Appendix E
Submitted Comments and Questions

For several panels of the workshop, participants were asked to submit cards with questions or comments for the panelists. Moderators chose among these questions and comments to stimulate discussion regarding recurring themes and specific questions. Not all comments or questions could be addressed during the discussion period. Therefore, the questions and comments in this section represent a larger sampling of those submitted by workshop participants.

Panel on Current Oral Health Needs and the Status of Access to Care

  1. How can we recruit more Hispanics and African Americans into dental schools? Is the pool of applicants the same or has it increased? If so, why do we not have more under-represented minority students in our schools at this time?

  2. What are the current and expected debt loads for graduating dentists? What is the future projection for this? What is debt doing to career decisions?

  3. How do you define “productivity” or “professionally active”?

  4. What percentage of practicing hygienists belongs to ADHA?

  5. How many future ADHP candidates do you expect?

  6. Can we ethically accept “public health supervision” while still demanding direct or general supervision in private?

  7. What do studies say about the numbers of dentists in the workforce and access to care for the underserved?



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Appendix E Submitted Comments and Questions For several panels of the workshop, participants were asked to submit cards with questions or comments for the panelists. Moderators chose among these questions and comments to stimulate discussion regarding recurring themes and specific questions. Not all comments or questions could be addressed during the discussion period. Therefore, the questions and comments in this section represent a larger sampling of those submitted by workshop participants. Panel on Current Oral Health Needs and the Status of Access to Care 1. How can we recruit more Hispanics and African Americans into dental schools? Is the pool of applicants the same or has it increased? If so, why do we not have more under-represented minority students in our schools at this time? 2. What are the current and expected debt loads for graduating den- tists? What is the future projection for this? What is debt doing to career decisions? 3. How do you define “productivity” or “professionally active”? 4. What percentage of practicing hygienists belongs to ADHA? 5. How many future ADHP candidates do you expect? 6. Can we ethically accept “public health supervision” while still demanding direct or general supervision in private? 7. What do studies say about the numbers of dentists in the workforce and access to care for the underserved? 

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0 THE U.S. ORAL HEALTH WORKFORCE 8. What is the impact of more women as dentists on the dental work- force of the future? Will they work longer or more collaboratively to share practices or will there be other models as a result of there being more women in the dental workforce? 9. What is the potential impact of the accreditation of foreign dental schools upon the dental workforce in the United States? 10. If the Colorado experience with independent dental hygiene is showing constraints with funding and capitalization, then how will creating a higher level hygienist with a more costly education and demanding higher wages facilitate greater access to care? 11. How effective has direct access been at increasing access to dental hygiene services and at getting people to have access to comprehen- sive care? What is the evidence base? 12. How many independent practices of dental hygiene are in opera- tion in Colorado/Denver? 13. Explain the financing of Apple Tree. What is the funding source(s)? What role does Medicaid play? Who makes your portable dental equipment? 14. How would you address workforce requirements to deal with the major determinants of oral disease, namely lifestyle and socio- environmental influences? Who will ensure healthy public policy regarding prevention that obviates the need to treatment services? 15. What can be done now to take models like Apple Tree to scale nationally? 16. How many nursing home residents do not have a responsible party which is a family member and subsequently a state agency makes care decisions? How much longer does it take for them to receive dental care? 17. How safe is the dental loan repayment fund in the current economy? 18. Is the placement of unsupervised dental hygienists into primary care medical practices consistent with Colorado’s state dental prac- tice act? If yes, how did you do that? 19. Nationally, while the number of rural applicants to health pro- fession programs has remained stable, the number accepted (for example, medical school) has decreased. How has Colorado been able to prioritize and prepare rural health professions applicants? 20. How has the independent practice of dental hygiene in Colorado (for the past 14 years) increased access to care for the underserved elderly? Any data? 21. What is a reasonable distance for someone in a rural area to have to drive to the dentist? 22. Please define “remote populations.”

