There is currently international debate about

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1 Evaluation of a Pilot Bridging Program to Enable Australian Dental Therapists to Treat Adult Patients Hanny Calache, D.P.H.; Matthew S. Hopcraft, Ph.D. Abstract: This study evaluated a pilot educational bridging program designed to provide dental therapists in Australia with the appropriate knowledge and skills required to enable them to translate their current clinical scope of practice to adult patients. Ten dental therapists completed a bridging program consisting of forty-two hours of didactic content, fourteen hours of clinical observation, forty-two hours of clinical practicum under direct supervision, and 105 hours of clinical experience with supervision by mentoring dentists. Process and impact evaluation was undertaken at various stages of the program by participants and supervising dentists. Self-reported confidence and knowledge for dental therapists had increased at the completion of the course. Supervising dentists reported high levels of knowledge for dental therapists after completing the course and said that the course adequately prepared the dental therapists to translate their current clinical scope of practice to treat adult patients. Eight of the ten participants successfully completed the assessment at the completion of the course and were permitted by the Dental Practice Board of Victoria to extend their clinical scope of practice to adult patients aged twenty-six years of age or more. The dental therapists thought that the educational model was relevant in developing their clinical skills. The evaluation indicates that this model is an effective method of extending the scope of practice for dental therapists and has important implications in enhancing the flexibility of the dental team. Dr. Calache is Director, Clinical Leadership, Education, and Research, Dental Health Services Victoria, and Adjunct Professor, La Trobe University, Victoria, Australia; and Dr. Hopcraft is Associate Professor, Melbourne Dental School, University of Melbourne, Victoria, Australia, and Research Project Support, Dental Health Services Victoria. Direct correspondence and requests for reprints to Dr. Hanny Calache, Dental Health Services, Victoria, 720 Swanston Street, Carlton 3053, Australia; phone; fax; calacheh@dhsv.org.au. Keywords: dental therapist, adult patients, dental care delivery, dental education, mid-level dental providers, Australia Submitted for publication 9/21/10; accepted 2/16/11 There is currently international debate about how to address high levels of unmet dental treatment need in the community and particularly on how to improve access to oral health care services for lower-income and disadvantaged groups. 1-3 Workforce shortages and maldistribution are two of the factors associated with disparities in oral health by creating barriers to access. 3 Models of care utilizing dental therapists to provide care to parts of the community have been proposed to help address these access issues. 1,2 There is a need to redefine the roles of all members of the dental team so that appropriate services are able to be provided to the community. More than two decades ago, Barmes and Tala observed that changing disease patterns were resulting in a polarization in treatment needs between those requiring minimal simple intervention and those requiring high-technology care. 4 They suggested a re-evaluation of dentist to auxiliary ratios, with a need to increase the number of auxiliaries to provide the low- to medium-technology dental services while working in a team environment with dentists providing the high-technology care. This was supported in a recent analysis of the demand for dental services in Australia. 5 Dental therapists were introduced in New Zealand in 1921 to provide basic preventive and restorative dental care for children in the School Dental Service, and more than fifty countries currently make use of dental therapists. 6 Dental therapy training commenced in 1966 in Australia and was run under the auspices of state-based Health Department dental therapy schools, before transitioning to the tertiary education sector in 1996 in Victoria with a Diploma in Oral Health Therapy and later a Bachelor of Oral Health. 7-9 Currently across Australia, all oral health therapy education is provided through the tertiary education sector. In Australia and New Zealand, dental therapists have been responsible for examining, diagnosing, and developing plans for the oral health treatment they provide and referring to dentists those patients with treatment needs beyond their scope of practice. 10 In 2005, the oral health workforce in Australia comprised 10,067 practicing dentists and 1,521 practicing dental therapists, 11,12 with dentists supplying 85 percent of all dental visits Journal of Dental Education Volume 75, Number 9

