The Truth About Dental Hygiene Practitioners

What’s a Dental Hygiene Practitioner (DHP)?

A DHP is a licensed dental hygienist who receives an additional two years of education, clinical training, and credentialing in order to perform additional procedures under the supervision of a Texas dentist. These procedures are the most routine and commonly needed dental care procedures, such as filling cavities.

Claim: DHPs will put dentists out of business.

Fact: For dentists in Texas, it can make good economic sense to hire a DHP. Practices can earn additional net revenue even after accounting for the costs of hiring a DHP, additional support staff, and expanded facilities, and an increase in Medicaid patients (who have a lower reimbursement rate than privately insured patients). This has proven true in Minnesota where DHP-type providers have been practicing since 2011.

Claim: Access to oral health is not an issue in Texas.

Fact: Almost six out of ten Texas children have a history of dental decay and over one-quarter have untreated decay.[i] Almost one in five seniors have lost all their natural teeth.[ii] Over 3 million children have Medicaid coverage[iii] , but almost one-third of counties have no participating dentists.[iv] Twenty percent of counties have no dentists and 12% have only one dentist[v] Almost 60% of counties contain federally classified Dental Health Professional Shortage Areas.[vi]

Claim: A DHP has little or no supervision.

Fact: A DHP must be hired by a dentist and practice under the supervision of a dentist. The proposed bill allows dentists to limit the procedures DHPs can perform and strictly prohibits DHPs from having independent practices.

Claim: DHPs won’t be sufficiently educated or provide safe, high-quality care.

Fact: Real-world experiences of similar providers in Minnesota, Alaska and over 50 other nations and over 1,000 studies have proven this claim to be false.[vii] In fact, the Commission on Dental Accreditation (CODA), which is housed within the American Dental Association, recently adopted standards for programs that train DHP-type practitioners. CODA sets educational standards for programs that train dentists and other dental professionals.[viii]

DHPs will receive the same level of training as a dentist for procedures they can perform. For example, a general dentist in Texas is authorized and trained to perform over 500 procedures while a DHP would be trained to perform about 80. For the limited set of procedures that overlap, DHPs must meet the same level of competency as a dentist. The University of Minnesota trains their DHP-type providers side-by-side with dental students for those procedures. A 2014 report released by the Minnesota Board of Dentistry and Department of Health notes there have been no complaints filed against these practitioners for patient safety issues.[xxv] In Alaska, where similar providers have practiced for 10 years, not a single malpractice claim has been filed.[ix]

Claim: A DHP will do “irreversible, surgical” procedures.

Fact: When opponents of these practitioners say this, they are talking about filling cavities. It is important to note that the American Dental Association’s own Council on Scientific Affairs released a systematic review in 2013 that found patients treated by DHP-type providers have favorable oral health outcomes. The study’s lead author wrote in a commentary that accompanied the review, “The results of a variety of studies indicate that appropriately trained midlevel providers are capable of providing high-quality services, including irreversible procedures such as restorative care and dental extractions.”[x] Again, there have been no patient safety complaints against providers that do the same thing in the two states where they are operating—Minnesota and Alaska.[xi]

Claim: The available literature reveals no convincing evidence related to the cost-effectiveness of utilizing these providers in place of dentists.

Fact: This is false. A number of studies have been published that point to the cost-effectiveness of both private practices and public clinics that employ DHP-type providers.

