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Dispelling Myths About Dental Therapy

Dental therapy legislation keeps moving across the country with 13 states and several Tribal nations implementing this member of the oral health workforce. Dental therapists are working in Tribal clinics in Washington, Oregon, and Idaho.1,2 New dental therapy educational programs are also being developed in addition to the original programs in Alaska and Minnesota. The educational program in Alaska is now approved by the Commission on Dental Accreditation (CODA), and other programs are preparing for CODA accreditation. Peer-reviewed reports are documenting dental therapy’s improved health outcomes, high quality, safety, cost-effectiveness, and patient and employer satisfaction.3–10

Despite myriad success stories, some detractors continue to misrepresent data supporting the effectiveness of dental therapy. Following is a rebuttal to the most commonly spread false statements to better prepare advocates to defend dental therapy.

Myth: Dental therapists are insufficiently trained to provide safe, quality dental care

More than 1,000 studies on dental therapists in 26 countries, including the US, demonstrate dental therapists provide care at a level of quality equal to dentists for the procedures they have in common.11 Evaluations from Alaska found no evidence that restorative treatments provided by dental therapists differ from similar treatments provided by dentists.12–18 A systematic review by the American Dental Association (ADA) Council on Scientific Affairs concluded that well-trained dental therapists provide high-quality treatment, including restorative care.19

The Minnesota Board of Dentistry has not disciplined or required corrective actions on any licensed dental therapist due to quality or safety concerns. Neither have any claims been filed against dental health aide therapists in Alaska.

Malpractice insurance rates for dental therapists in Minnesota are less than $100 a year, similar to that of dental hygienists and significantly lower than that of dentists. Insurance companies acknowledge that dental therapists’ limited scope of practice poses less risk than dentists’ broader scope of practice.

In 2015, CODA issued standards for dental therapy training programs.20 With its charge to protect public safety, CODA would not have developed the standards in the absence of compelling evidence that dental therapists can be trained to provide the same level of safe, quality care as dentists.

Myth: Dental therapists have not increased access to care

Alaska dental therapists have provided dental care to more than 40,000 Alaskans, and the oral health outcomes after 12 years show improvements in oral health.5–8,10 All reports about Minnesota dental therapists demonstrate increased access to care.7–9,12–17,20–23

Some claim that Minnesota dental therapists are not improving children’s access to care, as evidenced by the declining portion of children covered by Medicaid receiving dental care in the state. This is a misrepresentation of the data. The numbers demonstrate that between 2010 and 2019, the number of children covered by Medicaid receiving dental care by dentists increased by 67,532, an increase of 5% over the decade. It is true that during the intervening years, the utilization rate decreased slightly because the number of children actually covered by Medicaid increased significantly, hiding the surge in the numbers of children receiving dental services.

The number of dental therapists in Minnesota is tiny compared to the oral health workforce—about 120 at the time vs more than 4,000 dentists.23 Such a small cohort “cannot yet produce statistically valid changes in statewide or regional access,” to quote a letter from Minnesota Health Department officials to Wisconsin legislators. But the evidence is clear that dental therapists are making a difference. A recent study of Appletree Dental, a large Minnesota not-for-profit, demonstrates a significant increase in services provided after it hired a number of dental therapists.10

Myth: Minnesota dental therapists have been concentrated only in urban areas

First, the legislation authorizing dental therapy did not stipulate that they could only work in rural areas. The only requirement was that at least 50% of their patients were classified as underserved or that they were working in a dental health professional shortage area. Furthermore, in Minnesota, more than a quarter of the state’s dental shortage areas are in the Twin Cities, an urban area.24

In addition, dental therapists are geographically distributed in proportion to the state’s population. Approximately 55% of Minnesotans live in the Twin Cities metro area, where 59% of working dental therapists are employed; 45% of Minnesotans live outside the Metro area, where 41% of working dental therapists are employed.22,23,25

Myth: Dental therapy cannot survive without significant government subsidy

Dentistry has historically received millions in government subsidies. Governments do this because they want to ensure an adequate supply of healthcare providers for their residents.24,26

In 2016, federal funds to dental education neared $36 million. In the same year, state and local government funding to dental schools totaled more than $445 million. Neither of the Minnesota dental therapy education programs receive any additional state support. Both run their training programs with existing general funding and contributions from nongovernment sources and student tuition.

Dental therapist employers in Minnesota operate with the same revenue sources as all other practices. Because of the decrease in practice expenses due to lower dental therapist salaries, dental therapists add to net revenue. Maine, Vermont, Michigan, and Arizona all passed dental therapy legislation with no funding included to train this new profession.

