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ADA Releases Systematic Review of Dental Midlevel Providers

The January 2013 edition of JADA (the peer-reviewed Journal of the American Dental Association) includes a report on the systematic review of dental midlevel providers requested by the 2011 ADA House of Delegates. The authors constructed the following question for the systematic review: "In populations where non-dentists conduct diagnostic, treatment planning, and/or irreversible/surgical dental procedures, is there a change in disease increment, untreated dental disease, and/or cost-effectiveness of dental care?"

A systematic review is a critical assessment and evaluation of all research studies that address a particular clinical issue. The article's authors reviewed over 7,000 references on dental midlevel providers but only found 18 studies that addressed the clinical question and presented data that could be reviewed. The article as it appears in the January 2013 edition of JADA can be found here.

The Report ends with the following conclusions:

  • The quality of the evidence was poor.
  • In select groups that received irreversible dental treatment by teams that included midlevel providers, caries increment and severity decreased across time. However, there was no difference in caries increment and severity compared with those in populations in which dentists provided all irreversible treatment.
  • In select groups that received irreversible dental treatment by teams that included midlevel providers, untreated caries decreased across time and untreated caries decreased compared with that in populations in which dentists provided all treatment.
  • No data was found in the following domains: diseases other than caries for which midlevel providers performed irreversible procedures; outcomes of interest for midlevel providers performing irreversible diagnostic procedures such as excisional biopsies for oral cancer; and cost effectiveness, defined as the real cost of reducing disease burden, of midlevel providers.

The January Issue of JADA also includes commentary from ADA President Dr. Robert A. Faiella. Here is an excrept from his piece:

Advocates for improving public oral health increasingly have called for the creation of alter-native providers in the United States, citing a perceived shortage of dentists and a lack of sufficient numbers of dentists willing to care for underserved populations. Among the arguments for doing so is the “proven success” of various workforce models in improving access to care in numerous other countries. But the ADA systematic review found no evidence to support claims that utilizing new workforce models to perform surgical treatments improves the caries experience of the affected populations. In fact, one of the most significant findings is that despite decades of use of these workforce models in numerous countries, there is no apparent reduction in disease incidence.

Of course, the availability of more personnel to treat disease means that more disease will be treated. This extensive systematic review did find scientifically valid studies that supported this simple observation and expectation. However, there is no indication that using new workforce models to treat caries surgically will have any impact on the larger problems specific to U.S. populations, such as declining adult utilization; the lack of adequate, effective financing mechanisms; poor oral health literacy; and the need for better case management.

The intense focus among various stakeholders on the issue of whether to use alternative workforce models as dental surgeons is distracting attention from the “bandwidth” of access issues, and it threatens to sap resources from the need to solve a complex set of problems. The barriers that impede millions of Americans from attaining good oral health are numerous. No single solution, no single group can foster the kind of change needed to improve the dentally underserved.

The entire article can be found here.

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