2 Recent regulatory changes have seen adjustments in the roles of dental therapists internationally. In the United Kingdom, a new regulatory framework permits a range of clinical duties determined by reference to training and competence rather than a defined list of duties. 14 Therapists work from a prescribed treatment plan undertaken by a dentist and can treat children and adults with direct restorations, periodontal and oral hygiene treatment, and extraction of deciduous teeth. In both Canada and two states in the United States (Alaska and Minnesota), dental therapists work predominantly in indigenous communities and with varying supervision arrangements. 6,15 The undergraduate education of dental therapists in Australia supports competent clinical practice, including the ability to undertake the clinical procedures outlined in Table There has been a gradual shift by the Dental Practice Board of Victoria (DPBV) towards a model of care based on education and competence rather than a prescribed list of duties and an increase in the patient age limit from eighteen to twenty-five years, with an intention to allow treatment of adult patients aged twenty-six years or more for therapists with the appropriate education and training. 17 Therapists have been shown to be capable of providing direct restorative dental care to adult patients aged twenty-six years or more on the prescription of a dentist. 18 However, currently in Victoria, no educational program exists that will enable the translation of the dental therapists current scope of practice to adults who are over twenty-six years of age. The aim of this study was therefore to assess the development and implementation of a pilot educational program designed to enable dental therapists with a university qualification to gain the knowledge and skills required to translate their current clinical scope of practice to patients aged twenty-six years or more. Methods Ten dental therapists with university qualifications were self-selected to participate in the pilot educational bridging program. These therapists had an average of 5.7 years of clinical experience as dental therapists, and nine had previous clinical experience treating adult patients aged eighteen to twenty-five years. The pilot educational bridging program was developed based on a review of the literature on educational models shown to be effective in changing clinicians performance or patient outcomes The aim of the educational program was to enable participants to undertake clinical procedures that are within the existing scope of practice for dental therapists on patients twenty-six or more years of age. Participants would also be expected to provide appropriate referral of adult patients when their oral health treatment needs are beyond their scope of clinical practice. The current scope of clinical practice for dental therapists relevant to management of adult patients is shown in Table 1. Treatment needs considered beyond the scope of clinical practice of the dental therapist included restorative treatment of root caries and carious lesions associated with crowns, bridges, and abutment teeth for removable prostheses; complex restorations extending onto root surfaces; complex restorations requiring multiple cusp replacement; restorations on teeth affected by advanced periodontal disease; endodontic therapy (apart from pulp capping and pulpotomies) on permanent teeth; indirect restorations; restorative Table 1. Scope of clinical practice for dental therapists in Australia Oral Diagnosis Prevention Operative Care Orthodontics Oral Surgery Oral examination Intraoral dental radiography Extraoral dental radiography Impression taking (but not for prosthodontic treatment) Application of therapeutic solutions to teeth (excluding insurgery bleaching) Fissure sealants Scaling and prophylaxis Local anesthesia Restoration of coronal tooth structure (excluding indirect restorations) Pulpotomies Orthodontic procedures, under the supervision of a dentist (excluding diagnosis, treatment planning, initial fixation of bands and brackets, design of orthodontic appliances, and activation and adjustment of orthodontic appliances) Extraction of deciduous teeth On the prescription of a dentist September 2011 Journal of Dental Education 1209

3 treatment for patients with implants; and extraction of permanent teeth. The educational program consisted of didactic and interactive workshops, clinical observation sessions, clinical practicum sessions, and clinical experience sessions (Table 2). The didactic and interactive workshops consisted of forty-two hours of content covering oral health examination and treatment planning for adults; management of the older adult patient; communication skills; management of medically compromised patients; periodontology; dental materials; prosthodontics; local anesthesia; emergency management of oral conditions; managing medical emergencies; oral medicine; pharmacology; and case presentations. The clinical observation component consisted of fourteen hours over two days, including observation of public dentists in primary care, general dentistry, and oral medicine providing treatment to adults. Participants were able to observe and discuss various treatments and engage in interactive one-on-one conversation with the dentist to facilitate application of knowledge to practice. The participants then undertook forty-two hours of clinical practicum, providing dental care to adult patients aged twenty-six years and over at the Royal Dental Hospital of Melbourne under the direct supervision of a dentist with extensive experience in clinical teaching. This enabled participants to apply new knowledge and skills to their own clinical practice and also facilitated more interactive one-on-one conversation with the supervising dentist. A log book was completed by both the supervising dentist and the participant to provide performance feedback. Participants then undertook 105 hours of clinical experience, providing dental