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Special Issue: Dental Workforce
Survey of Expanded Duties for Allied Dental Personnel By Eric S. Solomon, DDS
U
nder the direction of the TDA Board of Directors, the Council on Dental Education, Trade and Ancillaries (DETA) developed a survey to assess the attitudes towards potential expanded duties for dental auxiliaries (allied dental personnel). The survey questions were limited to those duties that were speciďŹ cally prohibited by the Dental Practice Act of the state of Texas. In addition, a limited number of demographic questions were included to verify an unbiased response and further explore the data. The TDA had conducted 24 Workforce Forums around the State in an eort to involve as many TDA members as possible in this issue. These forums aorded every TDA member the opportunity to listen to a discussion of the workforce issues and provide their input. Prior to administration, the survey underwent an extensive review by the Board. The survey was made available to all active, life, and graduate student members of the TDA. At the end of the ďŹ rst week of January 2008, a paper copy of the survey was mailed to each of these members, and the option of completing the survey on the TDA website was also made available to them. As a result, the survey was mailed to a total of 6,933 TDA members and emailed to 59 percent of the membership for which TDA has email addresses. Three subsequent emails were sent to the membership encouraging them to participate in the survey along with speciďŹ c emails targeting component society presidents and component society executive sta. The deadline for return of the survey was extended to February 11, 2008, in order to obtain the highest possible response rate. By the deadline date, TDA sta had received 4,579 completed surveys for an overall response rate of 66 percent. Table 1 shows how the response to this survey compared to previous membership surveys. The number of responses to this survey was more than twice as many as any previous survey eort over the past 12 years. Given the fact there were no follow-up surveys sent to non-respondents, the response rate to this survey was truly extraordinary. Nevertheless, DETA made an extensive eort to ensure that there was no evidence of bias in the survey responses. The ďŹ rst series of checks were for time sequence bias. The survey responses were analyzed by the time of their receipt to ensure that responses from the early returns did not signiďŹ cantly dier from survey responses received late in the process. This was an especially important investigation since the survey deadline date was extended. No evidence of variance in survey responses by time of return was found. In fact, the survey responses were very similar throughout. Two out of every three surveys were returned by mail with the remaining third of the surveys entered via the TDA website. No signiďŹ cant deviation in survey responses was detected when analyzed by mode of entry. Because each member was mailed a survey form and had the opportunity to enter their survey response via the TDA website, a check for duplicate survey entries was conducted to ensure the fact that no member had inadvertently submitted two surveys. Twelve duplicate entries were found and removed from the database. A more extensive analysis of potential bias was conducted by comparing survey respondents to TDA members by gender and age group. Table 2 shows this comparison. The population of respondents was very similar to the overall TDA membership. Since this was a state-wide survey, the survey respondents were categorized by TDA divisions. The adjacent map (Table 3) shows the survey response rate by the four divisions of the state. There was a high response rate from each region. The regions with the lowest response rates, the Southeast and the Northeast, also had the highest number of survey respondents, with 1,452 and 1,269 respectively. As a result of an extensive analysis of the survey respondents, no evidence was found of bias in this survey. Expanded Duties for Dental Assistants The survey asked for the members’ level of support for the following questions concerning expanded duties for dental assistants: • Placement of pit and ďŹ ssure sealants (expanded to all dental assistants) • Final impressions for crowns, bridges and dentures (partial and complete) • Placement of metallic and non-metallic restorative materials • Carve and ďŹ nish restorations • Coronal polishing • Change selected duties now delegated under direct supervision to general supervision Overall, survey respondents indicated support for: placement of pit and ďŹ ssure sealants (64 percent), coronal polishing (67 percent), and changing selected duties now delegated under direct supervision to Continued on page 2
Table 1. History TDA Survey Responses 0
1,000
2,000
3,000
4,000
5,000
Dental Hygiene Needs, 1996 Dental Hygiene Needs, 2000 Legislative Survey, 2002 Strategic Plan, 2004 0HPEHU %HQHĂ€WV 66.0%
Expanded Duties, 2008
Table 2. Response Rates by Demographic Group Males Females
Under 40 40 to 49 50 to 59 60 to 69
Members
Over 69
Respondents 0%
10%
20%
30%
40%
50%
60%
70%
Table 3. TDA Divisions
Northwest 70%
Southwest 70%
Northeast 65%
Southeast 63%
80%
90%
Survey of Expanded Duties for Allied Dental Personnel, continued from Page 1
general supervision (54 percent). The survey respondents did not support the following duties: final impressions for crowns, bridges and dentures (25 percent), placement of metallic and non-metallic restorative materials (13 percent), and carve and finish restorations (20 percent). These results were further analyzed by dividing the responses by age group, gender, practice type, and specialty status. Some differences were found — especially among the oldest age group (they were most resistant to any expansion of duties); however, these difference were relatively small and did not alter the overall result. Table 4 shows all the responses to these questions.
Expanded Duties for Dental Hygienists The only questions on the survey regarding expanded duties for dental hygienists were related to the administration of local anesthetic. Members were asked whether they supported allowing dental hygienists to administer block injections and infiltration injections, or only infiltration injections. Overall, 39 percent of survey respondents indicated support for both block and infiltration injections. An additional 13 percent of respondents supported infiltration injections but not block injections. As a result, 52 percent of survey respondents indicated support for some type of local anesthesia administration by dental hygienists. Forty-three percent of the respondents were against any form of local anesthesia administration by dental hygienists, and 5 percent of the respondents indicated they were neutral on this issue. There were significant differences in support for local anesthesia administration by dental hygienists when the age of the respondent was considered. All age groups, except the survey respondents who were at least 70 years old, indicated support for some form of local anesthesia administration by dental hygienists. Support levels varied narrowly between 52 percent and 55 percent. Only 27 percent of respondents who were at least 70 years old indicated support for some form of local anesthesia administration by dental hygienists — two-thirds of this group opposed this expanded duty. Detailed responses to this issue can be found in Table 5. Less dramatic differences were found when support for some form of local anesthesia administered by dental hygienists was analyzed by the TDA Division of the state. At least 53 percent of the respondents supported some form of local anesthesia administration by dental hygienists in 3 of the 4 divisions. In the Southeast division, just under half (49 percent) of the respondents were in favor of some form of local anesthesia administration by dental hygienists, 46 percent were opposed, and 5 percent of were neutral (Table 6). The responses to the question of local anesthesia administration by dental hygienists were further analyzed by dividing the responses by gender, practice type, and specialty status. Minor differences were found; however, these differences were relatively small, not statistically significant, and did not alter the overall result.
