Mid-Level Dental Providers:Expanding Care to Every Community
Without dental care Many people live in pain, miss school or work And in extreme cases, develop life-threatening infections This all could be prevented if we improved access to routinedental care.
In Columbus, Ohio, 52-year-old MatthewThorpe yanked out his own infected toothwhen a dentist refused to treat him because hedidn’t have insurance. In Gallup, New Mexico,a 15-year-old Native American boy fell into apermanent coma after a preventable dentalemergency went wrong. Four hundred milesaway, in Clayton, New Mexico, Don Wiedemann,the CEO of Union County Hospital, had to waitfour months to get a new filling for his wisdomtooth because there are no dentists where helives.In Washington state, April Ritter callednumerous dental practices every morning forthree weeks before she could find one willingto accept her Medicaid insurance and pull her8-year-old daughter’s abscessed tooth. And inMaryland, Deamonte Driver, a little boy with abright smile, lost his life to an infection causedby untreated tooth decay.Such stories are not uncommon.Tooth decay is the leadingchronic disease among children— more common than asthma. Yet 16.5 millionchildren a year go without any oral healthtreatment or preventive services.Some people think of dental care as a luxury —separate from health care and not as important.They view a toothache as something minor,something that children lose sleep over untilthey see the dentist the next day.For those who can’t get dental care when theyneed it, the reality is far different. They can’tmake the pain stop. They can’t eat easily orsleep through the night. The pain forces themto miss school or work. And it can go on formonths — not hours or days, but months.Left untreated, tooth decay can affect overallhealth and lead to a lifetime of chronic illness.It can cause life-threatening infections or leadto complications that require major surgery.And it is linked to increased risk of stroke,heart disease and diabetes.It affects people of all ages, in every state, inremote areas and in cities.Everyone wants and should have access togood oral health care where and when theyneed it: in their own communities. But, acrossthe U.S., that is not the case.
Dental ProviderShortage in America 1A Broken SystemThe current dental delivery system fails one-thirdof the U.S. population: Nearly 45 million people live in federallydesignated dental shortage areas where thereare not enough dentists to provide neededcare. Millions more can’t afford dental care. Across the U.S., an additional 6,600 dentists areneeded TODAY to provide necessary services.Yet dentists are retiring at a rapid rate. Approximately 80 percent of dentists do notaccept Medicaid insurance, making it difficultfor millions of low-income families to getdental care. Many people who can’t get dental care in theircommunities turn to local hospital emergencyroom departments when their problemsbecome severe. In 2009, more than 830,000people visited ERs for preventable dentalproblems, even though ER care is much morecostly and less effective than regular dentalcare.Dental care in the U.S. generally is providedby small, independent practices of dentistsand hygienists. In medical care, primary carephysicians have extended their practices bybringing in mid-level providers such as nursepractitioners and physician assistants. Dentistscould do the same. By adding mid-level dentalproviders such as dental therapists to their teams,dentists could expand access to care where peopleneed it most: in their own communities.
Mid-Level DentalProviders Are a WiseInvestmentIncreasing access to oral health care willrequire action on many fronts, includingeducating the public on the importance of oralhealth, increasing Medicaid reimbursementrates for dental services, training moredentists and further expanding the dentalcare workforce by adding mid-level dentalproviders.Mid-level providers are critical to expandingaccess. They bring new capacity and flexibilityto the dental care team, working withdentists and hygienists to provide preventiveand routine dental services, oral healtheducation and a dental home in underservedcommunities. They can work remotely inrural or low-income areas, consulting with asupervising dentist via telemedicine or phone,so that people who previously lacked accesscan get the care they need.Currently, mid-level dental providers operatein Alaska and Minnesota, where they aresuccessfully expanding access to preventiveand routine dental services. Other states arein various stages of exploring their use. InAlaska, mid-level providers known as dentalhealth aide therapists have brought dentalcare access to 40,000 people since they startedpracticing there in 2005. In Minnesota, 78percent of patients seen by dental therapistsare publicly insured.Mid-level providers make sense on manylevels. They are authorized to practice off-sitein an arrangement that extends the reach ofthe entire dental care team. They are trainedto provide culturally competent care forunderserved populations and often returnto practice in their home communities. Theirintense training period is shorter than that ofa dentist, allowing them to move into the fieldmore quickly and making them less costly toemploy. And they provide some of the mostcommonly needed dental services to thepeople who need them most.
