1. Advanced Dental Hygiene Practitioner: The North American Model
Cindy Fletcher
Executive Director
British Columbia Dental Hygienists’ Association

2. American Dental Hygienists Association
Ann Battrell, RDH, MSDH(c)
ADHA Executive Director
National Oral Health Conference
April 30, 2006

3. MISSION STATEMENT
To improve the public's total health, the mission of the American Dental Hygienists' Association is to advance the art and science of dental hygiene by ensuring access to quality oral health care, increasing awareness of the cost-effective benefits of prevention, promoting the highest standards of dental hygiene education, licensure, practice and research and representing and promoting the interests of dental hygienists.

4. Dental Hygiene Projections
U.S. Department of Labor, Bureau of Labor Statistics:
Occupational Outlook Handbook
Dental hygienists noted within the top 10 fastest growing occupations and occupations having the largest numerical job growth from
Noted by level of education and training
(retrieved )
According to the U.S. Department of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook, dental hygiene is listed as one of the top ten fastest growing occupations and occupations projected to have the largest numerical increases in employment between 2004 and 2014, by level of education or training. (Dental hygiene = #7 out of top 10.)

5. Oral Health Workforce
U.S. Dept. of Labor, Bureau of Labor Statistics: DENTISTS (general)
Industry
2004 employment
Projected 2014 employment
Change,
Number %
Total employment, all workers
128,000
        
145,000
17,000
13.5   
The U.S. is experiencing a crisis shortage of dentists available to treat the populations who need oral care the most. Millions of Americans in both rural and urban areas are unable to obtain care because there are not enough dentists practicing in those areas. Further, with government statistics revealing a limited growth in the number of dentists …
Retrieved

6. Oral Health Workforce
U.S. Dept. of Labor, Bureau of Labor Statistics: DENTAL HYGIENISTS
Industry
2004 employment
Projected 2014 employment
Change,
Number
Percent
Total employment, all workers
158,000
   
226,000
       
68,000
43.3    
…and the much faster than average projected growth in the dental hygiene profession, it is clear that dental hygienists will be able to make a huge impact through this expanded role. The ADHP will expand the practice areas and offer this person the ability to serve the public in un-served areas by providing both preventive and restorative care.
Retrieved

7. Dental Health Professional Shortage Areas (D-HPSAs)
Critical issue
Distribution of dental workforce
Eliminating oral health disparities
Pockets of underserved areas
Rural
Inner city
DHPSAs increased to:
3296 (792 in 1993)
45,620,457 people affected
Designated Dental Health Profession Shortage Areas (DHPSAs).
“A critical issue is the distribution of the dental workforce and eliminating disparities in oral health and access to oral health care. There are many pockets of underserved areas, ranging from inner cities to rural locations. The number of designated dental health profession shortage areas has increased to 3296, encompassing over 45,620,457 people. PSAs.” --12/31/03, Shortage Designation Branch, National Center for Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration
*SOURCE:03/06/06, Shortage Designation Branch, National Center for Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration

8. ADVANCED DENTAL HYGIENE PRACTITIONER
As noted previously, the mission of the American Dental Hygienists’ Association is to advance the art and science of dental hygiene by ensuring access to quality oral health care, increasing awareness of the cost-effective benefits of prevention, promoting the highest standards of dental hygiene education, licensure, practice and research and representing and promoting the interests of dental hygienists.
This mission becomes particularly important as we consider the awesome responsibility before all dental health care providers and the current access to care issues that confront all of us. The ADHA has taken a proactive approach in this regard with the proposal of an Advanced Dental Hygiene Practitioner.
Dental hygiene has a role in meeting the U.S. oral health needs. The Advanced Dental Hygiene Practitioner initiative is a concept which defines the ADHA role in access to care.

9. ADHA HOD RESOLUTIONS, June 2004
That the ADHA advocates the creation of an advanced dental hygiene practitioner who provides diagnostic, preventive, restorative and therapeutic services directly to the public.
That the ADHA supports a standardized educational curriculum developed by the American Dental Hygienists’ Association, for the advanced dental hygiene practitioner.

