American Dental Association Comment on the Kellogg Foundation Report, "A Review of the Global Literature on Dental Therapists"
April 10, 2012
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Washington, D.C., April 10, 2012 – The ADA offers the observations below as a respectful but firm refutation of a report that claims to demonstrate the viability of one solution to a complex set of problems that impede too many Americans from attaining good oral health. The ADA’s firm stance against non-dentists performing surgical/irreversible procedures is well known. That said, the Association believes that all of the individuals and organizations involved in this discussion, whether regarding this paper specifically or the larger, ongoing discourse, want the same thing: a nation in which everyone who seeks it enjoys good oral health and the overall health to which it contributes. This mutual, overarching goal should eclipse our differences.
The report released today by the W.K. Kellogg Foundation is a comprehensive compilation of publications and anecdotes about the prevalence and use of midlevel providers, commonly referred to as dental therapists, worldwide. It does not, however, rise to the level of a systematic literature review, nor does it adequately address some of the key indicators of whether and to what extent the use of therapists improves public oral health. Rather than an evidence-based report, this article appears to be a 460-page advocacy document intended to support a predetermined conclusion.
Some additional observations from ADA scientific and public health experts:
- The monograph describes current utilization of dental therapists and concludes that they improve access to care and are effective in providing oral health care within their scope of practice. A more significant, long-term indicator would have been to assess the impact of dental therapists on the overall oral health status of the population.
- This monograph is similar to other reports that address access and cost. However, these are surrogate criteria for direct outcomes of reduced disease burden and cost-effectiveness, defined as the cost of treatment and the impact it has on oral health. Not measuring these direct outcomes diminishes the manuscript’s conclusions and compromises its value.
- The report notes the great diversity in training, scope of practice and supervision of dental therapists worldwide. But it fails to examine why there seems to be no consensus on these factors among the many countries it cites. It also fails to account for what amounts to a constant shifting of these factors within some of the very countries it cites as proof of dental therapists’ efficacy.
- While repeatedly referring to 54 countries that employ therapists in some capacity, the authors concede that "no documents could be located" for more than half (28) of those countries, and that they instead relied on "verbal reports from knowledgeable persons—that dental therapists practice in 16 of these countries."
To be sure, workforce innovations are one component of breaking down the barriers that impede too many Americans from attaining good oral health. ADA members have devoted millions of dollars to developing a curriculum to train Community Dental Health Coordinators (CDHCs), the first of which have begun working in such underserved areas as inner cities, remote rural communities and American Indian territories. These community health workers provide critical education and preventive services and act as patient navigators to help people needing restorative care receive that care from fully trained dentists. Many states are successfully employing expanded function dental assistants, who have been demonstrated to increase significantly the efficiency of dental practices. Some states also are relaxing supervision requirements for dental hygienists who practice in such public health settings as nursing homes or schools.
But no matter who is providing care, no amount of adjusting workforce scope of practice or supervision will effect significant, lasting change without the nation addressing other, greater barriers to oral health. The Medicaid system, intended to fund dental care for the poor and disabled, is dysfunctional in most states. A few states, such as Connecticut, Alabama, Michigan and Tennessee, have demonstrated dramatic increases in the number of children receiving care through relatively minor increases in Medicaid funding. But comprehensive Medicaid coverage for adults remains almost nonexistent.
The nation will never drill, fill and extract its way out of what amounts to a public health crisis among some populations. Throwing more "treaters" into the mix amounts to digging a hole in an ocean of disease. Instead, what is required is a fundamental shift in oral health from a model of surgical intervention to one of disease prevention, because virtually all dental disease is preventable.
Underlying the extent of untreated disease is a societal failure to understand and value oral health. When the nation decides to put its resources into preventive measures like community water fluoridation; first dental visits by age 1; oral health education, assessments and sealant programs in schools; better integration with the medical community; and realistic funding of care for those in greatest need, it will have made a dramatic step toward ending untreated oral disease. Absent these things, dental therapists will not have an appreciable, positive effect on the public’s oral health. And, if such measures actually are put in place, the debate over therapists will be moot—they will not be needed.
About the ADA
The not-for-profit ADA is the nation's largest dental association, representing 163,000 dentist members. The premier source of oral health information, the ADA has advocated for the public's health and promoted the art and science of dentistry since 1859. The ADA's state-of-the-art research facilities develop and test dental products and materials that have advanced the practice of dentistry and made the patient experience more positive. The ADA Seal of Acceptance long has been a valuable and respected guide to consumer dental care products. The monthly The Journal of the American Dental Association (JADA) is the ADA's flagship publication and the best-read scientific journal in dentistry. For more information about the ADA, visit ADA.org. For more information on oral health, including prevention, care and treatment of dental disease, visit the ADA's consumer website MouthHealthy.org