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Do midlevel providers improve oral health?

An ADA scientific literature review finds no evidence of disease prevention or cost effectiveness associated with midlevel providers such as dental therapists.

"The expert panel and the ADA can be proud of the work that went into this report," said Dr. Robert A. Faiella, Association president. "It is an unprecedented look at these issues." The report's principal author, Dr. J. Timothy Wright, said that "this analysis shows midlevel providers who provide surgical treatment do not result in reduced rates of dental caries in the population. Oral health disparities exist regardless of the provider workforce model."

The January 2013 peer-reviewed Journal of the American Dental Association includes the report on the systematic review with commentaries by Drs. Faiella and Wright. The nearly year-long systematic review responded to a request by the 2011 ADA House of Delegates and addressed the question of whether the use of midlevel providers to conduct  diagnostic, treatment planning or irreversible/surgical dental procedures produces change in disease increment, untreated dental disease or cost-effectiveness of dental care.

The study's authors "felt strongly that the conclusions are evidence-based and fully supported by the analysis of the included studies," the report said. A systematic review is a critical assessment and evaluation of all research studies that address a particular clinical issue.

"The potential function and benefit of oral health care workforce models that incorporate midlevel providers, such as dental therapists or dental nurses, remains a highly controversial and politically charged topic in the United States," the report said.

"A variety of studies indicate that appropriately trained midlevel providers are capable of providing high quality services including irreversible procedures such as restorative care and dental extractions. What is less clear is whether midlevel providers can provide these services in a cost effective manner and if incorporation of these providers into the workforce will result in improved oral health of the population."

The authors said they "cast a broad net to ensure inclusivity of all relevant research" that yielded 7,000 references but ultimately provided 18 studies that addressed the clinical question and presented data that could be reviewed. This was "limited evidence that overall has a high risk of bias," the report said.

"All but one of the studies reviewed were conducted on populations outside the United States and most were on school age children, making it tenuous to generalize the results to populations in the United States."

An Association media statement issued with publication of the JADA report said that the review found:

•    no difference in the overall caries rates between populations treated by therapists and those treated solely by dentists, as measured by diseased, missing and filled teeth (DMFT) scores;

•    a greater decrease in untreated caries in the therapist-treated populations than in dentist-only-treated populations, and

•    no data that addressed cost-effectiveness, defined as the real cost of reducing disease rates or about diseases other than caries.

"The data show that midlevel providers are not helping stem the tide of the caries epidemic nor reducing the population's need for these services," the report said. "They do help manage the sequelae of the disease and could decrease the negative outcomes that are well-known to occur with untreated dental caries."

"To put it simply, the report shows that if more personnel are treating cavities, more cavities get treated," said Dr. Faiella, the ADA president. "But that does nothing to reduce the number of people getting cavities. And it points up the futility of a delivery system based on surgically treating disease that could have been prevented."