Dental Therapists’ Impact on Access to Care and Oral Health Equity
Frank Catalanotto, DMD; and Lawrence F. Hill, DDS, MPH
Dental therapists (DTs) have been treating patients in the United States since 2004, and the evidence is unequivocal. DTs provide safe, high-quality, cost-effective care to thousands of patients.1-3 Presently, 12 states have authorized DTs, and an additional eight states are pursuing legislation to bring these professionals to the oral healthcare team.4,5 One might wonder why these numbers are not higher if DTs are such a great asset. In every state legislative battle, there are usually more than 50 bipartisan organizations that support dental therapy legislation and only one organization, the American Dental Association and its state affiliates, that opposes it. The ADA is effective at lobbying and using political action committee dollars in its conversations with legislators.
The ADA recently issued a statement indicating that dental care is essential healthcare,6 which, of course, is true. The value of oral health to normal everyday functions, such as eating and speech, is obvious. In recent years the impact of poor oral health on systemic health, along with its significant economic effect on this country, has been made much clearer.7 The major impediment to accessing oral healthcare is cost.8 This is where DTs can have an impact. Because DTs can be educated and employed much less expensively, they can help deliver basic dental services more economically, lowering the costs of delivering quality dental care. This is clearly documented in recent reports from both Alaska and Minnesota.1,2,8,9
The utilization of DTs can positively affect oral health equity. Racial, ethnic, and socioeconomic disparities exist in access to dental care and oral health.10 One concern about DTs that some may have is the quality of care they are capable of providing, and whether or not this is creating a two-tier system. In 2015, the Commission on Dental Accreditation, the same body that creates and monitors standards for the education of dentists and dental hygienists, published standards for the education of DTs.11 The scope of service by DTs meets the most basic and fundamental needs of the underserved, including oral assessments, routine restorations, and, in some cases, simple extractions. All of their service is done under the direct or remote supervision of licensed dentists who determine which services within the legal scope the dentist is comfortable providing via a therapist. Numerous reviews of the quality of this limited scope of service have demonstrated it to be equal to that of dentists.1-3 Thus, dentistry is actually expanding a one-tier system of care to those patients who have previously lacked access.
Evidence that DTs actually expand access is demonstrated in a 2018 evaluation of community-level dental outcomes associated with DTs in Alaska's Yukon-Kuskokwim Delta, where DTs were associated with more preventive care and fewer extractions. DTs have expanded care to more than 40,000 Native Alaskans.9 In Minnesota, several reports of the Minnesota Board of Dentistry attest that DTs shorten waiting time and travel time for appointments.8 DTs are proportionately geographically distributed in both metropolitan and rural areas of the state, practicing in federally qualified health centers, hospitals, schools, Head Start programs, community centers, Veterans Affairs hospitals, and nursing homes.8
The utilization of DTs can improve access and facilitate a financially viable alternative for low-income and Medicaid-enrolled patients. Numerous case studies demonstrate that the use of DTs in the aforementioned programs enabled significantly increased access to care along with both increased productivity and earnings. More people receive dental care at a lower cost. An early study from Minnesota reported the impact of DTs in two private practices,12 and a more recent study provided a detailed analysis of the significant impact of DTs in a large not-for-profit organization.13 In all cases, the practices were able to expand their care of low-income and Medicaid-enrolled patients, provide cost-effective care that actually produced a financial profit in the private practices, and allowed the hiring of additional dentists and DTs in the not-for-profit firm.
In short, dental therapy is a cost-effective way to increase access to care for low-income, Medicaid-enrolled, and other vulnerable populations. There is now model legislation that can direct states regarding how to pass appropriate laws to implement dental therapy.14 Based on the evidence, the authors urge dentists, health advocacy organizations, and policymakers to ignore the misinformation being spread about dental therapy and enact legislation implementing its use now.
The authors wrote this article on behalf of the National Coalition of Dentists for Health Equity. The viewpoints they have expressed are their own and do not necessarily reflect the official viewpoints of any other organizations with which they are affiliated.
1. Project Dental Campaign. Pew website. https://www.pewtrusts.org/en/projects/dental-campaign. Accessed April 5, 2021.
2. Dental Access Project. Community Catalyst website. https://www.communitycatalyst.org/initiatives-and-issues/initiatives/dental-access-project. Accessed April 5, 2021.
3. Catalanotto F. In defense of dental therapy: an evidence-based workforce approach to improving access to care. J Dent Educ. 2019;83(2 suppl):S7-S15.
4. American Dental Hygienists' Association. Expanding Access to Care through Dental Therapy. September 2020. https://www.adha.org/resources-docs/Expanding_Access_to_Dental_Therapy.pdf. Accessed April 5, 2021.
5. Simon L, Donoff RB, Friedland B. Dental therapy in the United States: Are developments at the state level a reason for optimism or a cause for concern? J Public Health Dent. 2021;81(1):12-20.
6. Statement on dentistry as essential health care. American Dental Association website. August 10, 2020. https://www.ada.org/en/press-room/news-releases/2020-archives/august/statement-on-dentistry-as-essential-health-care. Accessed April 5, 2021.
7. Alfano MC. The economic impact of periodontal inflammation. In: Glick M. The Oral-Systemic Health Connection: A Guide to Patient Care. 2nd ed. Batavia, IL: Quintessence Publishing; 2019:357-368.
8. Oral Health Workforce Reports. Minnesota Department of Health website. https://www.health.state.mn.us/data/workforce/oral/index.html. Accessed April 5, 2021.
9. Chi DL, Lenaker D, Mancl L, et al. Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta. J Public Health Dent. 2018;78(2):175-182.
10. Racial Disparity in Dental Care. The Numbers Tell the Story. Dentistry.com. https://www.dentistry.com/articles/racial-disparity-in-dental-care. Accessed April 5, 2021.
11. Commission on Dental Accreditation. Accreditation Standards for Dental Therapy Education Programs. Chicago, IL: CODA; 2015. https://www.ada.org/~/media/CODA/Files/dental_therapy_standards.pdf?la=en. Accessed April 5, 2021.
12. The Pew Charitable Trusts. Expanding the Dental Team. February 2014. https://www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2014/expandingdentalteamreportpdf.pdf. Accessed April 5, 2021.
13. Center for Health Workers Studies. The Contributions of Dental Therapists and Advanced Dental Therapists in the Dental Centers of Apple Tree Dental in Minnesota. August 2020. https://www.chwsny.org/wp-content/uploads/2020/09/CHWS_Contributions_of_DTs_ADTs_at_Apple_Tree_Dental_2020.pdf. Accessed April 5, 2021.
14. National Dental Therapy Standards Consortium. National Model Act for Licensing or Certification of Dental Therapists. January 2019. https://www.dentaltherapy.org/resources/file/Dental-Therapist-National-Standards-Report-and-Model-Act_FINAL.pdf. Accessed April 5, 2021.