Table 4. Expanded Duties for Dental Assistants
Sealants
Final Imp
Place Mat
Carve/Fin
Polish
Supervision 0%
20%
40%
60%
80%
100%
Table 5. Some Form of Local Anesthesia Administration for Dental Hygienists by Age Group
Under 40
40 – 49
50 – 59
Conclusions From a technical standpoint, the survey was a great success. A total of 4,579 completed surveys were returned to the Association, representing two out of every three TDA members. The number of responses was more than twice as great as any TDA survey over the past 12 years. Response rates were checked in a variety of ways to ensure that there was no bias in the survey response. This verification procedure included analyses by TDA District and Division, Gender, Age Group, and Practice Type. No evidence of response bias was found. In addition, this was the first survey that was available for completion on the TDA website, and one-third of the respondents completed the survey electronically. Of the six questions on the survey that related to Expanded Duties for Dental Assistants, the three that were support by a majority of the respondents were: • • •
Placement of pit and fissure sealants Coronal polishing Change selected duties now assigned under direct supervision to general supervision
The two questions on the survey that addressed expanded duties for Dental Hygienists related to potentially allowing dental hygienists the ability to administer local anesthesia. A majority of the survey respondents supported some form of local anesthesia administration by dental hygienists. Dr. Eric. S. Solomon, Executive Director for Institutional Research at the Texas A&M Health Science Center, obtained his undergraduate degree in Education, master’s degree in Economic Geography, and his Doctor of Dental Surgery degree from the University of Maryland. He has also earned a graduate certificate in Geographic Information Systems from the University of Texas. For over 25 years, Dr. Solomon has administered a broad range of surveys at both the national and state levels. His research specialties include: trends in dentistry, trends in dental education, dental manpower, and dental practice location. He is a widely published author and presenter and is considered an authority in his research areas. Dr. Solomon has conducted surveys for health professions schools, nationwide dental organizations such as the American Dental Education Association, and for Health Science Centers. He has also conducted survey research for the Texas Dental Association, including a Dental Hygiene Needs Survey in 1996, a Dental Hygiene Needs Survey in 2000, a Legislative Survey in 2002, a Strategic Plan Survey in 2003, an Association Member Benefits Survey in 2006, and an Expanded Duties Survey in 2008. Earlier this year, Dr. Solomon received the Texas A&M Health Science Center’s “Presidential Award for Excellence in Administrative Support” during the Health Science Center’s convocation. He also received a Texas Dental Association Service Recognition Award in 2003 and a President’s Award in 2004. Most recently, he was elected to membership in the National Dental Honor Society, Omicron Kappa Upsilon. +
60 – 69
> 69 0%
25%
50%
75%
100%
Table 6. Some Form of Local Anesthesia for Dental Hygienists by Division
Southwest
Northeast
Northwest
Southeast 0%
April 2008 / TDA Today / 2
20%
40%
60%
80%
100%
Let’s Talk By A. David May, Jr., DDS, TDA President, 2007–2008
Proposed Workforce Model: Possible Expansion of Duties Submitted by the Council on Dental Education, Trade & Ancillaries
T
he workforce survey results are now available, and they are every bit as controversial as we all knew they would be. The TDA Council on Dental Education, Trade, and Ancillaries (DETA) has spent 3 years plus on the research that provided the basis for the resolutions contained within the DETA report. Using that research and the results gleaned from the workforce survey, five resolutions are put forth for discussion at the TDA House of Delegates in May. The resolution to allow dental hygienists to administer local anesthetic agents by infiltration only is the topic that is certainly generating the most interest leading up to the TDA Annual Session. This debate once pitted dentists against dental hygienists, but now it is a debate pitting dentist against dentist. No issue in recent memory has generated as much interest as that of administration of local anesthetic. As you can tell from the report, the TDA membership is fairly evenly divided in its opinion on this matter. In traveling around the state and listening to your discussions, I will say I think the survey results prove that this is a procedure that does not have overwhelming support from the membership, but is supported by a very slight majority. The delegates will have a hard choice to make as they deliberate and vote on this resolution. Call your delegates and voice your feelings on this sensitive subject.
Now, What Do I Think? First, I think the survey is valid and represents the views of the membership. I think it was fair, well-done, and non-biased. Some members have questions regarding various aspects of the survey that in their minds tend to make it invalid. I think Dr. Solomon’s explanation of the mechanics of the survey on Thursday, May 1, 2008, in the TDA House of Delegates will reassure you that we do have survey results that we can accept as representative. Second, when you look at the decision made by the TDA Board of Directors on this resolution, you see the vote split along the same percentage as the membership split. There was a 7 – 7 tie, and I voted to break the tie. My vote was based solely on the fact that 52 percent of our membership is in favor of this change in policy. However, the Board of Directors does not change policy of the Association; this is the role of the House of Delegates. Third, scope of practice issues will be with us for as long as there is a dental profession. Future changes in scope issues should be based on what is best for the patient. Doing what is best for the patients we serve will ultimately be what is best for dentistry also. Your House of Delegates will decide in May whether administration of local anesthetic agents by dental hygienists is in the best interest of our patients and our profession. +
Executive Summary
F
or many years, the TDA has monitored issues facing Texas dentistry — most importantly, those relating to workforce. Workforce development started in 2003, when TDA held a twoday retreat wherein a diverse group of TDA members met to develop the goals and objectives for TDA 2009, Strategic Plan of the Texas Dental Association. Following the development of TDA 2009, the Association gathered workforce information from appointed task forces, work groups, and the Council on Dental Education, Trade & Ancillaries (DETA). Data gathering has included scientific research, surveys, and presentations from various stakeholders. Success in providing optimal oral health to the public requires effective, team-based dental care delivery systems. Given our state’s growing population, Texas dentists must address the profession’s workforce needs. Improving efficiency rather than increasing the number of professionals appears to be the most practical way to address these needs. In developing a new workforce model for Texas, TDA will continue to honor its core values: that all patients are entitled to a consistent and high standard of care and that a team headed by a dentist is the best way to provide quality oral health care. By enlisting DETA to design a new workforce model, TDA proactively addressed the future needs of the profession, rather than merely reacting to pressure from auxiliary groups who seek to expand their individual scopes of practice on a piecemeal or haphazard basis. After careful deliberation and consultation with TDA members, DETA recommends that TDA pursue expanding duties for allied personnel. Although this recommendation is not intended to solve the need for access to oral health care, it may be part of a larger initiative to address the issue.