Myth: Dental therapy in Canada has failed

The Saskatchewan Health Dental Plan (SHDP) was launched in 1974 to train dental therapists to work in school-based clinics. The government made this investment hoping that it would improve children’s oral health and it did: children served by SHDP saw about a 50% reduction in the average number of fillings over 6 years.27 SHDP was terminated in 1987 due to a change in political leadership that did not support funding for this social program. But dental therapists still practice in all Canadian provinces and territories except Ontario and Quebec.28

Myth: Dental therapists create a two-tiered system of care that will hurt minority groups

Even the ADA Health Policy Institute admits the US dental care system is broken, with cost serving as a significant impediment to accessing care.29 Thus, there is already a two-tiered system of dental care in the US: those who can afford the high costs of dental care and those who cannot. Organized dentistry promotes philanthropic care.30 However, forcing low-income Americans to rely on charity to obtain needed dental treatment is a two-tiered system of care. Providing no follow-up or regular preventive or basic restorative services to ensure problems don’t worsen is a two-tiered system of care.

Myth: Dental therapy in New Zealand is a failure because of high disease rates

Critics of dental therapy sometimes point to the high caries rates in New Zealand and the government suggesting an overhaul of the dental therapy system.31 First, much of New Zealand does not offer community water fluoridation, so disease rates are high. But treatment rates far exceed what we see in the US.32 Second, in the government’s report on dental therapy, the authors suggest an expansion of dental therapy to reach more of the population. Specifically, one of the recommendations was: “requests the Ministry of Health to examine enhancing the national school-based dental service with linkages into preschool and adolescent settings.”32

Myth: Dental therapy is an unproven model

This argument is basically a ruse to delay implementation. Dental therapy is not new nor is it unproven. Dental therapists have been employed in more than 50 countries for over 100 years. They have been employed in Alaska for 18 years, in Minnesota for more than 12 years, and in Washington and Oregon for a few years. Thirteen states have now authorized dental therapy is some setting. All of the studies document the quality and safety of dental therapists. All of the reports from Alaska and Minnesota support the cost-effectiveness of dental therapy and resultant positive oral health outcomes.

Advocates must consider that no matter what opponents of dental therapy say, all of the evidence supports dental therapy’s quality, safety, cost-effectiveness, as well as its impact on improving both access to care and oral health outcomes.

