Visiting the National School of Dental Therapy in Prince Albert, Saskatchewan, Canada in June are left to right, School of Dentistry faculty members Ron Grothe (Director, Advanced Education Program in Pediatric Dentistry), Karl Self (Group Leader, Division of Comprehensive Care Clinic), and Christine Blue (Director, Division of Dental Hygiene); MDA President Jamie Sledd; School of Dentistry faculty members Darryl Hamamoto (Assistant Dean of Academic Affairs), and Craig Phair (Pre-clinical Program Director for Operative Dentistry); MDA Trustee Mike Flynn, and Patrick Lloyd, School of Dentistry Dean.
Lawmakers returned to St. Paul in January to an ambitious agenda dominated by budgetary challenges. Also of importance to all Minnesotans is legislation that will determine the level of supervision, education, scope of practice and regulation of a midlevel dental provider.
The discussion this year follows on the heels of legislation passed in 2008 that directed the Board of Dentistry to authorize a person to practice as a midlevel dental provider (no sooner than 2011). Supporters advocated that the legislation would improve access to care for Minnesota’s underserved communities. They cited, as models, the success of dental delivery systems in Canada, Great Britain and New Zealand, where dental therapists are employed to provide primary dental services to children and adults.
The legislation also called for a 13-member workgroup to develop recommendations for the level of supervision, education, scope of practice, and regulation of this new provider. The University of Minnesota School of Dentistry was identified as having two representatives on the workgroup. Our Dental Hygiene Program Director Christine Blue and I represented the school.
Because this new provider will perform procedures until now performed only by a dentist — and because the University of Minnesota is the state’s only institution accredited to teach these procedures - the School of Dentistry announced plans to create a program to educate midlevel dental providers.
In preparation for our work group participation and to learn about how we might best develop our own education program for midlevel providers, we decided to visit dental therapist training programs in countries cited during the first round of legislative discussion. We chose carefully which programs to visit, selecting those with long histories of training midlevel providers. In May, five faculty members and I - representing the disciplines of general dentistry, operative dentistry, oral medicine, pediatric dentistry, and dental hygiene — visited the dental therapist program at First Nations University in Saskatchewan, Canada. We also stopped at the University of Saskatoon College of Dentistry to learn about its contribution to the training program. Traveling with us were MDA President Jamie Sledd and Trustee Mike Flynn.
In July, we headed for the oldest dental therapist training program in the world — the University of Otago in Dunedin, New Zealand. This time, we led a 12-member delegation, which included several work group members and other interested individuals. Our last trip, in September, was with the same delegation to England where there are 18 dental therapist training programs. All but two are based in dental schools.
We had several goals in mind for these visits. We felt a need to gain first-hand knowledge. We wanted to meet with faculty to learn about the curriculum and learning styles utilized and to tour the educational facilities and outreach clinics. We wanted to talk with practicing dentists and dental therapists, and with dental therapy students, to find out about things like why they chose to pursue dental therapy careers, what kind of job opportunities existed for graduates, and about job satisfaction and the role of dental therapists in addressing access challenges. I also believed there was an opportunity to develop professional partnerships and a shared understanding that would help us navigate the workgroup discussions ahead.
I learned something new and important at every visit.
University of Otago faculty member (L) evaluates the clinical skills of a dental therapy student. Observing are University of Minnesota School of Dentistry faculty members (R) Mike Madden (Pre-clinical Instructor, Division of Operative Dentistry) and Darryl Hamamoto (Assistant Dean of Academic Affairs).
To Infinity and Beyond
Our first stop was at the National School of Dental Therapy in the province of Saskatchewan. This was the only training program we visited that was not based in a dental school. Founded in 1972 with government funding and operated by the University of Toronto, the program trained northern Canadians to provide auxiliary dental services in remote northern Canadian communities. In 1995, the operating contract was awarded to First Nations University of Canada, the country’s only First Nations controlled university-college.
The main focus of the program is to prepare dental therapists for employment by First Nations and Inuit communities, as well as federal and territorial governments. The 18-month, post-secondary diploma program admits 20 first-year students per year. We were told that preference is given to Inuit and First Nations citizens. The program operates with significant government support: tuition, books, equipment and instruments are provided, and all dental treatment provided by dental therapists at the school is at no charge to patients.
Dental therapists provide preventive and restorative services, and extractions, under general supervision. Originally limited to a basic set of services for residents of remote communities and with an emphasis on children (associated with community schools), graduates now may also provide similar services to adults in private practice. They are not authorized to prescribe medications.
Of particular interest was the unique challenge posed by geography. We spoke with one student who was leaving the next day for a four-day drive to her territorial clinic, on the shores of the Arctic Sea. Many of these “remote” practice sites are truly isolated. And, with the next closest dental provider hundreds of miles away, the demand for services is significant and burnout rates are high. Of some 200-plus dental therapists in the country, only 37 were currently practicing in target areas and there was discussion about exploring options for a requirement that graduates commit to serving for two years in a targeted area of need.
Our second visit was to the University of Otago School of Dentistry in New Zealand. Midlevel providers have practiced in New Zealand for more than 70 years. To my surprise, I learned that dental hygiene is a relatively new profession in the country. The dental therapy program is in transition, after combining in 2007 with the dental hygiene program to form a 27-month, degree-granting Bachelor of Oral Health Program. Oral health professionals provide oral health assessment, treatment, management and preventive services for children and adolescents up to 18 years of age.
