Oral Health Advocates Say Dental Therapists Could Ease Shortages

The Oregon Dental Association remains skeptical about such an approach
December 20, 2010 -- Oral health advocates, bolstered by favorable national reports on dental therapists, told legislators that training and deploying mid-level providers could help ease the shortage of providers. But the Oregon Dental Association (ODA) remains skeptical of any legislation to change the scope of practice laws.
One possible solution to the access issue is by developing training programs for dental therapists, a new type of provider whose scope of practice falls between that of a dental assistant and a dentist, said Judith Woodruff, health work force program director with the Northwest Health Foundation. Dental therapists would be relatively inexpensive to train and hire, Woodruff said in testimony before the Senate Interim Committee on Health Care last week.
Woodruff presented some sobering statistics. According to the Department of Human Services, oral disease is five times more common in Oregon children than asthma, and are a significant part of  school absences in a given year.
Additionally, 22 of Oregon’s 36 counties have a shortage of dental professionals, which will pose greater problems in 2014, when federal healthcare reform extends coverage to more than 500,000 Oregonians.
“Oral health needs in this state are not being met,” Woodruff said. “We’re asking you to think about different models of oral health services.”
Dr. Tom Bornstein, who works with the Dental Health Aid Therapist program in Alaska, the nation’s first dental therapist initiative, joined Woodruff. The Kellogg Foundation, which funded that program, documented widespread patient and dentist satisfaction with dental therapists in rural Alaskan communities in a recent study.
Patients, dentists and dental therapists in five tribal villages were surveyed over two years, and asked about quality of care, job satisfaction and relationships with providers or colleagues. The study found that the level of patient satisfaction was generally high.” All the dentists who participated had positive professional relationships, and“felt that all of the therapists’ work was technically competent.”
Dental therapists’ ability to meet pressing oral health care needs in rural communities also saved residents a multi-hour trek to the nearest dentist.
 “A gold standard of [dental] care can be accomplished closer to home by mid-level providers under professional supervision,” Bornstein told legislators.
However, the American Dental Association isn’t convinced by those findings. Dr. Raymond Gist, its president, said the study “did not provide the robust examination or projectable metrics on which to base important policy and public health decisions.”
Introducing a new dental team member is just a partial answer to addressing access issues, said Dr. Rick Asai, immediate past president of the ODA. “We need to incorporate prevention or we’re never going to solve these problems.”
Senator Alan Bates (D-Ashland) remains skeptical of introducing new providers.
“We have a budget hole the size of the Grand Canyon, and we’re going to spend all our energy on scope of practice issues? I see this as a distraction from working to maintain the system we do have.”
But a recent report by the Pew Children’s Dental Campaign suggests that mid-level providers could be a financial boon. The report evaluated several scenarios using a “productivity and profit” calculator developed in part by dental professionals and designed to assess new healthcare models.
The report found that by adding an “allied provider,” such as a dental therapist not only increased a dental practice’s earnings by as much as 54 percent, but also the number of patients who were seen.
To find common ground, the ODA and the Oregon Oral Health Coalition, which includes stakeholders from Regence, BlueCross BlueShield Kaiser Permanente and the Oregon Dental Hygienists Association, have been working with a mediation group, Oregon Consensus.
Initially, the ODA refused to participate in mediation, said Senator Laurie Monnes Anderson (D-Gresham), who chairs the Health Care Committee. However, Sam Imperati, the mediator, said the two sides had a “constructive, problem-solving” initial meeting on Dec. 15. Another session is scheduled for January.
Meanwhile, numerous stakeholders who favor dental therapists are keeping mum about what’s taking place behind the scenes.
Lynn Ironside, who chairs the hygienists’ association government relations council, said details of the mediation were “not for conversation at this time.”
Whatever transpires next session, Dr. Mary Willard, Alaska’s training director, hopes Oregon and other states eventually embrace dental therapists.
“The U.S. is only industrialized nation that doesn’t utilize a therapist-type provider. It’s a very adaptable model that works.”