References

  1. 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 Pub Health Dentistry. 2021;81:12–20.
  2. Mertz E, Koggdk A, Wert M, Langelier M, Surdu S, Moore J. Dental therapists in the United States: health equity, advancing. Med Care. 2021;10(Suppl 5):S441–S448.
  3. Community Catalyst. Dental Therapy Policy Trends. Available at:communitycatalyst.org/​resources/​2020-tools/​DentalTherapyAdvocacyGuide-R1.pdf. Accessed October 26, 2021.
  4. Appletree Dental. An Advanced Dental Therapist in Rural Minnesota. Available at:appletreedental.org/​wp-content/​uploads/​2018/​02/​ADT-Rural-Jodi-Hagers-Case-Study-022118.pdf. Accessed October 26, 2021.
  5. PEW Charitable Trusts. Expanding the Dental Team: Increasing Access to Care in Public Setting. Available at:pewtrusts.org/​~/​media/​assets/​2014/​06/​27/​expanding_​dental_​case_​studies_​report.pdf. Accessed October 26, 2021.
  6. Minnesota Department of Health. Dental Therapy Toolkit: a Resource for Potential Employers. Available at:health.state.mn.us/​facilities/​ruralhealth/​emerging/​dt/​docs/​2017dttool.pdf. Accessed October 26, 2021.
  7. Chi DL, Hopkins S, Zahlis E, et al. Provider and community perspectives of dental therapists in Alaska’s Yukon-Kuskokwim Delta: A qualitative program evaluation. Comm Dent Oral Epidemiol. 2019;47:502–512.
  8. Chi DL, Lenaker D, Mancl L, Dunbar M. Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta. J Pub Health Dent. 2018;78:175–182.
  9. Chi DL, Mancl L, Hopkins S, et al. Supply of care by dental therapists and emergency dental consultations in Alaska native communities in the Yukon-Kuskokwim delta: a mixed methods evaluation. Comm Dent Health.2020;37:190-198.
  10. Langelier M, Surdu S, Moore J. The contributions of dental therapists and advanced dental therapists in the dental centers of Apple Tree Dental in Minnesota. Rensselaer, New York: Center for Health Workforce Studies; August 2020.
  11. Nash DA, Fridman JW, Mathu-Muju KR, et al. A review of the global literature on dental therapists. Commun Dent Oral Epidemiol. 2013;42:1–10.
  12. Wetterhall S, Bader JD, Burrus B, Lee JY, Shugars DA. Evaluation of the dental health aide therapist workforce model in alaska: final report. Available at:communitycatalyst.org/​initiatives-and-issues/​initiatives/​dental-access-project/​RTI-Program-Evaluation-of-DHAT-Workforce-Model-in-AK-Executive-Summary-1.pdf. Accessed October 26, 2021.
  13. Bolin KA. Assessment of treatment provided by dental health aide therapists in Alaska. J Am Dent Assoc. 2008;39:1530.
  14. Wetterhall S, Bader JD, Burrus BB, Lee JY, Shugars DA. Evaluation of the dental health aide therapist in Alaska. Available at:rti.org/​sites/​default/​files/​resources/​alaskadhatprogramevaluationfinal102510.pdf. Accessed October 26, 2021.
  15. Phillips E, Shaefer HL. Dental therapists: evidence of technical competence. J Dent Res. 2013;92(7 Suppl):11S–15S.
  16. Williard ME, Fauteux, N. Dentists provide effective supervision of Alaska’s dental health aide therapists in a variety of settings. J Public Health Dent. 2011;71(Suppl 2):S27–S33.
  17. Mathu-Muju K. Dental therapists provide technically competent clinical care when performing irreversible restorative procedures. J Evid Based Dent Pract. 2014;14:25–27.
  18. Hopcraft M, Martin-Kerry JM, Calache H. Dental therapists’ expanded scope of practice in Australia: a 12-month follow-up of an educational bridging program to facilitate the provision of oral health care to patients 26+ years. J Public Health Dent. 2015;75:234–244.
  19. Wright JT. Do midlevel providers improve the population’s oral health? J Am Dental Assoc. 2013;144:92–94.
  20. Commission on Dental Accreditation. Accreditation Standards for Dental Therapy Education Programs. Available at:ada.org/​en/​coda. Accessed October 26, 2021.
  21. Brickle CM, Self, KD. Dental therapists as new oral health practitioners: increasing access for underserved populations. J Dent Educ. 2017(Suppl):eS65–eS72.
  22. Minnesota Board of Dentistry. Early Impacts of Dental Therapists in Minnesota: Report to the Legislature, 2014. Available at:mn.gov/​boards/​assets/​2014DentalTherapistReport_​tcm21-45970.pdf. Accessed October 24, 2021.
  23. Minnesota Board of Dentistry. Dental Therapy in Minnesota, Issue Brief. Available at: health.state.mn.us/​data/​ workforce/​oral/​docs/​2018dtb.pdf. Accessed October 26, 2021.
  24. Department of Health and Human Services. HRSA Fiscal Year 2018. Available at:hrsa.gov/​sites/​default/​files/​hrsa/​ about/​budget/​budget-justification-2018.pdf. Accessed October 26, 2021.
  25. Minnesota Department of Health, Minnesota Department of Human Services, Health Reform Minnesota. Dental Therapy Toolkit: A Resource for Potential Employers. Available at: health.state.mn.us/​facilities/​ruralhealth/​emerging/​ dt/​docs/​2017dttool.pdf. Accessed October 26, 2021.
  26. American Dental Association. Dental Education, Report 3: Finances. Available at:ada.org/​en/​science-research/​health-policy-institute/​data-center/​dental-education. Accessed October 26, 2021.
  27. Mathu-Muju KR, Friedman JW, Nash DA. Saskatchewan’s school-based dental program staffed by dental therapists: a retrospective case study. J Public Health Dent. 2016;77:1-8.
  28. Leck V, Randall GE. The rise and fall of dental therapy in Canada: a policy analysis and assessment of equity of access to oral health care for Inuit and First Nations communities. Int J Equity Health. 2017;16:131.
  29. Vujicic M. Our dental care system is stuck and here is what to do about it. J Am Dent Assoc. 2018;|149:167-169.
  30. American Dental Association. Breaking Down Barriers to Oral Health for All Americans: The Role of Finance. Available at:ada.org/​~/​media/​ADA/​Publications/​ADA%20News/​Files/​7170_​Breaking_​Down_​Barriers_​ Role_​ of_​Finance.pdf?la=en. Accessed October 26, 2021.
  31. National Health Committee. Improving Child Oral Health and Reducing Child Oral Health Inequalities. Available at:aapd.org/​assets/​1/​7/​NZImprovingChildOralHealth.pdf. Accessed October 26, 20221.
  32. Ministry of Health. Our Oral Health: Key Findings of the 2009 New Zealand Oral Health Survey. Available at:health.govt.nz/​publication/​our-oral-health-key-findings-2009-new-zealand-oral-health-survey. Accessed October 26, 2021.

From Dimensions of Dental Hygiene. November 2021;19(11)12-15.

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