University entrance requirements apply; 40 dental therapy students/class are trained alongside dental students, and the programs share facilities and faculty. It was interesting to learn that Oral Health Program graduates earn a single degree but practice either as a dental therapist or as a dental hygienist. Each profession has a different scope of services. Some dental therapists practice as both a dental hygienist and a dental therapist, though not in the same setting. If practicing as a dental hygienist, they tend to work in private practices, under a collaborative agreement with the dentist, and their focus is on fee-for-service preventive services for adults. (Few New Zealand dentists treat children.) When practicing as a dental therapist, the majority treat children in public-school settings owned by a district health board, which also employs a dentist to oversee collaborative agreements with the therapists. Dental services are free for children (up to 18 years). Therapists do not prescribe medications or administer nitrous oxide.
Crossing the Atlantic
England was our final stop. Healthcare in the United Kingdom is publicly funded. The National Health Service (NHS) provides the majority of services, including dental services for children, full time students, pregnant women/new mothers, and some others in special circumstances. Adult services are provided at a set fee. Private dental care and private insurance exists, although generally as a ‘top-up’ to NHS-provided services. Dental therapists perform clinical and health promotion responsibilities in a variety of settings, with the dentist providing diagnosis and treatment recommendations.
Our first stop was the Eastman Dental Hospital in London, an independent postgraduate teaching hospital with training programs for dental specialists, dental nurses (assistants), dental hygienists, dental therapists and dental technicians. The hospital has no pre-doctoral dental program. Dental hygiene and dental therapy students train together in parts of the curriculum common to both. Ten students are accepted to the 27-month, diploma-granting dental therapy program. Dental therapy students treat patients referred by specialty residents, which results in exposure to more complicated treatment needs. Services rendered are predominately restorative. Tuition is NHS-funded for qualifying candidates at least 18 years of age. Graduates are awarded a dual diploma in both dental hygiene and in dental therapy, which allows them to register for both titles.
Our last stop was Sheffield School of Dentistry, about 170 driving miles north of London. Unlike Eastman, the program is based on a University campus and is part of an academic health center. Sheffield educates dentists, dental hygienists and dental therapists. Here, students of all three programs share faculty and facilities, patients are seen on inter-class referrals, and dental therapy students are mentored in a “buddy system” by dental students. The number one strength of the program, as identified by dental therapy students, was their integrated coursework with dental students. I was most impressed to learn that dental therapy students and dental students learn together in the same pre-clinical and clinical settings, intentionally making it difficult for faculty to distinguish one type of student from another. As a result, dental therapy students are rigorously trained to the same clinical standards as dental students. Like at Eastman, tuition is provided by NHS grant.
Returning Home, Lessons Learned
Our travel abroad provided invaluable insights into how we might structure our educational program and an important context for our contributions to the workgroup discussions. One lesson learned was that in some substantial way, every program was making curriculum adjustments - increasing the degree of integration with their dental and dental hygiene programs, increasing the length of their programs, adding courses and extending time in clinical rotations. At one site, they were developing areas of specialization - pediatric dentistry. And in another, they were considering reducing the scope of treatments being taught. The impetus for these changes was based on all sorts of findings, none of which, I might add, were the result of an outcomes assessment or scientific review. Much to the contrary, changes were being made based on the strongly held opinions of school officials, perceptions by a few, or some change in financial support for the program. This was disappointing and underscored the need for Minnesota’s model to be closely monitored to determine its impact and to make changes based on good, sound evidence.
Most important, our visits were opportunities to confirm some details we were already considering, such as what faculty and facilities will offer the best training, and what level of curriculum is best able to prepare graduates for practice. On the other hand, we also discovered that some of our plans would need to be changed. For instance, we initially believed that our existing curriculum would be appropriate. But after meeting with faculty at two of the sites, it became evident that additional program content was required in areas such as cultural competency and team building. It was clear that our graduates must be well prepared to manage and care for patients from diverse backgrounds, including, especially, recent immigrants from non-English speaking countries, places where health care delivery systems are not well developed, and areas of the world where dental care is suboptimal.
The need for team building coursework was apparent after seeing that the most effective utilization of dental therapists was in settings where the dentist, dental hygienist, and dental therapist worked together as a team. A formal course will help our students gain the insight and knowledge needed to best care for patients and fully capitalize on the unique skills set of each member of the dental team.
Take Home Lesson
Of the many things I learned on our travels, most important is that dental therapy is a discrete health care discipline and a viable career. It has a defined scope of practice and duties complementary to other members of the dental team — dental hygienists and dental assistants. I became convinced that dental therapists, working in a dentist-supervised oral health care delivery system, can appreciably help improve access to care. Not, as it turns out, by increasing the number of clinics operating in a community, but by increasing the capacity of an already-established network of providers throughout the state to care for greater numbers of patients and to offer these services at a reduced cost. I came to recognize that the most significant advantage a dental school-based educational program has is its ability to train to a single standard of care, thus ensuring public trust and the respect of the profession. Under such an arrangement, we learned that dentists were able to welcome dental therapists into their practices who, like dental hygienists, provide a meaningful service that was accepted and trusted by the public.
*Dr. Lloyd is dean of the University of Minnesota School of Dentistry.