10. ADHA HOD RESOLUTIONS, June 2004
That the following definition of Advanced Dental Hygiene Practitioner be adopted:
A dental hygienist who has graduated from an accredited dental hygiene program and has completed an advanced educational curriculum, approved by the American Dental Hygienists’ Association, which prepares the dental hygienist to provide diagnostic, preventive, restorative and therapeutic services directly to the public.

11. ADHP Vision Statement
The advanced dental hygiene practitioner will improve the underserved public’s health and access to quality, cost-effective oral health care and appropriate referrals within multidisciplinary healthcare teams.

12. Historical Perspective
Why is ADHA pursuing this?
Access to oral health care crisis in the U.S.
Heightened awareness for the need for a “mid-level practitioner”
Compliments the ADHA’s commitment to resolve health care disparities
Workforce Supply, Demand and Distribution
Access to preventive and therapeutic oral health care can be increased by maximizing the services hygienists are educated to provide, expanding dental hygiene practice settings, reimbursing directly for services delivered, and removing restrictive supervision requirements.
Almost 43 million Americans live in dental health professional shortage areas, as defined by the U.S. Department of Health and Human Services Health Resources and Services Administration, and 108 million people lack private dental insurance, which is more than 2.5 times the number of those who lack medical insurance.
Dental workforce data projects a decrease in the number of graduating and practicing dentists. According to the Bureau of Labor Statistics, the projected growth for dentists is 13.5% - about as fast as average for all occupations through However, for dental hygienists there is a projected growth of 43% - much faster than average -through 2014.
Currently, there are 128,000 general dentists in the U.S., compared to 158,000 dental hygienists. Given the difference in projected occupational growth among both professions, dental hygienists are the logical oral health care providers to play a key role in in addressing the needs of the underserved segments of the United States population.

13. Advanced Dental Hygiene Practitioner
Why Dental Hygienists?
Projected growth in workforce
Projected growth in educational programs
Market forces creating advanced practice
Advanced education already in place
15 MSDH Graduate programs in place
Avoid duplication in education and training
Potential for cost-savings in cross training
Opportunity to revise efficiency in delivery of oral health care

14. The ADHP … Follows the Rapid Practice Changes in the DH Profession:
Affiliated Practice (AZ)
Registered Dental Hygienist in Alternative Practice (CA)
Extended Care Permit RDH (KS)
Public Health Permit (ME)
Collaborative Practice RDH (MN)
Limited Access Permit with Public Health Supervision (MT)
Public Health Supervision (NH)
Collaborative Practice RDH (NM)
Public Health Endorsement (NV)
Public Health Supervision (IA)
Limited Access Permit (OR)
School Sealant Programs (WA)
The ADHP model follows changes to the scope of dental hygiene practice in various parts of the United States. In 19 states, dental hygienists can initiate treatment and provide dental hygiene services based on his/her assessment of patient needs without the specific authorization of a dentist. Some states have been highlighted including affiliated practice, alternative practice, extended care permits, collaborative practice agreements, public health endorsements, and limited access permits.

15. The ADHP would … Provide primary oral health care.
Be competent in working with populations with special needs:
children
medically compromised
adolescents and geriatric populations. 
Be able to evaluate oral health needs of populations with limited access to care.
Develop, implement and monitor dental hygiene care programs for these populations.
Participate as a member of a comprehensive health care team.

16. The ADHP… From the clinical perspective:
Including but not limited to:
cavity preparation, performing pulpotomies and competency in atraumatic restorative therapy (a temporary filling) among other preventive and restorative therapies. 
From the health promotion perspective:
Designing nutritional interventions, implement and evaluate smoking cessation programs and evaluate health promotion and disease prevention programs for specific populations.   

17. Advanced Dental Hygiene Practitioner (ADHP) Draft Curriculum

18. ADHP Draft Curriculum DOMAINS:
I. Provision of Primary Oral Health Care
II. Healthcare Policy and Advocacy
III. Management of Oral Care Delivery
IV. Translational Research
V. Professionalism and Ethics
The curriculum is structured by domains which provides the general framework for the curriculum. Domains represent broad categories of professional responsibilities, knowledge, and skills that define the ADHP. Within each domain are more specific competencies. The following slides illustrate the curriculum framework which will be explained in detail during Annual Session by the ADHP Task Force chair.
The ADHA seeks the input from various sources including the ADHA membership, students, and various healthcare organizations. Therefore, an input form will be created in preparation for Annual Session so individuals may provide their written comments for review and consideration during the next meeting of the ADHP Task Force.

