CODA standards provide uniformity, legitimacy to dental therapy

People who don’t have access to dental professionals – or can’t afford to see one – are going to have better opportunities now, thanks to national guidelines that will introduce a new type of dental professional.

People who don’t have access to dental professionals – or can’t afford to see one – are going to have better opportunities now, thanks to national guidelines that will introduce a new type of dental professional. 

On August 7, 2015, the Commission on Dental Accreditation (CODA) authorized the establishment of an accreditation process for dental therapy education programs. This allows the profession – currently only active in Alaska and Minnesota, with newcomer Maine in the initial stages – to be more readily adoptable by other states.

Dental therapistsare licensed oral health care professionals who practice as part of a dental team, providing educational, clinical and therapeutic patient services. They are mid-level providers, similar to nurse practitioners on a medical team. Dental therapists provide preventive and restorative treatment for both children and adults, and they can also extract primary teeth under the supervision of a dentist. They work primarily in settings that serve low-income, uninsured and underserved populations.

“The reason why it’s so important is that tooth decay is a horrific problem in the US,” says Jane Koppelman, research director for the Children’s Dental Program at The Pew Charitable Trusts in Washington D.C. “It’s the number one unmet health need for children. And, actually, the incidents of untreated tooth decay among adults is even greater than that for kids, so it’s great that little by little this profession is growing, and we have more providers who can treat the most basic dental needs that people have.”

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New guidelines

Before the CODA guidelines, it was up to individual states to decide what they would allow of dental therapists – or even if therapists would be endorsed.

“What the accreditation standards really do is legitimize them,” says Dr. Frank Catalanotto, DMD, a pediatric dentist and professor at the University of Florida. “The data on how well they perform and what they’re doing in Alaska and Minnesota is one form of legitimacy. But when you have accreditation standards, that’s saying an official body accredits all dental educational programs and is agreeing that this is a very important program, and it should be held to what we call accreditation standards, so the quality of the education is high.”

Also, a governing body establishing guidelines provides a national standardization of the profession. CODA, established in 1975, is recognized by the US Department of Education as the agency responsible for accrediting dental and dental-related programs.

“The other key issue is uniformity across the country,” says Dr. Catalanotto. “One of the things that I’m really pleased about with these standards is that we’ve got a two-year program in Alaska that has a clinical preceptorship program after. We’ve got a four-year program in Minnesota. This will start to standardize the length of education and the quality of education across the country.”

Standards also legitimize the profession, so states won’t have to debate whether or not this particular career is worthwhile.

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“I think the standards really provide a green light that many in the field have been waiting for,” says Koppelman. “It’s a green light for state legislators to feel comfortable authorizing dental therapists, because the national accrediting body that accredits all dental education institutions says that this is this is a valid profession, and this is a profession worthy of standards.

It’s a green light for academic institutions, for universities, community colleges and other training institutions that would like to have dental therapy programs, but there was no validation of the programs. Because there were no standards, and academic institutions don’t like to offer non-accredited programs, it’s a green light for potential students that are interested in this profession. There will be some mobility, because there will be a uniform standard of quality among training institutions. Dental therapists will be able to move from state to state, as more states authorized these programs.”

Adopting accreditation standards not only establishes that level of education, but it was a huge change in the dental team.

“It was a paradigm shift,” says Dr. Colleen Brickle, Normandale Community College Dean of Health Sciences. Normandale, in conjunction with Metropolitan State University, were two of the first to offer dental therapy education programs in Minnesota.

“It was like a seismic shift happened that day,” continued Dr. Brickle. “What it told me is that CODA is saying there is this new team member. I think the skies are going to open now. We’re going to see more dental therapy bills in the next year, because now CODA has confirmed it.”

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Addressing the need

Dental therapists grew from a need in communities where there are no dental professionals and are underserved (like rural areas), or where residents are low-income and can’t afford dental care.

“There is an incredible maldistribution of dentists around the country,” says Koppelman. “Dentists tend to cluster in suburbs and in urban areas, and there are a large swafts of the country where there are dentist shortages. The federal government estimates that about nearly 48 million people live in these dentist shortage areas, so we need a way to get more providers to these areas where, truthfully, oftentimes dentists don’t care to locate their practices, because sometimes they see it as not an attractive place to live, especially in rural areas. But if they can deploy a member of their dental team to these areas to provide this care, that’s a major contribution to solving the access problem in these underserved areas. A dental therapist will always work for a dentist. They will always be employed by a dentist. This is not an independent practitioner.”

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In some cases, lack of dental coverage was causing people to resort to extreme measures when care finally was needed.

“We started looking at emergency room data and found that almost $5 million was spent in one year by five area emergency rooms in the Twin Cities for dental or oral pain for treatable disease,” says Dr. Brickle. “It just doesn't seem to make sense, and they were using it as a safety net.”

Christy Jo Fogarty is an advanced dental therapist at Children’s Dental Services in Minneapolis, Minn. Children’s Dental Services provides oral health services for children and families with low incomes. Fogarty said she was attracted to the profession after working as a contract dental hygienist throughout Minnesota.