care to adults over a period of at least fifteen days, working in close collaboration with a dentist at a local community dental clinic. A log book was completed by both the supervising dentist and the participant to provide feedback on the participants performance during the clinical experience. At the completion of the education program, participants undertook a three-hour written examination and a ninety-minute oral examination (one hour to view a case and thirty minutes of examination) including one patient case presentation. The education program was evaluated by course participants and supervising dentists. The aim of the process evaluation was to assess the participants views on the appropriateness of the course. The aim of the impact evaluation was to assess the effect of the program on 1) the confidence level and knowledge of the dental therapists in the dental management of adult patients and 2) the appropriateness of the clinical educational model in developing the skills of dental therapists to provide appropriate care to adult patients within their scope of clinical practice. A pre-program evaluation questionnaire was sent to all participants prior to the commencement of the program to assess their self-perceived knowledge and confidence treating a range of clinical scenarios for patients aged up to seventeen years, eighteen to twenty-five years, and twenty-six years and over. This questionnaire was then repeated at the completion of the program to measure self-perceived changes in knowledge and confidence. The supervising and mentoring dentists completed questionnaires after the clinical practicum and clinical experience sessions to assess the ability of the educational program to adequately prepare the participants to treat adult patients. Evaluation questionnaires used a five-point rating scale to assess participants confidence (extremely confident, confident, somewhat confident, not confident at all, unsure) and knowledge (very high knowledge, high knowledge, good knowledge, poor knowledge, no knowledge at all) and for process evaluation of course components (strongly agree, agree, neutral, disagree, strongly disagree). This study was approved by the Human Research Ethics Committee, Dental Health Services Victoria. Results Prior to the commencement of the educational program, the dental therapists reported high levels of confidence in treating patients aged up to seventeen years across a range of treatment scenarios, with the exception of restorative treatment associated with dentures and crowns and management of oral pathology (Figures 1 and 2). They reported higher levels of confidence in treating patients aged up to seventeen years than for patients aged eighteen to twenty-five years and were least confident with the concept of treating patients aged twenty-six years and over. At the completion of the education program, the therapists reported higher confidence levels treating patient aged eighteen to twenty-five years and twentysix years and over, in many instances at a level similar to that reported for patients aged up to seventeen years prior to commencement of the course. Self-reported knowledge treating adult patients aged eighteen to twenty-five years and twenty-six years and over also increased after the completion 1210 Journal of Dental Education Volume 75, Number 9

4 Table 2. Curriculum content for pilot educational bridging program for dental therapists Hours Topics Self-Directed Learning Didactic Workshops Pre-reading material on topics in the didactic and interactive workshop component of the program was sent to participants four weeks prior to commencement of the course. Didactic and interactive workshop activities were delivered by specialist dentists and academics. Oral examination 3 Medical, dental, and social history; extra- and intraoral clinical examination, including coronal and root caries assessment; periodontal, occlusal, and oral mucosal assessment. Management of older adults 3 Management of attrition, erosion and abrasion, pulpal recession, root caries, xerostomia, oral changes resulting from disease/medication; management approaches for older adults. Communication skills 3 Utilization of appropriate communication skills in specific dental contexts; nature and process of skilled interpersonal communication; recordkeeping including informed consent. Medically compromised patients 3 Management of patients with disabilities, cardiovascular disease, endocrine, neurological, hematological, and oncological disorders, and polymedicated patients. Periodontology 6 Introduction to the periodontium; chronic periodontal disease; periodontal examination including periodontal probing; the importance of periodontium health in treatment planning. Dental materials 3 Materials including linings/bases, amalgam, composite resin, glass ionomer cement. Prosthodontics 3 Identification of appliances used in fixed and removable prosthodontics treatment and the implications of prosthodontics treatment on restorative care and vice versa. Oral medicine 3 Recognition and identification of oral pathological conditions in the clinical situation; drug interactions; management of dental pain; instigation of appropriate referrals; pharmacology. Local anesthesia 6 Techniques for dentate/edentulous patients; appropriate local anesthetics; maximum safe dose; implications of medical history; local/systemic complications and management. Dental emergencies 3 Emergency