Introduction In 2004, the TDA’s Manpower Task Force reported that future demographic trends — namely population growth — would strongly affect dentistry’s ability to assure quality oral health care to all Texans. The Task Force determined that, over the next 12 years, growth in the occupations that make up the dental team would not keep pace with population growth. As a result, the Task Force stressed the importance of improving the efficiency and effectiveness of the dental team. Increasing the dental team’s productivity is the most practical solution to the workforce issue. TDA 2009 stipulates that TDA will be the “Voice of Dentistry” in Texas. The plan further states that “TDA will be a national model for state associations, known for its foresight and creativity.” TDA 2009 directed DETA to develop a new workforce model for Texas. In keeping with TDA 2009, the proposed new workforce model envisions how Texas dental offices might function in the future. The model outlines the duties of the dentist and proposes expanded duties for other members of the dental team to increase efficiency while continuing to provide patients with comprehensive, high quality oral health care. TDA 2009 also included Resolution 155-2004-Taskforce on Manpower-H, which directed DETA to study expanded duties of allied personnel in all 50 states. DETA conducted that research in 2004, and presented the results to the TDA Board of Directors in October 2005. Additionally, DETA adopted a set of principles to guide the development process. These principles require a workforce model that: (1) addresses current workforce and economic trends; (2) preserves the role of the dentist as head of the dental team and the person ultimately responsible for quality of care; (3) reflects the perspective of the dentist and addresses the future configuration of the dental team; (4) requires minimal changes to current state law and Dental Board rules; and (5) benefits both small and large dental practices as well as those in both urban and rural areas.
Dental Workforce Update
T
his, the last installment of the Workforce Update, started as a result of a 2007 TDA House of Delegates’ request to share workforce development information every month. The Updates have chronicled a very busy year for your TDA Board of Directors and the Council on Dental Education, Trade & Ancillaries (DETA). From May 2007 to May 2008, the TDA Board and DETA conducted a variety of workforce information activities, including moderated workforce forums across the state in which the membership gave specific suggestions for possible expanded duties they wanted to include in a future workforce model, finalizing nationwide expanded duty research, and creating and administering a statewide membership survey. This special issue of the TDA Today includes the results of the 2008 TDA Workforce Survey along with DETA’s final Workforce Report and the accompanying workforce resolutions that will be presented to the 2008 TDA House. As you know from a previous Workforce Update, it is the House that makes the final decision as to whether there will be changes in TDA policy on expanded duties. During the upcoming TEXAS Meeting, you are invited to hear Dr. Eric Solomon’s workforce survey presentation on Thursday, May 1 in the TDA House of Delegates. Additionally, you will be able to give testimony at the Reference Committee C hearing on Thursday at 11:00 a.m. (or immediately following adjournment of the House). Most importantly, you should contact your delegates and alternate delegates in the House and let them know your views about expanded duties for allied personnel. The House has the power to shape the TDA’s policies on this very important issue and you need to make your voice heard! +
Communication with TDA Members, 2007–2008 Workforce Forums: Following the TDA House of Delegates in May 2007, TDA initiated a series of Workforce Forums to gather membership input about future workforce models. The process helped ensure that TDA moved forward with workforce models that accurately reflect members’ desires. As a part of that process, DETA created “Forum Fundamentals” to help TDA members fully participate in the forums. The “Forum Fundamentals” included a list of impermissible delegations to dental hygienists and dental assistants in Texas, an article about the administration of local anesthetic by dental hygienists, a state-by-state listing of restorative functions performed by dental hygienists, and a summary of states authorizing expanded duties for dental hygienists. This information was designed to foster informed and open communication with the TDA leadership. The TDA Board of Directors conducted 24 forums across the state. The forums were moderated by TDA President Dr. A. David May, Jr., and other TDA Board members and included four discussion questions designed to help DETA gather basic information about what TDA members wanted in a future workforce model. To help encourage participation at the forums, the TDA central office mailed reminder postcards to all members approximately one week before the forum took place in their area. Forums used the following discussion questions: (1) Overall, are you satisfied with the current Dental Practice Act relating to dentists and allied dental personnel in the State of Texas? (2) Are there any areas of Dental Practice Act relating to dentists and allied dental personnel that you currently think are too restrictive? (3) Are there any areas of Dental Practice Act relating to dentists and allied dental personnel that you think are too broad? (4) What changes would you make, if any, to the Dental Practice Act relating to dentists and allied dental personnel?
Continued on page 4
April 2008 / TDA Today / 3
Proposed Workforce Model, continued from Page 3
From the forums, DETA heard suggestions about expanded duties for allied personnel, education and certification requirements for the proposed new duties, and concerns about how the expanded duties might impact access to oral health care. Workforce Updates in TDA Today: DETA also published monthly “Workforce Updates” in the TDA Today newsletter. These updates included the locations of the workforce forums and an explanation of how TDA establishes policy. In every update, DETA solicited feedback about members’ wants and desires for a future workforce model. Members unable to attend a forum were encouraged to email their feedback to workforce@tda.org. Jurisprudence Continuing Education Modules: After careful review of state law and the rules of the Texas State Board of Dental Examiners, DETA determined that Texas dentists already have significant flexibility to delegate procedures to allied personnel. As a result, DETA identified the need to enhance TDA members’ understanding of current state law and TSBDE rules. To that end, DETA published three jurisprudence self-study modules in the November 2006, December 2006, and January 2007 issues of the Texas Dental Journal. Workforce Webpage: DETA created the workforce webpage in response to a May 2007 TDA House of Delegates request for more information regarding the TDA’s workforce research. The workforce webpage reviewed the Association’s workforce development efforts to date and offered a mechanism for TDA members to express opinions about workforce issues. The webpage also included information from other states and scholarly articles about expanded duties. TDA 2008 Workforce Survey: After DETA collected information from the workforce forums and other sources, it conducted a membership-wide survey to assess TDA members’ satisfaction with the current range of duties that can be delegated to allied dental personnel under the current Dental Practice Act, and identifying possible expanded duties for a future workforce model.
