New “Dental Therapists” Could Help Bridge Oral Healthcare Gap

If allowed, this position would function like physician assistants in the medical world.

Communities across the country and here in the Pacific Northwest are working to improve access to dental care by creating a new dental profession: dental therapists. Similar in nature to the medical field’s physician assistants or nurse practitioners, this new profession could help improve access to oral healthcare, especially in rural and native communities. However, it’s being met with resistance from the medical/dental establishment.

The U.S. Department of Health and Human Services estimates that over 47 million Americans currently live in areas with inadequate access to dental care. In Oregon, uninsured people are eight times more likely to visit the emergency room for dental problems. Lack of dental care access costs the state health system $8 million in emergency room visits annually, according to an Oral Health Funders Collaborative study.

A 2011 report from the Institute of Medicine of the National Academies indicates that access barriers include uneven geographical distribution of dental care providers, a large segment of the population that lacks dental insurance, and only about a 20% dentist participation rate in Medicaid. Put simply, most rural areas don’t have enough dentists, too many people lack dental insurance, and even in areas that do have dentists, the great majority do not accept Medicaid--making their services unattainable for the people who live there.

For people living in Native communities, the need and lack of access is even greater. According to the Northwest Portland Area Indian Health Board, 17% of Indian Health Service dentist positions are vacant, and IHS providers carry a patient load that is nearly double that of the general population.

Across the country, oral health advocates have been working with legislators to improve access to care. They are trying to amend state laws to permit dental professionals like dental hygienists to extend their practice and, in a supervised capacity that remains within the scope of their training and certification, increase the services they are able to offer patients. Many have advocated for the creation of a “dental therapist” profession that would work similarly to a physician assistant or nurse practitioner. Working under a dentist’s supervision, dental therapists educate patients about oral health and prevention, perform evaluations and fluoride treatments, place sealants and fillings, clean teeth and perform simple extractions. This expanded scope extends a dentist’s coverage and frees him or her up to perform advanced treatments and procedures.

In June of this year, The Pew Charitable Trusts released a report called “Expanding the Dental Team,” which examined programs in Minnesota, Alaska and California that used dental hygienists and dental therapists to increase access to care. The results were incredibly positive. More patients were served, dentists were able to handle more advanced cases, and costs were controlled because the hygienist and therapist positions do not cost as much as a dentist.

The situation is increasingly urgent for Indian communities. Jim Roberts, policy analyst for the Northwest Portland Area Indian Health Board, said, “For many years our tribes have had many issues related to oral health and provider shortages. We have difficulty filling positions in tribal communities, and we also can’t afford dentists for every service. If there is a more cost-effective way to provide care, we are very interested in providing those opportunities.”

The American Dental Association has not been supportive of efforts to create and expand midlevel provider positions. The organization’s local arm, the Oregon Dental Association, says they prefer other solutions that retain dentists as primary providers.

In a written statement Christina Swartz Bodamer, Oregon Dental Association’s managing director of public and professional affairs, said that “ODA feels the best solution is the community dental health coordinator, whose purpose is to prevent dental disease before it starts.”

Such providers, as their name indicates, coordinate care but do not provide it. “CDHCs focus on basic prevention and education services then act as a health navigator to get those who need more care to a dentist. Without promoting preventative oral healthcare in Oregon, anything we do will merely treat symptoms of the disease. The best approach for everyone’s health and the state budget is to prevent disease in the first place,” said Bodamer.

Midlevel providers like dental therapists have been active in Alaska for many years, said the Indian Health Board’s Roberts. “It’s been a phenomenal success for them,” he said. “Dental health aide therapists have to be one of the most studied providers in dental history--and the quality of care and results have been phenomenal.”

Roberts’s organization is supporting other legislative efforts to expand the scope of practice for dental hygienists, and is also actively working to develop and implement oral health pilot projects that will meet tribal needs more quickly.

The project favored by Roberts would replicate the work being done in Alaska. “Dental care in the last 10 years in Alaska has completely reversed itself,” he said. “In some communities, tooth decay has been eradicated altogether.”

