What is a Midlevel Provider?
ASDA identifies a midlevel provider as an individual, who is not a dentist with four years of post-collegiate education (three years in the case of University of the Pacific School of Dentistry), who may perform irreversible procedures on the public.
Due to barriers to care issues, midlevel provider pilot programs have begun to enter the mainstream world of dental health care.
ASDA Policy on Midlevel Providers
ASDA’s policy on midlevel providers states that only a qualified dentist should perform the following functions, including but not limited to:
- Examination, diagnosis and treatment planning
- Prescribing work authorizations
- Performing irreversible dental procedures
- Prescribing drugs and/or other medications
ADA Policy on Midlevel Providers
The ADA believes that it is the responsibility of the dental community to ensure that all populations are provided with the opportunity to access quality care by a fully trained dentist. According to the ADA Workforce Statement, pilot programs that test new workforce models should recognize the dentist as the leader of the team and be based on valid assessments of outcomes, cost savings and efficiencies to increase capacity without jeopardizing patients’ health.
Proponents of the midlevel provider model refer to the procedures to be undertaken by the practitioner as “simple.” Fully trained and experienced dentists argue that midlevels’ training cannot adequately prepare them to distinguish between “simple” and “complex” cases.
ADA’s Solution: Community Dental Health Coordinator (CDHC)
The Community Dental Health Coordinator is based on some of the ADA’s key principles for breaking down barriers to care: education, disease prevention and maximizing the existing system. As an alternative to midlevel provider models, the ADA has modeled a new philosophy that would not relegate patients to surgery by non-dentists, but rather the health worker would fulfill the community’s need for oral health educators providing limited, preventive clinical services. They would act as advocates assisting patients in navigating a sometimes complicated health care system and providing critical logistical support.
Existing Midlevel Provider Models
For an up-to-date reference chart of the following midlevel provider models, click here.
Dental Health Aide Therapist (DHAT)
The DHAT model, originating in New Zealand, is the only midlevel program currently operating in the United States. The training curriculum was a result of the collaboration between the University of Washington’s medical school and the creators of the model. DHATs work with supervising dentists to provide routine preventative and restorative care, and to be active ambassadors of oral health prevention in their communities.
According to the Yukon-Kuskokwim Health Corporation website, Dental Health Aides (DHAs) provide a range of services. Primary DHAs provide dental education, dental assisting, and preventive dentistry services. DHA hygienists provide dental hygiene services in regional dental clinics and villages, and DHA Therapists will provide oral exams, preventive dental services, restorations, stainless steel crowns, extractions and take x-rays. Expanded function dental assistant DHAs will place restorations in hub clinics.
The W.K. Kellogg Foundation funded a report in October 2010 on the DHAT model in Alaska. Though their report claims that the program is a success, it concedes to having not assessed the overall impact of the therapists’ work. The ADA submitted a response analysis that notes many weaknesses in the report’s methods and conclusions. Kellogg has since developed plans for the rollout of DHAT programs in five additional states: Kansas, New Mexico, Ohio, Vermont and Washington.
Advanced Dental Hygiene Practitioner (ADHP)
Envisioned by the American Dental Hygiene Association, this designation would allow the dental midlevel to practice independent of dentist supervision after earning a two-year Master’s degree. ADHP's would be able to perform are, among others: diagnosis of oral disease, creation of treatment plans and completion of “limited restorative procedures,” including preparation and placement restorations, extractions and pulpotomies.
Dental Therapist (DT) and Advanced Dental Therapist (ADT)
In response to the Minnesota legislature call for action, the state’s dental school compromised that two levels of dental therapists would be trained. The baccalaureate graduate would practice surgical procedures under the direct or indirect supervision of a dentist and non-surgical procedures under general supervision. In contrast, the advanced therapist would complete 2,000 hours of practice as a four-year dental therapist and graduate from a master’s-level advanced dental therapy education program.