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 APPENDIX E 23. Whose role in the workforce is the responsibility of converting unmet oral health needs to effective demand for services? 24. What is the vacancy rate in the Indian Health Service (IHS)? For dentists? For dental hygienists? Skilled assistants? Is there funding to hire willing dentists? 25. Many tribal governments are choosing their own dentists. How does that impact Indian Health Service plans for the future? Is it true that IHS uniforms are a barrier since this has a negative con- notation for those populations? 26. Who applies the majority of the sealants in the IHS clinics? 27. Is teledentistry used in the IHS? 28. Are family medicine physicians more or less accepting of medicine’s role in primary caries prevention than pediatricians? 29. How is the National Dental Association working with the National Medical Association? 30. What should follow if the Kellogg/CTI study of the ANTHC/ DHAT (therapist) shows highly positive clinical and behavioral outcomes? 31. How is dental training and education changing to meet population needs? In 1995, the IOM identified the need to change an outdated curriculum—what has happened? 32. Preventive oral health care needs to meet people where they are at and provide for their needs with integrity, empathy, and respect. 33. I’m on the Board of the ADA. Why do you choose not to comment on our activities or sensitivities? 34. The discussions so far have involved dental schools, medical schools, and dental hygiene programs. There has been no mention of schools of public health. 35. There is a growing tendency to put Medicaid dentistry into man- aged care, but there is difficulty getting data about these patients from the managed care companies—is this a potential policy issue as these data are critical in evaluating these approaches? 36. State dental practice acts impede innovation in developing new models of care delivery. Panels on Current Demographics and Future Trends of the Oral Health Workforce 1. Is the data presented based only on ADA member dentists? What percentage of practicing dentists are ADA members? 2. What percentage of dentists participated in this survey? Where these only members of the ADA or all dentists? 3. What constitutes “charitable care”? Is this care comprehensive?

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 THE U.S. ORAL HEALTH WORKFORCE 4. Does “Healthy Kids” reimburse non-dentist providers such as den- tal hygienists, physicians, and nurse practitioners? 5. Based on hours per week already worked among practicing den- tists, how is it likely that 82+ million of the American underserved can be cared for in a comprehensive manner? 6. “Boomers” are reaching retirement—many with little savings—and will depend on Medicare for their medical care. How will oral health needs be provided and funded? 7. Does the ADA data distinguish between “charitable” care and “bad debt”? 8. If dentists want to keep restorative procedures for their own activities, why not expand dental hygiene services to include more periodontal procedures? 9. What is the evidence base and strength of that evidence regarding documentation of the charitable service by dentists? 10. What barriers currently exist to prevent nurse practitioners from applying fluoride varnish in states where they are allowed to (and are paid for)? 11. If the medical home is comprehensive, why do we need a dental home? 12. Why expanded function dental assistants but no expanded function dental hygienists? 13. The ADA proposes expanding functions for dental assistants—do they also propose expanding functions for dental hygienists? 14. Regardless of the addition of other health care providers, how can the production of new dentists ever hope to meet the populations’ challenge into the future? 15. The solo dental practice seems like the most expensive, cost- ineffective business model imaginable. Also, has pro bono care increased or decreased from ten years ago? 16. About 35 state Medicaid programs reimburse physicians. What about private insurers? 17. Regarding American Academy of Pediatrics joint projects: where and when will you collaborate with nurses and dental hygienists? 18. Do state AAP chapters get involved with policy debates on chil- dren’s overall health? Specifically, do they take a stand on dental workforce? Medicaid reimbursement? 19. The dental practice acts could be changed to allow dental hygienists to work for pediatricians. They have already been tested for their dental skills and ability to educate parents on homecare and prevention. 20. Hygienists should be able to work for primary care physicians and pediatricians. Why shouldn’t they be able to work in these alternate practice settings?

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 APPENDIX E 21. What percentage of family physicians take Medicaid reimbursement? 22. What are the reasons for dropout from hygiene school? 23. Why not encourage the development of dental therapy programs if there are too many dental hygiene programs? Flooding the market with hygienists is not socially responsible. 24. From all the oral health curricula available, what is the consensus of which one is evidence-based and recommended? There are so many of them and all are different. 25. To facilitate medical and dental integration, should we call caries “strep tooth?” 26. Bottom-up change occurs much more quickly since these are the individuals who are directly integrated with the target popula- tion—they have first hand knowledge of the needs. Top-down change occurs much more slowly because these individuals are disconnected from the target population. Integration of the medical and dental workforces would allow oral health providers to work alongside other health care providers. 27. One group of professionals that have not been mentioned as part- ners in this effort are non-clinical public health professionals or health promotion specialists. Another group is the licensed social workers. There are many more groups with which to collaborate. 28. Physical diagnosis instruction during medical school is an appro- priate time to teach oral anatomy as students are taking a tongue blade and looking into the oral cavity. 29. The term “medical model” is out of date and implies a treatment approach instead of a preventive public health approach (such as addressing all determinants of public health). 30. Terminology such as “unsupervised,” “auxiliary,” and “mid-level practitioner” needs to be modernized. 31. If dental assistants want equal pay as dental hygienists, shouldn’t they have equal education requirements? 32. Rather than having to train “non-dental” providers to provide dental assessments and fluoride treatments, wouldn’t it make more sense to put dental hygienists to work with pediatric and geriatric offices to provide preventive care rather than training already-busy nurses or doctors to handle this? This would add to medical-dental integration and coordination as well as provide employment for the glut of dental hygienists that is forecast. 33. This workshop has focused on a range of clinical practitioners, but has completely omitted the public health model and dental public health workforce. 34. It is surprising to me that no updated supply requirements model- ing or analysis of the oral health workforce was presented. Has this