management of pain associated with acute oral infections (excluding extraction of permanent teeth); instigation of appropriate referrals. Medical emergencies 3 Principles of emergency care and management of life-threatening situations including the unconscious patient, respiratory difficulty, myocardial infarction, and allergic reaction. Case presentations 3 Adult patient case reports for presentation and small-group discussion for treatment planning. Clinical Observation 14 Conducted over two days with observation of public dentists in primary care/ general dentistry and dental specialists (oral medicine) treating adults. Clinical Practicum 42 Provision of dental care to adult patients under dentist supervision to apply knowledge and skills learned in didactic sessions. A logbook completed by the dentist and participant provided feedback. Clinical Experience 105 Provision of dental care to adult patients over 15 days working in close collaboration with a dentist at their local dental clinic. A logbook completed by the dentist and participant provided feedback. September 2011 Journal of Dental Education 1211

5 Figure 1. Dental therapists pre- and post-course confidence in treating patients in various age groups on the first seven treatment scenarios (mean and 95% CI) Figure 2. Dental therapists pre- and post-course confidence in treating patients in various age groups on the second seven treatment scenarios (mean and 95% CI) 1212 Journal of Dental Education Volume 75, Number 9

6 of the education program (Figures 3 and 4). Prior to the commencement of the course, the therapists rated their knowledge in various treatment scenarios as generally much higher for patients aged up to seventeen years compared with patients aged eighteen to twenty-five years. After completion of the course, the participants reported that their knowledge related to treating patients aged eighteen to twenty-five years had increased substantially, and in many cases they reported better knowledge than they had reported pre-course for patients aged up to seventeen years. When the participants were asked to rate the didactic subject area that they felt was the most useful in preparing them to treat adult patients, 22.2 percent reported oral medicine and 22.2 percent management of medically compromised patients. Two-thirds thought that the communication skills lectures were the least useful in preparing them to treat adult patients, followed by local anesthesia (22.2 percent) and case presentation/treatment planning (11.1 percent). The therapists felt that the amount of material covered for each subject area was about right, although 30 percent thought there was too much time spent on local anesthesia and 30 percent thought there was not enough material provided on the management of medically compromised patients. Similarly, most participants thought that the content of the material provided was about right to assist them in treating adult patients, although 30 percent felt the material on local anesthesia was too detailed, whilst 20 percent thought the material on management of medically compromised patients and prosthodontics was not detailed enough. Overall, eight of the ten therapists felt that the clinical observation sessions were the least useful component of the program, whilst four of the ten thought that the clinical experience was the most useful component and four of the ten found the clinical practicum to be the most useful. The therapists rated the clinical practicum and experience sessions as being more beneficial to their ability to treat adult patients aged twenty-six years and over compared with the clinical observation sessions (Figure 5). However, most agreed that clinical observation sessions were useful with regard to assisting with the clinical practicum sessions and that the clinical practicum sessions were useful in undertaking the clinical experience component. The supervising and mentoring dentists evaluated the knowledge of the dental therapists at the conclusion of the clinical practicum and clinical experience sessions (Figure 6). The knowledge of course participants was rated to be at least good for all treatment scenarios except for restorative treatment associated with fixed and removable prostheses and occlusion; also, knowledge was rated higher at the completion of the clinical experience sessions than at the completion of the clinical practicum sessions. The mentoring dentists evaluated how the education program prepared dental therapists to manage a range of clinical scenarios for patients aged twenty-six years and over, based on their interactions, observations, and supervision of dental therapists during this pilot project. They were concerned that therapists were only adequately prepared for pulp treatment, restorations associated with crowns and dentures, assessment of occlusion, and identification and management of soft tissue pathology. However, they felt that the therapists were well prepared to very well prepared to undertake the majority of clinical scenarios. The process evaluation completed by the course participants and supervising dentists identified some gaps in content of the education program. These included cariology and minimal intervention dentistry, understanding the provision and implications of fixed and removable prosthodontics and implant treatment, emergency management of oral conditions, and oral medicine/pathology. At the completion of the clinical