The dental therapist movement in the United States: A critique of current trends.

Dental therapists are members of the oral health workforce in over 50 countries in the world typically caring for children in publically funded school-based programs. A movement has developed in the United States to introduce dental therapists to the oral health workforce in an attempt to improve access to care and to reduce disparities in oral health. This article critiques trends in the United States movement in the context of the history and success of dental therapists practicing internationally. While supporting the dental therapist movement, we challenge: a) the use of dental therapists treating adults, versus focusing on children; b) the use of dental therapists in the private versus the public/not-for-profit sector; and c) requirements that a dental therapist must also be credentialed as a dental hygienist.

The virtual dental home: a critique.

The Virtual Dental Home is a concept of the Pacific Center for Special Care of the Arthur A. Dugoni School of Dentistry in San Francisco. It is designed to improve access to dental care for underserved populations, specifically children and institutionalized adults. This article describes the development and implementation of the Virtual Dental Home, subsequently critiquing the concept. The criteria for a dental home are not met by the program. It is the equivalent of a traditional public oral health prevention and screening program, with the additional dimension of allowing dental hygienists and assistants to place interim glass ionomer restorations in dental cavities. The critique questions the need to insert a "cloud" dentist into the process. The routine utilization of radiographs is also challenged. The VDH not only lacks the attributes of a dental home, it has not been shown to be as efficient and effective as traditional programs staffed by dental hygienists and dental therapists. The article concludes by describing how programs utilizing dental therapists could address the deficiencies of the Virtual Dental Home, effectively improving access to oral health care for underserved populations.

Saskatchewan's school-based dental program staffed by dental therapists: a retrospective case study.

OBJECTIVES: The poor oral health of Saskatchewan's children, in concert with a significant shortage of dentists, prompted the province in the early 1970s to seek an alternative method of addressing the oral health care needs of children. The result was the Saskatchewan Health Dental Plan (SHDP), which trained and employed dental therapists in school-based clinics to provide basic dental care to all children. The program was initiated over the opposition of Saskatchewan's dentists. The purpose of this research was to provide information and data previously not documented in the refereed dental literature regarding the only school-based program staffed by dental therapists to ever exist in North America. METHODS: This case study reviews the program's planning, opposition, implementation, and achievements based on a comprehensive review of published articles as well as a search of the grey literature. Additionally, Saskatchewan Health provided annual reports for each year of the program's existence. RESULTS: During its thirteen years of existence, the school-based program proved popular with parents and achieved significant success in providing necessary dental care for children. It was terminated in 1987 by the newly elected provincial Conservative government, which was not supportive of such social programs. CONCLUSIONS: The SHDP serves as a successful model of school-based dental care for children. However, the termination of the plan demonstrates the vulnerability of publicly funded dental health programs to conflicting political ideologies and special interest groups.

Money in Tension with Ethics: A Commentary.

Monetary incentives are frequently in tension with evidence-based and cost-effective clinical care, thus posing an ethical concern in the practice of dentistry. The purpose of this commentary was to examine the issue of treating children in the context of caries risk assessment and with specific reference to the periodic oral examination, radiographic surveillance, topical fluorides, and the pumice rubber prophylaxis.

Technical Note: Development of a 3D printed subresolution sandwich phantom for validation of brain SPECT analysis.

PURPOSE: To make an adaptable, head shaped radionuclide phantom to simulate molecular imaging of the brain using clinical acquisition and reconstruction protocols. This will allow the characterization and correction of scanner characteristics, and improve the accuracy of clinical image analysis, including the application of databases of normal subjects. METHODS: A fused deposition modeling 3D printer was used to create a head shaped phantom made up of transaxial slabs, derived from a simulated MRI dataset. The attenuation of the printed polylactide (PLA), measured by means of the Hounsfield unit on CT scanning, was set to match that of the brain by adjusting the proportion of plastic filament and air (fill ratio). Transmission measurements were made to verify the attenuation of the printed slabs. The radionuclide distribution within the phantom was created by adding (99m)Tc pertechnetate to the ink cartridge of a paper printer and printing images of gray and white matter anatomy, segmented from the same MRI data. The complete subresolution sandwich phantom was assembled from alternate 3D printed slabs and radioactive paper sheets, and then imaged on a dual headed gamma camera to simulate an HMPAO SPECT scan. RESULTS: Reconstructions of phantom scans successfully used automated ellipse fitting to apply attenuation correction. This removed the variability inherent in manual application of attenuation correction and registration inherent in existing cylindrical phantom designs. The resulting images were assessed visually and by count profiles and found to be similar to those from an existing elliptical PMMA phantom. CONCLUSIONS: The authors have demonstrated the ability to create physically realistic HMPAO SPECT simulations using a novel head-shaped 3D printed subresolution sandwich method phantom. The phantom can be used to validate all neurological SPECT imaging applications. A simple modification of the phantom design to use thinner slabs would make it suitable for use in PET.