  • A study conducted by the Minnesota Department of Health and the Board of Dentistry on the state’s experience to date with midlevel providers found that two-thirds of the clinics employing them reported significant savings in personnel costs. Several noted that a midlevel provider costs roughly half as much as a dentist; one clinic calculated their savings at $62,000 per midlevel while others estimated the savings to be $35,000-$50,000 per midlevel.[xii]
  • Data collected by the Alaska Native Tribal Health Corporation, the organization that trains Alaskan midlevel providers, found that providers bill on average $150,000-$250,000 per year more than the cost to employ them and their dental assistant.[xiii]
  • A private practice in Minnesota that employed a DHP-type provider was able to make an additional $24,000 in profit after employing a midlevel provider, and serving an additional 500 Medicaid patients. This is notable given that the American Dental Association ranked Minnesota last in pediatric Medicaid reimbursement in 2013 (Texas ranked 10th).[xiv]
  • A 2013 study conducted by Community Catalyst, Inc. of midlevel dental providers practicing in Alaska and Minnesota found that they cost their employers less than 30 cents for every dollar that they bill.[xv]

Because they have a limited scope and lower salary, a DHP allows dentists who choose to hire them to expand their patient base. The proposed bill does not force dentists to hire DHPs, it simply provides them with the option if they would like to expand their practices using these practitioners.

Claim: There is no credible evidence that new scope and workforce models decrease the prevalence of caries (cavities) in affected populations. In fact, despite decades of use of these workforce models in numerous countries, there is no apparent reduction in disease incidence.

Fact: In a response to an American Dental Association study that found that midlevel providers as well as dentists have little impact on preventing decay, the American Academy of Public Health Dentistry had this to say:

“Given that therapists, within their scope of practice, provide similar services as dentists (e.g., reactive treatment of existing disease and individual level health promotion and preven­tion), there is little reason to presume that they would have a greater or lesser influence on disease increment than would be found among populations treated by dentists only. The benefit therapists offer is not to provide unique or novel treatment not provided by dentists, rather it is to provide the same treatments offered by dentists at lower costs and to populations that have both high needs and poor access to care.” [xvi]

Nearly 7 million Texans are living with untreated decay. Their needs are urgent and, alongside dentists, DHPs can safely and cost-effectively help address this need.[xvii]

Claim: Midlevel dental providers create a two-tier system of care.

Fact: Midlevel dental providers hold the promise of offering routine and continuous care to millions more people than the current patchwork system of charity care. Under the current system, uninsured, publically insured and low-income Texans frequently must rely on free care days to obtain needed dental treatment. They rarely receive follow-up care or regular preventive or basic restorative services to ensure dental problems don’t turn from small cavities to major infections.

Claim: Texas dentists provide charitable care to thousands of Texans every year, in addition to free care provided daily in dental practices throughout Texas.

Fact: The American Dental Association itself says “charity is not a sustainable health care system.”[xviii] It is commendable of Texas dentists to provide this care, but it is not a sustainable alternative to a reliable source of dental care to prevent cavities or stop a small cavity from turning into a large infection.

Claim: All Texans deserve comprehensive care from a dentist.

Fact: All Texans deserve high-quality dental care from trained professionals performing procedures for which they are trained. Decades ago, opponents of nurse practitioners (NPs) and physician assistants (PAs) used the same argument against NPs and PAs performing some procedures then only performed by physicians. Now, midlevel dental providers in Alaska, Minnesota, and over 50 other countries perform a small set of procedures currently only being performed in Texas by dentists. Overwhelming evidence shows these midlevel providers deliver comprehensive, high-quality care at the same level of quality as a dentist.[xix] They work in a team under the supervision of a dentist. These types of midlevel dental providers reduce the rate of untreated dental decay more than do oral health teams that employ only dentists.[xx]

Claim: Increasing Medicaid reimbursement would solve access problems for Medicaid enrollees.

Fact: Increasing Medicaid reimbursement is important but is no silver bullet to solving access problems, and it does not always translate into increased access. In North Dakota, continued increases in reimbursement over the last five years until ND had one of the highest rates in the country did not translate to more children with Medicaid coverage receiving care.[xxi] Additionally, twenty percent of Texas’ counties have no dentists and 12% have only one dentist – increasing Medicaid reimbursement does nothing to help residents in these areas.[xxii] Finally, raising the rate cannot help Texans with Medicaid coverage who have difficulty getting to the dentist’s office. DHPs would be able to practice under general supervision, enabling them to deliver care in schools, nursing homes, and clinics to people unable to visit a dentist.