19. DOMAIN I: Provision of Primary Oral Health Care
The advanced dental hygiene practitioner demonstrates competence in providing primary oral health care and case management in diverse populations. Practitioners use the process of care and target the underserved including those with special needs using a multidisciplinary approach.
The description for Domain I.

20. DOMAIN II: Healthcare Policy and Advocacy
The advanced dental hygiene practitioner contributes to health policies that address disparities in oral health and access to care for the underserved. The practitioner supports and applies health policy at the institutional, local, state, regional, and national levels.
The description for Domain II.

21. DOMAIN III: Management of Oral Care Delivery
The advanced dental hygiene practitioner integrates practice management, finance principles, and health regulations to analyze, design and develop initiatives that will improve clinical outcomes, the quality of care and patient safety. The practitioner demonstrates effective leadership for changing healthcare and practice environments.
The description for Domain III.

22. Domain IV: Translational Research
The advanced dental hygiene practitioner uses sound scientific methods and accesses evidence-based information when making decisions and providing client care.
The description for Domain IV.

23. Domain V: Professionalism and Ethics
The advanced dental hygiene practitioner demonstrates professional behavior and clinical decision-making skills consistent with dental hygiene parameters of care, legal regulations and the ADHA Code of Ethics. The advanced dental hygiene practitioner possesses the values and behaviors which promote service to the public, professional involvement, and lifelong learning.
The description for Domain V.

24. In what settings will the ADHP work?
Hospitals
Nursing homes
Public health settings
Community Health Centers
Federally Qualified Health Centers
Homebound
Elementary and Secondary Schools
Other…
In hospitals, nursing homes, public health settings or wherever there is a need for this position. The ADHP could be applicable in any setting. As this concept is further developed, defined and implemented in the states the practice settings will be determined.

25. What level of education and credential will be necessary for the ADHP?
Point of entry for all
Flexibility
Potential exists for distance education
Proven success in dental hygiene education
Currently 58 degree-completion programs (35 designated with some/all distance education)
Master’s Degree
Credentialing process
The task force has noted and will continue to discuss the issue of a point of entry for dental hygienists with varying educational backgrounds and clinical experience. It is the intention to provide a point of entry for all; however, the specific mechanisms have not yet been defined. The potential may exist for some incorporation of distance education as this has been a proven modality in dental hygiene education.
To date, some of the preliminary curriculum feedback has included questions and concerns about the content of the preliminary curriculum, the length of the educational program required to obtain the credential, and the mechanism by which these decisions will be made and implemented. The curriculum is still in draft form and ADHA seeks the feedback from multiple sources. The Task Force has made every attempt to be sensitive to the feedback received to date and will continue to carefully consider the feedback received regarding the draft curriculum.
With the initiation of the ADHP concept, the Council on Education recognized that the educational preparation for the ADHP would require a master’s degree due to the advanced nature of the services an ADHP would provide to the public. This is similar to the public’s recognition of the expertise and educational preparation of a nurse practitioner.
The process of making curriculum decisions even with respect to content and length of the program encourage input from all. This process is ongoing.
Lastly, the ADHA is exploring the development of a credentialing program within the Association. This will allow the ADHA to have a defined credentialing process which will recognize the advanced and specialized education of the ADHP.

26. How will the ADHP differ from the dental therapist or dental aide positions available elsewhere?
ADHA has and will continue to examine related models
Unique in design
Oral health needs and U.S. health care delivery system
ADHA will examine all related models of oral health providers such as the dental therapist or dental health aide as background information and research for the advanced dental hygiene practitioner. However, the ADHP will be developed in a unique way that considers the oral health needs and the health care delivery system in the U.S.

27. Will this replace the entry-level position for the registered dental hygienist?
No.
Answering an unmet public health need.
Intended to go beyond entry-level education.
Similar to the precedent set in the nursing profession, ADHA is answering an unmet public health need in the oral health care of the un-served populations in the U.S. This initiative is intended to go beyond the entry-level education for dental hygienists. Not every dental hygienist will choose this option to advance their education in this way. There will always be dental hygienists who are happy and please with their chosen professional role. We believe this advancement in our profession gives dental hygienists more professional practice opportunities.