Recommendations to the TDA Board After analyzing the survey results, along with feedback from TDA members, DETA agreed on the following recommendations to the TDA Board of Directors: (1) The Texas Dental Association supports a change in law and regulations to allow Texas licensed dentists to delegate to a properly trained, registered dental hygienist the administration of local anesthetic by infiltration under direct supervision of the dentist. (2) The Texas Dental Association supports a change in law and regulations to allow Texas licensed dentists to delegate to a properly trained and certified dental assistant the placement of pit and fissure sealants. Under the current Dental Practice Act, only dentists that are Medicaid providers or who practice in underserved areas have the authority to delegate to their dental assistants the application of pit and fissure sealants. (3) The Texas Dental Association supports a change in law and regulations to allow the delegation by a Texas licensed dentist to a properly trained and certified dental assistant the removal of plaque and extrinsic stain from exposed natural and restored tooth surfaces, utilizing an appropriate rotary instrument with rubber cup or brush and polishing agent. (4) The Texas Dental Association supports a change in law and regulations to allow a Texas licensed dentist to delegate to a properly trained dental assistant interim treatment for the temporary alleviation of a “minor emergency dental condition” under general supervision, providing that the treatment is rendered to a patient of record and that the dentist has been contacted and has delegated treatment prior to treatment being rendered. Interim treatment is that which is considered reversible and does not require cutting hard or soft tissue. A minor emergency dental condition is defined as a condition which causes the patient discomfort and can be relieved by interim treatment, such as re-cementing a temporary crown, re-cementing a permanent crown with temporary cement, placing a temporary restoration such as an Intermediate Restorative Material (IRM), or stabilizing an orthodontic condition such as loose arch wires or brackets which are cutting the patient. (5) The Texas Dental Association supports a change in law and regulations to allow a Texas licensed dentist to delegate the performance of radiologic procedures to a properly trained, registered dental assistant under general supervision.
Practice Model Flexibility and Scalability DETA decided to develop a workforce model that would be more flexible than our present model and focus on the role of the dentist as the team leader. The model would better utilize allied personnel and provide them with more professional opportunities. Furthermore, this approach would allow dentists to adapt the model to the needs of their particular practices, as opposed to conforming to a single, rigid template. By defining new duties for allied personnel, the proposed workforce model would create opportunities for greater efficiency and increasing the number of patients a dentist may successfully treat regardless of their practice setting. In contrast to the ADA’s recent approach to create new categories of auxiliaries that could potentially balkanize the dental team, DETA proposes to expand the duties of existing auxiliaries. Access to Care Dental workforce and related access to care issues are complex, and many of the factors involved are outside the realm of the dental profession. While workforce issues may
relate to access to care, the access problem encompasses larger societal and public policy issues. The proposed new workforce model is neither a panacea nor a single solution to any or all of these problems. The workforce model, however, could be a key part of a comprehensive access to care proposal. After a thorough analysis, DETA determined that the best approach to a new Workforce Model is to increase dental office productivity by improving the utilization of dental auxiliaries by expanding the their duties. This approach would enable Texas dentists to deliver more care more effectively while ensuring patient safety and high quality care. As head of the team, the dentist retains ultimate legal and ethical responsibility for patient care and quality control. All delegated duties must be rendered in accordance with the patient’s needs as determined by the dentist’s diagnosis and treatment plan. Recently, the TDA Board held a “mega-issue” discussion to define access to oral health care. As a result of that meeting, the Board added new objectives to direct the Association to collect, compile, and disseminate data on unmet oral healthcare needs and to increase TDA members participation in Texas Dental Medicaid program.
Political Implications It is important to note that the process of amending the Dental Practice Act can’t be done in a vacuum. Once TDA initiates legislation to amend the Dental Practice Act, that legislation could be subject to amendments that would further the interests of dental auxiliaries at the expense of Texas dentists. The excerpts below illustrate some of the potential pitfalls of pursuing legislation to expand duties for allied personnel. Excerpt from Workforce: A View from the Capitol By Dr. David Sibley, TDA Lobbyist Texas Dental Journal, October 2007, pg. 1039 The single biggest risk involved in trying to change the scope of practice for allied dental personnel is the risk involved in opening the Dental Practice Act. Once a bill that amends the Dental Practice Act enters the legislative process, particularly one that addresses the scope of practice for one profession or occupation, that bill is subject to both friendly and unfriendly amendments. While the former are usually harmless, the latter can turn a dream bill into a nightmare. Like other professions at the Capitol, organized dentistry is strongest when its members are united. If, at the end of its workforce deliberations, TDA ultimately decides to pursue some type of expanded duties, we must strive to achieve consensus among members of our profession. Any proposed scope of practice legislation should be based on sound public policy that is both well thought out and as specific as possible. Excerpt from Why Change What Works? Texas Dentistry Already Has It Right! By S. Jerry Long, D.D.S., Trustee, 15th District, American Dental Association and Past Chair, TDA Council on Legislative and Regulatory Affairs TDA Workforce Webpage, http://tda.org/displaycommon.cfm?an=1&subarticlenbr=939 Those who support expanding dental hygienist scopes of practice into the realms of examination, diagnosis, prescriptive powers and irreversible procedures, argue that once these objectives are achieved legislatively, the traditional scope of practice battles in the Texas Legislature will be a thing of the past. In reality, other state dental associations that have voluntarily “given up” or “lost” certain clinical privileges to mid-level providers, have continued to experience emotional, divisive legislative scope “fights.” Consequently, those state dental associations are now playing the same game, but with much higher stakes.
