摘要：Dental therapists—midlevel dental providers who are roughly analogous to nurse practitioners in medicine—might constitute a disruptive innovation within US dentistry. Proponents tend to claim that dental therapists will provide more equitable access to dental care; opponents tend to view them from a perspective that focuses on retaining the current attributes of the dental profession. Therapists display traits similar to those of disruptive innovations: their attributes are different from dentists’, they may not initially be valued by current dental patients, they may appeal to current dental underutilizers, and they may transform the dental delivery system. Whether dental therapists constitute a disruptive innovation will only be determined retrospectively. According to Christensen et al., In any industry … while the dominant players are focused on improving their products and services … they miss simpler, more convenient, and less costly offerings initially designed to appeal to the low end of the market 1(p104) Christensen et al. called such offerings “disruptive innovations.” 1 Dentistry in the United States may be facing a disruptive innovation in the form of dental therapists, midlevel dental providers who are roughly analogous to nurse practitioners in medicine. Dental therapists deliver services that in the United States are traditionally provided only by dentists, such as fillings and extractions. I examine whether dental therapy might constitute a disruptive innovation within US dentistry. I then report and analyze the antithetical position statements of organizations supporting dental therapy (primarily public health and advocacy groups) and opposing it (primarily associations of dentists) in light of this model. Bower and Christensen said that disruptive innovations have 2 essential characteristics: (1) they “present a different package of performance attributes—ones that, at least at the onset, are not valued by existing customers,” and (2) they develop “the performance attributes that existing customers do value” until they “invade established markets.” 2 The authors warned that by time the innovation is established, “it is often too late” for the preexisting providers to retain market control, and the “pioneers of the new technology dominate the market.” 2 This formulation, borrowed from the business literature and applied to health care, 1 captures proponents’ aspirations to equity as well as opponents’ protective concerns that opening the door to innovation will lead to a slippery slope of eroding market share or professional authority. For proponents of dental therapy, development and deployment of therapists in the United States constitutes an appropriate, albeit potentially disruptive, innovation. Such deployment, they assert, could increase dentists’ efficiency and effectiveness while allowing safe, high-quality essential dental services to be provided to the “low end of the market”—those whose social and financial circumstances limit their access to dental care. For opponents, the development and deployment of therapists in the United States constitutes an inappropriate and definitely disruptive innovation that threatens the very definition of the term “dentist.” Opponents also believe that the advent of dental therapy augurs poorly for dentists’ preeminence because once a therapist is established, he or she may seek ever-greater authority and autonomy. Dental therapists differ from other existing and proposed midlevel dental providers in their potential to be disruptive. Nondentist oral health care providers include dental hygienists, dental assistants, expanded-function dental hygienists or assistants, advanced dental hygiene practitioners, pediatric oral health educators, and community dental health coordinators. 3 – 5 Unlike most of these others, the therapist's duties include functions that, in the United States, until recently have been reserved for dentists alone. In sharp distinction to the United States, dental therapy has been established in many other countries for many decades. 6 , 7 Its gradual introduction in the United States occurred in 2003 through the dental health aide therapist program administered by the Alaska Native Tribal Health Consortium, 8 and in 2009 through authorizing action by the Minnesota state legislature. 9 Considering the potential for innovation to better serve the public's health, Christensen et al. suggested 4 approaches for system transformation: (1) “Create—then embrace—a system where the clinician's skill level is matched to the difficulty of the medical problem,” (2) “invest less money in high-end complex technologies and more in technologies that simplify complex problems,” (3) “create new organizations to do the disrupting,” and (4) “overcome the inertia of regulation.” 1
