Abstract
Increased awareness of oral health disparities in the United States has highlighted the need to expand the workforce and access to both primary and preventive dental care. Achieving oral health equity will require new dental team members with appropriate clinical skills dedicated to reaching historically marginalized populations through intra and interprofessional practice. Collective efforts by health care advocates in Minnesota led to legislation that created a dental hygiene-based workforce model inspired by the vision and foresight of the American Dental Hygienists’ Association’s “Advanced Dental Hygiene Practitioner.” In July 2023, there were 141 licensed dental therapists and 99 certified advanced dental therapists, with the majority being dual-licensed dental hygienists/dental therapists, providing primary care services in a variety of settings throughout the state. Current data confirm their contributions to increasing access to primary oral health care services for Minnesotans across the lifespan. While surmountable challenges remain, new opportunities are emerging for dental therapists within Minnesota’s transforming health care system. The purpose of this paper is to describe the implementation of this new workforce model in Minnesota, its challenges and successes to assist other states in developing new models for intraprofessional dental team members.
- access to care
- oral health
- healthcare workforce
- dental therapy
- dental hygiene-based dental therapy
- intraprofessional collaboration
Introduction
Collaborative leadership is needed when an innovative idea rocks the foundation of the status quo. Collective efforts by Minnesota health care advocates brought a new intraprofessional oral health care team member to life in the state. Minnesota’s legislation created a pathway for a dental hygiene-based dental therapy workforce model grounded in the vision, educational foresight, and advocacy efforts of the American Dental Hygienists’ Association (ADHA) toward development of an “Advanced Dental Hygiene Practitioner.”
In 2005, in response to inadequate access to affordable oral health care for Minnesota’s most vulnerable populations, advocates began to actively explore a workforce model built upon the existing educational foundation of a dental hygienist. With legislative authorization in 2009, Minnesota became the first state government to license dental therapists and certify advanced dental therapists to provide care to children and adults. The purpose of this paper is to describe the evolution of the Minnesota model, its successful implementation, impact on the delivery of primary oral health care since 2011, and future directions to guide states pursuing similar workforce initiatives.
Global and National Perspective
Dental therapists have been part of the global oral health care workforce for over 100 years.1,2 Research has shown dental therapists to be competent and valued oral health care providers who safely perform the procedures within their scope of practice to improve access to care.2,3 Internationally, dental therapists primarily care for pediatric patients in public health or school-based clinics and have variable lengths of education and training depending on the country of licensure.2
Some countries have explored integrating the education and scope of practice of the dental hygienist with that of the dental therapist. This dually licensed oral health care professional has the potential for providing more comprehensive preventive as well as restorative services to the patients in their care.4 Australia has had dental therapists since 1965 and has been a leader in the movement to combine dental hygiene education and licensure with dental therapy. Australian oral health therapists have been dually licensed in dental hygiene and dental therapy beginning in 1996 when the education and training programs were moved to university settings and began to focus on the provision of oral health care across the lifespan.5 New Zealand’s first dental nurse program began in 1921, and became a university-based, dual degree in 2006 due to new legislative requirements for registering oral health care providers, workforce shortages and enhanced educational and practice requirements.6 The intended goal of a dual degree was to create a collaborative approach with multiple benefits, allowing practitioners to use their strengths, provide variety in the workplace, and increase professional fulfillment.7
In the United States (US), momentum to explore new workforce models intensified after release of Oral Health in America: A Report of the Surgeon General. The report, issued in 2000, enhanced awareness of oral health disparities among races and socioeconomic groups and emphasized that oral health means much more than healthy teeth.8 Three years later, A National Call to Action to Promote Oral Health report heightened awareness of the urgent need to enhance and expand capacity of the oral health workforce.9
In response to the two reports, the American Dental Hygienists’ Association (ADHA) proposed the Advanced Dental Hygiene Practitioner (ADHP) workforce model.10 In June 2004, the ADHA House of Delegates adopted development of an ADHP to be a cost-effective response to the oral health crisis of underserved populations in the United States.11 The ADHP was modeled after the nurse practitioner (NP) and physician assistant (PA) mid-level providers that emerged in medicine nearly 60 years ago.12
Similar to the broader political and social movements of the 1960’s that were influencing the delivery of medical care, there has been increasing pressure on dentistry to increase access to care for all populations across the life span. Legislation has been enacted in 13 states to open the way for new workforce models in dentistry. The specific model, scope of practice, and settings for the delivery of care vary greatly.13 Historically, restrictive dental practice acts have had a profound impact on the preventive services of licensed dental hygienists. Legislative efforts for new dental therapy-based workforce models must be focused on increasing the availability provided by licensed oral health care professionals.