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At some point during the nation’s real-time experiment in dental care by novices, I expect stakeholders in the dental therapist market, like Judith Woodruff, Dr. Tom Bornstein and Dr. Mary Willard who were mentioned in the article, to do the right thing and properly disclose to the principals - that would be the patients who aren’t involved in dentistry for profit - that the discounted care they will receive from non-dentists is of lesser value than more expensive, but arguably less costly dentistry done by properly trained dentists “the first time.” What’s especially frightening to me is that the three ambitious entrepreneurs seem unfazed by the obvious danger of sending inadequately-trained - but cheap - providers into the remote areas of the US. These are less desirable parts of the nation where infrastructure is less reliable, and where poor parents have no choice in care for their children. Let’s at least be honest with those less fortunate if we are too cheap to provide their children with care from real dentists. Dentistry is difficult enough in the suburbs with oral surgeons close by - in case an unanticipated problem arises which is beyond even the training of a general dentist. How could dentalcare stakeholders possibly make this deception any more harmful to naïve and poverty-stricken families in Texas? How about mixing in harmful temptations inherent in capitation (pay per head instead of pay per filling) dentistry run by Dental Health Maintenance Organizations (DHMO)? If the Texas Dept. of HHS has its way, in a few years, it’s possible that almost-dentists working in a clinic in the middle of a poor neighborhood in Fort Worth will be rewarded for neglecting decay until it can no longer be ignored, and has to be treated by a real dentist. In my opinion, the ADA’s new President, Dr. Raymond Gist, is a wonderfully fresh change for the ADA. He has already proven by his numerous press releases his desire to become part of the community he serves. I just think he needs to be a little more forceful to be effective. It’s not unprofessional to be assertive, it just looks bad. D. Kellus Pruitt DDS

I treat low income ptns, teach courses in health policy and participate in advocacy in OR. there is reasonable question as to whether midlevels will lower the cost of providing service in any given market thus increasing access over the aggregate. However your assertions about quality are completely unsupported by a large body of evidence in blind evaluation of prep design and other metrics. When bold statements are made that are based solely in opinion and anecdote it diminishes the credentials behind your name (and since they are my credentials I have a stake in what you say). I know Ms Woodruff and have spend a little time with Dr. Willard in Alaska and regardless of your opinion of what they choose to advocate for, they do what they do in good faith so for you to put that into questinon also diminishes those credentials MP

A dental assistant primarily serves as a dentist's extra set of hands during procedures, passing instruments, making impressions, holding suction devices, etc. Dental therapists have a wider range of responsibilities, such as filling cavities, applying sealants and cleaning teeth. (It should be noted that the specific rules and regulations governing dental assistants and therapists vary by state.)

If the choice is between prevention and detection and nothing, I do not understand why someone would object to allowing persons from lower-income cohorts to do a rewarding job as is proposed.

A gold standard of [dental] care can be accomplished closer to home by mid-level providers under professional supervision,” Bornstein told legislators. This is better if they told how to do that whit some home health aide help, more easy that way.

The dental therapist model will not help with most of the access to care issues. The real issue with access to care has more to do with efficiency, technology, and the economics of education. I have practiced general dentistry for 12 years. In those years I have practiced at a hospital on a reservation with the IHS, a large educational hospital, a private practice, and various clinics that used a sliding scale for payment. The clinics I practiced in that where the dentistry was free were by far the most inefficient. At times the cancellation/no show rates in those clinics were around 50%. One of the clinics in which most services where free, only averaged about 4 patients per doctor a day. Between a colleague of mine and myself, we offered 15 different patients free root canals in a 6 week period of time and only 3 out of the 15 showed up for their appointment. Even in a well run private practice the cancellation/no show rate is around 5%. If the average dentist has 2400 patient visits a year and has a 5% cancelation rate they are 120 patient visits that are essentially are going unused that the practice is having to absorb because the overhead is still incurred. The higher the cancellation rate in the clinic the more appointments there are that are paid for that are never used. If you can't control that then it does not matter if you are dental therapist or not the overhead cost is still there. If a dental therapist makes 70k and the average general dentist makes 140k and each see 2400 patients per year then you will see a savings of about 30 dollars per patient. So a filling that was $170 is now a $140. Is that really the the bang for your buck that you are looking for with the new legislation and the cost of establishing new therapist programs? If you were really looking for bang for your buck you should better educate general dentists so they could provide more services. If I refer out a root canal to a specialist it can cost the patient up to $500 more for the same service. If I refer out an orthodontic case it can be over a $1000 more for the same service. The rural areas need well trained general dentists that offer a variety of services so they don't have to drive 2 hours to a specialist. Having a dental therapist in the area would not solve this problem. A better solution would be to change the structure of dental education as it currently exists. Currently dentists spend 4 years in dental school seeing approximately 2 patients a day(if you are lucky) in your 3rd and 4th year. During these 4 years most dental students amass over $200,000 in debt to attend school and live. This can be quite a burden. The prospect of purchasing or opening up a practice and adding another 300k to 500k to the 200k is daunting to say the least. To help solve the debt and access problem you could cut the classical dental school education down to 3 years and require a 2 year residency where the dentist could receive advanced education and be paid like a resident for those 2 years. This type of program would help reduce the debt of the dental student, increase the educational opportunity for the dentist, and provide better access to care. A resident's salary would probably be less than a dental therapist and he or she would be able to provide more services. There are currently GPR programs that place residents at rural hospitals. These programs tend to actually provide a good source of revenue for the school. Just some thoughts. I did not even touch on the cost of technology, taxes, and support staff salaries that keep increasing costs. Those things are present regardless of a dentist or dental therapist. DH