9
The International Experience

A panel of experts discussed the workforce strategies of other countries to care for the unmet oral health needs of their populations.

CHILDREN’S ORAL HEALTH: INTERNATIONAL SUCCESSES

David A. Nash, D.M.D., M.S., Ed.D.

University of Kentucky


Dental therapy is becoming more popular around the world due to the inadequacy of the current dental workforce to provide access to oral health care services for all populations. Many countries around the world provide noteworthy lessons on how to address children’s unmet oral health needs.

New Zealand

In the early 1920s, New Zealand began the training of school dental nurses. Now called dental therapists, these practitioners transformed the oral health of the children in New Zealand. The dental therapist curriculum requires 2 academic years after high school followed by a 1-year preceptorship with a school dental therapist. Today, dental therapists care for virtually all of New Zealand’s children in school-based programs. Dental therapists practice with general (indirect) supervision of a district dental officer and provide basic care including diagnosis, education, treatment planning, preventive therapies, restorations, and the extraction of primary teeth. A recent report documented that at the end of any given school year,



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9 The International Experience A panel of experts discussed the workforce strategies of other countries to care for the unmet oral health needs of their populations. CHILDREN’S ORAL HEALTH: INTERNATIONAL SUCCESSES Daid A. Nash, D.M.D., M.S., Ed.D. Uniersity of Kentucky Dental therapy is becoming more popular around the world due to the inadequacy of the current dental workforce to provide access to oral health care services for all populations. Many countries around the world provide noteworthy lessons on how to address children’s unmet oral health needs. New Zealand In the early 1920s, New Zealand began the training of school dental nurses. Now called dental therapists, these practitioners transformed the oral health of the children in New Zealand. The dental therapist curriculum requires 2 academic years after high school followed by a 1-year precep- torship with a school dental therapist. Today, dental therapists care for virtually all of New Zealand’s children in school-based programs. Dental therapists practice with general (indirect) supervision of a district dental officer and provide basic care including diagnosis, education, treatment planning, preventive therapies, restorations, and the extraction of primary teeth. A recent report documented that at the end of any given school year, 

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 THE U.S. ORAL HEALTH WORKFORCE none of New Zealand’s children had untreated tooth decay. This school- based model has spread to many other countries. Malaysia In 1949, Malaysia established the Malayan School for Dental Nurses, patterned after the New Zealand program. In Malaysia, health care for elementary school children is provided through a network of public and school clinics that employ dental nurses. The implementation of school- based dental programs has shown dramatic improvements in children’s oral health, reaching 96 percent of all elementary school children and 67 percent of secondary school children (Ministry of Health Malaysia, 2005). In Malaysia, dental nurses also treat toddlers and preschool children. Australia In 1965, Australia approved the practice of school dental nurses (now called dental therapists), largely in response to the success of the program in New Zealand. Today, the overwhelming majority of dental care for children in Australia is provided by dental therapists. Recently, the training of dental therapists and dental hygienists has been merged. Canada In 1972, a dental nurse program was established in Canada’s North- west Territories under the guidance of the dental faculty at the University of Toronto. In that same year, the province of Saskatchewan began to train school dental nurses and provide dental services to children. A few years later, the province of Manitoba established a school-based program and contracted with Saskatchewan to train the school dental nurses. By the mid-1980s, the Saskatchewan Dental Service had enrolled almost all of Saskatchewan’s children, and school dental nurses examined and treated almost all of these children annually. Despite broad public support, there was opposition to these programs by dentists in both provinces that led to both programs being transferred to private practice. Saskatchewan’s program was less successful under the fee-for-service basis and was eventually eliminated. The National School for Dental Therapy in Saskatchewan continues to train about 20 dental therapists annually in a 2-year curriculum to care for the Indian and Inuit populations on reserves and in the Northern Terri- tories. Today, about 300 dental therapists practice in Canada, primarily in Saskatchewan, Manitoba, and the Canadian north (Nash et al., 2008). About half the dental therapists in Saskatchewan practice alongside dentists in private offices.

