The evidence from both the United States and around the world suggests dental therapists provide high quality care to patients who typically have trouble accessing dental care, and lower the unit cost of care.1 Studies of private dental offices, nonprofit clinics, and federally qualified health centers show that dental therapists increase access and are cost-effective providers.2
In Minnesota, half of the dental therapy workforce is employed outside of the Twin Cities area, which includes rural and remote areas of the state.3 A 2014 report on the early impacts of dental therapy in Minnesota showed that, on average, 84% of new patients seen by the dental therapists were enrolled in public programs.4 Patients in practices served by dental therapists also experienced reductions in travel and wait times since the dental therapist was employed, especially in rural areas.5 The clinics that employed dental therapists reported that hiring dental therapists increased dental team productivity and improved patient satisfaction.6 Furthermore, the personnel cost savings allowed the clinics to expand capacity and care for more underserved patients.7 The report showed that seven full-time equivalent dental therapists served 6,338 new patients in the first two years dental therapists practiced.8
Alaska Native children are seeing significant oral health improvements since the start of their dental therapy program.9 The Yukon Kuskokwim Health Corporation (YKHC), a part of the Alaska Tribal Health System, serves 25,000 Alaska Natives representing 58 federally recognized tribes. An analysis from 2006 to 2015 showed that high exposure to dental therapists was associated with lower rates of tooth extractions and more preventive care for children and adults.10
There is also evidence that dental therapists are cost-efficient providers. Main Street Dental Care, a private practice in Minnesota, made an additional $24,000 in profit and served 200 more Medicaid patients in the therapist’s first year (despite, at the time, Minnesota having the lowest pediatric dental reimbursement rate in the country).11 Similarly, private, for-profit dental clinics located in designated dental health professional shortage areas in Minnesota significantly increased cost efficiency with the addition of dental therapists.12 The net benefit for Grand Marais Family Dentistry was 13% of its average monthly revenue, and for Midwest Dental it was 2.4 times the average monthly revenue.13 People’s Center Health Services, a federally qualified health center (FQHC) in Minnesota, found that after the first year (2012) the dental therapist generated more than $30,000 in net revenue.14 Apple Tree Dental Clinic, a non-profit organization in Minnesota, sends a dental team, including a dental therapist, to provide on-site care at a nursing home for veterans. The dental therapist provided 8-10 dental visits each day for an average daily production up to $3,122.15 The average employment costs per day for the dental therapist were $222 less than for a dentist, totaling savings of $52,000/year for Apple Tree.16
- A day-in-the-life profile of MN dental therapist Jodi Becker
- New Study Suggests Dental Therapists Improving Oral Health In YK Delta
- 9 Reasons Dental Health Aide Therapist Programs Are Good for Native Kids
- Report Backs Dental Therapist as a Way to Increase Accesss to Dental Care / As Americans age, the Gerontological Society offers roadmap to improved oral health for seniors
- Dental Therapy Helps Increase Revenue, Access to Oral Health Care
- Apple Tree Nursing Home Case Study
Dental therapy is safe.
Dental therapy is proven safe both in the states that have implemented it and around the world.17
In a global literature review on dental therapy that reviewed 1,100 assessments, the authors concluded that, “Dental therapists provide technically competent care” in accordance with their scope of practice, “Dental therapists improve access to care, specifically for children,” and in areas where they are practicing, “The public values the role of dental therapists in the oral health workforce.”18
The American Dental Association’s (ADA’s) Council on Scientific Affairs conducted a systematic research review of dental therapy, about which Dr. J. Timothy Wright—the past chair of the Council—stated, “The results of a variety of studies indicate that appropriately trained midlevel providers are capable of providing high-quality services, including irreversible procedures such as restorative care and dental extractions.”19
According to a 2010 evaluation of dental therapists in Alaska, quality of care provided by the dental therapists was equivalent to that provided by dentists, and patient satisfaction was high.20 In this evaluation, 125 direct restorations were evaluated; there were 19 deficiencies noted, with the relative proportion of deficient restorations smaller for therapists (12%) than for dentists (22%).21
In 2015, the Commission on Dental Accreditation (CODA)—the nationally recognized agency that accredits all dental and allied dental education programs—implemented standards for dental therapy education programs.22 This decision signifies that CODA, and its stakeholders within the dental community, have confidence that dental therapists provide high-quality and safe care. CODA would not have implemented standards for dental therapy training programs were there evidence to suggest that the safe practice of dental therapists was in question.
Dental therapists make innovations like teledentistry much more viable.
For teledentistry to be most effective there needs to be a provider in the field who is licensed to provide the necessary treatment. If a dental hygienist working in rural areas—receiving guidance from a supervising dentist—isn’t trained and licensed to perform the needed procedures, teledentistry is merely a diagnostic tool, because the patient is still required to find a dentist willing to treat them and travel to a second appointment before their needs can be met. A dental therapist is trained to provide many of the most commonly needed dental procedures, including fillings. Therefore, allowing dental therapists to utilize teledentistry to communicate with their supervising dentist and to provide needed treatment would be a much more efficient and effective use of teledentistry.