component of the education program, evaluation of the log books determined that eight of the participants were clinically competent to provide oral health care to adult patients without the supervision of a dentist. All except one successfully passed the assessment component of the program. The DPBV granted permission to extend the scope of practice for eight participants to treat adult patients aged twenty-six years and over without supervision or prescription from a dentist, with the remaining two participants requiring a further period of clinical experience and assessment in order to extend their scope of practice. All ten course participants were also required to undertake an additional twenty-four hours of continuing professional development in areas where gaps in content of the pilot program were identified. Discussion This study reports on a pilot educational program designed to translate the existing clinical scope of practice for university-educated dental therapists in Victoria, Australia, to adult patients. Dental therapists September 2011 Journal of Dental Education 1213

7 Figure 3. Dental therapists pre- and post-course knowledge in treating patients in various age groups on the first seven treatment scenarios (mean and 95% CI) Figure 4. Dental therapists pre- and post-course knowledge in treating patients in various age groups on the second seven treatment scenarios (mean and 95% CI) 1214 Journal of Dental Education Volume 75, Number 9

8 Figure 5. Evaluation of clinical observation, practicum, and experience sessions by the dental therapists (mean and 95% CI) Figure 6. Evaluation of clinical practicum and clinical experience by the supervising and mentoring dentists (mean and 95% CI) September 2011 Journal of Dental Education 1215

9 are currently able to perform dental examinations and preventive and simple restorative treatment for children without the supervision of a dentist. Translation of these clinical skills to adult patients potentially provides a mechanism for improving access to dental care in underserved sections of the community. It is important to note that this study reports on a pilot educational program that was targeted towards dental therapists with a university qualification. The study had a number of limitations, including the small sample of dental therapists in the pilot project and the fact that participants were self-selected into the study. As a result, these results may not be representative for all dental therapists. Notwithstanding these limitations, the evaluation of this pilot educational bridging program indicates that the program was able to meet its objectives and was able to successfully prepare university-educated dental therapists to treat adult patients aged twenty-six years and over within their existing scope of clinical practice. Both the participating dental therapists and the supervising dentists provided strong evidence that the structure and content of the course allowed the dental therapists to enhance their knowledge, confidence, and clinical skills derived from treating children and to successfully use this in the management of adult patients. The mentoring dentists unanimously agreed that this pilot educational program met the educational needs of the dental therapists. Confidence has been recognized as an important educational outcome, and increased confidence has been linked to increased clinical competence, with a number of studies demonstrating the ability of various programs to improve self-reported confidence of predoctoral dental students in providing clinical care. 26,27 This pilot educational bridging program was effective in increasing the confidence of the participants to treat adult patients to similar levels reported for treating children. Moreover, self-reported confidence and clinical competence are reflected in the high levels of patient satisfaction reported during the clinical practicum and clinical experience sessions in this study. 28 Improved clinical knowledge was reflected in the performance of the participants in the various evaluations and assessments undertaken by dentists experienced in undergraduate education. Nine of the participants successfully completed the assessment component of the course, and eight were deemed to be clinically competent to treat adult patients without supervision and were provided with an extended scope of practice by the DPBV. Although the participants had on average 100 patient clinical sessions over the length of the course, several felt that the course could have been longer in duration, particularly with more clinical experience to consolidate the new knowledge and skills. There was some concern that the intensive nature of the course was not the most productive method and that perhaps the course could also be spread over a longer time frame. Based on the evaluation of this project, future bridging programs should be expanded to include additional content to address some gaps identified by the course participants and supervising dentists. This includes additional clinical observation and didactic content covering cariology and minimal intervention dentistry, prosthodontics, emergency management of oral conditions, and oral medicine/pathology. These recommendations for additional course content were supported by the Dental Practice Board of Victoria in their endorsement of the extended scope of practice for the therapists who completed this pilot education