California Dental Hygiene Educators' Perceptions of an Application of the ADHA Advanced Dental Hygiene Practitioner (ADHP) Model in Medical Settings

Discussion

The current study assessed California dental hygiene educators' perceptions of an ADHP who would work in medical settings. Among the study population, almost all of the respondents supported the proposed modification of the ADHA ADHP Model to medical settings, and slightly over half agreed the level of education needed for the ADHP Model should be at the master's level. These findings are consistent with educational levels required for the ADHA ADHP, the Nurse Practitioner (NP) and the Clinical Nurse Specialist (CNS) models that require a master's degree.^22,23 The proposed ADHP services to be provided in medical settings were consistent with the NP model that allows explicit authority to diagnose, order tests, prescribe medications and refer patients as needed while working in collaboration with the medical team in a medical setting.²² The proposed ADHP functionality was also consistent with those of the CNS model and includes major services related to expert clinical practice, education, research, consultation and clinical leadership.²³ Similar to the NP and CNS model, the proposed ADHP application to medical settings envisions an ADHP who would practice in medical settings focusing on inter-professional collaboration to improve oral health outcomes, especially for our most vulnerable populations - children, the elderly, the disabled, and many members of racial and ethnic minority groups.

The fact that most respondents believed that the application of the ADHP would help reduce oral health disparities and access to care issues is consistent with publications related to the need to expand the role of dental hygienists and reports of general support among dental hygienists for a mid-level oral health care provider to help meet the oral health needs of the public.²⁴

In addition, most of the study respondents agreed with the services the proposed ADHP would provide, except for the prescription of narcotic analgesics. This finding is not surprising considering reports of increased drug-seeking behavior in patients and the rising epidemic of prescription opioid dependency.²⁵ Two of the proposed services interim therapeutic restorations and prescription of radiographs are currently being studied in the pilot study Health Workforce Pilot Project (HWPP) authorized by the California Office of Statewide Planning and Development (OSHPD). This project is designated as HWPP #172 and is entitled the “Virtual Dental Home” (VDH).^26,27 The VDH allows RDHs, RDHAPs and registered dental assistants (RDA) to place interim therapeutic restorations (ITR) and decide which radiographs to take in order to facilitate an oral evaluation by a dentist under a special exemption under California law. Patient treatment started in January, 2011 and the locations for treatment by the RDHs, RDHAPs and RDAs include Head Start programs, elementary schools and long term care facilities. The dentists in the program are remote and use telehealth technology to communicate between the dentists in private and community clinics with the providers in the different settings. Preliminary findings indicate a high satisfaction rate among patients and site administrators, and cost effectiveness compared to Denti-Cal.^26,27 Moreover, none of the procedures performed have had adverse outcomes.²⁷

The VDH is an important model and patients have benefitted from the opportunity to receive many services. Since it is reasonable to think that patients and medical staff in medical settings would also benefit from the proposed application of the ADHA ADHP Model within medical settings, a pilot project is needed to test its acceptability and feasibility to implement. Studies indicate that many medical staff are not comfortable providing orally-related treatments due to lack of knowledge, training and time, nor are they aware of the bidirectional relationship between oral and systemic health, such as that between diabetes and periodontal diseases.²⁸

Moreover, in another study regarding emergency department dental visits, researchers concluded that emergency departments are an important point of care for dental-related complaints and recommended that emergency department staff be trained in triage, diagnosis, basic treatment and the provision of follow-up care for dental concerns.^29,30 Emergency departments could be another site for integration of the ADHP although less than half of the respondents in this study agreed emergency department patients were an appropriate target population for the proposed application of the ADHP within medical settings. Other researchers also have called for dentists or other “oral health experts” to be integrated into hospitals settings.³¹ The ADHP could be more cost effective and valuable than dentists because of the ADHP's intense focus on oral disease prevention and health promotion, especially with additional education at the master's level. Our study respondents agreed that the ADHP could directly provide those services listed in this study including dental referral when needed in the medical setting, collaboration with and education of medical staff to increase awareness and knowledge of the oral/systemic health link among medical health care providers. Most of the respondents agreed with the workplace settings for this application of the ADHA ADHP Model as well. Therefore, we recommend that in addition to further research regarding acceptance of this application of the ADHP model in medical settings among dental professionals (educators and clinicians), that perceptions of medical professionals also be assessed.

Most of the study respondents agreed with the patient populations targeted by the proposed ADHP model. The one exception was emergency room patients. This finding was surprising considering the number of studies of emergency room visits that are due to dental concerns,^32-37 and the findings of a recent study by the American Dental Association (ADA). These latter findings indicate that over 4 million emergency department visits occurred in the U.S. from 2008 to 2010 involving the diagnosis of a dental condition which was slightly over 1% of all emergency department visits occurring in the entire U.S. These emergency department visits for dental conditions cost $2.7 billion over a 3-year period.³² With estimates of approximately one-third of the population not receiving regular dental care,^38,39 the large number of emergency departments visits due to dental concerns supports the need for the ADHP as an oral health mid-level provider. It is reasonable to think that an ADHP could be a major asset to the public and the medical community.

This study has several limitations. First, due to the low response rate, it cannot be assumed that the findings are representative of the population of dental hygiene educators in California or elsewhere. The low response rate may be explained by the timing of the survey distribution (around spring break for some programs), how busy the dental hygiene program directors and faculty were, lack of interest in the topic, or the need to rely on dental hygiene directors to send out the survey as e-mail addresses for faculty were not available.

Another important limitation was the failure to include an item asking respondents about what level of supervision, if any, should be required for the ADHP in medical settings and by whom, with response items listing different levels of supervision and appropriate supervisors from which to choose. This information may have affected the level of support for the proposed model.

Finally, although respondents were asked about a proposed list of services for the ADHP, such as prescribing certain medications and referring patients as needed, no questions were asked about explicit diagnostic authority, a function to be expected of a practitioner with a broad scope of practice while liaising and working in collaboration with medical and dental teams. Darby and Walsh have proposed a human needs conceptual model to define the dental hygiene process of care (assessment of 8 human needs related to dental hygiene, diagnosis of deficits in these needs, planning goals to meet the deficits, implementation, evaluation of goals met, partially met, or unmet and documentation of outcomes) that is based on human need theory related to oral disease prevention, management and health promotion.⁴⁰ In this model, they define a dental hygiene diagnosis as a clinical decision made by a dental hygienist that identifies an actual or potential human need deficit that the dental hygienist is educated and licensed to treat and/or refer for care. This diagnostic approach defines the scope of dental hygiene practice broadly and clearly distinguishes a dental hygiene diagnosis from a dental diagnosis.