Any patients in need of procedures that are beyond a dental therapist’s scope of training and practice are referred to their supervising dentists.
We have a significant access problem in Arizona.
The reality is that every county in Arizona is in part or in whole designated by the federal government as a dental professional shortage area.23
Among adults in Arizona who did not see a dentist in the past year, 22% said that they had trouble finding a dentist, and 28% cited inconvenient location or time.24 Under the general supervision of a dentist, dental therapists can help extend hours of operation for dental offices and clinics, and provide care in community settings in mobile dental clinics, school based clinics, community health centers, and nursing homes.
In addition, far fewer dentists choose or prefer to work in rural areas, as seen by this map of coverage and access in Arizona.
In it you can see that while we have almost 3,000 dentists in Maricopa County, there are only 11 in all of Apache County, home to over 70,000 people.25 Dental therapists, working in conjunction with dentists, can fill in these gaps to treat the most common needs and dramatically increase access to care.
Dental therapists could increase access to dental care across Arizona, especially among vulnerable populations who are at higher risk for poor oral health and more unmet needs.
- Dental therapists good for tribes, good for Arizona: Chester Antone of the Tohono O’odham Nation on why and how Dental therapy can help his people
- It’s Incredibly Hard to Get Dental Care in Rural America / Dental therapists could help—but many professional dentists are fighting them.
- ADA survey of Arizona adults
Dental therapists are similar to physician assistants (PAs) and nurse practitioners (NPs), although there are differences.
As a health care model, NPs and PAs are an example of successful integration of allied professionals in medicine. Both NPs and PAs are required to complete training to prepare them with competencies for their specific scope of practice and perspective. NPs and PAs are most similar to dental therapists in that they are intended to extend the reach of the physician to make care delivery more efficient.
Physicians and organized medicine originally opposed allied health professionals’ licensure and scopes of practice, however now NPs and PAs practice in all 50 states and in D.C.26 They allow physicians to work at the top of their licenses, while NPs and PAs take care of the procedures they are trained and licensed to perform.
Just as NP and PA educational programs are accredited, dental therapy training and educational programs in Arizona will be required to meet standards set by the Commission on Dental Accreditation (CODA), the national organization that accredits all dental and dental-related education programs. In 2015, CODA implemented standards for dental therapy education programs.27
Vulnerable populations in Arizona struggle to access regular dental care.
There are many barriers to accessing dental care and low-income families, children covered by Medicaid, seniors, people with disabilities, American Indians, and those living in rural communities or dental health professional shortage areas (DHPSAs) are particularly impacted.28 Some people cannot find a dentist who accepts public insurance while others cannot get to a dental office due to mobility or transportation challenges.29
In Arizona today, over 2.8 million people live in areas designated by the federal government as DHPSAs.30 Arizona is similar to other parts of the county, where long lines are common for people seeking free dental services. People spend the night in tents hoping for the chance to receive much needed dental care—but even that doesn’t guarantee that they’ll get it. The demand often overwhelms the number of volunteers and resources available through these events.31
In a survey conducted by the ADA, a reported 99% of adults surveyed in Arizona said they value oral health.32 However, among those who did not visit a dentist in the past year, 66% cited “cost” as the reason.33 The other two most cited reasons were “inconvenient location or time” and “trouble finding a dentist.”34
The fact is that far fewer dentists choose or prefer to work in rural areas, as seen by this map of coverage and access in Arizona. In it you can see that while we have almost 3,000 dentists in Maricopa County, there are only 11 in all of Apache County, home to over 70,000 people.35 Dental therapists, working in conjunction with dentists, can help fill these gaps to treat the most common needs and dramatically increase access to care.
In a recent article in the Phoenix Business Journal, (September 1, 2017) Kevin Earle, Executive Director of the Arizona Dental Association (AzDA) stated “We need better incentives to delivery care in rural areas to make it economically viable …” If serving rural areas requires “incentives” to dentists, perhaps the better answer is to allow skilled providers who make less per hour than dentists to locate or travel to rural areas to provide care. This model makes economic sense without taxpayer funded incentives to dentists.
In another example, in the Valley there were 481 dentists serving a population of about 246,600 in a geographic area of 184 square miles.36 In Coconino, Yavapai, Gila, and Navajo counties there are 280 dentists to serve a population of about 530,000 over an area of 41,451 square miles.37
Many dentists believe the answer to increasing access for the Medicaid population is to raise the Medicaid reimbursement rates.
We agree that state Medicaid reimbursement rates for dental care are woefully inadequate. The American Dental Association (ADA) Health Policy Institute (HPI) found that in 2013, Arizona Medicaid payments for children’s dental services were about 55% of commercial fees.38 However, raising Medicaid reimbursement rates is a necessary but insufficient step to in expanding dental access for Medicaid enrollees.