program. Consideration should also be given to undergraduate programs for dental therapists to include aspects of this educational bridging program to enable newly graduating dental therapists to apply their existing scope of clinical practice for patients of all ages. Conclusions The model of this pilot educational bridging program specifically designed to extend the scope of practice for dental therapists has been shown to be effective. Analysis of curriculum content and evaluation by participants and supervising dentists indicated that the program was successful in achieving its aim of providing university-educated dental therapists with the knowledge and skills necessary to translate their current clinical scope of practice to patients aged twenty-six years and over. This study has important implications for enhancing the flexibility of the dental team. Acknowledgments The authors would like to acknowledge the assistance of Julie Butcher in the administration of the dental therapist educational bridging program, as well as the participation of the dental therapists, lecturers, supervising and mentoring dentists, examiners, administrative and support staff from the community health agencies, and members of the 1216 Journal of Dental Education Volume 75, Number 9

10 Reference Group involved in this project. This project was funded by Dental Health Services Victoria and the Victorian Department of Health. REFERENCES 1. Russell B. A new day coming? A productive discussion on dental workforce change. J Am Assoc Public Health Dent 2008;68(3): Nash DA. Adding dental therapists to the health care team to improve access to oral health care for children. Acad Pediatr 2009;9: Hilton IV, Lester AM. Oral health disparities and the workforce: a framework to guide innovation. J Public Health Dent 2010;70:S15 S Barmes DE, Tala H. Health manpower out of balance: conflicts and prospects for oral health. In: Bankowski Z, Mejia A, eds. Health manpower out of balance: conflicts and prospects. Geneva: CIOMS, 1987: Spencer AJ, Teusner DN, Carter KD, Brennan DS. The dental labour force in Australia: the position and policy directions. Population Oral Health Series No. 2. Canberra: Australian Institute of Health and Welfare, Nash DA, Friedman JW, Kardos TB, Kardos RL, Schwarz E, Satur J, et al. Dental therapists: a global perspective. Int Dent J 2008;58: Dunning JM. Deployment and control of dental auxiliaries in New Zealand and Australia. J Am Dent Assoc 1972;85: Gussy M. Background to the accreditation or training and education of allied oral health professionals. Paper prepared for the Australian Dental Council, April 2001, University of Melbourne. 9. Satur J. Australian dental policy reform and the use of dental therapists and hygienists. Ph.D. thesis, Deakin University, Satur J, Gussy M, Marino R, Martini T. Patterns of dental therapists scope of practice and employment in Victoria, Australia. J Dent Educ 2009;73(3): Australian Institute of Health and Welfare. Dentist labour force projections, Research Report No. 43. Canberra: Australian Institute of Health and Welfare, Australian Institute of Health and Welfare. Dental therapist labour force in Australia, Research Report No. 35. Canberra: Australian Institute of Health and Welfare, Teusner DN, Spencer AJ. Projections of the Australian dental labour force. Population Oral Health Series No. 1. Canberra: Australian Institute of Health and Welfare, Sun N, Burnside G, Harris R. Patient satisfaction with care by dental therapists. Br Dent J 2010;208:E Bolin K. Assessment of treatment provided by dental health aide therapists in Alaska. J Am Dent Assoc 2008;139: Dental Practice Board of Victoria. Practice of dentistry by dental hygienists and dental therapists. Code of Practice No: C Dental Practice Board of Victoria. Practice of dentistry by dental hygienists and dental therapists. Code of Practice No: C002 [2008]. Issued January Calache H, Shaw J, Groves V, Marino R, Morgan M, Gussy M, et al. The capacity of dental therapists to provide direct restorative care to adults. Aust N Z J Public Health 2009;33: Davis DA, O Brien MAT, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282: O Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2001, Issue Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274: Acquilla S, O Brien M, Kernohan E. Not too much, not too little, but just enough? Observations on continuing professional development in public health in north England. Public Health 1998;112: Groll R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients care. Lancet 2003;362(9391): Armson H, Kinzie S, Hawes D, Roder S, Wakefield J, Elmslie T. Translating learning into practice: lessons from the practice-based small group learning program. Can Fam Physician 2007;53: Behar-Horenstein LS, Schneider-Mitchell G, Graff R. Faculty perceptions of a professional development seminar. J Dent Educ 2008;72(4): Lynch CD, Ash PJ, Chadwick BL, Hannigan A. Effect of community-based clinical teaching programs on student confidence: a view from the United Kingdom. J Dent Educ 2010;74(5): Smith M, Lennon MA, Brook AH, Robinson PG. A randomized controlled trial of outreach placement s effect on dental students clinical confidence. J Dent Educ 2006;70(5): Calache H, Hopcraft MS. Provision of oral health care to adult patients by dental therapists without the prescription of a dentist. J Public Health Dent (forthcoming). September 2011 Journal of Dental Education 1217