Nursing and Dental Hygiene intersect in their efforts to improve the oral health of individuals who are vulnerable and dependent in residential care and group home settings–this shared scope of practice was the heart of discussion between an Licensed Practical Nursing instructor and myself (Dental Hygiene instructor) as part of this blog assignment.
An oral health survey of elders in long term care facilities in Nova Scotia (Matthews, Clovis, Brillant, Filiaggi, McNally, Kotzer, Lawrence (2012) found that only 25% reported having regular dental care, 51% had untreated cavities on the crowns of teeth, and 44% had untreated cavities on the roots of the teeth. Tooth decay is an immense burden in these settings and contributes to pain, loss of function, septicemia and even death. But other populations face poor oral health and unmet needs due to limited access to dental care.
In BC, in my experience working in residential care, group homes, and with the homebound, there are few Dentists who work in mobile outreach to under-served settings, and the reality is that Nurses and Dental Hygienists who work in these settings struggle to find access to care by a dentist.
But for a long time now, Dental Therapists have been practicing in under-served areas within Canada and over 50 countries for decades, a mid-level provider trained to drill and fill teeth, do minor extractions, and open and drain infected teeth to relieve pain, and do minor surgery (extractions) in field conditions without a typical dental clinic. Canada used to have a federally funded school at the First Nations University of Canada in Prince Albert, Saskatchewan that trained Dental Therapists specifically to work in rural and remote indigenous communities within federal jurisdiction. But this school was de-funded in 2011. The number of practicing Dental Therapists with mobile outreach abilities is dwindling with retirements on the horizon and employment vacancies rising in indigenous communities (personal communication, Yawikchuk, C, Manager Oral Health, First Nations Health Authority). There is no potential to draw this uniquely skilled dental professional to under-served residential care and group home settings. There is not enough Dental Therapists to meet the demand. And many political and regulatory barriers exist. And so unmet needs are poised to rise in indigenous communities, and the vulnerable and dependent in residential care and group home settings have no looming solutions to what is truly an oral health crisis there as well.
The Canadian Dental Hygienists Association (2017) has developed an evidence-based position statement titled Filling the Gap in Oral Health: DH-DT Dual Provider that highlights the need for a dually trained and licenced Dental Hygienist – Dental Therapist (DH-DT) to provide access to dental care. There are over 33,000 Dental Hygienists in Canada–providing an extra year of curriculum in existing schools so that Dental Hygienists could attain the skills of a Dental Therapists could provide a skilled dually trained workforce with the ability for more comprehensive dental care in residential care and group home settings, or anywhere needed.
A dually trained Dental Hygienist-Dental Therapist provider could complement the efforts of the Nursing team in residential care and group homes to provide timely access to oral assessments (identify at an early stage: periodontal disease, tooth decay, lesions suspicious of oral cancer, thrush, trauma), plan oral care interventions (cleanings, fillings, fluoride, denture adjustments, management of sores and infections), ensure the mouth is kept clean and comfortable every day (brushing, pain and dry mouth management with prescriptions) and make referrals to dentist when needed. To meet this goal, the Fraser Health region refreshed its Oral Health Adult Integrated Standards for Residential Care Facilities and Group Homes (2017). Vancouver Coastal Health has stepped up and recently launched its Policy Guideline, Mouth Care, Residential Care (2017). These documents detail the protocols and products to support maintenance of oral health in these settings. But we desperately need a dually skilled DH-DT provider to support Nursing teams.
A dually trained DH-DT provider is a powerful and cost effective solution with a proven track record in safety and quality in the United States and other countries that have adopted this curriculum model due to sharing of many competencies in Dental Hygiene and Dental Therapy schools (Edelstein, 2011). A dual model is deemed to be cost effective for accreditation (accreditation of one DH-DT schools, instead of two separate schools) academic institutions (training one provider, instead of two separate providers), board examination (examing one DH-DT provider, instead of two separate providers), dental regulation (regulation of one DH-DT provider, instead of two separate providers), and public health agencies (transporting and housing one DH-DT provider in an underserved area, instead of two separate providers). Yet, many of these organizations need to adapt their policies and administrative structures to remove barriers–this requires a broad commitment and systems approach to change (Caswell, 2011; Gelman & Tressider, 2011; Yoder & De Paola, 2011).
So, if you have a loved one in a residential care facility, group home, or is homebound, living in a shelter, or in an underserved indigenous community who lacks access to care–please raise your voice and demand a Dental Hygienist-Dental Therapist for equitable access to dental care. There is lots of work to do and the agenda is on the table finally. Innovation in Canada will tip the balance to oral health! It’s coming.
Canadian Dental Hygienists Association. (2017). Position Statement: Filling the Gap in Oral Health: DH-DT Dual Provider. Ottawa Ontario. Retrieved on Oct 6, 2018 from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=2ahUKEwiKjqn63PTdAhVT7lQKHQGzDuQQFjAAegQIBBAC&url=http%3A%2F%2Fwww.cdha.ca%2Ffillingthegap&usg=AOvVaw3MKiw8Wg5zcFcdWYSrB5HJ
Caswell, E. (2011). The principles, competencies, and curriculum for educating
dental therapists: a report of the American Association of
Public Health Dentistry Panel. Journal of Public Health Dentistry, 71, S9-19.
Edelstein, J. B. (2011). Training new dental health providers in the United States. Journal of Public Health Dentistry, 71, S3–S8.
Fraser Health (2017). Oral Health Adult Integrated Standards for Residential Care Facilities and Group Homes. British Columbia.
Gelman S. B., Tressider A.F. (2011) Accreditation of emerging oral health professions:
options for dental therapy education programs. Journal of Public Health Dentistry, 71, S20-26.
Matthews D.C., Clovis J.B., Brillant M., Filiaggi M.J., McNally M.E., Kotzer R.D., Lawrence H.P. (2012). J Can Dent Assoc, 78, c3.
Vancouver Coastal Health and Providence Health Care (2017). Policy Guideline, Mouth Care, Residential Care. Vancouver, British Columbia.
Yoder K., De Paola, D.. (2011). Navigating career pathways – dental therapists in
the workforce: a report of the career path subcommittee. Journal of Public Health Dentistry, 71, S37-41.