurisdiction
25.36over health care and higher education issues by January 15, 2009.
26.1    Subd. 4. Costs of implementation. The commissioner of health may seek private
26.2funding or grants to support the activities of the oral health practitioner work group, and
26.3any money received is appropriated to the commissioner of health for that purpose. To the
26.4extent the costs cannot be covered with grants and external funding, the commissioner
26.5of health may charge a fee to the Minnesota State Colleges and Universities and the
26.6University of Minnesota Dental School proposing to develop oral health practitioner
26.7education programs to cover the remaining costs. Any fees collected shall be deposited
26.8in the state government special revenue fund and appropriated to the commissioner for
26.9the activities of the work group.
26.10    Subd. 5. Expiration. This section expires on the date the report required under
26.11subdivision 3 is submitted to the specified legislative members.
26.12EFFECTIVE DATE.This section is effective the day following final enactment.

Day at the Capitol 2008

Thank you to all who participated in MNDHA's very successful 2008 Day at the Capitol. The annual lobby day was held on Wednesday, February 20th with over 125 dental hygienists and dental hygiene students in attendance. Over 100 legislators were greeted and given information on the dental access to care issue in our state, along with information relating to the new legislative bill to create the ADHP in Minnesota! If you would like to receive information regarding this event's happenings, or how to contact your legislators, please contact MNDHA for more information.

Get the Facts on the ADHP in Minnesota

Statewide, dental and medical professionals along with legislators and the general public have been asking the who's, what's, and why's of the introduction of the Advanced Dental Hygiene Practitioner. As the Minnesota Dental Hygienists' Association, we feel that you need the facts straight from the source. In partnership with the MN Oral Health Safety Net Coalition and Minnesota State Colleges and Universities (MnSCU), the Minnesota Dental Hygienists' Association has put together many handouts, fact sheets, and Q & A documents to help you learn the truth about the ADHP and how it relates directly to access to care needs in MN. Please see the links below to download these files.

ADHP Facts and Q & A

What Else is Important to Know about the ADHP?

MN Dental Hygiene Practice Models Comparison

Tragic Death a Driving Force to Initiate ADHP in U.S.

The flurry of dental legislative activity over the past year is directly attributable to the tragic death of young Marylander Deamonte Driver (http://www.adha.org/media/releases/03012007_post.htm ) which has prompted members of the Maryland congressional delegation to take concrete steps in order to improve access to dental care for underserved populations. Given the intense interest of Maryland legislators, ADHA leaders, members, and staff are working with the offices of additional Maryland legislators.

Some of the above information has been prepared from information posted on the ADHA's public website. If you are an ADHA member and would like more detailed information, please check out the members section at www.adha.org

If you have any additional questions, or would like more information about legislative issues pertaining to dental hygiene in the state of Minnesota, please contact Candy Hazen at candyhazen@hotmail.com

Updated 2-23-08

ADHP Bill Released in MN House and Senate

The 2008 Legislative session has officially begun, and the state House and Senate have now both received identical bills that would introduce the Master's degree level Advanced Dental Hygiene Practitioner (ADHP) to Minnesota. Please see the links below to access the bills directly on the legislature's website.

HF 3247 - http://wdochouse.leg.state.mn.us/leg/LS85/HF3247.0.pdf

SF 2895 - https://www.revisor.leg.state.mn.us/bin/showPDF.php

Dental Hygienists are encouraged to please contact your local representative and senator to let them know you support the introduction of the ADHP in MN and ask them to do the same. Please click here to view the letter introducing the bills from Mary Beth Kensek, President MNDHA.

The first hearing is scheduled for February 25, 2008 in the House Licensing Subcommittee.

Day at the Capitol 2008