Opponents of these pilot programs have it wrong, Roberts said. “The Dental Association has made this program seem to be people who go to school for two years, running around willy-nilly practicing dentistry without proper schooling, internship and supervision. What exists in Alaska is a rigorous program with strict education and scope of practice requirements. They have continuing education requirements, a limited scope of practice, and there have been no documented cases of egregious activities as a result of dental therapists performing within their scope of service.”

Roberts said the dental health therapist program for tribal communities is at least a year out from being implemented, but the outlook is positive. In the meantime, efforts are also being made to authorize such therapists in the general dental community, and to expand roles and scope of practice for dental hygienists.

In Oregon, expanded practice dental hygienists have been authorized by the legislature since 1997. With additional education and clinical practice experience, they can provide services without the supervision of a dentist. About 10% of the approximately 3,500 dental hygienists in the state have this additional training. Most are in predominantly rural areas. A 2011 Senate bill allowed for the creation of pilot projects to focus on new skills for existing providers or the creation of new professions, like dental therapists. These bills allow for the projects that Roberts’s organization wants to build in Oregon; they are also pursuing similar legislation in Washington state.

The Oregon Health Authority, the state’s health agency, affirmed in a written statement that the agency is deferring to the Oregon Board of Dentistry on issues related to expanding the scope of practice for hygienists and increasing access to care.

“OHA trusts the board,” wrote spokeswoman Christine Stone, “to set appropriate scope of practice for dental hygienists and expanded practice dental hygienists. OHA trusts the board to make decisions that are appropriate and safe for patients.”

Stone did affirm that the OHA believes access to dental care is an important part of overall quality physical health, and that related agencies are “also exploring ways to better meet oral health needs. These approaches include increasing access to dental care through co-location of medical and dental services, and providing a wider array of oral health services for children at schools.”


Washington Post editorial about dental therapists

Assn of Healthcare Journalists article about Pew study of midlevel providers

Statesman Journal article about midlevel providers


Temple can be reached at [email protected].

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As long as we all think the solution for decayed teeth with cavities is restorative/replacement dentistry and do not recognize that cavities are the result of an oral infection, the problem will never be solved. Drilling teeth and putting in fillings will not stop this infection. Once we begin to realize that this is a chronic medical disease we can begin to make progress on the ultimate solution, which is a cavity free world. Putting a drill in the hands of a "midlevel" provider will not stop the problem. Restorative dentistry is not like a physicians assistant for physicians assistants do not do surgery, they take histories, order lab tests, write scripts and take care of minor patients issues. The highly trained doctor specialists do the surgery. Dentists are like surgeons, they cut holes in teeth, cut bone, cut tissues, etc. There is nothing like trying to scoop the decay out of a cavity with a spoon excavator and have that exactor drop into the nerve (pulp) of the tooth. This then requires a hole drilled through the top of the tooth in a way that one does not put the drill out the side of the tooth so the nerve (pulp) of the tooth can be removed and a RCF done. The community does not need more people to drill teeth regardless of what they are paid, what the community needs is dentistry's knowledge on how to prevent the drill. This oral infection's prevention does not even need a dentist or even a hygienist. It can be prevented very simply if only the correct knowledge is applied at the appropriate place by the appropriate person. The infection cycle needs to be broken in children while taking care of those that are already affected. One of my mentors in dentistry who brought dental prevention to the forefront of dentistry said many years ago the following. It is as appropriate then as it is now. Developing mid level providers is an example of what he is talking about going towards where the needs are greatest rather than where the results are. "Aid, by its very nature will flow toward the problems rather than toward opportunities. It will go where the needs are greatest rather than where the results are. It will, therefore, tend to create, or at least perpetuate dependence … Reliance on aid also encourages diversion of scarce resources to the wrong projects whose developmental impact is minimal.” ~ Robert Barkley, DDS Successful Dental Practices Published by Yeast Offset Printing in 1972 We need better use of the knowledge we already have, not another licensed professional.
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