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 THE INTERNATIONAL EXPERIENCE Great Britain Great Britain began training dental nurses in the 1960s and has con- tinued to expand their numbers. Today, about 200 students are accepted annually into 15 programs, most of which are affiliated with (or part of) den- tal schools or dental teaching hospitals (Nash et al., 2008). In the mid-1990s, a combined dental hygiene and dental therapy curriculum was introduced. Today, most programs offer a combined program ranging from 2 to 3 aca- demic years (depending on the degree offered). The curriculum is governed by Britain’s Dental Council and includes training in traditional dental hygiene skills as well as instruction in restorations and procedures for primary and permanent teeth, including stainless steel crowns, pulp therapy, and extrac- tion on primary teeth. Today, about 700 dental therapists practice in a variety of settings across Great Britain and are considered full members of the dental team. A 2003 survey found that 70 percent of dentists regarded dental thera- pists as valued members of the dental team (Gallagher and Wright, 2003). Conclusions Many lessons may be learned from looking at the international expe- rience in caring for children’s oral health. First, dental therapists provide quality care for children. This is especially seen through the nearly 90 years of success of the New Zealand school-based dental programs and multiple studies evaluating their competency (Ambrose et al., 1976; Nash et al., 2008; Riordan et al., 1991). Second, dental therapists can be effectively trained to provide compe- tent care in a 2-year program. Dental therapy programs emphasize caring for children’s oral health and provide comparatively more hours of training in pediatric dentistry than the typical general dentistry curriculum. Inter- nationally, the model for training dental therapists is similar to the 2-year dental hygiene programs in the United States; therefore, a 2-year dental therapy curriculum could be developed and offered alongside associate degree dental hygiene programs, allowing flexibility in choice of study and offering efficiency in that no new infrastructure would be needed. Alterna- tively, curriculum could be designed to combine the skills of dental thera- pists and dental hygienists, as has been seen in other countries. Third, placing dental therapists in school-based programs effectively addresses access concerns. By going where the children are located, these programs help overcome some of the social, cultural, and educational barriers that prevent children from being brought to a dentist’s office or other clinical setting to receive oral health services. Finally, dental therapists provide cost effective, economical care. The typical child does not require the level of expertise of a general or pediatric

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4 THE U.S. ORAL HEALTH WORKFORCE dentist in order to receive basic preventive and restorative care. Instead, a lesser trained and lower-salaried individual can provide competent care safely for many basic procedures, reserving dentists for those problems that can only be managed by a dentist. DENTAL AND ORAL HEALTH THERAPISTS IN AUSTRALIA Julie Satur, Ph.D., M.H.Sci. (H.Prom.), Dip.Appl.Sci (D.Therapy) Melbourne Dental School, Uniersity of Melbourne In Australia, dental therapy preceded dental hygiene as a profession, and in New Zealand dental therapy is nearly as old as dental hygiene in the United States. In fact, in Australia, the first dental hygienists did not begin training until the early 1970s, and many states did not legalize the profession until the year 2000. In 1965, Australia first replicated the dental therapy model that had been implemented in New Zealand for decades, but the profession has evolved significantly to the dental therapy practitioner seen today. Dental Therapy in Australia About 90 percent of children and adolescents in Australia receive care once every 2 years and the caries-free rate is just over 50 percent (Armfield et al., 2007; Ellershaw and Spencer, 2006). The caries rate has decreased significantly in the past few decades due to many factors including water fluoridation and improved quality of life. However, about 10 percent of children have higher caries levels, usually children from disadvantaged pop- ulations (e.g., low-income children, aboriginal children, new migrants, dis- abled children). Overall, the regular contact that children and their parents have had with school dental services has created a culture that emphasizes the importance of oral health. Participation rates in school-based programs vary greatly depending on the state due to factors such as resource alloca- tion to the programs, presence of copayments, and workforce shortages. Since their inception, dental therapists have practiced autonomously, including diagnosis, treatment planning, care provision, and referrals to dentists as appropriate. Health promotion and disease prevention forms the basis of dental therapy, but dental therapists also provide restorative care including pulpotomies, and they extract teeth. Today, dental therapists tend to extract mostly deciduous teeth because the need for permanent extractions has decreased. Until the year 2000, dental therapists were public-sector employees, tied to school-based programs, restricted to treat- ing patients up until the age 18 and licensed but exempt from the regulatory process (e.g., not registered or represented on dental boards). Since the year