Anywhere I went, I was finding that people were having trouble accessing dental care. Everywhere,” adds Fogarty. “Certainly the rural areas where there is a shortage of dentists, but even the suburban areas, because if they were on public assistance, the dentists couldn’t or wouldn’t take their insurance, and they couldn’t find any care. I just wanted to find a way to open up some of that access.”

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Fogarty was a dental hygienist for seven years before joining the first class of dental therapists. She became the first advanced dental therapist in the country.

Dental therapists earn a Bachelor of Science in dental hygiene and advanced dental therapists earn a Master’s degree.  The major difference between the two lies in their level of supervision. The dental therapists who have both dental hygiene and dental therapy licenses are even more attractive to employers.

“What we’re finding is that the graduates who are dual licensed, right out of the chute, did not have any problems finding employment,” says Fogarty. “Mostly that employment barrier had just to do with people not knowing how to incorporate a dental therapist into a practice. There is beginning to be a pretty good demand out there for them.”

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While there are many dental therapy supporters, not every one believes that it is useful for the dental field.

The American Dental Association (ADA) – while ultimately supporting CODA and its guidelines – still opposes the use of dental therapists. The ADA and most state dental associations have resisted allowing dental therapists to perform restorations and extractions, citing safety concerns.

In a statement, the ADA writes, “The ADA believes it is in the best interests of the public that only dentists diagnose dental disease and perform surgical and irreversible procedures.”

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The ADA also notes several existing initiatives to serve the needs of underserved communities, including support of loan repayment assistance to attract dentists to those areas, and the creation of the Community Dental Health Coordination (CDHC) position.

Their statement continues, “When it comes to affordability and access to health care, there is no one-size-fits-all solution. That’s why the ADA launched Action for Dental Health, a nationwide, community-based movement that provides care now to those already suffering from dental disease, strengthens and expands the public/private safety net and brings dental health education and disease prevention into underserved communities.”

The ADA notes that another program, Action for Dental Health, is already in place, ready to serve, while dental therapists will take time to be ready. CODA estimates that the earliest an existing or developing dental therapy program could be accredited is January 2017.

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Dental therapists and their supporters say that the ADA’s objections are unfounded, stemming from fear.

“I think it was loss of power and control a little bit, and maybe fear that it was going to impact their practices,” says Dr. Brickle. “It’s fear of the unknown, and it’s kind of like when dental hygienists came on board. When we first came out, that was kind of scary, and dentists didn’t want them, and now it’s so common. This was even more frightening because it really went into their scope – filling, restorative, extractions.

It shouldn’t have been scary, because the law says 50 percent of a dental therapist or an advanced dental therapists’ patient base – not the practice, but theirs – has to be underserved public program, or you work in a health professional shortage area, and the whole reason for the legislation was access to care. It was never to compete with dentists. It was to work with them. It was to substitute when they’re not there and working with populations that weren’t even being served.”

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Good for business

Not every doctor is opposed to dental therapy. Dr. Catalanotto notes that those dentists who are open to the new position see its benefits.

“Dentists who are familiar and who have read the literature on dental therapists like the program,” says Dr. Catalanotto. “Dentists who work with dental therapists like the program and the new model. Dentists who don’t have any knowledge, or are listening to what I call the ‘canned messages’ from the leadership of organized dentistry, don’t like the program. They are afraid of it. They’re getting the wrong information from their leadership.”

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In spite of opposition to dental therapy, once the providers were added to practices, they have not only done their job well, but now doctors are seeking them out.

“My personal experience with private practice dentists that I knew, and certainly had respectful relationship with, most of the private practice dentists didn’t care one way or another, but organized dentistry certainly did oppose it,” says Fogarty. “There was a lot of resistance at first. Incorporating me into my first practice, where I still work, it was challenging. A lot of dentists didn’t know what to make of this new provider.”

She says that one of the dentists that she works with, and speaks about the benefits of dental therapists, was told in dental school that therapists were a bad idea.

“She was told that this will be the end of the world,” says Fogarty. “It will be so bad for dentistry, that she adamantly opposed it. So when they brought a dental therapist on board to the practice, she really didn’t want much to do with it, and now she’s out there advocating for it. We are seeing that turnaround as people are exposed to dental therapists, and realize we are well-skilled in our scope of practice.”

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“Dental therapists are safe, they produce high quality work,” adds Dr. Catalanotto. “They are cost-effective. But most dentists won’t even engage in the discussion. If they do engage in the discussion, they use emotional sound bites to respond, but not data – not hard, factual data. And that is a major concern to people like me and others who have looked carefully at the model. The CODA accreditation standards are going to be a next step in making those dentists stand up and take notice, and then maybe read the literature.”

One criticism of dental therapists is that they will be a financial drain on the practice. However, by performing some of the basic services, the dentist is now free to accomplish more complex cases.