Can Dentistry Have Two Contracts with the Public?

The social contract is an implicit agreement between parts of society and society as a whole. Since the Middle Ages, the learned professions, recently including dentistry, have had a covenantal relationship with the public based on trust, exchanging monopoly privileges for benefiting the public good. Unlike commercial trade in commodities, professional relationships are grounded in ensuring an adequate level of oral health to all. A second contract is emerging where dentists relate to society as business operators, exchanging commodity services for a price. Recent actions by the Federal Trade Commission and the U.S. Supreme Court make it unlikely that dentistry will be able to enjoy only selected aspects of each contract while avoiding obligations that it finds unfavorable.

On the symbolism of the white coat.

The white coat ceremony has become an academic ritual in the health professions: a ceremony that signals a transformation of status from ordinary student to that of one studying to become a health professional. While donning the white coat is a sign of a changed role, the white coat is also a powerful symbol of transformation. White is a symbol of purity, and the white coat symbolizes the purity of purpose being affirmed in becoming a health professional. Dentistry is afforded the status of a learned profession as a result of the power dentists possess over patients seeking care; this power is based in sophisticated knowledge. Patients must trust that the dentist's knowledge and skills will be used in their best interest-always to benefit, never to exploit. The white coat symbolizes an affirmation on the part of aspiring dentists that their purpose will be pure and that they can be trusted to honor the tradition of the learned professions in placing the interest of patients above self. Absent an emphasis on the symbolic nature of the white coat ceremony, it can simply become an opportunity to publicly congratulate individuals for their success in gaining entrance to the study of dentistry. By understanding its significance, however, the white coat ceremony can serve as a powerful, meaningful ritual emphasizing the transformation occurring within an individual who is entering the profession of dentistry.

Antenatal and intrapartum risk factors for use of emergency and restorative Medicaid dental services for children.

PURPOSE: To investigate the relationship between antenatal/intrapartum factors and Medicaid use. METHODS: Three databases were used: (1) birth records; (2) Medicaid files; and (3) Medicaid dental claims. RESULTS: Children of Caucasian mothers were 34 percent more likely to have more than one restorative claim versus children of African American mothers (odds ratio [OR] equals 1.34, 95 percent confidence interval [95% CI] equals 1.10 to 1.65, P<.005). Children born with low birth weight were 37 percent more likely to have emergency claims (OR equals 1.37, 95% CI equals 1.02 to 1.83, P=.03). The adjusted analysis found that Caucasian mothers had higher odds ratio of having a dental claim than African American mothers (P<.001): 33 percent for a restorative claim and 56 percent for an emergency claim. When race was analyzed, the odds of a restorative claim among African American mothers were 2.5 times higher in children delivered by C-section versus those vaginally delivered (OR equals 2.52, 95% CI equals 1.02-6.2, P<.001). CONCLUSIONS: This study found: an association between children of Caucasian mothers and the likelihood of experiencing claims; and a relationship between children born with low birth weight and C-section and the likelihood of use of Medicaid services.

Identifying demographic variables related to failed dental appointments in a university hospital-based residency program.

PURPOSE: The objective of this study was to identify characteristics of pediatric patients who failed to keep the majority of their scheduled dental appointments in a pediatric dental clinic staffed by pediatric dental residents and faculty members. METHODS: The electronic records of all patients appointed over a continuous 54 month period were analyzed. Appointment history and demographic variables were collected. The rate of failed appointments was calculated by dividing the number of failed appointments with the total number of appointments scheduled for the patient. RESULTS: There were 7,591 patients in the analyzable dataset scheduled with a total of 48,932 appointments. Factors associated with an increased rate of failed appointments included self-paying for dental care, having a resident versus a faculty member as the provider, rural residence, and adolescent aged patients. Multivariable regression models indicated self-paying patients had higher odds and rates of failed appointments than patients with Medicaid and private insurance. CONCLUSIONS: Access to care for children may be improved by increasing the availability of private and public insurance. The establishment of a dental home and its relationship to a child receiving continuous care in an institutional setting depends upon establishing a relationship with a specific dentist.