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 THE INTERNATIONAL EXPERIENCE 2000, legislative changes in all states in Australia and in New Zealand have required the registration of all dental therapists and hygienists, represen- tation of dental therapists and hygienists on dental practice boards, and removal of employment limits. In some states, dental therapists and hygien- ists may own dental practices, but may not practice independently. A great deal of research was carried out in the 1970s and 1980s that demonstrated that the quality of care provided by dental therapists for the services they provide is equivalent to that of dentists. Today’s research has focused more on the role of dental therapists in providing care to adults as well as the effect of moving dental therapists into the private sector. These changes have allowed dentists and dental therapists to become more col- laborative, but there are still political disagreements about their roles in some areas. Dental Therapists and Dental Hygienists Today, Australia has a population of approximately 21 million, with about 1,800 dental therapists and 1,000 dental hygienists. Generally speak- ing, dental hygienists tend to focus on periodontal disease whereas dental therapists tend to focus on caries. However, the two professions are quite similar in their preventive approaches, health promotion philosophy, and minimal intervention. When dental therapists were limited to school-based, public-sector employment, there were greater differences in the professions due to the dental therapists’ being located in schools treating children, whereas dental hygienists were in private practice treating people of all ages. After the legislative changes, the differences became less clear. For example, some states now allow dental therapists with additional train- ing to treat adult patients. Courses for this additional training are not yet available, although in New Zealand there are a number of therapists registered with adult scope of practice based on a grandfather clause in their act arising from the removal of age limits in 1988. This is an issue of innovation in service provision that is one of the newer directions for dental therapy practice in our countries, and the educational models are still under discussion. The Oral Health Therapist With the distinction between the two professions becoming more blurred, the solution has been to combine the practitioners (dental hygien- ists and dental therapists) into a new type of practitioner—the oral health therapist. Oral health therapists are primary oral health care professionals who focus on primary oral health care, promotion, prevention, assessment (including diagnosis and treatment planning), treatment, and referral to

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 THE U.S. ORAL HEALTH WORKFORCE higher-level practitioners when needed. These practitioners are generalists with the capacity to focus on specific areas or populations in need (e.g., older adults, aboriginal populations, disabled populations). Oral health therapists provide both complementary and substitute services for dentists. Currently, about 300 practitioners in Australia are qualified as oral health therapists. Oral health therapists are educated in 3-year bachelor’s degree programs in both Australia and New Zealand, usually within a dental or health sciences faculty in a university and now represent the vast majority of graduates. Conclusions Many of the same regulatory debates exist in Australia as in other countries regarding the use of other types of oral health practitioners, such as the oral health therapist. However, in 2004, Australia’s National Advisory Committee on Oral Health (established by the Australian Health Ministers’ Conference) declared that regulations should “not impose bar- riers to the full use of the skills of the whole dental team (general and spe- cialist dentists, dental hygienists, dental therapists, oral health therapists, prosthetists, dental assistants) in the provision of high-quality, accessible, and affordable dental care for the whole community” (National Advisory Committee on Oral Health, 2004). ORAL HEALTH CARE PROFESSIONS IN THE NETHERLANDS Jos. an den Heuel, D.D.S. Netherlands Institute for Health Serices Research (NIVEL) In the 1970s, the Netherlands experienced a heavy rate of caries com- bined with a significant shortage of dentists. As a result of the experiences in New Zealand and Australia, the dental school at the University of Amsterdam started a project that provided additional training to dental hygienists for simple restorative treatments, exemplifying a strong tenet that some parts of dental care do not need academically trained personnel. This new style of dental hygienist was a harbinger of the changing scene of oral health profes- sionals due to continued shortages in the oral health workforce. Over the last decades, instead of educating more dentists, the Nether- lands has tried to fundamentally modernize the oral health workforce not simply by increasing the numbers of professionals but by removing barriers between the traditional professions and changing the skills mix to develop a more efficient and effective workforce based on a team approach. Objec- tives of these changes have focused on access to care, quality of care, and labor satisfaction rather than cost reduction.

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 THE INTERNATIONAL EXPERIENCE Many societal trends are affecting the dynamics of the oral health pro- fessions. First, there has been a growing trend toward evidence-based den- tistry; however, a lot of evidence is lacking and so there is still a place for the “art” of dentistry. There is also a deepening awareness of the relation- ships between oral health, general health, quality of life, and demographic changes in both the patient population and the workforce. Finally, there continue to be rapid changes in technological advancements that affect the dynamics of the professions. As a result of all these considerations, the Netherlands recognized that traditional professions need to change within the scope of a dental team that would be interrelated with and communicate with each other. In that vein, the professions were engaged in discussions regarding the professional autonomy and responsibility of each member of this team. All of these changes are difficult and require strong leadership of govern- ment due to the conflicting interests of stakeholders and requirements for legislative change. In the modern system of the dental team, dentists focus on the general diagnosis and care coordination of a patient’s treatment, treating those with the most complex problems. Dental hygienists focus on prevention (primary, secondary, and tertiary), screening and monitoring, and the delivery of basic dental services. Dental assistants focus on pri- mary prevention, organizing the practice, and assisting dentists and dental hygienists. Finally, clinical dental technicians (denturists) focus on the field of removable prosthodontics. In this new system, patients have free access to dental hygienists for traditional preventive care, but require orders from a registered dentist to access their expanded duties for the treatment of the tertiary prevention of caries, including administration of local anesthesia and drilling of cavities. To promote this team-based approach, legislative change was the key to success. Legislation affected education by legally describing the compe- tencies of each member of the dental team. As a result, a new curriculum for dental hygienists developed that requires 4 years of training leading to a bachelor’s degree. Subsequently, the dentists’ curriculum changed from 5 to 6 years leading to a master’s degree. Additionally, courses were ex- tended for dental assistants to allow them to perform some preventive tasks. To date, a gradual evolution is occurring among the dental professions with more team-based care, more structured collaboration, and larger practice organizations. To address workforce planning for the future, the Ministry of Educa- tion and Ministry of Health installed a political committee that estimated that the Netherlands would need less dentists in the future, but more den- tal hygienists, leading to a reduction in dental school intake. Today, more detailed research is being performed to determine future workforce needs. These estimates depend largely on several assumptions, including labor time