Dental TherapistsAre a Smart Investment 2What is a Mid-levelDental Provider?Mid-level dental providers, variously referred toas dental therapists, dental health aide therapistsand registered or licensed dental practitioners,work as part of the dental team to providepreventive and routine dental services, suchas cleanings and fillings. Similar to how nursepractitioners work alongside physicians, midlevel dental providers work under the generalsupervision of a dentist. In some situations, thesupervising dentist is off-site, so that the midlevel can practice in remote and underserved areasthat do not have dentists. In addition to providingroutine care, mid-level dental providers play thecritical role of patient educator, bringing greaterawareness to the importance of good oral health.Who is Most in Need?Children in low-income families, children of colorand people living in rural areas have the greatestdifficulty getting dental care: More than 33 percent of all children of low-income families ages 2 to 9 have untreatedcavities, compared with 17 percent of childrenwho are not in low-income families. Thirty-seven percent of black children and 41percent of Hispanic children have untreatedtooth decay, compared with 25 percent of whitechildren. The highest rates of untreated tooth decay — 72percent — are found among American Indianand Alaska Native children.
Nationally, more than 14 million childrencovered by Medicaid received no dental careat all in 2011. Rural adults are significantly more likely tohave untreated tooth decay — nearly onethird suffer from it compared with only aquarter of non rural adults.An economic study conducted of dentaltherapists practicing in Alaska and Minnesotafound that these mid-level dental providers areexpanding access to care: 78 percent of theirpatients were publicly uninsured; the majorityof the services they provided — 84.7 percent —were preventive and routine; and their salariesrepresented just 30 percent of the revenue thatthey generated. They are cost-effective and arereaching the populations most in need.Education and TrainingMid-level dental providers complete a rigorouseducation program that fully prepares them forcommunity practice.Essentially, they obtain an associate’s degreethat equips them to provide preventiveservices, education and routine dental care,including fillings and non-surgical extractions.Their training also includes an additional 400hours of practice alongside a dentist in thefield. The 400-hour internship, which maylast three months to a year, enables them tohone their skills, working closely with theirsupervising dentists.Children Most at Risk for Oral Disease 3
By the time they begin practicing, mid-levelproviders have as much clinical experience inthe procedures they are certified to perform asa dentistry school graduate. They use the sametextbooks as dental school students, and theyare taught by university professors.Like other health care professionals, mid-leveldental providers have continuing educationrequirements that must be completedperiodically. In Alaska, they must be observeddirectly every two years to retain theircertification.Because education for mid-level providersis highly focused and limited to a specificset of services, it requires fewer years and isless costly than education for dentists. As aresult, mid-level providers carry less educationdebt than dentistry school graduates, andtheir salaries typically are about half those ofdentists, making it easier for practices to hirethem and expand the services they offer. In Alaska, dental therapistsALASKA: Expanding theReach of the Dental TeamSince 2005, the Alaska NativeTribal Health Consortiumhas employed dental healthaide therapists to provideroutine, preventive andrestorative oral health servicesin tribal health clinics in ruralAlaska. The results have beengroundbreaking:have increased oralhealth care access to morethan 40,000 people at asignificant savings to thesystem. The average dentaltherapist salary in Alaska isabout half that of a dentist— 60,000 per year versus 120,000 — so the savingsare very real. The majority of careprovided by dentaltherapists is preventive.They have already madea dent in the cavity rateamong children and arepracticing less restorativeand acute care, which ismuch more costly. Dental therapists, whocome from the communitiesthey serve, also provideimportant education andcommunity-based care thatmakes a lasting impact.
