It’s common knowledge that the W.K. Kellogg Foundation recently released review that suggests dental therapists have offered safe and cost-effective dental care in most counties in which they practice. DOCS Education breaks down the main points of the review as well as dental organization responses. By now most dentists, if not all, are aware that the W.K. Kellogg Foundation released a review this month that suggests dental therapists, commonly known as midlevel providers, have offered safe and cost-effective dental care in most counties in which they practice. Titled “A Review of the Global Literature on Dental Therapists” (also referred to as “the monograph”), the lengthy 460-page document was created from 17 contributors, all of which are considered academics or public health officials knowledgeable about dental workforce issues in their respective countries. Researchers for the monograph identified 54 countries where dental therapists practice, 26 of which the report reviews. The methods used for the review, as stated in the review, are as follows: • A consultant was identified in each country considered to have substantive literature on dental therapists. • Contributors conducted comprehensive searches for literature relating to the practice of dental therapists in their respective countries. • Contributors focused on indentifying reports of government agencies and nongovernmental organizations (“grey” documents) and prepared written summaries and translated those that were not into English • 1,100 documents were identified that directly or indirectly related to the use of dental therapists in the global oral health workforce • 2/3 of the documents are cited in monograph Among the conclusions, as stated in the monograph, include: • Dental therapists provide technically competent care. • Dental therapists improve access to care, specifically for children. • Dental therapists are effective in providing oral health care within their scope of practice. • Dental therapists have a record of providing oral health care safely. • Dental therapists included in the oral health workforce have the potential to decrease the cost of care, specifically for children. The American Dental Association holds a firm stance against non-dentists performing surgical/irreversible procedures, and states the review “does not rise to the level of a systematic literature review, nor does it adequately address some of the key indicators of whether and to what extent the use of therapists improves pubic oral health.” The ADA also states in a recent press release that: • The monograph describes current utilization of dental therapists and concludes that they improve access to care and are effective in providing oral health care within their scope of practice. A more significant, long-term indicator would have been to assess the impact of dental therapists on the overall oral health status of the population. • This monograph is similar to other reports that address access and cost. However, these are surrogate criteria for direct outcomes of reduced disease burden and cost-effectiveness, defined as the cost of treatment and the impact it has on oral health. Not measuring these direct outcomes diminishes the manuscript’s conclusions and compromises its value. • The report notes the great diversity in training, scope of practice and supervision of dental therapists worldwide. But it fails to examine why there seems to be no consensus on these factors among the many countries it cites. It also fails to account for what amounts to a constant shifting of these factors within some of the very countries it cites as proof of dental therapists’ efficacy. • While repeatedly referring to 54 countries that employ therapists in some capacity, the authors concede that “no documents could be located” for more than half (28) of those countries, and that they instead relied on “verbal reports from knowledgeable persons—that dental therapists practice in 16 of these countries.” The American Academy of Pediatric Dentistry responds in a recent press release with concern that much of the literature cited is based on opinions rather than data and that due to the scope of countries reviewed, it is hard to make a genuine evaluation of “the fit of dental therapy in the U.S. mainstream dental care system.” The AAPD also states in the press release: • The report includes about 1,056 citations, the majority of which are commentaries, opinion pieces and news releases. The AAPD encourages the Kellogg Foundation to base such reports on evidence and current data rather than opinions and commentaries. • An estimated 44 of the citations provided include actual data on dental therapists, but the majority of those examine therapist knowledge, acceptance and technical performance. None examine effectiveness and impact on oral health status. • None of the studies compare any improvements in oral health among targeted populations to the potential outcomes had the same resources been directed to providing these patients with care from dentists. Other options than dental therapists? While the ADA states that dental therapists will not have an appreciable, positive effect on the public’s oral health until the “nation decided to put its resources into [oral disease] preventative measures,” the organization does mention other workforce innovations to aid in “breaking down the barriers that impede too many Americans from attaining good oral health.” These include Community Dental Health Care Coordinators (CDHCs), first of which have begun working in underserved areas, rural communities and American Indian Territories. The ADA’s recent press release also notes that many states are employing expanded function dental assistants and or/relaxing requirements for dental hygienists who practice in public health setting such as nursing homes or schools.
