Independent midlevel providers are dental auxiliaries who work outside the dental team and without dentist supervision, accepting responsibility for patient diagnosis, treatment and coordination of dental services. Midlevel providers are not required to reach the same level of education as a practicing dentist. Utilizing such providers for the care of underserved patients is not economically feasible or in line with the prevention model.
According to a 2005 American Dental Association (ADA) study, “The Economic Aspects of Private Unsupervised Hygiene Practice and Its Impact on Access to Care,” the overhead of maintaining a practice drives independent midlevel providers away from underserved areas.
Additionally, data has not demonstrated that midlevel providers help reduce untreated dental decay. A March 2013 report from the Pew Children’s Dental Campaign, “Dental Therapists in New Zealand: What the Evidence Shows,” made a faulty comparison between New Zealand and the United States, so the AGD cautions against taking this report as evidence of the midlevel provider model’s success.
New Zealand has had a dental therapist program since the 1920s, but its percentage of children with untreated dental decay is almost identical to that of the United States, which indicates that a dental therapist model would not help to decrease untreated dental decay in children. Authors of the report write that 3 percent of children ages 5 to 11 in New Zealand have untreated dental decay in their permanent teeth, as compared with 20 percent of the same age group of children in the United States. However, the 20 percent refers to decay in primary and permanent teeth in U.S. children. In reality, while 2.7 percent of children in the age group in New Zealand have untreated dental decay in their permanent teeth, another 17.3 percent of these children have untreated dental decay in their primary teeth. The amount of decay is almost the same in both nations, thereby invalidating the argument that a dental therapist model may reduce the prevalence of children’s dental decay.
The authors of the Pew report also write that more than 1,000 studies exist to show that dental therapists offer quality care worldwide. ADA refuted this, explaining that those studies failed to demonstrate that dental therapists have a positive impact on a population’s overall health status.1
In July 2008, AGD published its “White Paper on Increasing Access to and Utilization of Oral Health Care Services,” and in 2012 published "Barriers and Solutions to Accessing Care" which both question the need for independent midlevel providers and suggest that funding and effort be directed toward other solutions to the access to care problem.
AGD would like all patients to receive the best possible oral health care and maintains that direct supervision by a licensed dentist is necessary to ensure patient safety. Although the access-to-care issue is complex, AGD has focused on oral health literacy and fluoridation as two viable strategies for eliminating oral health disparities. AGD members are encouraged to communicate with their state legislators and encourage them to support the solutions presented in AGD’s white papers (accessible below), rather than midlevel provider models.
1 "An Analytical Review of the Pew Report Entitled, 'It Takes A Team' and the Accompanying Productivity and Profit Calculator"; American Dental Association, March 2, 2011.