Little effort made to fill dental services gap despite high demand

A new national study promotes the efficiency of dental therapists in delivering care to underserved populations, just as the possibility of dental therapists operating in Oregon appears more remote than ever.

Oregon for years has had one of the nation’s worst records for providing dental care. More than half of children on the Oregon Health Plan, in one study, received no dental care in the course of a year. Another study found that fewer than one in five elderly Oregonians in long-term care saw a dentist. Experts say oral disease can contribute to a host of maladies, including heart disease, and dental pain is the No. 1 cause of children missing school. - Few use food stamps at Farmers Markets

The Washington, D.C.-based Pew Charitable Trusts have been pushing dental therapists as part of the answer. Dental therapists, currently practicing in Minnesota and Alaska and soon coming to Maine, are the dental equivalent of nurse practitioners, who are able to perform some, but not all of a physician’s treatments and often are willing to work in areas where doctors are scarce.

In 2011 the Oregon Legislature adopted a bill authorizing pilot projects to explore the possibilities for training and using dental therapists. And last year, the Legislature authorized $100,000 for a staffing position at the Oregon Health Authority to oversee dental pilot projects.

Nevertheless, nobody in Oregon is currently pursuing a dental therapist pilot project, according to state officials. Officials at the state’s only dental school, at Oregon Health & Science University, say it won’t get involved in training dental therapists, and its dean says training dental therapists is not the best way to address the gap in dental services around the state.

Therapists go untapped

Yet the evidence for dental therapists as part of the solution is persuasive. The Pew study found that a dental therapist hired by a safety net medical clinic in Minnesota conducted 1,756 patient visits for a population of people who were mostly low-income immigrants. Medicaid payments made to the therapist exceeded the costs of employing her by more than $30,000, leading the clinic to hire a second dental therapist.

In Alaska, two dental therapists provided care to 1,352 patients, many of whom previously had not had access to dental care. Those two therapists generated $216,000 in net revenue.

The Pew study noted that millions of U.S. citizens simply don’t have access to dental care. Most dentists will not see Medicaid patients because reimbursement is low. In addition, many people in rural areas and in low-income urban neighborhoods do not have dentists nearby.

Dental therapists are viewed by Pew as a solution, once they receive training at dental schools to perform basic dental care, including drilling and filling cavities. Supervised by a dentist, they can actually boost the dentist’s income as they free the dentist to perform more sophisticated and expensive surgeries, according to a previous study.

State Sen. Laurie Monnes Anderson, D-Gresham, sponsored the bill to authorize dental therapist pilot projects in Oregon, and says she is disappointed that neither nonprofits nor the dental school have stepped forward to train therapists. The Oregon Dental Association and the American Dental Association have opposed state licensing of dental therapists.

“I really think there’s a fear of market share,” Monnes Anderson says. “That’s the story all the way around. Without the dentists having full control over what should be done, there is a fear that oral health will go out of the hands of dentists, which I know will never happen.”

Dr. Phillip Marucha, dean of the OHSU school of dentistry, says Oregon dentists simply have a different view of how best to get dental care to those Oregonians who don’t currently receive it. Marucha envisions providing a few weeks of advanced training to the state’s many dental hygienists, and says that represents a better alternative than taking two years to train dental therapists.

Dental needs change

Marucha says that in the future, there will be much less need for traditional responses to cavities, and dental hygienists will be better able to handle a wider range of problems. “We’re moving away from drilling teeth and more like treating (decay) like a chronic disease,” he says.

Marucha says new therapies that scoop out decayed tooth structures and fill cavities using tooth-colored materials and sealants are becoming more popular, and dental hygienists can be trained to perform those procedures. Hygienists cannot legally use drills, needed in traditional approaches to filling cavities.

Marucha says he’s hoping to help start a pilot program at the dental school in which hygienists can be trained in the scoop-and-fill treatments and says using hygienists for the program makes sense.

“They don’t need a lot of advanced training because they’re already working in the mouth,” Marucha says.

Marucha also supports a new idea being tested in California called a Virtual Dental Home, in which low-income residents receive dental education and preventive care from hygienists who collaborate with dentists through telemedicine systems.

But that simply isn’t enough to help the nearly one in three Oregonians who receive no regular dental care, says Dr. Leon Assael, dean of the University of Minnesota School of Dentistry, the only dental school in the United States that currently trains dental therapists. Prior to becoming dean at the University of Minnesota, Assael spent nine and a half years at the OHSU dental school and was chairman of OHSU’s department of oral and maxillofacial surgery.

Money at root

In Assael’s view, hygienists, even with extra training, cannot perform the dental work needed by thousands of Oregonians who have no other access to dental care. Scooping and filling techniques, he says, are a solution for only about a third of patients with cavities. The rest need and will continue to need traditional drilling and filling.

Assael says Oregon’s problem in providing dental care to its residents mostly comes down to money.

He says dentists are making significantly less money than they did five years ago, from a national average of about $450,000 per year to just more than $200,000 per year. That helps explain why they won’t take low-reimbursement Medicaid patients.

Last year, Assael says, just more than one in three U.S. residents saw a dentist, a dangerously low figure. Some of that, he says, is due to a lack of dentists in key areas, but the greater reason is that many people do not have dental insurance coverage and cannot afford to pay out of their own pockets. He says he observed many people in Oregon nursing homes with deteriorating teeth, which can lead to other health problems ranging from weight loss to life-endangering infections.

“You’ve got dental demand down and dental disease is up,” he says. “This is a perverse state of affairs.”

Assael says he has seen dental therapists fill a great need in Minnesota, primarily by drilling and filling cavities for much less than dentists charge. Minnesota’s dental therapists, in fact, are required to take on low-income patients.

On average, according to Assael, Minnesota dental therapists are earning between $50,000 and $75,000 a year. They don’t take business away from dentists, he says, because they’re mostly working with patients dentists won’t take.

“Dental therapy is the greatest vehicle we’ve come up with to deal with the problem of untreated tooth decay from the standpoint of access,” Assael says. “It’s great to teach people how to scoop and fill, but it’s not the treatment of dental (decay). To say that all of it is, is silly.”

Assael’s take on why Oregon dentists oppose the authorization of dental therapists? “They’re afraid to give them a drill,” he says. “It’s a matter of professional identity and economics.”

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