Advancing New Workforce Models

Deamonte Driver would have turned 20 this year—had he received care for an untreated tooth abscess. He could have been starting his senior year in college—had there been enough dentists who accepted Medicaid in his Maryland town. But Deamonte died 8 years ago because of the continuing, if not worsening, shortage of dental practitioners in low-income communities and communities of color.

Deamonte’s death in 2007 at age 12 made headlines across the country. Many of us at the W.K. Kellogg Foundation (WKKF) were terribly saddened when we read about Deamonte, but we weren’t shocked. WKKF has been keenly aware of America’s dental access crisis for decades, which is why the foundation has made more than 400 grants over the years to promote oral health in general and to help ensure that children can receive the care they need. Many of our recent grants have gone to organizations in states that are working to expand the dental workforce to include additional professionals willing to treat patients in underserved areas.

We’ve believed from the beginning that a community’s oral health needs can be addressed best by a team of professionals working within their respective scopes of practice. Will Keith Kellogg himself talked about the importance of “extending the number of dentists’ hands”—especially in communities where few, if any, dentists practiced—because he witnessed the consequences of an inadequate oral health care workforce. Dentists were few and far between in many of the counties surrounding Battle Creek, Michigan, where Kellogg started the cereal company and the foundation that would bear his name. The first project undertaken by his new foundation in the 1930s was the Michigan Community Health Project, a comprehensive program designed to improve all aspects of the lives of children living in seven counties in south central Michigan. As part of this public health program, children received an annual dental exam in their schools.

With that history in mind, WKKF staff was intrigued by a request for funding from the Alaska Native Tribal Health Consortium (ANTHC) in 2006, to help extend dentists’ hands. Because of the scarcity of dentists in most parts of Alaska, dental disease had reached crisis proportions in Alaska Native villages. Tribal leaders had tried several approaches to improving oral health in their communities, all to no avail. They ultimately concluded that midlevel practitioners, or dental therapists, might make a difference, just as they have in more than 50 other countries.

With initial funding from the Rasmuson Foundation, the ANTHC sent the first group of students to the University of Otago in New Zealand for an intensive 2-year educational program. Dental therapists have been working in New Zealand for nearly 100 years. Those first five students were pioneers in dental therapy in the United States. When they returned to Alaska, their impact on the oral health of the villages they served was immediate and dramatic.

The ANTHC applied for funding from the WKKF to start an educational program in Alaska. Ultimately, WKKF provided a multiyear grant that enabled students to receive training in Anchorage and Bethel through a training program—modeled after the one in New Zealand—provided by the University of Washington School of Medicine.

Dental therapists are trained to provide a limited scope of routine dental services, including:

• Preventive care such as patient instruction, oral health outreach, and screenings
• Dental exams, X-rays, and fluoride treatments
• Prophylaxis and placement of sealants
• Some fillings and extractions

There are now 27 certified dental therapists, called dental health aide therapists—or DHATs—in Alaska, serving 45,000 people in 81 communities. On average, a DHAT sees 800 unique patients per year in more than 1,200 visits. More than 700 of those visits are now preventive in nature.

The results have been so impressive that WKKF began considering requests from community coalitions to explore dental therapy models in the lower 48 states. Before making a final decision, WKKF, Rasmuson, Murdoch, and Bethel Community Services foundations contracted with the Research Triangle Institute (RTI)—an independent, nonprofit institute that provides research, development, and technical services—to evaluate the Alaska dental therapy workforce model. RTI’s 2010 report found that DHATs are providing safe, effective dental care, and that patients are highly satisfied with the care they receive.

Minnesota became the first state to authorize the training and licensure of dental therapists. A 2014 evaluation by the Minnesota Department of Public Health found results similar to those in Alaska—the 32 dental therapists practicing in Minnesota at the time of the evaluation were providing safe and effective care and making significant improvements in access to care in rural and low-income communities.

The RTI report and others have given momentum to the dental therapy movement in the US. Several states are considering the expansion of the dental workforce. This expansion most certainly includes dental hygienists. In fact, some states are considering proposals in which the access-to-care problem is addressed by broadening the scope of practice for dental hygienists. In California, a new law allows dental hygienists to place low-cost, temporary fillings and to treat caries without direct supervision. Dental hygienists are also an integral part of a new teledentistry initiative being piloted in the state that enables them to work remotely under the general supervision of a dentist after the completion of additional training.

These and other models are part of a multipronged effort to end the disparities in dental care that prevent children from thriving. Dental therapists and dental hygienists, with additional tools and training, are ideally suited to extend dentists’ hands in communities where they are in short supply and the demand for dental care continues to grow. We’re confident that this expanded workforce will soon make tragic stories like Deamonte Driver’s a thing of the past.

ABOUT THE W.K. KELLOGG FOUNDATION

The W.K. Kellogg Foundation (WKKF), founded in 1930 as an independent, private foundation by breakfast cereal pioneer Will Keith Kellogg, is among the largest philanthropic foundations in the United States. Guided by the belief that all children should have an equal opportunity to thrive, WKKF works with communities to create conditions for vulnerable children so they can realize their full potential in school, work, and life.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2015;12(10):28–29.