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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