A review of the global literature on dental therapists.

OBJECTIVE: Access to adequate oral health care is deficient in many parts of the world. Many countries are now using dental therapists to increase access, particularly for children. To inform the discussion on dental therapists in the workforce, particularly in the United States, the W.K. Kellogg Foundation funded a review of the global literature to identify as many documents as possible related to the practice of dental therapists since the establishment of the School Dental Service in New Zealand in 1921. METHODS: Consultants in each of the countries considered to have a substantive literature on dental therapists were asked to participate in the research; seventeen in total. In addition to identifying and reviewing published articles, a focus of the research was on identifying 'gray' documents. Standard databases were searched for key words associated with dental therapists. In addition, searches were conducted of the governmental and dental association websites of all countries known to have dental therapists in their oral health workforce. RESULTS: Fifty-four countries, both developing and developed, were identified where dental therapists are members of the workforce. Eleven hundred documents were identified from 26 of these countries, with over 2/3 of them cited in the published monograph. Reliable evidence from the related literature and verbal communication confirmed the utilization of dental therapists in an additional 28 countries. Thirty-three of the countries were members of the Commonwealth of Nations, suggesting a mechanism of spread from New Zealand. Variable lengths of training/education existed for dental therapists with the tradition being 2 years postsecondary. In a few countries, the training of therapists and hygienists is now being combined in a three academic year program. Historically, dental therapists have been employed by government agencies caring for children, typically in school-based programs. Initiatives in some countries allow limited care for adults by dental therapists with additional training. CONCLUSIONS: The evidence indicates that dental therapists provide effective, quality, and safe care for children in an economical manner and are generally accepted both by the public and where their use is established, by the dental profession.

Alfred Owre: revisiting the thought of a distinguished, though controversial, early twentieth-century dental educator.

Many in dental education are unfamiliar with the professional life and thought of Dr. Alfred Owre, a distinguished though controversial dental educator in the early twentieth century. Owre served as dean of dentistry at both the University of Minnesota, 1905-27, and Columbia University, 1927-33. He was also a member of the Carnegie Foundation's commission that developed the report Dental Education in the United States and Canada, written by Dr. William J. Gies. Owre was a controversial leader due to his creative and original ideas that challenged dental education and the profession. His assessment and critique of the problems of dental education in his era can readily be applied to contemporary dental education and the profession, just as his vision for transformative change resonates with ideas that continue to be advocated by some individuals today. This article also documents his tumultuous relationship with Gies.

Oral health care for children in countries using dental therapists in public, school-based programs, contrasted with that of the United States, using dentists in a private practice model.

The United States faces a significant problem with access to oral health care, particularly for children. More than 50 countries have developed an alternative dental provider, a dental therapist, practicing in public, school-based programs, to address children's access to care. This delivery model has been demonstrated to improve access to care and oral health outcomes while providing quality care economically. We summarize elements of a recent major review of the global literature on the use of dental therapists, "A Review of the Global Literature on Dental Therapists: In the Context of the Movement to Add Dental Therapists to the Oral Health Workforce in the United States." We contrast the success of a school-based model of caring for children by dental therapists with that of the US model of dentists providing care for children in private practices.

Randomized controlled trial: parental compliance with instructions to remain silent in the dental operatory.

PURPOSE: The purposes of this study were to: (1) determine compliance in requesting parents to remain silent (noncommunicative) when accompanying their child into the dental operatory for restorative care; and (2) determine if any difference in parental compliance existed when combined written and verbal instructions were given to a parent vs written instructions only. METHODS: Thirty-nine parents of 4- to 9-year-olds presenting for restorative care met eligibility criteria for the study. Parents were randomly assigned to a written instructions-only group or a group that received combined written and verbal instructions. RESULTS: Thirty-two of 39 parents (82%) followed instructions to remain silent. There was no statistical difference in parental compliance to remain silent comparing written instructions (78%) to combined written and verbal instructions (86%). CONCLUSION: Parents may be expected to comply with instructions to remain silent in the operatory when given either written or combined written and verbal instructions.

Envisioning an oral healthcare workforce for the future.

