AJPH PERSPECTIVES Expanding the Dental Workforce to Improve Access and Reduce Disparities in Oral Health “Twelve-year-old Deamonte Driver died of a toothache Sunday.” Those were the first words of a 2007 Washington Post1 story that identified by name a young victim of what former US Surgeon General David Satcher had called a “silent epidemic,” seven years earlier. After that unforgettable lead sentence, the reporter went on explain why this was such an unnecessary tragedy. “A routine, $80 tooth extraction might have saved him,” she wrote. Driver’s mother, however, did not have the money to pay for the extraction, and the family did not have dental insurance. They also had recently lost their Medicaid coverage. Even when they had it, finding a dentist who would accept Medicaid patients was a challenge. What undoubtedly surprised many readers was that tooth decay is not only a painful annoyance but a serious infectious disease that, left untreated, can be fatal. And probably just as surprising to many was just how difficult getting timely and appropriate care can be for people of all ages who lack dental benefits—including most Medicare and Medicaid beneficiaries—or who live in areas where few dentists practice.
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In his 2000 report,2,3 Satcher wrote that the burden of dental and oral diseases affects members of racial and minority groups disproportionately. More than 15 years later, that is still the case.4 Some progress has indeed been made. More children receive dental sealants to help prevent cavities now than in 2000, fewer adolescents have tooth decay, and more adults are retaining their natural teeth. But progress in other areas has been slow, especially among children in low-income families, as former US Surgeon General Vivek Murthy wrote in a 2016 report.4 Here is just one statistic from that report: a fourth of preschoolaged children living in households below the federal poverty level have untreated tooth decay, compared with one in 10 living above the poverty level.4 Among the reasons for the enduring disparities and lack of access are shortcomings that policymakers have not adequately addressed. Although members of Congress included dental care for children among the Affordable Care Act’s essential health benefits, relatively few dentists accept new Medicaid patients—20% or fewer in some states. Medicaid reimbursement rates are considerably lower than are commercial reimbursement rates in most states, ranging in a recent year from 26.7% in
Minnesota to 81.1% in Delaware.5 And instead of narrowing, the difference between Medicaid reimbursement and commercial reimbursement actually widened in all but six states and the District of Columbia over a recent 10-year period.5 In the Medicare program, dental benefits remain very limited. Medicare Part A will pay for certain dental services provided during hospitalization, but routine visits and cleanings are not covered. The Affordable Care Act made preventive medical care a covered benefit but not preventive dental care. It is little wonder, then, why an increasing number of both children and adults are seeking treatment in hospital emergency departments—where the cost is typically much higher than in a dentist’s office—when a toothache becomes unbearable. According to an analysis by the American Dental Association (ADA), the number of dental emergency department visits doubled, from 1.1 million to 2.2 million, between 2000 and 2012. The ADA estimated that by 2012, emergency department
dental visits cost the US health care system $1.6 billion annually, with an average cost of $749 per visit.6 There are other costs of America’s continuing silent epidemic of dental disease. People with diseased and missing teeth are at a disadvantage when applying for employment. Pregnant women with untreated decay can pass disease on to their unborn children. Toothaches also contribute to children missing school and parents missing work.7 The ADA and state dental societies lobby lawmakers to increase Medicaid reimbursement, but few states have done so. What many lawmakers are showing more interest in are solutions that do not require government spending and that have the additional benefit of creating jobs. Programs to improve access by strengthening the oral health workforce at little or no cost to taxpayers are under way in several states. They are to a certain extent the fulfillment of Murthy’s recommendations to expand the capabilities of existing providers and to promote models that incorporate other clinicians. The ADA, which maintains that there are enough dentists in the United States but acknowledges that many areas are underserved, launched a pilot project in 2006 to train
ABOUT THE AUTHOR Wendell B. Potter is with To Be Fair, Inc., Philadelphia, PA, and Tarbell.org. Correspondence should be sent to Wendell B. Potter, To Be Fair, Inc., 601 Walnut Street, Suite 1200W, Philadelphia, PA 19106 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted April 5, 2017. doi: 10.2105/AJPH.2017.303832
AJPH
Supplement 1, 2017, Vol 107, No. S1
AJPH PERSPECTIVES
community dental health coordinators. Community dental health coordinators, whose focus is education and prevention, are currently working in nine states. Paul Glassman, director of the Pacific Center for Special Care at the University of the Pacific, has pioneered a dental telehealth project featuring a collapsible dental chair and other portable equipment that enable dental hygienists to examine patients in schools and other locations and transmit x-rays via a laptop computer to a dental office. The project is being piloted in several locations. Several other states and tribal communities have broadened or are considering broadening the dental workforce to include midlevel providers, often called dental therapists, whose scope of practice is considerably broader than is that of the community dental health coordinators. Although dental therapists practice in at least 50 countries (starting in New Zealand in the 1920s), they are relatively new to the United States. Alaska Native communities were the first to use them in this country. Dental disease had become so prevalent among Alaska Natives, most of whom live far from a dentist’s office, that tribal leaders decided in 2004 to see if dental therapists—or dental health aide therapists, as they are called in Alaska—could make a difference. More than 30 dental health aide therapists are now providing care to 45 000 people in 81 communities. As elsewhere, they work as part of a broader dental team and are supervised by dentists. Their scope of practice ranges from education and prevention to uncomplicated extractions and fillings. When a patient requires care beyond their scope of practice, they refer the patient to a dentist.
