Demand for oral health care is forecasted to increase dramatically over the next decade, and there are great concerns that the current model of service delivery will not address the need adequately. Disparities in service delivery leave an increasing segment of the population with limited or no access to dental care.¹ The social and financial effect of these shortages has far-reaching consequences and calls for a restructuring of oral health care delivery.

Three types of allied oral health care professionals are being considered and are supported by different organizations and stakeholders—the Community Dental Health Coordinator (the American Dental Association); Advanced Dental Hygiene Practitioner (the American Dental Hygienists’ Association) and Dental Health Aide Therapist (the Community Health Aide Program).² The proposed scope of practice of these new oral health care professionals may provide increased access to and use of oral health services, but also will change the role of the dentist in the direct delivery of oral health care drastically. Although the effect will be felt mostly among working dentists, the potential effect of these evolving disciplines on dental education also must be addressed.

These discussions are reminiscent of a similar evolution of the medical profession that began in the 1970s as nurses, physician assistants and nurse practitioners struggled to define their identities and roles in health care.

The emergence of a midlevel medical professional was fraught with political and personal agendas that continue to cloud the functions of these valuable providers to this day. Disagreements with regard to specific scope of practice, accreditation, educational preparation and need for supervision still govern both public and professional appreciation of the contribution made by these providers. Although not feasible at that time, many of the obstacles could have been avoided by creating a planned strategy of role delineation. The dental profession finds itself on the threshold of an opportunity to create a model of dental service that provides high-quality care and a chance for these news dental practitioners to evolve in terms of their experiences, responsibilities, tasks and rewards.

Academic dental institutions have the opportunity to structure a system of oral health care education that is unparalleled. Such a system could provide a pathway for people who desire to progress through stages of increasing competency as oral health care practitioners. Such "career ladders" may be particularly attractive to potential students who are increasingly challenged by family responsibilities, financial concerns and a host of other issues that often prevent the quest for a professional education. But there is only a narrow window of opportunity for action in this regard.

By immediately assuming a leadership role, the academic dental institution can establish a consistent and coordinated set of professional outcomes and degree levels that will avoid the confusion that has echoed through the nursing, physician assistant and nurse practitioner professions for decades. These competencies will form the structure for uniform scope of practice legislation that ultimately will lead to a structured system of care that gives patients access to affordable, high-quality, comprehensive oral health care.

A principal concern in the structure of an integrated approach to the dental workforce is the role and education of the dentist. Physicians are only now recognizing the significant changes in their role as economic realities demand that physician assistants and nurse practitioners assume greater responsibility for primary medical care. Physicians have had to learn leadership, management and teamwork skills that never had been part of their formal education or training. As the oral health care workforce evolves, it is imperative that academic dental institutions learn from the past and educate future dentists as effective managers and leaders of oral health care teams.

Academic dental institutions must assume a leadership role in this evolutionary process. These institutions need to serve as catalysts for open discussion and ensure representation and equal voice for each member of the dental workforce. Informed dialog is the heart and soul of academia. Open discussion needs to move quickly to planning. Coordination of issues such as defining accreditation standards that complement and build dental knowledge and skills throughout a career represents a difficult but far from impossible challenge. State practice acts also must be refined to reflect evolving scopes of practice in a stratified oral health service delivery model. Left unplanned, the state scope of practice laws and license definitions will continue to complicate and confuse oral health service roles in much the same manner they did for the physician assistant and nurse practitioner in the 1980s.

It is the responsibility of our professional organizations to define the new role of dentists and not let it be dictated by other stakeholders. A proactive effort is needed before we are told what to do.

The past serves as a road map on which the future of oral health care service delivery can be planned. The academic dental institutions are in the driver’s seat with the chance to guide the development of a coordinated system of education and practice. The trip will take time and require the energy of leadership, but arrival at the destination will reward practitioners and patients alike.

It also is the responsibility of our professional organizations to define the new role of dentists and not let it be dictated by other stakeholders. A proactive effort is needed before we are told what to do. We must create opportunities for practicing dentists to learn how to incorporate and coordinate oral health care services for their patients together with other allied health professionals who will be given the opportunity to carry out many of the procedures that today can be performed only by dentists. We should not feel threatened by these emerging groups of oral health care providers but invite them into our midst to maximize access to and use of much-needed oral health care.