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8 THE U.S. ORAL HEALTH WORKFORCE reduction and job delegation. Due to the wide variety of assumptions about oral health care in the future, workforce planning in the Netherlands and around the world continues to be a major challenge. REACTION AND DISCUSSION An open discussion followed the panelists’ presentations. For this ses- sion, workshop participants were asked to submit cards with comments and questions for the panelists. The following sections summarize the discussion session. (See Appendix E for a broader sampling of the submitted questions and comments.) Moderator: Shelly Gehshan, M.P.P. Pew Center on the States Implementing the Dental Therapy Model in the United States Several participants submitted questions regarding how to implement the dental therapy model in the United States. Nash said a demonstration project should be done wherein an institution integrates their dental hygiene curriculum to include dental therapy. Nash asserted that there is a lot of overlap of these two professions and that it would not take much to add dental therapy to the dental hygiene program, creating an oral health thera- pist. Van den Heuvel noted that in the Netherlands, legislators resisted the creation of a new profession in oral health therapy due to its similarity to dental hygiene. As a consequence, the new type of dental professional kept the protected title of dental hygienist. Satur added that legislative protec- tions are necessary with any new professional model because the public deserves and trusts in that process. She added the need to recognize that the therapist is a bachelor degree-level practitioner who must think critically, appraise evidence, and make treatment decisions. Overcoming Opposition Several participants submitted comments and questions related to how to overcome the opposition in the United States to the use of dental thera- pists. Participants also asked if there was any evidence of the economic impact of the use of dental therapists on dentists. Satur stated that she did not have evidence, but she expressed an impression that there is so much dental disease and unmet need for care that the use of therapists and hygienists would likely not have any impact on dentists’ income. She added that one successful element is that in Australia, students of dentistry and oral health therapy are integrated during the final year of both programs.

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 THE INTERNATIONAL EXPERIENCE For example, these students work together to provide services to patients in rural areas in which they are required to collaborate on care planning and delivery. Satur added comments about the long-standing practice of dental therapists in New Zealand referring patients beyond their scope to local dentists (in private practices) that has reinforced the integrated nature of the model and enhanced acceptability by dentists. Nash pointed to research in the United Kingdom that demonstrates that dentists’ opposition to dental therapy markedly decreased after dental schools began educating dental therapists alongside dentists. Nash said all members of the dental team should be trained and educated together to encourage appropriate understanding of role relationships and collabora- tion. However, Nash noted that in the United States, dental programs and dental hygiene programs are usually not located within the same institution. Nash also said that dentists might become more amenable to the use of therapists once they understood the profitability of such a collaboration. Educational Model Several participants submitted questions about the dental therapy edu- cational model, including the costs. Van den Heuvel said the total cost of training of dental hygienists is less than half the total cost of training of dentists. Satur commented that the Melbourne Dental School offers a number of programs under a global budget (based on a fee scale set by the government); she said oral health therapy students are charged the same tuition fees as dental students, but their programs are shorter. Nash added that many international programs are 3-year bachelor’s degree programs, and in the United States, dental hygiene directors are considering adding a third year to dental hygiene programs, possibly in collaboration with larger universities. Dental Referrals Participants submitted questions regarding the process of referral to a dentist by a dental or oral health therapist. Satur stated the therapist has a duty of care that requires collaboration and referrals when needed. She said the therapist acts as a primary care provider and identifies problems that are beyond his or her scope. In the school-based dental programs, a dentist usually has regular visitation to that program, so the therapist will book a child to be seen by the dentist on that particular day. Satur added that the therapist and the dentist will confer about the patient, including the reason for referral, and discuss what each of them will do in the team-based treatment plan. Satur said that in the private-practice setting, dentists have a similar relationship with therapists as they do with dental hygienists.

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