Increasing Medicaid payment rates does nothing for the 2.8 million Arizonans who live in dental professional shortage areas, where they already have trouble finding a dentist.39 Nor can it help those—like children, people in assisted living facilities, or seniors in nursing homes—who have difficulty traveling to a dentist’s office. Further, raising Medicaid payment rates to perpetuate a system where only dentists provide routine restorative care is a highly inefficient use of Medicaid dollars. It is now common practice for dentists to delegate lower-skill procedures such as cleanings and radiographs to lower-paid employees, freeing their time to do more complex and costly procedures. Allowing dentists to use dental therapists to treat decay would lower the per-unit cost of care, allowing dentists to serve more Medicaid patients with the revenues they collect.
We do not know what will happen with health care reform over the next few years, however we know that it is unlikely that there’s going to be big injections of new money into Medicaid, so we MUST find more cost-effective ways to deliver dental care.
This is good for patients, as they have greater access to preventative care, and for dentists, who can expand their own practices at lower costs while retaining high quality.
In many of the countries that have had long standing dental therapists, such as New Zealand, there has been a decrease in untreated decay. Early evidence shows similar improvements in Alaska.
Reducing rates of untreated decay has always been a central goal of dentistry. Dental disease is the result of physical, biological, environmental, behavioral, and life-style related factors.40 However, problems arise not because of the presence of dental decay, but because the decay is left untreated. In New Zealand, the untreated decay rate for 5-11 year olds in 2009 was 3% compared to 8% for a similar age group (6-11) in the U.S. (2005-2008).41 Of particular note is that in 2009, it was rare for 12-17 year olds in New Zealand to have any missing teeth due to decay.42 U.S. data (1999-2004) show that for every 100 12-19 year olds, seven teeth were missing due to decay.43
Much of the consequences of the burden of dental disease – pain, missed school and work days, lower academic achievement – are the result not of the presence of decay, but of untreated decay that has progressed to the point of causing significant harm. The ADA study on the burdensome cost of emergency room care for dental problems found that up to $1.7 billion was spent on dental conditions that could have been prevented, much of it due to untreated decay.44
If one is addressing untreated decay, as teams including midlevel dental providers have shown to do better than dentist-only teams, then the nation’s oral health is improving by preventing future pain, root canal treatment and extensive restorations, extractions, and medical complications due to abscesses.45 Oral health improvement is measured by our impact on preventing as well as arresting the progression of decay.
A state-wide study in Minnesota showed that seven full-time equivalent dental therapists served 6,338 new patients in the first two years dental therapists practiced.46 The clinics that employed dental therapists reported that hiring dental therapists increased dental team productivity and improved patient satisfaction.47
Dental therapists have practiced in Alaska since 2004 and have increased access for over 45,000 Native Alaskans living in rural communities.48 An analysis of 25,000 Alaska Natives from 2006 to 2015 showed that high exposure to dental therapists was associated with lower rates of tooth extractions and more preventive care for children and adults.49
According to a Minnesota Department of Health report, 50% of dental therapists work in the Twin Cities metro area, and 50% work throughout the rest of the state.50 This distribution mimics the population distribution in the state, as approximately 54% of Minnesotans live in the Twin Cities metro area.51 As of December 2016, there were 63 dental therapists with active licenses in Minnesota.52 According to a 2014 report on the early impacts of dental therapy in Minnesota, nearly one-third of patients in practices employing dental therapists experienced reductions in travel and wait times since the start of the dental therapists’ employment, especially in rural areas.53
In a global literature review on dental therapy that reviewed 1,100 studies and assessments, the authors concluded that, “Dental therapists provide technically competent care” in accordance with their scope of practice and “Dental therapists improve access to care, specifically for children,” and in areas where they are practicing “The public values the role of dental therapists in the oral health workforce.” 54
Dental therapists are highly trained dental professionals who can help expand the reach of the dental team especially to vulnerable Arizonans, including seniors, American Indians, and other vulnerable populations.
Studies consistently show that these professionals can safely and effectively expand care people in need.57 Research from Minnesota and Alaska show that dental therapists can safely and effectively care for high need communities.58 In fact, a case study in Minnesota found that the dental therapist could complete most of the work needed in a nursing home setting.59 Further, it doesn’t make fiscal sense to have the most expensive person on the dental team, the dentist, perform every restorative service from a filling on a primary tooth to permanent crowns and implants.
The Commission on Dental Accreditation(CODA)—the national agency that accredits all dental and dental-related education programs—adopted training standards to ensure that dental therapists are properly trained for the procedures in their scope of practice and to care for people of all ages and with special needs. CODA requires a minimum of three years of education. In Arizona, dental therapists would be required to meet the CODA educational standards, and would then be allowed to perform about 80 procedures, while dentists—who have four years of dental education—have a scope of practice that includes, for general dentists in Arizona, about 435 procedures.60