American Dental Association Each year since 2004, as part of a broader national effort to evaluate workforce and oral health access, the ADA House of Delegates has created a series of task forces and directed them to study dental workforce issues. The 2004 Workforce Task Force was directed to identify the best way to utilize the dental workforce to increase access for the underserved. During the 2005 ADA House, the Task Force unveiled a new workforce model that failed to receive House approval. Instead, the House created a presidentially appointed Task Force to gather and analyze data about availability of dental care to the underserved and recommend workforce changes needed to increase access to care. The 2005 Workforce Task Force presented a revised workforce model to the 2006 ADA House. The ADA House enacted Resolutions 3H-2006 and 25H-2006, which created two new types of dental team members: Oral Preventative Assistant (OPA) and Community Dental Health Coordinator (CDHC), and provided guidelines that individual states could use to expand duties for allied dental personnel. The CDHC will be responsible for promoting oral health through organized and dentally coordinated community based promotion and prevention programs. As a member of the dental team led by a dentist, the CDHC will work in underserved communities where residents have no or limited access to dental care. They will influence local health and community organizations to adopt initiatives to promote oral health. The CDHC will be new mid-level allied dental personnel employed by Federally Qualified Health Clinics, the Indian Health Service and tribal clinics, state or county public health clinics, or private practitioners serving the dentally underserved areas. As a member of the dental team, the CDHC will enable the existing dental workforce to expand its reach deep into underserved communities and influence local health and community organizations to adopt initiatives to promote oral health.
April 2008 / TDA Today / 4
Continued on page 5
Editor’s Quick Summary
Proposed Workforce Model, continued from Page 4
Pilot program training sites are: Urban: Michigan Coalition for Development and Implementation of the Community Dental Health Coordinators, in collaboration with the Wayne County Community College District. Pending state approval, this training will occur in Federal Qualified Health Centers.
By Christopher F. Anderson, DDS, TDA Editor
Rural: University of Oklahoma, with Rio Salado College (Arizona) delivering the on-line components of the curriculum. The hands-on clinical training will occur in Indian Health Service facilities. Pending final approval by the Oklahoma Dental Board, it will also occur in Federally Qualified Health Centers. Native American: University of California — Los Angeles and Salish Kootenai College, with Rio Salado College (Arizona) delivering the on-line components of the curriculum. The hands-on clinical training will occur in Indian Health Serve facilities in several different states.
T
As soon as the curriculum is done for the CDHC, the ADA will turn their attention to the curriculum for the OPA.
•
viewed a demonstration and approved implementation of the Board Docs program for electronic document handling for Board meetings; also updated source of finances for project;
During 2007, the American Dental Hygienists’ Association (ADHA) widely publicized a proposed new category of hygienist, the Advanced Dental Hygiene Practitioner (ADHP).
•
approved TDA’s participation in the Texas Head Start Save Our Smiles project in selected cities October 2–3;
In February 2007, a bill to establish an ADHP was developed and promoted by the ADHA in Minnesota. The bill would create a new kind of dental hygienist who, after completing a corresponding masters degree program at Metro State University or Normandale Community College, would be able to:
•
approved revisions to the strategic plan, TDA 2009;
•
approved a resolution redefining the Committee on Communications and its responsibilities;
•
adopted a substitute for a resolution previously submitted by Dr. Adcock regarding Community Health Centers;
•
approved a resolution from the Committee on Access, Medicaid & CHIP regarding local Medicaid provider recruitment;
•
approved new Bylaws language transferring duties from the old Council on Dental Care Programs & Community Oral Health to the new Council on Dental Economics and delineating the duties of the new Council; and
•
approved a new resolution from District 18 regarding the problem of tooth-whitening by non-dentists.
Advanced Dental Hygiene Practitioner (ADHP)
• • • • • • • • • • •
render a final diagnosis; prepare treatment plans; prepare and restore primary and permanent teeth using direct placement of appropriate dental materials; place preformed crowns; perform pulpotomies on primary teeth and direct and indirect pulp capping in primary and permanent teeth; place atraumatic temporary restorations; perform extractions of primary and permanent teeth; prevent or intercept potential orthodontic problems and parafunctional habits by early identification, space maintenance, and appropriate referral; provide reparative services to patients with defective prosthetic appliances; supervise registered and unregistered dental assistants; and prescribe, administer, and dispense legend drugs.
An ADHP would be able to perform the procedures listed above under a collaborative management agreement with a dentist under the following circumstances: • • • •
without the patient first being examined by a licensed dentist; without the presence of a licensed dentist; without the dentist’s diagnosis and treatment plan, and at a location other than the usual place of practice of the dentist or advanced dental hygiene practitioner.
Conclusion The proposed new workforce model is both realistic and achievable. All of the expanded duties would require allied personnel to receive appropriate education and training and to be evaluated to ensure their competency. If the TDA House of Delegates approves the workforce model, the next step will require refining the education and training standards for each expanded duty. This step would require close collaboration among dentists, dental educators, and allied health personnel educators. It is imperative that TDA design education requirements that are practical for the dentist and the team, and that ensure the health and best interests of the patients served. The proposed workforce model retains the dentist’s ability to be the sole authority to diagnose and treat dental disease and to lead the dental team with full responsibility for the performance of each team member. In this capacity, the dentist leader will ensure that all patients receive a uniform standard of high quality oral health care. + TDA Council on Dental Education, Trade & Ancillaries: Drs. Glenn R. Walters, Sr. (chair); Michael J. Goulding; Gregory W. Rashall; Eric S. Solomon; Patricia L. Blanton (consultant); and Jacqueline M. Plemons (consultant).
Letter to the Editor Dear Editor: The 2008 Texas Dental Journal (March 2008) had both the 2009 proposed budget and the Editor’s plea for approval of the $50.00 assessment to pay for the proposed building acquisition. Examination of this budget and previous budgets is educational. The expenses are compared to the revenues. Looking at the 2005 actual budget, there was an excess [revenue minus expenses] of $608, 610.00. That is $608, 610.00 more money, some of it our dues, than was needed to fully fund the budget. In the following budgets, 2006, 2007, 2008, the carry over has never been used. It has been budgeted but not used. The carry over continues to grow each year since it has not been needed. Present carry over is estimated to be $775,000.00. Assuming there are approximately 5,500 full dues paying members, multiplying by $50.00 gives $275,000.00 per year for building payments. Is the assessment really needed with $775,000.00 in presently unused excess funds? Please let your district delegate know your feelings on this matter before the state convention. Sincerely yours, Judd Graves, D.D.S. Kermit, Texas P.S. Don’t forget there is a proposed dues increase of $45.00 in addition to the assessment. + April 2008 / TDA Today / 5
he TDA Board of Directors met in Austin on Friday and Saturday, March 14 and 15. Board actions affecting Association policy included:
The Board also took the following actions on non-policy issues: •
approved the nominations to the TDA Smiles Foundation Board;
•
approved the recommendations of the Awards Committee; and
•
approved grants from the interest on the Relief Fund.