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4 THE U.S. ORAL HEALTH WORKFORCE type of modeling and analysis been ongoing? Who is doing this? What are the results? 35. What is the impact of degree inflation on the cost of health care? (Example—Doctorate of Nursing Practice) Panel on Current Delivery Systems 1. Why do you not mention empty chair time (use of) as a way to make Medicaid work for the private dentists? 2. The current evidence is that the “dentist-based” delivery system does not work (i.e., so many people can’t access care). On that basis, why should we continue the current system, or why not test other models? 3. What percent of the underserved population is being treated and served by community health centers? How many adults? How many children? 4. Why are there so few hygienists working in public health centers? 5. What are the “vacancy rates” for dental workforce at the commu- nity health centers? What are the best ways to address this? 6. What would it take to change the law to ensure that community health centers provide comprehensive oral health care (prevention, treatment, emergency) for all children, adults, and elders? 7. Do HRSA dental clinics operate under state dental practice acts, or are they considered Federal programs? 8. How can tax dollars be spent on an agency that refuses to release data showing utilization and outcomes? 9. How about training general dentists how to deal with the scream- ing 1–2 year olds? 10. To what extent will the economic downturn serve to drive new dentists away from private practice and toward salaried services? 11. What has been the impact of rising educational debt on dentists’ career choices? 12. For Medicaid management companies, any thoughts on quality of care? There’s been many TV “on the spot” exposures of these clinics’ use of papoose boards, etc. 13. Please discuss intergovernmental transfers (IGT). Is there is a model that has been working whereby the county sends money to the state, which sends money to a contractor non-profit pro- vider with Federal match. The IGT improves funding for indigent care. 14. What evidence supports various models for delivery of care that assess quality of care rather than who delivers those models? And who pays? What do we know/don’t know?

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 APPENDIX E 15. By way of promoting the development of a national prevention workforce, how do we unify the disciplines around training, fund- ing, and program implementation of prevention practice that engages patients and communities? 16. Is there agreement on outcomes for oral health populations, especially those who are economically disadvantaged? What are those outcomes? How are they the same/different from other pay- ing populations? 17. Community health center physicians provide a significant amount of medical care to Medicaid recipients. Is there a mechanism to mandate that they provide oral health preventive services to these children in those states which allow such reimbursement? 18. What is HRSA doing to assist community health centers to provide optimal services? 19. How can the reported average hours per week be related to demand when there are low-income patients who report that they can’t find a dentist willing to treat them? Panel on the International Experience 1. Regarding dental therapists in Australia: For those students requir- ing the services of a dentist, how is that referral done and who has the responsibility to follow up? 2. In the New Zealand model, what happens to young adults after graduation in terms of dental utilization and health care outcomes? 3. Since permanent teeth come in well before kids leave school, why can’t dental therapists care for adults? 4. If dental therapists were so effective, why are they not placing them as dental hygienists? Can you elaborate on the political issues that influenced that move? 5. Which state shows the most promise in starting a pilot program for dental therapists? 6. Regarding Netherlands, what preventive services will the preven- tive dental assistants be able to perform? Why has the dental pro- gram been increased to 6 years? 7. Are there any anticipated difficulties for dental professionals trained outside the United States to help fill gaps in workforce or in education? How quickly can we use international “experts” in oral health to practice in the United States or pursue a U.S.-based DMD/DDS degree? 8. What is the role of sugared soda pop in the dietary pattern of Australian schoolchildren? Is it present in the elementary schools?

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 THE U.S. ORAL HEALTH WORKFORCE 9. In the United States, there really are no 2-year dental hygiene programs; all have 1 year of prerequisites. Is that the same for the dental therapy programs? 10. How difficult is it to develop dental therapy programs in high school? Will there be any issues for payment of dental therapists through school systems given the disparate/disproportionate fund- ing of schools? 11. The average “2-year” dental hygiene program is not 2 years—the average hours of an associate degree now is 90 hours. Community colleges are not allowed to offer any degree higher than an associ- ate degree—even 90 hours is pushing it in credit hours and length. Dental hygiene hours, with 90 hours being the average, is only 30 hours away from a bachelor’s degree in the United States. 12. What is the cost of educating dental therapists (2-year program)? 13. How can we reduce opposition to dental therapists in the United States? Educate them with dentists? Pay dentists more than thera- pists? Other ideas? 14. Is there any evidence that dental therapists have adversely impacted the economic well-being of dentists? 15. The international data seem quite clear about the cost effectiveness and safety and efficacy of pediatric dental therapists. Do you know of any states in the United States who are considering implementa- tion of this model of care? 16. The New Zealand dental therapist—once registered has complete portability (licensure is accepted in every state). Twenty-five years ago it was determined that lack of license portability would be one of the largest hindrances to access and the workforce. Why do we still employ states rights to scope and portability in the United States? 17. What would it take to implement pilot projects now in the United States to educate dental therapists in the New Zealand model? 18. Denturism was a “hot topic” in the 1970s–1990s. No mention was made about them in any of today’s presentations. With the bur- geoning “baby boomer” cohort entering into retirement age, will this resurface as a workforce issue within the next decade especially as most seniors will lose their dental insurance when they retire? 19. New Zealand is not a model to test any longer but is a proven, viable workforce example that should be copied and implemented.

