February, 2017 - SUPPORT Summary of a systematic review | print this article |

Do midlevel dental providers improve oral health?

Access to dental care and dentists is difficult around the world, particularly in low- income countries. Consequently, many nations have employed alternative non dentist midlevel providers to conduct diagnostic, treatment planning, or irreversible surgical dental procedures.

Key messages

 

  • It is uncertain whether midlevel providers decrease the incidence, prevalence, or severity of dental caries, or increase treatment of caries.
  • None of the included studies was conducted in a low-income country.

 

 

 

Background

Dental caries are the most common chronic disease in children and adults. In low income countries they disproportionately affect those of lower socioeconomic status. It is precisely in these countries where access to dental care and dentists is more limited. As training of dentists is long and expensive, alternative oral healthcare providers have been developed. They perform some of the reversible and irreversible procedures traditionally performed by dentists. Both the names (dental assistant, dental auxiliary, dental nurse, dental hygienist, dental technician, dental therapist) and the range of duties they perform vary widely from country to country. They are often referred to as professions complementary to dentistry or midlevel providers.



About the systematic review underlying this summary

Review objectives: To determine the effect of a model of provision of dental care that utilizes midlevel providers compared to no care or care by dentists.
Type of What the review authors searched for What the review authors found
Study designs & interventions Experimental, observational and descriptive studies evaluating the provision of irreversible and surgical procedures by midlevel providers 18 retrospective or cross-sectional studies
Participants People of any age School children (15), Indian communities (2), military servicemen (1)
Settings Urban or rural The studies were conducted in Aus-tralia (6), Canada (3), Hong Kong (3), New Zealand (5) and the United States (3).
Outcomes Dental disease incidence, prevalence, or severity; un-treated disease; and cost-effectiveness

Caries, diagnostic procedures, treat-ment

planning, irreversible or surgical pro-cedures

 

Date of most recent search: February 2012
Limitations: This is a well-conducted systematic review with only minor limitations.

Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. J Am Dent Assoc 2013; 144:75-91. 

To compare DOT with self-administration of treatment or different DOT options for people requiring treatment for clinically active tuberculosis or prevention of active disease.

Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. J Am Dent Assoc 2013; 144:75-91.

Summary of findings

Eighteen studies were included, involving 6042 participants, receiving irreversible dental treatment from teams that included midlevel providers.

 

Seven studies reporting caries outcomes showed a consistent trend of reduction in caries severity across time. Twelve studies that compared populations treated by dental therapists with private dental care or no care had inconsistent results.

 

Five studies reporting on untreated caries found a consistent trend of reduction in caries severity over time. Thirteen studies comparing populations treated by dental therapists with private dental care or no care found inconsistent results.

  • It is uncertain whether midlevel providers decrease the inci-dence, prevalence, or severity of dental caries, or untreated caries. The certainty of this evidence is very low.

Dental care by midlevel providers

People:  Children from 9 to 16 years that received irreversible dental treatment
Settings
:  Mostly schools in urban or rural areas
Intervention
: Dental care by midlevel providers (dental therapists or school dental service known to employ dental therapists)
Comparison
: Private dental care by dentists or not having received care recently
Outcomes Impact Certainty of the evidence
(GRADE)
Comments
Caries severity scores across time
Reductions from 6% to 79%

Very low

 Based on data from 7 uncontrolled before-after studies
Caries increment and severity scores 
Reductions of 27% to increments of 38% compared to dentists and reductions from 0% to 21% compared to no dental care

Very low

 Based on data from 9 observational studies with private care by dentists as the comparison and 3 studies with no dental care as the comparison
Mean levels of untreated caries across time Reductions from 17% to 79%

Very low

Based on data from 5 uncontrolled before-after studies
Mean levels of untreated caries From reductions of 78% to increments of 70% compared to dentists and reductions from 1% to 83% compared to no dental care

Very low

Based on data from 10 observational studies with private care by dentists as the comparison and 3 studies with no dental care as the comparison
GRADE: GRADE Working Group grades of evidence (see above and last page)

 


 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
Most studies evaluated school children from urban or rural areas in high-income countries.
The provision of oral healthcare requires a complicated infrastructure, including appropriate supervision, dental offices, and a financing system. Therefore, the findings may not be directly applicable to low-income countries.
EQUITY
Few studies included disadvantaged populations and populations without dental care. The benefits of dental care by midlevel providers are potentially larger and more consistent for underserved populations, and therefore could reduce inequities.
ECONOMIC CONSIDERATIONS
The systematic review did not address economic considerations.
Scaling up midlevel providers requires re-sources, but probably less resources than scaling up dental care by dentists.
MONITORING & EVALUATION
Good quality data from experimental studies is lacking.

New workforce models incorporating midlevel providers should be launched with robust evaluation plans. Ideally cluster randomised trials or quasi-experimental studies should be used to determine the effectiveness and cost-effectiveness of these interventions. In addition to health outcomes, intermediate outcomes (such as wait times, travel distance, and retention of personnel who are trained and employed) should be measured. 


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Rodriguez TE, Galka AL, Lacy ES, et al. Can midlevel dental providers be a benefit to the American public? J Health Care Poor Underserved 2013; 24:892-906.

 

Phillips E, Shaefer HL. Dental therapists: evidence of technical competence. J Dent Res 2013; 92(7 Suppl):11S-5S.

 

Nash DA, Friedman JW, Mathu-Muju KR, et al. A Review of the global literature on dental therapists: In the context of the movement to add dental therapists to the oral health workforce in the United States. Oral Health Science Faculty Publications. 7. 2014. http://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1009&context=ohs_facpub

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Ar-gentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Timothy Wright and Tom Dyer.

 

This review should be cited as

Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. J Am Dent Assoc 2013; 144:75-91.

 

The summary should be cited as

Ciapponi A. Do midlevel dental providers improve oral health? A SUPPORT Sum-mary of a systematic review. February 2017. www.supportsummaries.org

 

Keywords

 

All Summaries:

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, clinical competence, delivery, dental auxiliaries, oral health

 

 



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