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Why are dental therapists good for both dentists and underserved patients?

By Frank Catalanotto, DMD, University of Florida, College of Dentistry

Dr. Frank CatalanottoWhen I introduce myself to discuss dental therapy, I like to say that I’m a recovering pediatric dentist. I was the typical dental faculty member, then the Dean of the University of Florida’s College of Dentistry where I’m proud to say that more women and minorities enter UF’s College of Dentistry than ever before. And our progress has been recognized by our 2016 HEED Award and our Summer Health Professions Education Program (funded by the Robert Wood Johnson Foundation) that just started accepting applications for 2017. I absolutely believe we need more young dentists who reflect our nation’s population – and we want them to choose to serve communities that don’t currently have the oral health care they so desperately need.

The reality is that the current U.S. dental care delivery system is broken for the approximately 190+ million people* who cannot access care for a variety of reasons. We must examine the reasons and look at a variety of solutions or approaches to address the problem. The other reality is Dental Therapy is one of the evidence-based approaches that appears to be working.

When dental therapist critics rattle through their concerns about safety, quality and effectiveness, I have a standard initial response:“Doctor, I understand how you feel about dental therapists. But, can you provide me any published evidence that demonstrates that dental therapists are not technically competent for the procedures they perform or that they are unsafe or ineffective in doing what they do in providing oral health care to patients?” Then, I stop talking and await the answer. I’m usually greeted by deafening silence or a bit more bluster!

“There is no question that dental therapists provide care for children that is high quality and safe. None of the 1,100 documents reviewed found any evidence of compromise to children’s safety or quality of care. Given these findings, the profession of dentistry should support adding dental therapists to the oral health care team.”

– Dr. David Nash
A Review of the Global Literature on Dental Therapists
April 2012

Dental therapists are safe, qualified dental professions who work under the supervision of a dentist. Many dentists worry about the relatively short training of dental therapists (2-3 academic years vs. a dentist’s 8 years) but the scope of practice of a dental therapist includes only about 50 procedures . And for those procedures, they learn them at the same skill and quality level as a dentist. In fact, they may do more of these procedures while in school than a dental student might do.A dentist’s scope of practice includes roughly 500 billable procedures. And now, after years of discussion and debate, the Commission on Dental Accreditation (CODA) has adopted Educational Accreditation Standards for Dental Therapy. (CODA serves the oral health care needs of the public through the development and administration of standards that foster continuous quality improvement of dental and dental-related educational programs.)

Dental therapists can help dentists provide routine services to more patients, expand their practices, and generate additional revenue. Dentists can oversee dental therapists without being physically present, which offers maximum flexibility when employing dental therapists, whether in the dental office to expand operating hours or in community-based settings.Dental therapists earn lower salaries than dentists, so incorporating them into the team can also help dentists provide more cost-effective care. By delegating some of the routine procedures to these mid-level staff members, dentists can lower their per-unit costs, treat more patients, and generate higher revenue.

We can’t ignore the facts about poor oral health – for adults or children. For adults: employed adults lose more than 164 million hours of work a year related to oral health problems or dental visits; and adults who work in lower-paying industries, such as customer service, lose two to four times more work hours due to oral health-related issues than adults who have professional positions. For both children and adults, it is true that dental diseases are strongly associated with poverty, but we must recognize that children of color are less likely than white children to see a dentist and receive preventive care; Asian, Black, and Hispanic children are less likely than their white peers to have sealants; people of color are more likely than whites to suffer from untreated tooth decay; Black and Hispanic adults have more untreated dental decay; American Indian and Alaska Native Children have the highest rates of untreated decay; and adults and seniors of color are more likely than whites to lose their teeth.

Total charges for dental-related ED visits in FloridaWhat is worse is that deaths from preventable, treatable dental infections – like those of Deamonte Driver and Kyle Willis – are not isolated tragedies! A total of 66 patients died in hospitals over 9-year period in one study. And in another, 101 people who went to the ER for a dental problem died there, with the vast majority having no other presenting conditions.

Many of my dental colleagues agree with the ADA opinion that: “When speaking of access to dental care today, we must consider both the availability of care and the willingness of the patient to seek care.”I do not accept this perspective in light of low oral health literacy, high costs of care and the serious effects of lack of access to care. It is our professional responsibility and ethical commitment to turn need into demand. In order to do so, we must tackle the issues that will turn need for oral care into demand: Why do people not access available dental care? Why is care so expensive? Why aren’t there enough Medicaid/CHIP providers? How do we tackle the maldistribution of our dentists and health professions shortage areas? How and why should we tackle the lack of cultural competency? How can we improve the public’s oral health literacy?

I applaud the efforts of the ADA Health Policy Institute for their work on these issues, but I have two concerns with the data: it does not reflect state or regional differences; and many of us working in the field have doubts about the data’s accuracy. For example, the ADA estimates that about 33% of dentists participate in public assistance programs, yet we know in Florida only 8% of dentists participate in Medicaid.

Many dentists say that diversity, cultural competency and attitudes of the existing dental workforce aren’t important but the data shows otherwise: minority dentists were twice as likely as White dentists to accept Medicaid patients; a dentist’s sense of social responsibility is influenced by economics, professionalism, individual choice, and politics; there’s a social stigma attached to being a Medicaid provider; and dentists who are Medicaid providers are more altruistic than non-providers.

ethnic and racial diversity among dentists does not mirror that of the US population

Oral health literacy is also a problem because the public’s lack of knowledge is leading to a lack of care. The ADA Health Policy Institute developed a new, simplified measure of oral health knowledge. Nationally, (only) 50 percent of adults were able to respond correctly to each of the eight general knowledge questions regarding oral health facts. This ranges from 42 percent in New Jersey to 60 percent in Colorado and from 44 percent among low-income adults to 52 percent among high-income adults nationwide. Other literature supports this concerning lack of oral health literacy.

The bottom line is that organized dentistry is still fighting dental therapy but the training and employment of dental therapists are coming anyway because it’s good for patients and dentists. Educational programs that train dental therapists in Alaska and Minnesota are improving access to care for underserved populations. And now that legislation that creates a pathway to train dental therapists has passed in Maine and Vermont, we will soon have more data to prove their value. Legislation is pending or being discussed in Arizona, Massachusetts, Connecticut, South Carolina, Michigan, North Dakota, Oregon, Washington, New Mexico, North Dakota, Texas, Ohio and New Hampshire.

The existing data on the quality of work done by dental therapists is unequivocal, and confirms the quality for a set number of procedures is equal to that of a dentist. There are not two standards of care as many fear. If we consider ourselves an evidence-based profession, and we read the literature about dental therapy, we must draw this conclusion. To not do so would violate the ethical principle of veracity.We must also look at the principle of justice – treating patients fairly and working with allies in society to assure access to care. Dental Therapy offers a path to quality, expanded care for our communities. It is as simple and as important as that.

* This 190+ million total is extrapolated from a number of sources including HRSA, Kaiser Family Foundation and the ADA Health Policy Institute.

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