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Dental therapists began practicing in Minnesota in 2009. The Minnesota Department of Health noted in a 2014 report that the state’s dental therapists were providing quality care to predominantly low-income, uninsured, and underserved patients.8 Maine and Vermont are the most recent states to allow dental therapists to practice, and several other states may soon follow suit. In February, the Washington legislature approved a bill to allow the 29 Native American tribes in the state to use them.9 The Swinomish Native American community did not wait for the state to act. Swinomish leaders exercised tribal sovereignty in early 2016 and recruited one of the Alaska-trained dental health aide therapists. His presence on the team enabled the Swinomish dental clinic to see 20% more patients last year than in 2015 and reduced wait times from three to four months to less than three to four weeks. Legislation authorizing dental therapists to practice has received bipartisan support and usually has both Democrats and Republicans as sponsors. A growing number of dentists have become dental therapy champions, but the ADA and state dental societies have, for the most part, remained opposed. That appears to be changing. In New Mexico, the state dental association is working with advocates and lawmakers on a bill that would allow dental therapists to practice in that state. Dental societies in other states should do the same. Strengthening and expanding the dental workforce, by broadening the capabilities of existing providers and encompassing new clinicians like dental therapists, can make a big difference in access—and in the lives of millions of people—at little cost to taxpayers.
AJPH
Wendell B. Potter, BS ACKNOWLEDGMENTS I am working on a dental therapy knowledge product for the W. K. Kellogg Foundation, which supports expanding the dental workforce to include dental therapists.
REFERENCES 1. Otto M. For want of a dentist. 2007. Available at: http://www. washingtonpost.com/wp-dyn/content/ article/2007/02/27/AR2007022702116. html. Accessed May 10, 2017. 2. Satcher D. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services; 2000. 3. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services; 2000. 4. Murthy VH. Oral health in America, 2000 to present: progress made, but challenges remain. Public Health Rep. 2016;131:224–225. 5. Nasseh K, Vujicic M, Yarbrough C. A Ten-Year, State-by-State Analysis of Medicaid Fee-for-Service Reimbursement Rates for Dental Care Services. Chicago, IL: American Dental Association; 2014. 6. Wall T, Vujicic M. Emergency Use for Dental Conditions Continues to Increase. Chicago, IL: American Dental Association; 2015. 7. Otto M. Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. New York, NY: New Press; 2017. 8. Minnesota Department of Health; Minnesota Board of Dentistry. Early Impacts of Dental Therapists in Minnesota. Minneapolis, MN; 2014. 9. Myers A. Inslee signs bill to improve dental care for state tribes. 2017. Available at: http://www.seattletimes.com/seattlenews/inslee-signs-bill-to-improvedental-care-for-state-tribes. Accessed May 10, 2017.
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In his 2000 report,2,3 Satcher wrote that the burden of dental and oral diseases affects members of racial and minority groups disproportionately. More than 15 years later, that is still the case.4 Some progress has indeed been made. More children receive dental sealants to help prevent cavities now than in 2000, fewer adolescents have tooth decay, and more adults are retaining their natural teeth. But progress in other areas has been slow, especially among children in low-income families, as former US Surgeon General Vivek Murthy wrote in a 2016 report.4 Here is just one statistic from that report: a fourth of preschoolaged children living in households below the federal poverty level have untreated tooth decay, compared with one in 10 living above the poverty level.4 Among the reasons for the enduring disparities and lack of access are shortcomings that policymakers have not adequately addressed. Although members of Congress included dental care for children among the Affordable Care Act’s essential health benefits, relatively few dentists accept new Medicaid patients—20% or fewer in some states. Medicaid reimbursement rates are considerably lower than are commercial reimbursement rates in most states, ranging in a recent year from 26.7% in
Minnesota to 81.1% in Delaware.5 And instead of narrowing, the difference between Medicaid reimbursement and commercial reimbursement actually widened in all but six states and the District of Columbia over a recent 10-year period.5 In the Medicare program, dental benefits remain very limited. Medicare Part A will pay for certain dental services provided during hospitalization, but routine visits and cleanings are not covered. The Affordable Care Act made preventive medical care a covered benefit but not preventive dental care. It is little wonder, then, why an increasing number of both children and adults are seeking treatment in hospital emergency departments—where the cost is typically much higher than in a dentist’s office—when a toothache becomes unbearable. According to an analysis by the American Dental Association (ADA), the number of dental emergency department visits doubled, from 1.1 million to 2.2 million, between 2000 and 2012. The ADA estimated that by 2012, emergency department