The Board spent Saturday receiving and discussing the report of the Council on Dental Education, Trade & Ancillaries regarding the workforce model. Information on that report, the results of the membership survey and the resolutions that will be sent to the House of Delegates are reported elsewhere in this issue of TDA Today and on the TDA website. +
Texas Dental Association
BACKGROUND STATEMENT
Dental Workforce Resolutions BACKGROUND STATEMENT In 2004, the TDA House of Delegates passed Resolution 158-2004-H, authorizing the TDA Board of Directors to adopt the TDA Strategic Plan, also known as TDA 2009. In response to the mandate of the House, TDA 2009 directed the Council on Dental Education, Trade & Ancillaries to develop a new workforce model for Texas, retaining the role of the dentist as head of the dental team and maximizing the dentist’s ability to delegate expanded duties to dental team members; therefore be it 123-2008-B (P) Submitted by: Council on Dental Education, Trade & Ancillaries Strategic Plan Goal: Manpower Resolved, that the Texas Dental Association support a change in law and regulations to allow Texas licensed dentists to delegate to a properly trained, registered dental hygienist the administration of local anesthetic by infiltration under direct supervision of the dentist, and be it further Resolved, that a position paper be prepared detailing the change in policy of the Texas Dental Association regarding the delegation to a properly trained, registered dental hygienist the administration of local anesthetic by infiltration under direct supervision of the dentist, and be it further Resolved, that Resolution 69-1997-H, which reads as follows: “Resolved, that the following position paper be accepted as the policy of the Texas Dental Association regarding injection of local anesthesia by dental hygienists … ” be rescinded. FINANCIAL IMPLICATION: $0 MOTION, Dr. Dunsworth: PASSED (Approved: Drs. Harrison, McEntire, Oneacre, Cailleteau, Dunsworth, Lyman, Israelson, and May. Opposed: Drs. Armstrong, Loeffelholz, Peppard, Walton, Cazares, Bogan, and Rea.)
BACKGROUND STATEMENT
In 2004, the TDA House of Delegates passed Resolution 158-2004-H authorizing the TDA Board of Directors to adopt the TDA Strategic Plan, also known as TDA 2009. In response to the mandate of the House, TDA 2009 directed the Council on Dental Education, Trade & Ancillaries to develop a new workforce model for Texas, retaining the role of dentist as head of the dental team and maximizing the dentist’s ability to delegate expanded duties to dental team members. An emergent dental condition is defined as a condition which may cause the patient discomfort and can be relieved by interim treatment such as re-cementing a temporary crown, re-cementing a permanent crown with temporary cement, placing a temporary restoration (such as an Intermediate Restorative materials (IRM), or stabilizing an orthodontic condition such as loose arch wires or brackets which are cutting the patient; therefore, be it 126-2008-B (P) Submitted by: Council on Dental Education, Trade & Ancillaries Strategic Plan Goal: Manpower Resolved, that a Texas licensed dentist may delegate to a properly trained dental assistant interim treatment of an emergent dental condition, under general supervision, providing that the treatment is rendered to a patient of record and that the dentist has been contacted and has delegated treatment prior to treatment being rendered. Interim treatment is that which is considered reversible and does not require cutting hard or soft tissue. MOTION, Dr. Armstrong: PASSED (unanimously)
BACKGROUND STATEMENT In 2004, the TDA House of Delegates passed Resolution 158-2004-H authorizing the TDA Board of Directors to adopt the TDA Strategic Plan, also known as TDA 2009. In response to the mandate of the House, TDA 2009 directed the Council on Dental Education, Trade & Ancillaries to develop a new workforce model for Texas, retaining the role of dentist as head of the dental team and maximizing the dentist’s ability to delegate expanded duties to dental team member; therefore, be it
In 2004, the TDA House of Delegates passed Resolution 158-2004-H authorizing the TDA Board of Directors to adopt the TDA Strategic Plan, also known as TDA 2009.
127-2008-B (P) Submitted by: Council on Dental Education, Trade & Ancillaries Strategic Plan Goal: Manpower
In response to the mandate of the House, TDA 2009 directed the Council on Dental Education, Trade & Ancillaries to develop a new workforce model for Texas, retaining the role of dentist as head of the dental team and maximizing the dentist’s ability to delegate expanded duties to dental team member.
Resolved, that the Texas Dental Association support a change in law and regulations to allow a Texas licensed dentist to delegate the performance of radiologic procedures to a properly-trained, registered dental assistant under general supervision.
Under the current Dental Practice Act, only dentists that are Medicaid providers or who practice in underserved areas have the authority to delegate to their dental assistants the application of pit and fissure sealants; therefore, be it 124-2008-B (P) Submitted by: Council on Dental Education, Trade & Ancillaries Strategic Plan Goal: Manpower
MOTION, Dr. Dunsworth: PASSED (unanimously) +
Texas Dental Association
Reference Committee Hearings Thursday, May 1, 2008
Resolved, that the Texas Dental Association support a change in law and regulations to allow Texas licensed dentists to delegate to a dental assistant, who holds a pit and fissure sealant certificate, the placement of pit and fissure sealants under direct supervision.
All TDA reference committee hearings will be held Thursday, May 1, 2008 in the Henry B. Gonzalez Convention Center in San Antonio.
