Treating decay in the US oral healthcare system

Figure: Mary Williard, DDS (DENTEX program director) with a 2014 graduate.FigureConcerned about the deteriorating state of oral health in America, US foundation leaders met more than 10 years ago to see what they could do collaboratively. They decided that they could improve oral health with a series of linked, coordinated, and simultaneous projects. Signing on were the Pew Charitable Trusts, the W.K. Kellogg Foundation, the Robert Wood Johnson Foundation, the Macy Foundation, the Dentaquest Foundation, and Alaska's Rasmuson Foundation. One strategy was to increase oral health assessments and preventive services provided by all primary care providers. Physician assistant (PA) programs were early adopters of this idea, as PA educators learned about the shocking oral health status of America's children. Oral health content was added to PA curricula and the Physician Assistant Education Association offered sessions on how to develop and present this content. The American Academy of Pediatrics developed CME modules on pediatric oral health. PA faculty members participated in the construction of these materials. One seemingly lofty foundation goal was restructuring the US oral health workforce to include PA-like dental therapists, based on the successful and effective model that had been developed in New Zealand in 1916. Similar to the PA model, dental therapists would work with a supervising dentist. Compared with dental hygienists, their scope of practice would be limited to treating and preventing caries rather than treating periodontal disease. In addition to performing what the American Dental Association calls irreversible procedures (extracting teeth and “drilling and filling”), dental therapists would use a public health model that included community outreach and active work within the schools to teach—and participate in—regular toothbrushing experiences within the classroom. In this issue of JAAPA, Louis Fiset, BA, DDS, describes the Alaska development of the dental therapist as a new US health career (see the online-only article, “DENTEX: The emergence of dental therapists in the United States” at www.jaapa.com). Working in partnership with the Alaska Native Tribal Health Consortium (ANTHC), the MEDEX Northwest PA program at the University of Washington worked to apply the founding principles originally used by Richard Smith, MD, to create MEDEX in 1968. Overall, the development of the new dental therapy career felt like a time warp of the support and opposition that PA educators and graduates experienced in the early years of our own profession's existence. MEDEX became involved in this crusade based on our long-term relationships with Alaska tribal groups. In 1973, MEDEX deployed seven members of MEDEX Class 4 to Alaska to become Alaska's first PAs. Aside from providing clinical services, these PAs were assigned to develop the PA career in Alaska's remote and challenging settings. Beginning in 1982, MEDEX began to admit and train Alaska community health aides from native health corporations and also continued to deploy military veterans to fill PA jobs in the Alaska bush. The original plan called for the University of Washington Dental School to partner with ANTHC, with MEDEX providing consultation and support on the competency-based curriculum design and the training of dental preceptors. The dean of the dental school decided that the dental school could not participate based on threats from the Washington State Dental Association. In a complex but strategic negotiation led by John Coombs, MD, the School of Medicine's dean of regional affairs, a decision was made for MEDEX to become the University of Washington's academic partner with ANTHC, with regular informal reporting to the dental school's dean. This protected the dental school but put MEDEX on the front lines for threats and attacks. Fortunately, the MEDEX experience as a pioneering PA program provided examples and strategies for dealing with the opposing dental organizations. In addition to using curriculum materials from existent dental therapy programs in New Zealand and Canada, MEDEX used Dr. Smith's principles for creating a new health career. These principles were: a collaborative model using doctors and community stakeholders to participate in the development of the program the creation of a receptive framework of regulation and reimbursement to support the profession a deployment system to determine, as part of the admissions decision, where the students would be placed competency-based training built on the specific skills the trainees would need practitioner involvement to modify the curriculum based on the experiences of the graduates continuing education designed to constantly upgrade the skills of the new clinicians. Although it was finally possible to create a dental therapy program in Alaska, where tribal sovereignty lets dental therapists practice based on federal rather than state law, the Alaska dental therapy model was replicated in Minnesota—a state with a reputation for healthcare innovation. In 2014, the Maine legislature passed a law allowing the creation of dental therapists there. Other states, including Oregon, have rules that allow pilot or demonstration projects to try new workforce models. State-specific projects funded by the Pew Charitable Trusts or the Kellogg Foundation are building coalitions and infrastructure to introduce dental therapists. I hope that PAs will recognize the parallels between themselves and dental therapists and support their movement to increase healthcare access to everyone in America—regardless of whether they have dental insurance.

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