Minnesota Model
A common theme in health care education is to innovate and be responsive to the needs of future health care professionals and the communities they serve. Minnesota continues to be at the forefront of innovation to prepare and maintain a competent oral health care workforce. Some examples include being the first state to require continuing education, expanding the pathway for seamless completion of a baccalaureate degree in dental hygiene, and passing the first legislation in the country to authorize licensure for dental therapists and certification of advanced dental therapists.7,14 Advocacy and legislative efforts for the new workforce model were robust, organized and relentless. Minnesota’s oral health leaders set “disruptive innovation” in motion, creating a roadmap to introduce a new intraprofessional dental hygiene-based team member. What occurred in Minnesota sheds light on the importance of collaboration. From the outset, advocates for the Minnesota model were proud of their vision, coordinated efforts and collective leadership; demonstrating commitment to social responsibility in the development of a new workforce model to meet the needs of all Minnesotans.7 The advocacy goals for the new workforce legislation included the following:7
Expand the dental workforce to help improve access to preventive and therapeutic services for vulnerable populations.
Establish a new intraprofessional licensed dental team member to deliver competent, safe and quality care to populations across the lifespan.
Provide oral health and primary dental care by extending the reach of care beyond the traditional dental office.
To accomplish their legislative goals, the Minnesota Oral Health Committee of the Safety Net Coalition, the Minnesota State Colleges and Universities system, and the Minnesota Dental Hygienists’ Association sought collaboration among all stakeholder groups. Three major players interacted with nearly 60 statewide strategic alliances, coalitions, legislators, organizations and foundations, and other stakeholders, with the majority coming from outside of dentistry. This effort was a textbook example of collective impact, which is evident when diverse stakeholders work together in an intentional way to share information for the purpose of solving a complex problem.15
The two-year legislative process was not without challenges. Conflict in the political arena was intense, yet the dedicated and determined advocates stayed on message and their work prevailed. Negotiation skills were one of the most important advocacy tools in the professional toolbox. As a result of compromise, reference to “dental hygiene” was removed from the “Advanced Dental Hygiene Practitioner” title originally proposed. The final outcome resulted in two levels of practitioners, i.e., the dental therapist and the advanced dental therapist, to primarily treat underserved patients.7
The name change did not alter the goals set forth by the tireless work of the advocates. While passing Minnesota’s legislation was monumental, the implementation phase has been equally challenging. Advocates have remained resolute and vigilant by monitoring the statutes, regulation, research and data collection regarding policies and procedures which impact Minnesota’s public health care program enrollees and under-resourced populations.
Minnesota Model Today
It has been a decade since the initial cohort of dental therapy students graduated from Minnesota’s first established program, a joint endeavor between Normandale Community College and Metropolitan State University, both part of the Minnesota State Colleges and Universities system. Based on community needs and developed with stakeholder input, Minnesota’s new intraprofessional members of the dental team are practicing throughout the state, in a variety of practice settings, and providing care to all ages and populations who do not receive routine dental/oral health care.16 Access to care for public health care program enrollees has increased. Combining dental therapy with dental hygiene services provides core skill sets in preventive and primary oral health care. Additionally, the dual-licensed providers offer increased services, flexibility, and efficiency which are valued by patients, dentists and the communities they serve.11, 17 Further evidence of Minnesota’s success is that as of this writing, no complaints have been registered with the Board of Dentistry regarding quality of care. Most importantly, there are increased opportunities for all Minnesotans, especially for those enrolled in public health care programs throughout the state, to receive preventive and restorative oral health care.
In a leap of faith, the first cohort of Normandale Community College/Metropolitan State University students stepped into the classroom one week before Minnesota’s legislation was signed into law on May 16, 200918,19 The success of this cohort and subsequent cohorts demonstrates the passion and relentless dedication to serve in practice settings where these practitioners provide care as both a licensed dental hygienist and as an advanced dental therapist. According to the Minnesota Board of Dentistry, dental therapists and advanced dental therapists are employed in a range of practice settings across the state (Figure S1).