MOTION, Dr. Dunsworth: PASSED (unanimously)
Reference Committee
BACKGROUND STATEMENT In 2004, the TDA House of Delegates passed Resolution 158-2004-H authorizing the TDA Board of Directors to adopt the TDA Strategic Plan, also known as TDA 2009. In response to the mandate of the House, TDA 2009 directed the Council on Dental Education, Trade & Ancillaries to develop a new workforce model for Texas, retaining the role of dentist as head of the dental team and maximizing the dentist’s ability to delegate expanded duties to dental team member; therefore, be it 125-2008-B (P) Submitted by: Council on Dental Education, Trade & Ancillaries Strategic Plan Goal: Manpower Resolved, that the Texas Dental Association supports a change in law and regulations to allow Texas licensed dentists to delegate to a dental assistant, under direct supervision, who holds a coronal polishing certificate, the removal of plaque and extrinsic stain from exposed natural and restored natural and restored tooth surfaces, utilizing an appropriate rotary instrument with rubber cup or brush and polishing agent. MOTION, Dr. Oneacre: PASSED (unanimously)
A:
(Administration, Budget, Building, House of Delegates, and Membership Processing): Noon, Room 006A, River Level
Reference Committee
B:
(President’s Address, Miscellaneous Matters, Component Societies, Subsidiaries, Strategic Planning, Annual Session): Thursday, May 1, 2008, 1:30 p.m., Room 006B, River Level
Reference Committee
C:
(Dental Education and Health & Dental Care Programs): Thursday, May 1, 2008, 11:00 a.m. (or 15 minutes after adjournment of the House of Delegates), Room 004, River Level
Reference Committee
D:
(Legislative, Legal, and Governmental Affairs): Thursday, May 1, 2008, 2:00 p.m., Room 006D, River Level
Reference Committee
E:
(Constitution, Bylaws, Ethics & Peer Review): Thursday, May 1, 2008, 1:00 p.m., Room 006C, River Level
April 2008 / TDA Today / 6
MK’s Board Notes By Mary Kay Linn, TDA Executive Director
B
elow is a summary of actions of the TDA Board of Directors during the January 25–26, 2008 meeting, with TDA president Dr. A. David May, Jr., presiding.
Policy Resolutions BUDGET ISSUES • •
87-2008-B (P): Adopted the 2009 proposed budget for the Texas Dental Association. 88-2008-B (P): (2/3 approval vote required) Amended Chapter I, Membership, Section 70, Dues, paragraph A, Active Members to substitute “four hundred-fifty-five” ($455.00) for “four hundred-ten” ($410.00) in that paragraph.
Happy, Healthy Smiles … That’s Our Mission. Ways to Give to the TDA Smiles Foundation
F
or nearly 10 years now, the TDA’s foundation has been serving Texans through innovative oral healthcare programs and educational efforts. By your involvement in the foundation, we continue the good work and promotion of dentistry throughout the state. Please consider one or more of the following ways to get involved, through service, promotion, donations, and play!
Serve as a Texas Mission of Mercy or Texas Donated Dental Services volunteer. Thousands of Texans in need of dental care are served each year by our kind and generous dentists, hygienists, and community volunteers. Without the support of such individuals, our programs simply could not function. Please consider signing up to help at one or more of the upcoming TMOM events: • • •
April 19, 2008: Tyler TMOM, Tyler, Texas September 5 – 6, 2008: Williamson County TMOM, Leander, Texas November 14 – 15, 2008: Coastal Bend TMOM, Corpus Christi, Texas
Accept a Texas Donated Dental Services (TXDDS) patient. See a patient who is over the age of 55 or limited by a disability in the comfort of your own office. The TXDDS Program Coordinator will coordinate lab services for the patient. TXDDS volunteer dentists are needed year-round!
Promote your profession with the purchase of a Smile Texas Style license plate. Not only are these novelty plates attractive, but they fund and promote an answer to the access to care problems many Texans face. Portions of each plate sale are donated to the TDA Smiles Foundation, so you can proudly display your commitment to helping those without dental care in Texas.
MISCELLANEOUS
Donate to the TDA Smiles Foundation.
•
Your contributions are the life-blood of our mission. Each dollar donated means Texans without dental care are a step closer to receiving the treatment they so desperately need. Give a self-determined amount, or join the ranks of our Century Club donors, who generously support our efforts with tax-deductible $100 monthly contributions. No matter the amount, your contribution makes a difference in the lives of those struggling with poor dental health.
•
•
•
73-2008-(B) (P): Approved a $50 per year assessment to the membership of the TDA for four consecutive years, prorated according to the formulas in the Bylaws, for the purpose of debt retirement for the building located at 1920 S. IH-35, Austin, Texas. 82-2008-B (P): Approved the “Dental Tourism Reporting Form” developed by the TDA Council on Dental Economics. 84-2008-B (P): Directed the appropriate TDA entity(s) to investigate pertinent regulatory requirements for proper disposal of discarded patient documents and other items from dental offices, with the findings and recommendations for disseminating this information to the membership at the March 2008 TDA Board meeting. 142-2007-CODES-BS (P): Affirmed that the Texas Dental Association recognizes the importance of automated external defibrillators (AEDs), supports their use, and encourages dentists and staff training in the proper use of AEDs in dental offices in Texas.
Non-Policy and Board Policy Resolutions BUDGET ISSUES •
•
78-2008-B (NP): Approved line items over budget (office supplies, accounting and auditing services, gifts/memorials, meetings, recruiting, vice presidents, and other officers). 86-2008-B (NP): Approved the 2007 surplus allocation as recommended by the Budget Committee.