dental visits cost the US health care system $1.6 billion annually, with an average cost of $749 per visit.6 There are other costs of America’s continuing silent epidemic of dental disease. People with diseased and missing teeth are at a disadvantage when applying for employment. Pregnant women with untreated decay can pass disease on to their unborn children. Toothaches also contribute to children missing school and parents missing work.7 The ADA and state dental societies lobby lawmakers to increase Medicaid reimbursement, but few states have done so. What many lawmakers are showing more interest in are solutions that do not require government spending and that have the additional benefit of creating jobs. Programs to improve access by strengthening the oral health workforce at little or no cost to taxpayers are under way in several states. They are to a certain extent the fulfillment of Murthy’s recommendations to expand the capabilities of existing providers and to promote models that incorporate other clinicians. The ADA, which maintains that there are enough dentists in the United States but acknowledges that many areas are underserved, launched a pilot project in 2006 to train
ABOUT THE AUTHOR Wendell B. Potter is with To Be Fair, Inc., Philadelphia, PA, and Tarbell.org. Correspondence should be sent to Wendell B. Potter, To Be Fair, Inc., 601 Walnut Street, Suite 1200W, Philadelphia, PA 19106 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted April 5, 2017. doi: 10.2105/AJPH.2017.303832
AJPH
Supplement 1, 2017, Vol 107, No. S1
AJPH PERSPECTIVES
community dental health coordinators. Community dental health coordinators, whose focus is education and prevention, are currently working in nine states. Paul Glassman, director of the Pacific Center for Special Care at the University of the Pacific, has pioneered a dental telehealth project featuring a collapsible dental chair and other portable equipment that enable dental hygienists to examine patients in schools and other locations and transmit x-rays via a laptop computer to a dental office. The project is being piloted in several locations. Several other states and tribal communities have broadened or are considering broadening the dental workforce to include midlevel providers, often called dental therapists, whose scope of practice is considerably broader than is that of the community dental health coordinators. Although dental therapists practice in at least 50 countries (starting in New Zealand in the 1920s), they are relatively new to the United States. Alaska Native communities were the first to use them in this country. Dental disease had become so prevalent among Alaska Natives, most of whom live far from a dentist’s office, that tribal leaders decided in 2004 to see if dental therapists—or dental health aide therapists, as they are called in Alaska—could make a difference. More than 30 dental health aide therapists are now providing care to 45 000 people in 81 communities. As elsewhere, they work as part of a broader dental team and are supervised by dentists. Their scope of practice ranges from education and prevention to uncomplicated extractions and fillings. When a patient requires care beyond their scope of practice, they refer the patient to a dentist.
Supplement 1, 2017, Vol 107, No. S1
Dental therapists began practicing in Minnesota in 2009. The Minnesota Department of Health noted in a 2014 report that the state’s dental therapists were providing quality care to predominantly low-income, uninsured, and underserved patients.8 Maine and Vermont are the most recent states to allow dental therapists to practice, and several other states may soon follow suit. In February, the Washington legislature approved a bill to allow the 29 Native American tribes in the state to use them.9 The Swinomish Native American community did not wait for the state to act. Swinomish leaders exercised tribal sovereignty in early 2016 and recruited one of the Alaska-trained dental health aide therapists. His presence on the team enabled the Swinomish dental clinic to see 20% more patients last year than in 2015 and reduced wait times from three to four months to less than three to four weeks. Legislation authorizing dental therapists to practice has received bipartisan support and usually has both Democrats and Republicans as sponsors. A growing number of dentists have become dental therapy champions, but the ADA and state dental societies have, for the most part, remained opposed. That appears to be changing. In New Mexico, the state dental association is working with advocates and lawmakers on a bill that would allow dental therapists to practice in that state. Dental societies in other states should do the same. Strengthening and expanding the dental workforce, by broadening the capabilities of existing providers and encompassing new clinicians like dental therapists, can make a big difference in access—and in the lives of millions of people—at little cost to taxpayers.
AJPH
Wendell B. Potter, BS ACKNOWLEDGMENTS I am working on a dental therapy knowledge product for the W. K. Kellogg Foundation, which supports expanding the dental workforce to include dental therapists.
REFERENCES 1. Otto M. For want of a dentist. 2007. Available at: http://www. washingtonpost.com/wp-dyn/content/ article/2007/02/27/AR2007022702116. html. Accessed May 10, 2017. 2. Satcher D. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services; 2000. 3. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services; 2000. 4. Murthy VH. Oral health in America, 2000 to present: progress made, but challenges remain. Public Health Rep. 2016;131:224–225. 5. Nasseh K, Vujicic M, Yarbrough C. A Ten-Year, State-by-State Analysis of Medicaid Fee-for-Service Reimbursement Rates for Dental Care Services. Chicago, IL: American Dental Association; 2014. 6. Wall T, Vujicic M. Emergency Use for Dental Conditions Continues to Increase. Chicago, IL: American Dental Association; 2015. 7. Otto M. Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. New York, NY: New Press; 2017. 8. Minnesota Department of Health; Minnesota Board of Dentistry. Early Impacts of Dental Therapists in Minnesota. Minneapolis, MN; 2014. 9. Myers A. Inslee signs bill to improve dental care for state tribes. 2017. Available at: http://www.seattletimes.com/seattlenews/inslee-signs-bill-to-improvedental-care-for-state-tribes. Accessed May 10, 2017.
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