Claim: Educational standards don’t exist for this type of provider.

Fact: The Commission on Dental Accreditation, which is housed at the American Dental Association and considered the gold standard for dental education programs, recently approved educational standards after several years of careful study.[xxiii]

Claim: Access to dental care can be improved by funding dental loan repayment programs and adding oral health education to Promotora and Community Health Worker Training programs.

Fact: While important, loan repayment programs and greater health coordination do not provide the kind of comprehensive solution to dental provider shortages offered by DHPs. Community health workers need dentists to refer patients to, but almost one-third of Texas counties have no dentists participating in Medicaid and twenty percent of Texas’ counties have no dentists at all.[xxiv] In addition, the pipeline for training dentists is at least twice as long as that for preparing DHPs, who would be trained to fill cavities and thus prevent the type of larger and more costly dental problems that accompany decay that is neglected.

Claim: The proposed midlevel model ignores the importance of prevention.

Fact: DHPs are licensed dental hygienists, practitioners whose current scope is entirely preventive. A DHP’s scope will be approximately 75% preventive and 25% restorative. DHPs will provide preventive services and routine restorative procedures (like filling cavities) which prevent small problems from turning into major infections.

References:

[i] Texas Department of State Health Services, Division of Family and Community Health, Office of Program Decision Support. Second Assessment of Children Dental Health Status: As Required by Frew v. Janek. March 2014.

[ii] National Oral Health Surveillance System. 2008 Behavioral Risk Factor Surveillance System. http://apps.nccd.cdc.gov/nohss/DisplayV.asp?DataSet=2&nkey=10056&qkey=8

[iii] Texas Health and Human Services Commission. Texas Medicaid Enrollment Statistics.http://www.hhsc.state.tx.us/research/MedicaidEnrollment/MedicaidEnrollment.asp

[iv] Texas Health and Human Services Commission. Texas Medicaid Provider Database. As of July 2014.

[v] Texas Department of State Health Services, Center for Health Statistics, Health Professions Resource Center. As of September 2014. http://www.dshs.state.tx.us/chs/hprc/tables/dental/All-Dentists,-2014

[vi] U. S. Department of Health and Human Services, Health Resources and Services Administration. Find Shortage Areas: HPSA by State & County. As of 1/1/15. http://hpsafind.hrsa.gov/HPSASearch.aspx

[vii] Wetterhall et.al, An Evaluation of the Dental Health Aide Workforce Model in Alaska: Final Report, RTI International, October 2010 https://www.rti.org/pubs/alaskadhatprogramevaluationfinal102510.pdf ; Minnesota Department of Health and Minnesota Board of Dentistry. Early Impact of Dental Therapists in Minnesota: Report to the Minnesota Legislature 2014. February 2014. http://www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf ; David A. Nash et al., “Dental Therapists: A Global Perspective,” International Dental Journal 58 (2008): 61–70.

[viii] American Dental Association, Commission on Dental Accreditation. “Report of the Task Force on Development of Accreditation Standards for Dental Therapy Education Programs.” Page 1601, Subpage 1. CODA Winter 2015. http://www.ada.org/en/coda/accreditation/coda-meeting-materials

[ix] Patrick Blahut, Indian Health Service Deputy Dental Director, to Jane Koppelman, Research Director, Children’s Dental Campaign, The Pew Charitable Trusts via phone call February 19, 2015

[x] Wright JT. Do midlevel providers improve the population’s oral health? Special Commentary, JADA 2013;144(1):92-94

[xi] Minnesota Department of Health and Minnesota Board of Dentistry. Early Impact of Dental Therapists in Minnesota: Report to the Minnesota Legislature 2014. February 2014. http://www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf;

Patrick Blahut, Indian Health Service Deputy Dental Director, to Jane Koppelman, Research Director, Children’s Dental Campaign, The Pew Charitable Trusts via phone call February 19, 2015