“One way to look at it is: look at the business model of dentistry,” says Koppelman. “It’s a highly inefficient model – you have a dentist who is a highly paid professional, drilling and filling teeth when you can have a safe, quality care provider doing it at a lower rate. It’s the same equivalent with hygienists. Would you consider it strange that a dentist would spend the time to clean your teeth? We can say the same about treating basic tooth decay.”

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The Pew Center on the States released a report in 2010 called “It Takes a Team.” The report was comprised of expert assessments of the dental industry and addressed the concerns of dental practices and the affect on incomes if they incorporate dental therapists. The experts’ conclusions: Any practice will see a profit.

“What is showed is that even if you have a therapist you’re going to make money, but when you have somebody who’s both therapist and a dental hygienist, you can make even more money,” notes Dr. Brickle.

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Filling a void

In Minnesota, dental therapists have already become popular additions to dental practices. Dr. Brickle says that she regularly hears from doctors who want to bring therapists to their practices, and hears glowing reviews from doctors who already have therapists on staff.

“He’s going great guns, because he’s having the dental therapists do all the public programs – and they can see other patients, too – while he’s doing crowns and bridges and more complicated extractions and implants,” says Dr. Brickle. “So he’s raising the bar on his practice, because he’s seeing the higher end, and she’s seeing a public or community service. And now there are practices that had never seen public program until they hired a dental therapist in the last couple years. I know it’s small, and it’s going to take some time, but it’s going to help.”

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While the profession faced some early opposition, being out there doing the work is proving to be a strong affirmation of the therapists’ skills, professionalism, and value.

“I think it’s us out there practicing and showing them that we are skilled professionals with a huge knowledge base, especially those of us who have been hygienists,” says Fogarty. “It’s that depth of knowledge I think they’ve come to understand is invaluable.”

For example, therapists, especially those who have hygiene experience, can discern problems that others might not.

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“There are things, like juvenile periodontitis, that I’m able to pick up on very quickly, because I’ve seen it several times throughout my career,” says Fogarty. “Sometimes people won’t see that but maybe two or three times in their entire career. There are just certain things that being in the field of dentistry for a multitude of years, you have a knowledge base that’s wonderful. They understand that we are not killing people. We’re helping a lot of people. There was this fear that we would be so unsafe, and they’ve come to realize that, no, we’re very high quality practitioners.

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Interest by hygienists

Because of the new CODA guidelines, hygienists interested in becoming therapists will have an easier time pursuing the career. The guidelines open the doors to state legislatures adopting the profession, and to colleges and universities offering training programs. However, those seeking the title early on faced resistance.

“When this is all being so controversial, dentists were playing off dental hygienists to stop it – ‘You’re going to lose your jobs,’ ‘you’re not going to have a job,’ so there’s a lot of fear, and there’s still a lot of myths versus facts out there,” says Dr. Brickle.

But now, more and more are interested in the career and willing to pursue it.

“They’re coming,” says Dr. Brickle. “They want to do it. There are dentists now saying, ‘Hey, if you go, I’ll help you with this.’”

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In fact, Normandale and Metropolitan University changed their program so that therapists could get the training faster and could get right into dental practices.

“It was 26 months at first,” says Dr. Brickle. “We’ve changed it several times, and we now are full-time and we get it done in 16 months. And that’s to help accommodate, maybe, a dental hygienist who lives in a rural area to come here, live for a short time, and finish the program.”

The program has been successful enough to garner support for its expansion.

“We just got a huge $1.6 million dollar HRSA grant to really look at expanding it,” says Dr. Brickle. “It’s growing. It’s a big system change taking place, and then I think when dentists get more comfortable and understand it, we’ll be okay.”

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Bringing others on board

Dental therapy originated in New Zealand in the 1920s in response to the country’s lack of readiness for World War I – oral disease was rampant. The profession exists in 50 other countries around the globe, but didn’t come to the US until it was introduced in Alaska in 2003.

In Alaska, however, dental therapists are called dental health aide therapists, and only serve Native Americans. The profession started in Minnesota in 2009 after a few years of effort, including those of Dr. Brickle.

While Dr. Brickle was lobbying the Minnesota State Legislature for its stamp of approval, the first class of dental therapists was well on its way to completion.

“I said no matter what, if it’s passed right away, these hygienists getting this degree will have a public health emphasis,” says Dr. Brickle. “The first class of seven graduated before the legislation was passed, because they were that dedicated. Talk about gutsy.”

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In 2014 the Maine legislature approved dental therapists, however, they are still in the process of getting education in place. Twenty other states are at various stages of approving dental therapists.

Now, with the CODA guidelines, the path has been paved for other states.

“I just hope as people move forward in states that they stay focused on the goal,” said Dr. Brickle. “It’s really about access. I just hope that people really stay focus and do the right thing and really listen to all the stakeholders. If you’re on the right path and you get a lot of buy-in and stakeholders, it’s going to be fine.”

Dental therapists provide an invaluable service, and get more than just a good salary for their efforts.

It’s such a great profession,” says Fogarty. “I get a great paycheck, and I get hugs everyday from kids, so you really can’t go wrong.”