MISCELLANEOUS • •
•
•
•
74-2008-B (NP): Approved funding to replace the TDA central office building roof. 79-2008-B (NP): Approved transfer of Smile Texas Style license plate project to the TDA staff marketing team. 80-2008-B (NP): Appointed Relief Fund Grant Board Work Group (Drs. Craig S. Armstrong, Johnny G. Cailleteau, Arlet R. Dunsworth,, and J. Brad Loeffelholtz) to review letters of interest and report recommendations to the TDA Board in March 2008. 81-2008-B (NP): Appointed Retreat Board Work Group (Drs. Hilton Israelson and Johnny G. Cailleteau) to plan the August 2008 strategic planning retreat. 83-2008-B (NP): Approved logos for the TDA and the TEXAS Meeting as presented on January 25, 2008; approved the family concept for the proposed logos of the TDA FSI Perks Program, TDA Smiles Foundation, and DENPAC; and encouraged TDA FSI, TDA Smiles Foundation, and DENPAC boards to approve their individual logos within the brand family as presented to the TDA Board. +
Play
the 2008 Healthy Smiles Golf Classic, an annual must-not-miss event at the TEXAS Meeting in San Antonio, on Friday, May 2, 2008. Hosted by the Texas Association of Orthodontists and sponsored by Nobel Biocare, this tournament is a fun way to support the TDA Smiles Foundation. You’ll enjoy an invigorating morning of golf at San Antonio’s Pecan Valley Golf Club with a 7:30 a.m. shotgun start, breakfast waiting for you on your cart, and an awards ceremony and luncheon immediately following play, as well as the satisfaction of knowing you’ve spent a gorgeous morning playing 18 holes for the benefit of those without dental care. To give to the TDA Smiles Foundation and Texans in need of dental care, please call Kelli Slimp at (512) 448-2441 x100, or email the staff at smiles@tda.org. +
CODE: Report Form Now Available! Compiled by the Council on Dental Economics
Documenting Dental Tourism
D
ental tourism is a critical issue confronting Texas dentists. The first step in working towards a solution is gathering information. “We must first prove with facts what we know anecdotally before we can offer solutions.” (May AD. President’s Message — Dental Tourism. Texas Dental Journal August 2007; 124(8): 722) The Texas Dental Association’s Council on Dental Economics has created a Dental Tourism Reporting Form, which provides the opportunity for TDA members to document information concerning: (1) the problems TDA members are experiencing with patients who receive dental treatment in Mexico; and (2) the insurers and third party administrators that are paying claims submitted by dentists in Mexico. A copy of the form and instructions on submitting the form are available on www.tda.org. Please print out a copy of the form and review it in its entirety. Note that the reporting form is to be filled out by TDA member dentists only. The TDA will not accept reporting forms from non-member dentists and/or the general public. Receiving these forms from TDA members is an important first step at tackling this very difficult issue of dental tourism. Questions regarding the reporting form should be directed to Cassidy Neal at (512) 443-3675 or cassidy@tda.org. +
Texas Recognized for Membership Accomplishments
F
or the second year in a row, the TDA is proud to report that Texas won four very prestigious membership awards at the recent American Dental Association (ADA) Recruitment and Retention Conference held March 28–29, 2008, at the ADA headquarters in Chicago. All awards were given in the 3,501 to 7,500 member category (Florida, Illinois, Massachusetts, Michigan, New Jersey, Ohio, Pennsylvania, and Texas). ADA Membership Academy Best Practices awards were presented to the Texas Dental Association for the TDA Externship Program and to the Dallas County (Fifth District) Dental Society for its D1 Dinner and International College of Dentistry Great Expectations Mentoring Program. The Texas Dental Association received the following “top constituent society” awards: • •
• •
Greatest Percentage Membership Net Gain: TDA achieved a net gain of 198 members in 2007! Greatest Percentage of Non-Members to Members, End of Year 2007: Recognizes a conversion rate of 4.7 percent of non-members into membership. Greatest Increase in Retention Rate: Recognizes TDA’s 97 percent retention rate, which is a 0.7 percent increase from 2006! Greatest Percentage of New Dentist Members: This award represents a gain of 111 new dentist members (those dentists who are 1-to-9 years out of school).
Look for more membership information related to TDA strategic planning in your May 2008 TDA Today. + April 2008 / TDA Today / 7
From left: Members and staff present and accepting awards on behalf of TDA were: Dr. William (Ben) Taylor, San Antonio District Dental Society; Dr. Ingrid Duebbert, Greater Houston Dental Society; Ms. Lee Ann Johnson, TDA Director of Member Services; Dr. Carolyn Walker, San Antonio District Dental Society; Dr. Pamela Baldassarre, chair of the ADA Council on Membership
This recurring section is designed to help TDA members keep up with important Texas State Board of Dental Examiners (TSBDE) rules, other regulations, and state law affecting their practices.
TDA
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I recently treated a patient who later presented at the emergency department of a local hospital complaining of treatment-related pain and was ultimately hospitalized for three days. Am I required to report the patient’s hospitalization to the Texas State Board of Dental Examiners? If so, how much time do I have to make the report? This issue is addressed by TSBDE Rule 108.6 – “Report of Patient Death or Injury Requiring Hospitalization.� Yes, you must report the patient’s hospitalization within 30 days of the hospitalization or as soon as you become aware — or reasonably should have become aware — of it. The full text of Rule 108.6 reads as follows:
A dentist must submit a written report to the SBDE as provided below: (1) The death of a dental patient which may have occurred as a consequence of the receipt of dental services from the reporting dentist must be reported within 72 hours of the death, or such time as the dentist becomes aware or reasonably should have become aware of the death; (2) The hospitalization of a dental patient, as a possible consequence of receiving dental services from the reporting dentist, must be reported within 30 days of the hospitalization or such time as the dentist becomes aware of or reasonably should have become aware of the hospitalization. For purposes of this section, “hospitalizationâ€? shall be deďŹ ned as an examination at a hospital or emergency medical facility that results in an in-patient admission for the purpose(s) of treatment and/or monitoring. (3) In the evaluation of sedation/anesthesia morbidity or mortality, the SBDE shall consider the standard of care necessary to be that applicable to the patient’s state of consciousness during the procedure. +
Join us at the TDA Internet CafÊ at the 2008 TEXAS Meeting! Come by to check your e-mail, look up directions, print boarding passes, check out the new TDA Express portal, or sign up for a Personal Web Page. The cafÊ will be located in the registration area May 1-3, 2008. Sponsored by Dental Symphony. Purchase photos from the 2008 TEXAS Meeting! Attendees will also have an opportunity to purchase photos taken at the TEXAS Meeting. TDA’s sta photojournalist, Paul Schlesinger, will be taking candid shots during the meeting. Once you are photographed, you’ll receive a ticket that will let you know when and where you can pick up your printed photo in a protective folder. The photos will be available the next day at the Internet CafÊ located in the registration area. All photos taken at the 2008 TEXAS Meeting will also be available for purchase on TDA’s website after the meeting. Photos from the 2007 TEXAS Meetings are still available at www.texasmeeting/estore.
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Questions? Contact Stefanie Clegg at (512) 443-3675 or stefanie@tda.org. +
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at The TEXAS Meeting. Visit the TDA Perks Program endorsed-vendor area ERRWKV DQG Ă&#x20AC; OO RXW DQ HQWU\ IRUP IRU D FKDQFH WR ZLQ RQH RI VHYHUDO L3RG QDQRV Visit tdaperks.com for information on your Perks Programs.