ADA News

They asked for dialogue, they got invigorating conversation.

They wanted different perspectives and to hear what was going on in neighboring states, and their peers responded.

What had the potential to be a contentious debate over divisive issues turned out to be a professional discussion that yielded a lot of shared opinions.

Nearly 170 state volunteer leaders including constituent presidents, presidents-elect, dental association executives, ADA trustees and council members convened at ADA Headquarters July 18 for the Conference on Workforce Issues. The conference was facilitated by the ADA at the request of state dental society leaders who wanted to get more information about workforce issues in other states.

"If we're going to lead this country in dentistry, we're going to have to speak with one voice. One," said Dr. Jake DeSnyder, chair of the Council on Dental Practice.

The constituent associations responded in droves, traveling from as far as Puerto Rico, Hawaii, Maine and Alaska in addition to 47 other states and the District of Columbia to brainstorm, talk about their local issues and hear what others are doing in response. The seating was purposely random, allowing the volunteer leaders and executive directors to meet their counterparts from other states and exchange ideas they may not hear otherwise. Some tables were engaged in such intense discussions that they worked through the breaks and others carried over their conversations into lunch.

"I thought it was really worthwhile. I know that there were people that were afraid that it was going to be a waste of time," said Dr. Mark Zust, president-elect of the Missouri Dental Association and member of the Council on Dental Practice's Subcommittee on Workforce Issues. "I liked the opportunity to share ideas with people of all the states across the U.S. and let them know what was going on in our state."

The conference centered on the efforts of some to create a midlevel provider both within and outside of the dental team. Models or pilot programs have been proposed in various states, and different groups and foundations are lobbying legislators to support the position in other states.

Those who attended may share different opinions regarding workforce but some common themes emerged. Many said that access to oral health care could be improved by increased communication to the public about how to prevent dental disease and by increasing reimbursement to the dentists providing dental services through public health programs.

"We consider these midlevel provider discussions an unfortunate distraction that delays implementation of proven solutions like proper funding of safety net programs, oral health literacy initiatives and preventative services," said ADA President Dr. Ronald Tankersley in his opening remarks.

Workforce at annual session

The workforce issue is one that will be highlighted by the ADA House of Delegates at annual session in October in a special reference committee on the subject. The CDP will be sending a supplemental report on resolutions concerning workforce that were referred to it in 2009. This report, along with a minority report, will be forwarded to the House of Delegates for deliberation at the 2010 annual session. The Board of Trustees will review the reports during its July 25-27 meeting as part of its regular review of resolutions and reports that are being transmitted to the House.

Many also believe that communicating with legislators, patients, the public and each other is the key to understanding current workforce models and the complexity of the dental profession.

Charlie Leonard, partner from Chlopak, Leonard, Schechter & Associates, the national public affairs firm working with the ADA on the State Public Affairs program, presented information from focus group research conducted across the country on public perceptions of dental workforce issues. The qualitative research showed people were willing to expand the workforce model based on the belief it would be cheaper to provide care to underserved patients. Mr. Leonard's data also showed that the public is unaware of the complexity of dental procedures and the number of years it takes to become a dentist.

"The truth is what people believe it is," Mr. Leonard said.

The public has a hard time understanding the concept of an inadequate distribution of dentists and they think there's a shortage of dentists, Mr. Leonard said.

"We need to become better at telling our story," said Dr. Roger Newman, past president of the Montana Dental Association and member of the Subcommittee on Workforce Issues.

Dentists at the conference said they wanted to change the public's perception about what it takes to be a dentist and the intensity and complexity of a dentist versus other positions within the profession.

"The profession needs to take a proactive approach to telling the public what they are," said Dr. Pasco Scarpella, president of the Colorado Dental Association.

There is also an observation that cosmetic dentistry in particular has negatively affected the training and scientific background of dentists, Mr. Leonard said.

Many were interested in launching a public campaign that appealed to their patients, the public and especially legislators. Several speakers emphasized the importance of developing relationships with state legislators early when it comes to workforce. Mr. Leonard said research indicates that when organized dentistry is the first group to present an agenda for improving access to oral health care, it's favored over other group's proposals.

Many at the conference believe the state associations wouldn't be engaged in this debate if there were proper funding to provide dental services for low-income children. According to the research Mr. Leonard's company conducted, the focus group participants, many of whom are covered by dental insurance or can afford to pay for dental care, believe that midlevel providers are fine to treat underserved people but they prefer their dental care to be provided by dentists.

"They're OK for the other person, but they're not OK for them," said Dr. Red Stevens, delegation chair for the Alabama Dental Association. "If everything was funded, we wouldn't be here today."

The debate would also be tempered if more people could be persuaded to practice oral disease prevention, thus helping them avoid emergency or more frequent trips to the dentist.

"The issue should be how do we prevent the disease from happening in the first place?" said Dr. Jonathan Shenkin, president of the Maine Dental Association.

Driving this issue are several foundations that have dedicated their efforts toward solving the access problem through the creation of a midlevel provider.

The Kellogg Foundation has been promoting the Dental Health Aide Therapist model developed in Alaska. Last year, Kellogg began to inquire with American Indian tribes in New Mexico, exploring ways to expand the DHAT model. Late last year, that effort was expanded to bring DHATs to five states—Vermont, Ohio, Kansas, New Mexico and Washington—as a licensed practitioner sanctioned by the state.

To achieve this, Kellogg plans a three-year grant program to each of the five states, awarding between $100,000-$150,000 annually.

The Pew Charitable Trusts have also taken an interest in access to dental care and the workforce model. Their approach has been to foster a variety of models, including the Community Dental Health Coordinator model proposed by the ADA, and try to determine the viability of each.

Dr. David Holwager, member of the Council on Access, Prevention and Interprofessional Relations, stated that the CDHC model is not a midlevel dental provider. CDHCs are based on the community health worker model and would be responsible for providing patient education, helping people navigate resources available to them under public health programs and connecting people who need treatment with dentists who will provide the care. More information on the ADA's CDHC program may be found at www.ada.org/cdhc.aspx.

A CDHC does not do surgery or diagnose. The ADA is opposed to non-dentists making diagnoses or developing treatment plans or performing irreversible procedures.

Pew launched the "Children's Dental Health Campaign" to ensure that Medicaid and Children's Health Insurance Programs work better for kids and providers so that insurance coverage translates into real access to needed care. Another goal of the campaign is to expand the sealant programs for kids who need them most; expand access to optimally fluoridated water; and expand the number of professionals who can provide care to low-income children.

While not as visible a player as Kellogg or Pew, the Macy's Foundation recently partnered with Kellogg to provide a grant to the American Association of Public Health Dentistry to develop the curriculum for the DHAT model that Kellogg is promoting.

To read about the ADA's current policies on a number of issues visit www.ada.org/currentpolicies.aspx.

"I'm confident that if we stand united, we can convince open-minded decision makers that we have the best solutions for ensuring the oral health needs of the nation," Dr. Tankersley said. "We know that we can't drill, fill and extract our way out of this situation."