[xii] Minnesota Department of Health and Minnesota Board of Dentistry. Early Impact of Dental Therapists in Minnesota: Report to the Minnesota Legislature 2014. February 2014. http://www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf; Patrick Blahut, Indian Health Service Deputy Dental Director, to Jane Koppelman, Research Director, Children’s Dental Campaign, The Pew Charitable Trusts via phone call February 19, 2015

[xiii] Alaska Native Tribal Health Consortium. Connector. May 2014

[xiv] The Pew Charitable Trusts. Expanding the Dental Team: Studies of Two Private Practices. February 2014. http://www.pewtrusts.org/en/research-and-analysis/reports/2014/02/12/expanding-the-dental-team;

American Dental Association. Medicaid Fee-for-Service Reimbursement as a Percentage of Commercial Dental Insurance Charges, Pediatric Dental Care Services, 2013.

[xv] Kim, Frances, Viability of Dental Therapists, May, 2013. Accessed on February 6, 2015 at http://www.communitycatalyst.org/doc-store/publications/economic-viability-dental-therapists.pdf;

[xvi] ADA Scientific Study Finds Surgical Midlevel Providers Improve Access to Care and Population Health Outcomes. January 7, 2013. Press Release of the American Association of Public Health Dentistry. Accessed on February 5, 2015 at http://www.aaphd.org/assets/press-releases/ada%20scientific%20study%20-%20aaphd%20press%20release%202013.pdf

[xvii] Texas Department of State Health Services, Division of Family and Community Health, Office of Program Decision Support. Second Assessment of Children Dental Health Status: As Required by Frew v. Janek. March 2014; U.S. Department of Health and Human Services. National Health and Nutrition Examination Survey, 1999-2004. http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesAdults20to64.htm; U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000; 2014 Texas Population Estimates from U.S. Census Bureau. State & County: QuickFacts: Texas. Accessed February 25, 2015. http://quickfacts.census.gov/qfd/states/48000.html.

[xix] David A. Nash et al., “Dental Therapists: A Global Perspective,” International Dental Journal 58 (2008): 61–70.; Wetterhall et.al, An Evaluation of the Dental Health Aide Workforce Model in Alaska: Final Report, RTI International, October 2010 https://www.rti.org/pubs/alaskadhatprogramevaluationfinal102510.pdf

[xx] Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. JADA 2013;144(1):75-91.

[xxi] University of North Dakota, Center for Rural Health. North Dakota Oral Health Report: Need and Proposed Models, 2014. December 2014. http://ruralhealth.und.edu/projects/nd-oral-health-assessment/pdf/north-dakota-oral-health-report-2014.pdf

[xxii] Texas Department of State Health Services, Center for Health Statistics, Health Professions Resource Center. As of September 2014. http://www.dshs.state.tx.us/chs/hprc/tables/dental/All-Dentists,-2014

[xxiii] American Dental Association, Commission on Dental Accreditation. “Report of the Task Force on Development of Accreditation Standards for Dental Therapy Education Programs.” Page 1601, Subpage 1. CODA Winter 2015. http://www.ada.org/en/coda/accreditation/coda-meeting-materials

[xxiv] Texas Health and Human Services Commission. Texas Medicaid Provider Database. As of July 2014; Texas Department of State Health Services, Center for Health Statistics, Health Professions Resource Center. As of September 2014. http://www.dshs.state.tx.us/chs/hprc/tables/dental/All-Dentists,-2014; Texas Department of State Health Services, Center for Health Statistics, Health Professions Resource Center. As of September 2014. http://www.dshs.state.tx.us/chs/hprc/tables/dental/All-Dentists,-2014

[xxv] Minnesota Department of Health and Minnesota Board of Dentistry. Early Impact of Dental Therapists in Minnesota: Report to the Minnesota Legislature 2014. February 2014. http://www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf

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