The recognition that NPs and PAs—so-called (if reluctantly) midlevel providers—are enormously beneficial to the functioning of the US health care system has led to the introduction of similar practitioners in specialty areas such as dentistry, EMS, and radiology. Unlike PAs and NPs, with their broad areas of expertise and primary care focus, this new generation of health care professionals tends to have a more limited scope of practice.
What impact their presence may ultimately have on NPs and PAs is, for the moment, mostly hypothetical; resistance to these new professional categories has limited their use and acceptance in this country. But their positions within the health care team—and their struggles to practice and prosper—may remind PAs and NPs of their own professional journeys.
Dental Health Aide Therapists
Dental health aide therapists (DHATs) were introduced in Alaska in 2003 to meet a very specific need: dental care among Alaska Natives. This population experiences tooth decay at 2.5 times the national average, creating a substantial burden on both children and adults.
Further complicating matters, an estimated 85,000 people live in small villages (population 400 or below) in rural areas, according to the Alaska Native Tribal Health Consortium. Many cannot afford health or dental insurance and find that high travel costs prohibit them from seeking care in more developed, populous areas. (Sound familiar?)
So how can the dental health needs of this underserved population be met? Enter the DHAT, which was developed under the auspices of the Community Health Aide/Practitioner Program (CHAP). Since the 1960s, this federal program—a collaboration of the Indian Health Service with Alaska Native tribes—has brought more than 550 midlevel medical providers to work in small community clinics.
Taking its cue from more than 40 other countries in which DHATs or their equivalent are fairly common, CHAP conferred upon DHATs a rather broad therapeutic mandate. These practitioners are trained to do cleanings, fillings, and uncomplicated extractions, as well as to provide preventive services, under the general supervision of dentists who work at regional hospitals in the state.
Ironically, DHATs currently must complete their two-year education program through a New Zealand university, because there are no midlevel dental practitioner training programs in the US. While state licensure is not a requirement for DHATs, federal certification, continuing education, and biannual recertification are.
DHATs have been seen as an important solution to Alaska’s dental health problems and have earned praise from organizations involved in Native American health (as well as from former US Department of Health and Human Services Secretary Tommy Thompson).
But—cue the development that PAs and NPs may recognize from their own professional experiences—the American Dental Association (ADA) has been less than enthusiastic. In fact, the ADA and the Alaska Dental Society sued to abolish DHATs, insisting that their very existence violated state law regarding dental licensing. They were unsuccessful.
Despite this setback, opponents to the DHAT model persisted. Their lobbying efforts began to pay off in late February, when the reauthorization of the Indian Health Care Improvement Act—with amendments—passed the US Senate. (It is currently languishing in the US House of Representatives.)
If the act becomes law in its current form, the amendments would prevent DHATs from performing any oral or jaw surgeries and would allow extraction and pulpal therapy only in an emergency and only after consultation with a licensed dentist. The idea is that DHATs would not be allowed to engage in irreversible procedures—and while this would not entirely negate their purpose, it would certainly limit their utility.
Further keeping a lid on these midlevel practitioners, the Senate version of the bill would also prevent—at least for the time being—any expansion of the DHAT program to other states. But a similar concept is already in development in the lower 48 states.
Advanced Dental Hygiene Practitioners
Advanced dental hygiene practitioners (ADHPs) resemble DHATs both in their therapeutic role and in the necessity of slugging it out in the political arena just to be allowed to exist. The Minnesota legislature is the first state political body to consider bestowing official sanction upon the ADHP and has made itself a battleground in a drawn-out fight. The primary combatants are the Minnesota Dental Hygienists’ Association (MNDHA), which supports the new designation, and the Minnesota Dental Association, which (surprise!) opposes it.
According to Mary Beth Kensek, RDH, RF, President of the MNDHA, the idea for the ADHP originated from the American Dental Hygienists’ Association in response to the Surgeon General’s 2000 report that highlighted issues of access to dental care in the US. In other words, much like the situation in Alaska, a lot of people who need dental care are not getting it for a variety of reasons, and the midlevel practitioner has been seen as part of the solution to that problem.