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 APPENDIX E Panels on Workforce Strategies 1. For OHIP, can you give us an idea of numbers—how long ago did Philadelphia start this? Any students that have actually gone into dentistry, dental hygiene, dental assisting? 2. How is Resilient Public Healthcare funded? 3. For OHIP, how do you address the time the child is away from their studies while they are being treated? 4. How can we develop a dual strategy to address both perinatal and infant oral health? 5. Have you done a cost/benefit analysis of the pediatric oral health educator? 6. You cite the diabetes educator as a model for the pediatric oral health educator. How successful are diabetes educators in the man- agement of diabetes mellitus? 7. Why subsume the pediatric oral health educator under the role of dental therapist? Isn’t that what the dental health aide therapist (DHAT) is all about? 8. Do you think the Health Commons approach could survive finan- cially in a non-federally qualified health center (e.g., private prac- tice, academic practice)? 9. All of the models presented today except one require additional education. 10. For the DHAT, community dental health coordinator (CDHC), and oral health practitioner (OHP), who will pay for the training and education of students? What are those costs? What is the estimated school debt on graduation? 11. What is the status of drinkable, fluoridated water in the villages of Alaska? 12. What were the specifics of “political” pressures which affected the University of Washington Dental School participation in the DHAT program? 13. How does the scope of practice for the proposed OHP in Minnesota compare to dental therapists or the Australian oral health practitioner? 14. Why did Minnesota opt for an OHP as opposed to a dental therapist? 15. How will we know if these models are “successful” in terms of population outcomes? 16. Can an out-of-state or foreign-trained dentist credential in as an OHP in Minnesota? 17. Regarding evaluation of the OHP, is your institution’s Human Research Committee reviewing and approving the project?

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8 THE U.S. ORAL HEALTH WORKFORCE 18. How does a CDHC address access in areas where there is a signifi- cant shortage of providers? 19. In Boise, ID, there are only two dentists who will accept new Medicaid patients. How would CDHCs refer those they have examined? 20. Who will hire CDHCs—private dentists, public programs, com- munity health centers? And what are their incentives/motivations to hire? 21. What collaborative partners were involved in the development of the OHP and CDHC? 22. Please define remote supervision. 23. How can a CDHC work with remote supervision when many hygienists can’t? 24. Would the CDHC be licensed? Would the CDHC provide irrevers- ible procedures under remote supervision? 25. Why have the dentist (the provider in shortage) supervise the CDHC? 26. Can the CDHC be linked to multiple dentists? To pediatricians? 27. Why can’t we incorporate the CDHC as a part of the dental hygiene curriculum? 28. Why, if all other models are moving toward a higher degree of learning, does the CDHC model have less education? 29. Has the Commission on Dental Accreditation established a way for the CDHC programs to become accredited? Has the ADA requested that CODA investigate this? 30. How would the work of the CDHC be funded and paid for? 31. How will the CDHC be evaluated in terms of an independent evidence-based evaluation? What data base(s) will serve as the “control” or “comparison” experience? 32. How will pilot testing of CDHCs be carried out given state prac- tice act restrictions that limit the provision of many of the clinical skills included in the CDHC curriculum to licensed oral health care providers? 33. How is it possible that someone who only has a high school diploma can place temporary fillings and do assessments in the remote field when a licensed, college-educated dental hygienist is prevented from doing that now? 34. Public health dental hygienists and public health dental assistants are already doing the work described for the CDHC. Why reinvent the wheel? 35. If a dentist cannot change the behavior of a patient to prevent recur- ring decay one year after restorations are completed, how will a

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 APPENDIX E CDHC? What will they know or what special skills will they have that their supervising dentist does not have? 36. Why doesn’t the ADA support testing the dental hygienist and dental therapist models? 37. Why are demonstration projects utilizing dental therapists in par- ticular so highly resisted by organized dentistry and dental schools in America despite the evidence of benefit? 38. Are you recommending a second tier of services for the poor and/ or underserved? Why is it that we are focused on the access to care solution by recommending dental providers that have fewer qualifications for the high risk populations with huge amounts of disease? 39. Does the supervisory dentist share malpractice liability? 40. Does Medicaid reimburse the OHP? 41. Do the Alaskan DHATs also treat adults? 42. How can we develop a license qualification for foreign-trained dentists who are not able to provide dental services?

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