Fixes looks at solutions to social problems and why they work.
What’s the most common chronic childhood disease in the United States? It’s worth remembering on Halloween that the answer is tooth decay, which is five times more common than asthma and 20 times more common than diabetes.
Tooth decay affects children from all backgrounds, but it’s concentrated among low-income and rural populations, who have the most difficulty accessing and affording dental care. Most dentists in private practice don’t accept Medicaid or public insurance, and tens of million of Americans live in areas with dentist shortages. In 2008, only about a third of children on Medicaid received dental care under the program (PDF). (The elderly and people with disabilities are also badly underserved.) In 2009, untreated, preventable dental problems led to 830,000 emergency room visits.
The United States health care system has many absurdities, but one of the craziest is that it treats the mouth as if it were disconnected from the rest of the body. It’s easier, and more affordable, to get treated for an infection in, say, the toe.
From a health perspective, this makes no sense. “Your mouth is an essential human organ system,” said Leon A. Assael, dean of the School of Dentistry at the University of Minnesota. “And tooth decay will destroy it through an infectious process that [if untreated] will go deep into the bone of your jaw and spread into your blood stream with potentially negative systemic consequence.” Dental disease is connected to many health problems and is particularly worrisome for pregnant women and diabetics.
One approach gaining momentum in the United States to extend access to underserved groups is based on an idea that was pioneered in New Zealand 93 years ago, and has been adopted in more than 50 countries. The idea is to train “dental therapists,” who, like dental hygienists, work under the supervision of dentists, but who can also drill teeth and perform non-complex extractions.
So far, in the United States, dental therapists provide care in three states. In Alaska, they work in 80 villages, serving about 40,000 Alaska Natives on tribal lands. “Most of them didn’t have a dental provider working or living in their communities previously,” said Mary Williard, a dentist who heads the Dental Health Aide Training Program for the Alaska Native Tribal Health Consortium. In 2009, Minnesota authorized the training of dental therapists to serve predominately low-income patients. Maine recently followed suit.
The American Dental Association has resisted the idea for decades, arguing that it doesn’t make economic sense and will consign some people to second-class care. “I always smile when I hear the term ‘simple extraction,’ ” said Maxine Feinberg, the association’s president. “I’ve been a dentist for a long time and one never knows what’s going to happen with an extraction.”
However, researchers have found dental therapy to be safe and reliable, particularly for treating children, whose care is less complex than that of adults. “The evidence internationally is that you can provide outstanding care to children with dental therapists in school-based programs,” said David A. Nash, a professor of dental education at the University of Kentucky, and a lead author of a major report on the practice (PDF). Two reports released this summer by the Pew Charitable Trusts also suggested that dental therapists were cost-effective in public clinics and private dental offices.
More than a dozen states are now exploring the model, part of a general trend in medicine to broaden access to care and rein in costs by reducing the dependency on specialists for care that can be well managed by others. “When you look at the advent of nurse practitioners, and physician assistants, and even dental hygienists, there’s always resistance initially,” said Shelly Gehshan, director of children’s dental policy at the Pew Charitable Trusts. “But after a couple of years it fades. Once five or six states authorize dental therapists, it will hit a tipping point. It’s really a question of when it will become part of the dental system, not if.”
Among proponents of dental therapy, there is one key area of disagreement. Globally, dental therapists have mainly been placed in schools, and some researchers recommend that the United States remain faithful to this model. “This is really the only place where dental therapy has truly been proven economical and effective,” said Jay W. Friedman, a dentist and leading researcher who has studied the subject extensively. “And children should receive priority consideration. They are basically ‘non-ambulatory.’ If you don’t have someone take them to a dentist, then you have to bring the dental care to them.”
In the United States, by contrast, dental therapists are being placed in public clinics, private practices and federally qualified health centers, and they are permitted to treat adults as well as children. The AARP supports dental therapy to improve care for elderly people, whose need is also great.
In Alaska, after two years of post-secondary training, therapists may see patients on their own. Their supervising dentists are often a long way away, reachable by plane, boat or snowmobile (see this map). Despite this fact, studies suggest that their care is effective and in line with their expertise (PDF).
“The studies showed that the therapists were providing services that were appropriate and weren’t doing things that didn’t need to be done,” Williard said. “They were making good judgment calls and practicing less invasively.”
One advantage is that the therapists come from the Alaska Native communities they serve; they can connect better with patients and are more likely to continue to live among them. (Dentists from minority groups are more likely to treat minority patients, but the vast majority of dentists are white.) “The therapists also study how to do motivational interviewing techniques to help patients change their behaviors,” Williard said. “In the stores, the kids see them and say, ‘Oh no, the therapist is here. I shouldn’t buy this soda pop.’ Those kinds of things are hard to quantify but are really important.”
In Minnesota, the state legislature has created two dental therapist roles — a four-year bachelor’s degree and a two-year master’s degree — and providers are required to practice as part of a team, with a dentist in the office. To date, 42 therapists have received licenses and 35 are employed. The state’s early impact study reported that they were, as intended, serving thousands of new, predominantly low-income and uninsured patients, practicing safely, lowering costs, and improving patient satisfaction.
The People’s Center Health Services, a federally qualified health center in South Minneapolis, provides care primarily to immigrants from Somalia and Ethiopia. It has two dental therapists and is looking to bring on a third. “They’re a tremendous resource,” explained Ashley Johnson, the center’s chief dental officer. “With the Affordable Care Act, we have more people flooding in. Many have never had dental care before. A lot of kids come in with rampant dental decay. The therapists are able to do quite a bit of dental work and allow the dentists to focus on patients who have more complex problems, like root canals and implants.”
“Due to low reimbursement rates, dentists cannot afford to treat tooth decay in most practices in Minnesota for patients on public assistance for whom the reimbursement is just 38 percent of usual fees,” said Leon Assael of the University of Minnesota’s School of Dentistry, one of two schools in the state to train dental therapists. “Dental therapists reduce the unit cost of care by treating patients with dental decay on public assistance who would not otherwise be seen in the dental practice.”
And for some ideas on how children can enjoy Halloween fun and keep their mouths healthy, see this advice from the American Academy of Pediatric Dentistry.
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David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.