Location of dental therapists and advanced dental therapists and practice type as of December 2022 (Courtesy of the University of Minnesota, School of Dentistry analysis of collaborative management agreements submitted to the Minnesota Board of Dentistry).
Dental therapy has been a successful new dental workforce model for over a decade in Minnesota. Some of the original opponents of legislation for the new dental team member are seeing the positive impact being made and now speak in favor of the dual dental hygiene-dental therapy model to enhance patient care in both private practice and public health settings.20
Minnesota Dental Therapy Programs
In Minnesota, only colleges and universities award baccalaureate and master’s degrees. Minnesota law states that a basic level of dental therapy requires a minimum of a baccalaureate degree and an advanced level of dental therapy requires a master’s degree.7 Minnesota ‘s three dental therapy programs teach basic and advanced scope of practice; all three programs award master’s degrees. The law does not dictate to educational institutions what the admission requirements should be or how to structure the programs. Each institution may establish different types of dental therapy programs as long as they appropriately educate and train students to the necessary levels of competency for licensure.
Another important section of Minnesota’s dental therapy law states that only graduates of a program approved by the board or accredited by the American Dental Association Commission on Dental Accreditation (CODA), or another board-approved national accreditation organization, may apply for licensure.18, 19 To this end, the Minnesota Board of Dentistry hired a nationally recognized dental education consultant to assist with the development and implementation of dental therapy (DT) and advanced dental therapy (ADT) standards, competencies, and the approval process. The Academy for Advancing Leadership (AAL), an organization with over 15 years of experience in academic health care, was chosen for this project.21 At that time, AAL had consulted with clients for over 15 years to provide expertise in areas such as leadership development, organizational change, strategic planning and curriculum development.
Four years after the first students enrolled in the Metropolitan State University and University of Minnesota School of Dentistry programs, CODA voted to implement accreditation standards for dental therapy educational programs.22 In the spring of 2023, the University of Minnesota School of Dentistry’s dental therapy programs received CODA accreditation. Metropolitan State University and Minnesota State University-Mankato dental therapy programs are preparing their CODA self-study documentation.
Research and Evaluation
Over one-hundred years have passed since dental nurses began practicing in New Zealand and 12 years since dental therapy began in Minnesota during which time a significant body of research has been conducted. A review of the literature by Nash et al. provides a comprehensive view of the history and practice of dental therapists from around the world. This review concluded that dental therapists provide effective, quality, and safe care for children world-wide.1
As part of advocacy efforts, proponents of the new workforce model, including critical access dental providers, estimated the potential impact that the addition of dental therapists could have on their organizations. For example, Apple Tree Dental, a non-profit critical access dental organization with free standing clinics and mobile programs across Minnesota, retrospectively analyzed actual treatment they had provided.16 Many of the necessary services were included in either the dental hygienist’s actual or the dental therapist’s hypothetical scope of practice, demonstrating the utility of the dual-licensed oral health care professional.16
In 2009, as part of HRSA funded “Minnesota Oral Health Assessment and Planning Project”, MDH convened an expert panel to develop recommendations for an analysis of Apple Tree database of treatment provided to nursing home residents to examine current and emerging workforce skill and capacity. The analysis included an estimate that the number of full-time-equivalent (FTE) dentists needed to serve Minnesota nursing homes could be reduced from 32 to 21 with the addition of dental therapists providing services within their scope of practice. (Figure S2).23
Number of FTE dental personnel required for Minnesota (MN) nursing homes under different workforce models.23
National interest in the early practice of dental therapists in Minnesota has led to evaluation of their deployment in a variety of settings. A study of dental therapists working at Apple Tree Dental found that the dual scope of practice and flexibility of providers helped advance its “mission to overcome barriers to oral health” both in a mobile program serving residents of the Minneapolis Veteran’s Home24 and in a rural dental center in southcentral Minnesota.25 Additional public reports on Minnesota’s dental workforce can be found on the Minnesota Department of Health Office of Rural Health and Primary Care website.26
The Oral Health Workforce Research Center (OHWRC) analyzed data for more than 75,000 Apple Tree patients spanning the three years before and seven years after the addition of dental therapists.27 The quantitative study found that therapists allowed more and higher value procedures to be delivered by the dental team, resulting in positive outcomes for patients, providers, and the organization generally.27 The qualitative analysis surveyed Apple Tree clinicians and administration, and 898 Apple Tree patients.28 Overall survey findings attest to high levels of satisfaction with the dental therapy workforce. Among staff, therapists were viewed as a complementary rather than a competitive workforce. Researchers concluded that patient satisfaction and quality of care exceeded opponents’ initial concerns.28
Lessons Learned
The importance of broad advocacy and stakeholder groups cannot be overstated. For example, the inclusion of consumer advocates, health plans, nursing and medical providers, legislators and educators contribute breadth of perspective. Higher education institutions must also help shape each state’s model and be prepared to enroll students upon authorization. Continual communication among the stakeholders during advocacy and implementation is essential. It cannot be assumed that the public and the dental community share a common understanding of the new intraprofessional roles; the real work starts after the legislation has been passed. Preparing data and reporting systems prior to any program implementation will facilitate the evaluation of outcomes and impact of the new model. Setting clear goals that meet the unique needs of the state plays a critical role in all aspects of the legislation and implementation process. Health equity and the public good, rather than professional preferences, should be the focus driving the process for change.