Health is critical to human well-being. Oral health is an integral component of health. One is not healthy without oral health. As health is essential to human flourishing, it is important that an oral healthcare delivery system and workforce be developed and deployed which can help ensure all citizens have the potential to access oral health care. As such access does not generally exist today, it is imperative to advance the realization of this goal and to develop a vision of an oral healthcare workforce to functionally support access. Public funding of basic oral health care is an important element to improving access. However, funding is only economically feasible if a workforce exists that is structured in a manner such that duties are assigned to individuals who have been uniquely trained to fulfill specific clinical responsibilities. An essential element of any cost-effective organizational system must be the shared responsibility of duties. Delegation must occur in the oral health workforce if competent, cost-effective care is to be provided. Desirable members of the oral health team in an efficient and effective system are as follows: generalist dentists who are educated as physicians of the stomatognathic system (oral physicians), specialist dentists, dental therapists, dental hygienists, dually trained hygienists/therapists (oral health therapists), oral prosthetists (denturists), and expanded function dental assistants (dental nurses).

Practice patterns of general dentists treating children in Kentucky: implications for access to care.

PURPOSE: The purpose of this study was to determine the impact of general dentists on access to care for children in Kentucky by assessing the extent to which they provide care for children. METHODS: A 41-question survey was mailed to all 1,774 general dentists practicing in Kentucky. It had 6 sections: (1) demographic data; (2) dental school education; (3) knowledge of national guidelines for the age 1 visit; (4) treatment of children; (5) clinical practices and desirability of additional education; and (6) participation in public insurance. RESULTS: The response rate was 33%, with a final sample size of 486. Ninety-four percent of respondents reported treating children younger than 12-years-old; however, 74% of children treated were between the ages of 7 and 14, with only 11% being younger than 3 years old. Children 3-years-old and younger and those on public insurance were represented in low numbers. CONCLUSIONS: While most general dentists reported treating children, few provided care for children 3-years-old or younger. Also, general dentists did not treat children with extensive numbers of carious lesions, and rarely performed pediatric restorative procedures such as pulpotomies and stainless steel crowns.

Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims.

PURPOSE: The purpose of this study of closed malpractice insurance claims was to provide descriptive data of adverse events related to child sedation and anesthesia in the dental office. METHODS: The malpractice claims databases of two professional liability carriers were searched using pre-determined keywords for all closed claims involving anesthesia in pediatric dental patients from 1993-2007. RESULTS: The database searches resulted in 17 claims dealing with adverse anesthesia events of which 13 involved sedation, 3 involved local anesthesia alone, and 1 involved general anesthesia. Fifty-three percent of the claims involved patient death or permanent brain damage; in these claims, the average patient age was 3.6 years, 6 involved general dentists as the anesthesia provider, and 2 involved local anesthesia alone. Local anesthetic overdoses were observed in 41% of the claims. The location of adverse event occurrence was in the dental office where care was being provided in 71% of the claims. Of the 13 claims involving sedation, only 1 claim involved the use of physiologic monitoring. CONCLUSIONS: Very young patients (≤ 3-years-old) are at greatest risk during administration of sedative and/or local anesthetic agents. Some practitioners are inadequately monitoring patients during sedation procedures. Adverse events have a high chance of occurring at the dental office where care is being provided.

Pediatric and general dentists' attitudes toward pulp therapy for primary teeth.

PURPOSE: The purpose of this survey was to assess and compare the attitudes of pediatric and general dentists regarding treatment planning of indirect pulp therapy (IPT) in primary teeth. METHODS: A 15-item electronic survey was sent to 3,883 general dentists and 3,691 pediatric dentists nation-wide to assess their knowledge and attitudes regarding the treatment planning of IPT through the presentation of clinical scenarios. RESULTS: Of the 7,574 electronic surveys distributed, 1,259 (17%) were completed. When presented with a clinical scenario where IPT would be an appropriate choice, 41% of general dentists and 28% of pediatric dentists selected IPT as treatment of choice (P<.01). CONCLUSION: Most general and pediatric dentists do not regularly treatment plan indirect pulp therapy for primary teeth. Pediatric dentists are less likely than general dentists to do so. Most surveyed believe pulpotomy is a more successful vital pulp therapy than IPT. There are significant differences between pediatric and general dentists in terms of treatment planning and materials utilized in vital pulp therapy.