Momentum is Buildingfor Expanding theDental TeamMid-level providers are highly skilled atproviding routine and preventive care. In 2013,eight states either put forward legislation orlaunched serious efforts to allow mid-levels topractice. Another three states have planninggrants to explore the option. And NativeAmerican tribes are working to add mid-levelsto their dental provider networks.MINNESOTA: HelpingSafety-Net ProvidersProvide Cost-Effective CareIn Minnesota, the first licenseddental therapists beganpracticing in December 2011.Immediately, they helpedincrease access to care andreduce costs for communitybased dental providers. Seventyeight percent of their patientsare publicly uninsured; themajority of the services theyprovide — 84.7 percent — arepreventive and routine.A Dentist’s Vision for Adding Mid-LevelProviders to The TeamIn Kansas, more than 28,000 people covered byMedicaid live in counties where there are nodentists who accept Medicaid. But one dentist,Melinda Miner, DDS, has a vision for helpingmore Kansans get the dental care they need.Miner and her husband are the only twodentists in Ellis County who see patients withMedicaid coverage. Together, they have builta practice with a 30 percent Medicaid base.Miner says that if she could hire two mid-leveldental providers, she could schedule 2,000to 3,000 additional appointments per year, inpart by opening satellite clinics in neighboringunderserved communities for preventive andother basic dental services.One practice, Children’s DentalServices, which primarily serveslow-income patients throughoutMinnesota who are eitherpublicly insured or uninsured,employs three dental therapists.The practice reports that: Each dental therapist savesChildren’s Dental Services 1,200 a week, allowing thepractice to not only maintainbut expand services in theface of declining Medicaidreimbursement rates and achallenging philanthropicenvironment. There have been nocomplaints or problemsregarding the quality ofcare provided by dentaltherapists. The dental therapist modelis working so well thatChildren’s Dental Servicesis paying the tuition for twoof its current employees tobecome dental therapists andoffering it to a third.
The potential benefits of this vision are notunique to Kansas. Across the country, mid-leveldental providers could allow clinics and dentiststhe opportunity to greatly expand their servicecapacity.All children and families — whether they livein rural Kansas, on a remote Indian reservation,or in downtown Detroit — deserve access topreventive and routine oral health care that willhelp them maintain good oral health, whichis critical to overall health. Mid-level dentalproviders can bring much-needed oral health careto millions of underserved children and adults inAmerica.123Sources: Dye BA, Li X, Beltrán-Aguilar ED. Selected oral health indicators in the United States, 2005–2008. NCHS data brief, no 96. Hyattsville, MD: National Center for Health Statistics. 2012; Phipps, KR, Ricks, TL, Manz, MC and Blahut, P. Prevalence and severity of dental caries among American Indian and Alaska Native preschool children. Journal o fPublic Health Dentistry. doi: 10.1111/j.1752-7325.2012.00331.x. 2012; Synder, A. Increasing access to dental care in Medicaid: Targeted programs for four populations. N ationalAcademy for State Health Policy. 2009.
Aurora in PracticeAurora Johnson grew up north of the ArcticCircle in Noorvik, a village where dentistsare an expensive plane trip away and freshfruits and vegetables — unlike sugary softdrinks — are hard to come by. From herearliest years, a family member showedAurora how to take care of her teeth. Butwith routine dental care out of reach, someof her classmates graduated from highschool with full sets of dentures.In 2003, Aurora seized an opportunity tomake a difference in her community. Sheapplied to become one of the first DentalHealth Aide Therapists (DHATs) in aninnovative program under development bythe Alaska Native Tribal Health Consortium(ANTHC). With training available onlyin New Zealand, she uprooted her family,including three young children, and movedacross the globe for two years of intensivepreparation.Today, thanks to the DHAT program,the state of oral health in Alaska’s tinyvillages is changing. The ANTHC,working in partnership with the Universityof Washington, now trains DHATs inAnchorage and Bethel, and more than twodozen therapists bring regular dental care tothe farthest reaches of the state. Southwestof Nome, in the village of Unakaleet, Aurorahas been practicing as a DHAT since 2005.“When I started, the kids were half my sizeand now they are taller than me,” she says.And she’s seeing progress. “Each year, as Iprovide care to the kids in the communities,I am building a relationship of trust. Ourpreventive care has helped to fight theenormous decay rate here in our region. Itused to be that nearly every child I saw hadcavities, but now we are seeing more andmore that strive to be cavity free.”
Expanding the Dental WorkforceMid-Level Dental Providers:Fewer People in Pain, Missing School or Work.Fewer Life-Threatening Emergencies.Join the National Movement to Close the Dental Care Gapand Expand Care to Every Community.AK2 0 1 4 De n ta l Wo r kf o r c e M a pStates with midlevel providersStates pursuing or exploring midlevel HDCMARICT
Mid-level dental providers, variously referred to as dental therapists, dental health aide therapists and registered or licensed dental practitioners, work as part of the dental team to provide preventive and routine dental services, such as cleanings and fillings. Similar to how nurse practitioners work alongside physicians, mid-level dental .
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