Dental Therapy Seen as a Best Practice for Boosting Access to Care

State policymakers should consider dental therapy a best practice when assessing how to boost access to oral health care for underserved populations, according to a recent report by the Association of State and Territorial Dental Directors (ASTDD).

The association, a national nonprofit organization representing directors and staff of state-based oral health programs, publishes reports on best practices to provide examples of effective evidence-based public health strategies. The most recent report includes illustrations of successful workforce development initiatives that can improve the accessibility and availability of oral health services.

Although many states have made significant progress, access to regular dental care remains a pressing issue for millions of Americans. Numerous factors and barriers affect individuals’ ability to access care. The report focuses on one critical aspect of this problem: the capacity of the oral health workforce and its ability to increase access to care and serve a diverse population. ASTDD emphasizes the need to reform current dental delivery systems to meet the demand, including implementing approaches that allow greater flexibility with scopes of practice and alternative models that expand oral health teams.

The report highlights practice examples from five states, including two that successfully use dental therapists to improve access to care. Under the supervision of a dentist, these midlevel providers perform preventive and routine restorative care services such as filling cavities, placing temporary crowns, and extracting severely diseased or loose teeth. 

The ASTDD analysis specifically refers to Apple Tree Dental and Children’s Dental Services (CDS), two nonprofit dental providers in Minnesota. They were early champions of the dental therapy model and were integral in that state’s move in 2009 to authorize dental therapists to practice.

Apple Tree and CDS both serve vulnerable individuals and families. The vast majority of their patients receive coverage through Medicaid, which reimburses at lower rates than commercial insurance plans.  This can make it difficult for providers serving a large population of Medicaid patients to stay financially solvent.

But the annual employment cost for a dental therapist averages at least $50,000 less than the cost of a dentist. The integration of these midlevel providers into their clinical dental teams has helped Apple Tree and CDS efficiently increase access for underserved populations.

Both organizations deliver care to people who face barriers to service in a traditional dental office, such as transportation or mobility issues, residence in a remote area, or an inability to find providers who accept public insurance. In addition to their offices, the providers also offer services in satellite locations, such as Head Start centers, schools, and other community-based locations.

From 2012 through 2018, dental therapists employed by Apple Tree provided over 58,000 dental visits. Practice officials estimate that therapists dispensed over $11 million in dental services. CDS dental therapists, meanwhile, served 12,000 patients in 2018.

Dental therapy is one strategy that states can explore to help expand care to wider populations. The report also highlights these workforce policies and strategies as examples of best practices:

• California implemented the Virtual Dental Home in 2009. This community-based delivery system uses telehealth services, which include digital information and telecommunication technologies, so that dental hygienists and dental assistants providing care in community settings can connect and consult with dentists in traditional practices.
• Louisiana conducted a comprehensive oral health workforce assessment in 2018. That effort synthesized data on social, economic, and health indicators, examined existing oral health programs, and surveyed and interviewed a broad range of stakeholders, including dentists, physicians, dental hygienists, school nurses, and public health administrators. The assessment included recommendations for how the entire health care community can better address oral health needs.
• Maryland implemented the Maryland Dent-Care Loan Assistance Repayment Program in 2000. To qualify, participating dentists must commit to maintaining a patient base that includes a minimum of 30 percent Medicaid beneficiaries for three years.
• Vermont in 2014 convened a work group—run by the Department of Health and the state Medicaid agency—to develop recommendations on how to increase access to dental services for adults insured by Medicaid. One strategy that grew out of that effort was enrollment of dental hygienists as Medicaid providers to expand the availability of preventive oral health care.

Jane Koppelman is a senior manager and Allison Corr is an officer with The Pew Charitable Trusts’ dental campaign.