Future of Dental Therapy
The US will continue to research and learn from international workforce models in which these professionals have shown to provide high quality services, recognize the boundaries of their own abilities and contribute significantly to increasing access to dental services.4 The significant growth, recognized utility, and evolving roles in Minnesota bode well for the future of this dual-licensed dental professional. Each states’ advocacy groups, higher education systems and, foremost, the needs of the communities to be served by the practitioners, will best guide selection of the appropriate education and training models. In addition to the scope of services delivered using the dental hygiene license, the dual-licensed professional is perfectly suited to deliver care using minimally invasive techniques and digital technologies, thereby complementing dentists’ advanced restorative and surgical skills. Through “top of license” practice, skilled team members can reach more people in need of oral health care.
Nationally, resistance to innovative oral health workforce policy persists. In 2020 dental therapists were authorized to practice in 13 states; however, only 5 states had licensees actively providing oral health services.13 Delays to implementation have been attributed to rulemaking, educational program development, scope of practice delineation, and reimbursement policies. Currently, Maine and Michigan are two of several states where licensure portability is allowed for Minnesota licensed dental therapists.29,30 A standardized education program approval process has been established by CODA. However, this process becomes fragmented by state policy and implementation variations. Articulation agreements and career laddering for educational mobility have been encouraged by CODA. A seamless pathway to dual licensure has been challenging for dental hygiene programs. Collaboration with CODA on future revisions to the dental therapy standards is needed to eliminate barriers such as duplication of coursework, lowering tuition and competency-based graduation standards.31
Continued advocacy efforts at the federal and state level will assist with the implementation and sustainability of programs being challenged in today’s higher education environment. In July 2022, the Federal Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) released its 19th annual report, Supporting Dental Therapy Through Title VII Training Programs.32 The report recommendations were sent to the US Secretary of the Department of Health and Human Services (DHHS) and to Congress, hoping to assist promotion of this new workforce model in meeting the needs of the population and to jumpstart stalled implementation efforts. Recommendations for supporting dental therapy through Title VII training programs includes the following strategies:29
Update congressional authorizing legislation, Public Health Service Act.
Increase annual funding for dental therapy training programs.
Authorize eligibility of dental therapy faculty for loan repayment.
Add dental therapy as an eligible profession for scholarship and loan repayment.
Implement a tracking mechanism to measure impact.
The ADHA has been instrumental in supporting efforts to expand access to oral health care. The association’s policies highlight flexibility in considering various workforce models in response to the needs of the public. In addition, ADHA supports the ongoing professional development of providers who are appropriately educated and committed to deliver safe, high quality oral health care to all populations in need.33
CONCLUSION
The future of an optimized oral health care team depends upon ongoing trust-building and collaboration between all providers to achieve positive outcomes for the dental team and the public in a system that works for everyone. The goals that sparked the innovation efforts in Minnesota remain as its health equity north star, offering a guide for other advocates on their journey to create new members in the dental workforce.
Footnotes
NDHRA priority area: Professional development: Regulation (emerging work force models).
DISCLOSURES
The authors have no conflicts of interest to disclose. No outside funding was received.
- Received August 30, 2023.
- Accepted September 19, 2023.
- Copyright © 2023 The American Dental Hygienists’ Association
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