The Academy of General Dentistry (AGD) Cautions Against Misuse of Kellogg Foundation's Evaluation of Dental Health Aide Therapists

Oct 28, 2010, 17:45 ET from Academy of General Dentistry

CHICAGO, Oct. 28 /PRNewswire-USNewswire/ -- On October 26, 2010, the W.K. Kellogg Foundation, the Rasmuson Foundation, and the Bethel Community Services Foundation (Kellogg) released their Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska (the Evaluation).

The AGD has seen misleading reports from a number of organizations in response to the Kellogg Evaluation. The AGD would like to provide its analysis of the Evaluation and caution against misinterpretation of the results.

The Evaluation found that five Dental Health Aide Therapists (DHATs) who had acquired two years of experience working closely with dentists after completion of DHAT education had improved the oral health of a few hundred rural Native residents of Alaska.  

The Evaluation used three methods to examine the practical achievements of DHATs: oral health surveys, clinical technical performance measures, and evaluation of patient records.  

As documented in the Evaluation, a 1999 survey of Alaska's Native oral health status "[underscored] the significant unmet need of these populations, regardless of what measure of oral health was examined." Evaluation, 2-2.  

However, Kellogg cautions readers against drawing broad and inaccurate conclusions from its findings.  

First, the Evaluation cautions against a conclusion that it includes definitive findings on quality of care or patient oral health outcomes:

Some of these evaluations are considered by many to measure the "quality of care" that has been provided, although that interpretation equates quality of care with technical excellence while ignoring the more important consideration of patient outcomes. Also, no norms for comparison of technical performance using these evaluation measures are available. Evaluation, 3-3 to 3-4.

As the Evaluation notes, "it would be premature to attempt to evaluate the DHAT experience on the basis of oral health outcomes at this time." Evaluation, 2-7.

Second, the Evaluation is not intended as a comparative study of the quality of services provided by DHATs versus those provided by dentists. With regard to the clinical technical performance evaluations, the Evaluation makes the following observations:

Several opportunities for bias in these evaluations should be noted. For the evaluations of cavity preparations and oral hygiene instruction, therapists were aware they were being evaluated. For evaluations of restorations performed during the oral health status survey, which represent the large majority of all restorations evaluated, restoration placement could have occurred up to 2 years earlier. Length of exposure can affect many of the criteria employed in restoration evaluations. The numbers of evaluations performed is small in all instances, and some sites are not represented in some evaluations. Finally, all such technical performance evaluations are subjective. Evaluation, 4-18.

Similarly, Kellogg cautions readers not to misinterpret the assessment of patient records. In its records-based assessment, Kellogg utilized MetLife's practice improvement tool, known as the Office Assessment Instrument (OAI), for its "preferred provider program." As Kellogg notes, "there are no published reports on how practices of licensed dentists comply with these measures. There are also no studies evaluating the association of these measures with independent quality of care or patient outcome assessments." Evaluation, 3-6 and 3-7.

The Evaluation also affirms that the availability of dentists is important to the provision of oral health care. As Kellogg notes, "All of the therapists said that supervisory dentists were always available for consultation, regardless of the time or day of week." Evaluation, 4-37. Continuous dentist availability would likely be unsustainable outside the pilot study environment.

Further, the Evaluation highlights the pervasive challenge of utilization that has not been solved by the Alaskan DHAT program:  

The problem of broken appointments is not specific to the DHAT program; it is a system-wide issue and has multiple causes. Often a patient would schedule an appointment with one of the itinerant therapists (or a dentist) because of a toothache. When the itinerant therapist arrived the following week, the patient's tooth no longer hurt, so he did not see the need to keep his appointment. In the villages where the therapist was stationed full time, the therapists reported that this availability appeared to make the patients complacent about keeping their appointments. Evaluation, 4-38.

Underutilization of oral health care services is a serious matter that must be addressed by all of us. The AGD's White Paper on Increasing Access to and Utilization of Oral Health Care Services (AGD White Paper) proposes numerous solutions to address this challenge, not the least of which is dedicated to funding to increase oral health literacy: "Oral health literacy must be the cornerstone of improving utilization of care by underserved populations." AGD White Paper, p. 6.

Numerous dentists volunteer each day to provide care through various programs, and it would not have been a challenge to find a mere five dentists to volunteer in Alaska and provide high-quality care to the same patients. However, utilization is the challenge, and any discussion of level of education or the quality of care that can be provided pales in significance compared to the lack of understanding of oral health in the United States.  

"The bottom line is that special vested interests are using this admittedly premature report to justify their unwarranted advocacy of still unproven concepts," says AGD President Fares M. Elias, DDS, JD, FAGD. "While the AGD applauds the five DHATs for providing some care to an area of atypically dire need, the Evaluation did not find the answers to questions of quality of care or utilization of care." Indeed, it appears that the results of the Evaluation should be taken at face value only, as Kellogg itself cautions against extrapolating the findings to larger populations.

With funding scarce, the AGD reiterates that now is not the time for diversions such as research into the independent practice of practitioners who have less education than dentists. Instead, the AGD believes that state and federal legislatures should be encouraged to direct funding toward oral health literacy and other utilization programs.

The AGD will continue to monitor this issue on behalf of its members to ensure that accurate and up-to-date information is presented to the public.

About the Academy of General Dentistry

The Academy of General Dentistry (AGD) is a professional association of more than 35,000 general dentists dedicated to staying up to date in the profession through continuing education to better serve the public. Founded in 1952, the AGD has grown to become the second-largest dental association in the United States, and it is the only association that exclusively represents the needs and interests of general dentists. More than 772,000 persons in the United States are employed directly in the field of dentistry. A general dentist is the primary care provider for patients of all ages and is responsible for the diagnosis, treatment, management and overall coordination of services related to patients' oral health needs. For more information about the AGD, please visit

SOURCE Academy of General Dentistry