Michelle Healy, USA TODAY
At Maplewood Community Dental Care outside of Minneapolis, dental therapist Megan Meyer regularly fills cavities, extracts primary teeth and puts in crowns and spacers. In most dental practices around the USA, such procedures are the sole responsibility of a dentist. But that's not the case at this community clinic and at a handful of others in Minnesota, where a new type of dental-care practitioner handles these and other basic preventive and restorative services under the supervision of a dentist on-site.
With a growing number of people on medical assistance or without insurance needing dental care and an insufficient number of dentists, "The need for dental therapists is huge," says Meyer, among the first nine graduates of the University of Minnesota School of Dentistry's Dental Therapy program in 2011. The school's second graduating class of nine students received their degrees earlier this month.
Although Minnesota is currently the only state to license dental therapists, a number of others, including California, Kansas, Maine and New Hampshire, are considering such midlevel providers as one possible way to get more care to people in need. Dental therapists get a 2½-year degree (compared with four years for dentists) and earn roughly half what a dentist does.
Meyer, 28, likens the role to a nurse practitioner or physician assistant. "It's adding a new, valuable member to the dental-care team," she says. "Dentists can't see everyone who needs to be seen. I am able to free them up from some procedures, allowing them to concentrate on more higher-level, complex services."
The nation's unmet dental health needs have been the focus of numerous recent reports, all noting that untreated oral diseases can contribute to increased risk for serious medical conditions, including diabetes and heart disease.
A Senate subcommittee report earlier this year noted that 130 million Americans have no dental insurance; 47 million live in areas where it's difficult to access dental care; and 17 million low-income children go without dental care each year. It also noted that 830,000 emergency room visits in 2009 were due to preventable dental problems, up 16% from 2006, and that more dentists retire each year than there are dental school graduates to replace them. While 5 million more children will have dental coverage in 2014 because of the Affordable Care Act, coverage alone does not guarantee access to dental care.
"Many Americans assume that if you have insurance from Medicaid, it means you can get dental care, but that's not true," says Shelly Gehshan, director of the Pew Center on the States Children's Dental Campaign. "Most dentists don't participate, and that means a lot of low-income children and adults struggle to find care."
Although rare in the U.S., midlevel dental providers are not new. An April report by the non-profit W.K. Kellogg Foundation looked at dental therapists in 54 countries, from New Zealand to Canada to the United Kingdom, and concluded that they have been "providing quality preventative and restorative services to patients for nearly 100 years."
Since 2005, a program operated by the Alaska Native Tribal Health Consortium has used dental therapists to treat patients living in remote tribal areas of the state.
The 157,000-member American Dental Association opposes the use of dental therapists, because it conflicts with the group's policy that excludes team members "who work under the guidance or supervision of dentists" from "performing surgical or irreversible procedures," says President Robert Faiella.
In addition, "There's no evidence that using a new workforce model to treat decay will have any impact on the larger (oral health care) problem," he says. The ADA instead favors insurance reforms, community water fluoridation, oral health education and helping people overcome cultural, geographic and language barriers that keep them from getting regular dental care, he says.
"We absolutely do not agree that there's a lack of providers," he adds.? "The evidence and data that we have certainly shows that there is an adequate workforce in place. The distribution of those providers is something we're continually trying to work on."
Minnesota's decision to license dental therapists, approved in 2009, is based on the idea that "by educating a provider in a shorter amount of time, at less cost to the health care system, you could have an individual who can provide a basic set of preventative and restorative services to underserved populations, at a lower cost to the system," says Karl Self, a clinical associate professor and director of the University of Minnesota School of Dentistry Dental Therapy Program.
The state requires that the practitioners graduate from an approved bachelor's or master's degree program that takes about 2½ years to complete. Their employment is also restricted to dental practices where 50% or more of the patients are on medical assistance or are low income.
At Community Dental Care, Meyer works under a "collaborative management agreement" with three licensed dentists who agree to provide assistance when needed. A dentist must diagnose patients and formulate a treatment plan before delegating a prescribed set of procedures that she carries out.
In addition to the dental therapy program at the University of Minnesota, Metropolitan State University in St. Paul offers a master's degree program designed for students who are already licensed dental hygienists. After acquiring 2,000 hours of clinical experience as a dental therapist (DT), graduates from this program can be certified as an advanced dental therapist (ADT), approved to perform additional basic procedures, such as extractions of adult teeth, when authorized by a supervising dentist who does not have to be on the premises, says Ann Leja, interim dean, Nursing and Health Sciences at Metropolitan State.
This will allow the ADT to provide services in more varied locations, such as nursing homes, homeless shelters, schools and emergency rooms at a fraction of the cost of a dentist, says Sarah Wovcha, executive director of Children's Dental Services in Minneapolis. The private, non-profit program sees nearly 30,000 low-income children and pregnant women annually in clinics and other settings throughout the state. It currently employs two dental therapists and plans to hire others, says Wovcha.
"What we're seeing on the ground is that not only is this an effective dental workforce provider, but it's also well accepted by patients and by dentists when they have actual exposure to it," Wovcha adds.
Emily Eggebrecht, a dentist with Children's Dental, says she was initially "a little skeptical" of the dental therapists concept, but no longer. The team approach that's required "has been wonderful" and "it really increases the amount of patients that we can see and therefore access for patients who otherwise would not be seen," she says.
Strategies to improve dental care
-- Expanding the dental care workforce
-- Ensuring that Medicaid and the Children's Health Insurance Program work better for kids and for providers so that insurance coverage translates into real care
-- Expanding access to fluoridated water
-- Increasing sealant programs for kids who need them most
Source: Pew Children's Dental Campaign