28. Where will the classes be taught?
Curriculum development in process.
Educational collaboration with universities.
Credential offered through the ADHA.
As this process will be taken one step at a time, we don’t have locations to provide at this time. However, the curriculum development process is progressing. We see the implementation of the ADHP curriculum as a collaborative effort between ADHA and universities. We will be working with various universities to develop pilot programs. It is intended that the ADHA would be the organization to offer the ADHP credential, with the educational institution offering the degree.

29. What would it mean for an ADHP to serve as a collaborative partner?
Working with public health, allied health, and medical professionals.
Variety of practice settings.
Patients to receive a well-rounded approach to health services.
The ADHP will be able to work with a host of public health, dental and medical professionals in a variety of settings. This collaborative, integrated, interdisciplinary working partnership will offer patients and clients a well-rounded approach to health service.

30. “The idea that got the broadest support was expansion of scope of practice to include simple restorative procedures for dental hygienists.”
--Policy Issues in Dental Workforce Diversity and Community-Based Dental Education, November 2004
In addition to the feedback from the members of the advisory committee, support for the expanded role of hygienists comes from other organizations. For example, the National Association of Community Health Centers noted that not only are there not enough primary care providers in their communities, over 90% also lack sufficient financial resources to provide adequate primary and preventive care. While these statistics speak to the medical arena, they also highlighted that the services that most health centers need to provide but are unable to because of insufficient resources include preventive and restorative dental care. Specifically in a policy issues report from November 2004, there was support for expansion in the scope of practice for dental hygienists.

31. Legislative Success…
19 states without overly restrictive supervision requirements
10 States with Medicaid provider status
43 States with general supervision
38 States that allow dental hygienists to administer local anesthesia
19 states include: Arizona, California, Colorado, Connecticut, Iowa, Kansas, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, New York, Oklahoma, Oregon, Texas, Washington
Medicaid Provider status: California, Colorado, Connecticut, Maine, Minnesota, Missouri, New Mexico, Nevada, Oregon, Washington.

32. ADHP Legislative Success
July 2005:  ADHP language is inserted into HR 3010, the Fiscal Year 2006 Appropriations Bill for the Labor, Health and Human Services. 
The language is considered ‘report language’ – it does not carry the weight or law or appropriate any federal funding.  It is encouragement to the lead health agency, HRSA, to explore development of the ADHP. 
July 2005:  HR 3010 is passed by the Senate Appropriations Committee. 
October 2005:  HR 3010 passes the full Senate. 

33. Canadian Dental Therapists
Dental therapists work mainly for the federal government and the provincial and territorial governments to provide services in rural and remote communities.
Dental therapists complete the two year diploma program offered by First Nations University of Canada at the National School of Dental Therapy in Prince Albert, Saskatchewan.

34. “Dental therapists are primary oral health care professionals who are trained to perform basic clinical dental treatment and preventive services within a variety of practice settings. As members of a multidisciplinary team, dental therapists provide restorative dental treatment services, disease prevention and oral health promotion programs to maintain and improve health. Dental therapists also advocate for the needs of clients, assist them in accessing care and refer them to other health professionals for services beyond the scope of the dental therapist’s practice.” Canadian Dental Therapists Association
Dental therapists who have completed post-graduate orthodontic modules approved by the regulatory bodies may also provide basic orthodontic procedures.

35. Dental therapists practice in both private and public health settings within a general consultative/referral relationship with a dentist. Dental therapists practice in private dental clinics, government health programs, public health agencies, training institutions, First Nations organizations and other practice settings, in varying capacities as clinicians, educators, health promoters, administrators or dental consultants.

36. Dental therapists are competent to provide the full range of professional services within their scope of practice. However, their practice may vary, depending upon health care legislation or employment policy that may exist within different settings or jurisdictions in Canada.
Upon graduation dental therapists will demonstrate competency and provide the full range of professional care in the following four broad categories:
Diagnostic Dentistry
Operative Dentistry
Community and Preventive Dentistry
Practice Management, Principles of Professionalism and Ethics.

37. Legislative Changes to Dental Hygiene Legislation Canada
Alberta
Ontario

38. What role can Canadian/BC dental hygienists play in meeting the oral health needs of ALL Canadians/British Columbians?