Expanded dental teams benefit rural, low-income patients, but Oregon bows out

Dentists who make use of dental therapists provide care to more low-income people, including children, who otherwise cannot get dental care. Those dentists also make more money for themselves, according to a new study by the Washington, D.C.-based Pew Charitable Trusts.

But underserved Oregonians and dentists are unlikely to see those benefits anytime soon, say a number of experts. While Oregon’s Legislature adopted a bill in 2011 authorizing pilot projects testing the possibilities for training and using dental therapists, the one local nonprofit that attempted to organize a project says it is turning its attention elsewhere.

Dental therapists are comparable to nurse practitioners, and have been a part of the dental practice for years in a variety of other countries and in Minnesota and Alaska. They generally perform the most mundane dental work under a dentist’s supervision, freeing the dentist to work on the most complicated cases.

In most models, dental therapists are seen as a way to provide basic dental care to low-income Medicaid patients who often cannot find dentists willing to serve them. The federal government reimburses dentists for only about 50 percent of what they bill on Medicaid cases. As a result, few dentists accept a significant number of Medicaid patients, if any.

According to Pew, more than half of Oregon children on Medicaid did not receive any dental care in 2011, the last year for which data is available.

The Pew study analyzed a year’s worth of data for one dentist in a small town in Minnesota and another in Saskatchewan, Canada. At the Minnesota practice, use of a dental therapist led to a 27 percent increase in the number of patient visits. The number of visits by Medicaid patients increased from 26 percent to 39 percent of the practice. Finally, even after subtracting the salary of the therapist, the dentist’s income for the year increased by $23,831.

Minnesota law requires that at least half of the patients served by a dental therapist be underserved, which generally means either low-income or in a rural area with few dentists. At the Minnesota dental practice studied by Pew, 62 percent of the patients treated by the dental therapist were Medicaid patients. All screenings were done by the dentist, but the dental therapist performed the majority of simple fillings and baby tooth extractions. That left the dentist to perform many more root canals, implants and surgical extractions than he otherwise would have been able to.

Though groups that represent dentists, including the Oregon Dental Association, have come out against the training of dental therapists, Shelly Gehshan, director of the Pew Children’s Dental Campaign, says eventually dentists will see the benefits they can accrue by hiring therapists.

“Dentists have been reluctant to accept Medicaid patients because they’re afraid they will lose money,” Gehshan says. “These studies show it could be a good business decision for them.”

Gehshan says dental therapists are the wave of the future. “Eventually all states will have them,” she says. “It’s just a question of when.”

A better solution

But a future with dental therapists does not look so certain for Oregon. Last year the nonprofit Northwest Health Foundation was hoping to spearhead efforts to find a school to train dental therapists as part of a pilot project, but a foundation spokeswoman told the Tribune Thursday that it no longer is involved in the effort. The state’s lone dental school, at Oregon Health & Science University, has said it will not train dental therapists.

State Sen. Laurie Monnes Anderson, a Gresham Democrat who sponsored the bill to authorize dental therapist pilot projects, says she’s disappointed that nobody has stepped forward to start training dental therapists in Oregon.

“Until we can change the culture and get another foundation like the Northwest Health Foundation to put this as a priority, we won’t be able to have a dental therapist pilot in this state,” Monnes Anderson says.

Monnes Anderson says she’s still a fan of the idea. “It would save money for the health care system, it would get more people dental health care, especially youth. All the reasons are there why we should have gone for it, but the stars weren’t aligned,” she says.

The legislation authorizing dental therapist projects did not come with state funding. That means some other organization, most likely a nonprofit, would have to find money not only for the training, but also to fund state oversight of the program.

“It’s really the dental association and the dental board that have to embrace this,” Monnes Anderson says. “They’re very parochial and set in their ways. Health care reform is changing so fast, and I don’t feel they’re keeping up to speed.”

But the Oregon Dental Association takes a different view. According to Jill Price, a dentist and immediate past president of the association, the answer to Oregon’s poor dental environment isn’t dental therapists, but better education. The association, Price says, favors placing community dental health coordinators in underserved communities to promote education on dental issues.

Price says there already are enough dentists and dental assistants in Oregon, but that they are poorly distributed, with an abundance in Portland but too few in rural and poorer communities. The state needs to attract some of them to underserved areas.

“We think there is a better solution,” Price says. “We don’t think putting more people out there to drill and fill is really getting to the root of the problem.”

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