Reconnecting Practicing Hygienists with the Nation's Leading Educators and Researchers.

Expanding Access Through Midlevel Practitioners

The Pew Charitable Trusts investigates the conditions surrounding the nation’s access-to-care crisis and proposes solutions.

For decades, millions of Americans have been receiving minimal oral health care, or none at all. Tragically, 101 people died in hospital emergency departments from 2008 to 2011 due to preventable dental disease.1 More than 18 million low-income children with Medicaid coverage received no dental care in 2014—not even a routine exam.2 The consequences are serious: children with poor oral health are more likely to have pain, miss school days, and experience deterioration in their overall health.3,4 When patients are unable to receive preventive or early dental care, their oral health needs often go unaddressed until the pain becomes so severe they seek relief in a hospital emergency department. The American Dental Association estimates that in 2012, the United States health care system spent $1.6 billion on dental-related emergency department visits.5 At the same time, there are not enough dentists to treat all of the patients who require care. Additionally, nearly 48 million people across the country live in areas with a shortage of dentists.6 This grim statistic is likely to worsen: the federal government projects that by 2025, the shortage of dentists will more than double, even though several new dental schools have opened.7


Some states are helping patients access oral health care by authorizing midlevel practitioners—often called dental therapists—to work with dentists. Similar to physician assistants, these providers enable public and private dental practices to expand their reach so they can care for more patients. The Pew Charitable Trusts is working closely with dental organizations, legislators, providers, and other advocates and partners to support efforts to allow dentists to hire midlevel practitioners.

The evidence demonstrating the efficacy of such providers is growing, with research showing that midlevel practitioners provide high-quality, cost-effective care.8Midlevel practitioners perform preventive and routine restorative procedures, such as filling caries lesions, allowing dentists to focus on more complex cases. The use of midlevel practitioners in the dental team also reduces the cost of care.9

Pew is adding to the body of knowledge about midlevel dental providers as it works with partners advocating for their use in more states. For example, our research found that by expanding the dental team, public health practices could stretch their dollars to reach more underserved people.10 Similarly, private practices were able to increase the number of underserved patients being treated and still achieve modest increases in overall profit.9

Dental therapists currently practice in Alaska, Minnesota, and more than 50 countries. They were recently authorized in Maine. Diverse groups in other states are working together to bring midlevel practitioners to their communities, with 10 states having introduced legislation to authorize the providers since 2013. Support for this common-sense effort spans the political spectrum and unites partners committed to increasing access to oral health care. Resolutions favoring midlevel practitioners have been passed by the National Black Caucus of State Legislators, National Caucus of Native American State Legislators, and National Foundation of Women Legislators.11,12 Dental organizations, such as the National Dental Association and the American Association of Public Health Dentistry, also support expanding the dental workforce.13,14

The field of dentistry is evolving, and we urgently need to modernize the care delivery system to address the oral health needs of the American people.15 We must act now to improve oral health in the US and ensure that patients get preventive and restorative treatment when and where they need it. The medical field has benefited from the work of midlevel professionals for decades. Working together, we can make sure that the oral health workforce has the same opportunity to care for its patients, and that the tragedy of lives lost due to untreated dental disease is not repeated.


The Pew Charitable Trusts has published a plethora of information regarding the access-todental- care problem in the United States and the use of midlevel practitioners to alleviate this crisis. Here is a sampling of the most recent offerings, which are available under the “Children’s Dental Policy” section of

  • Access to Care Could Worsen as Shortages Intensify
  • Inefficient Medicaid Spending for Dental Care
  • The Oral Health Crisis Among Native Americans
  • Pew Supports Tribe’s Expansion of Dental Workforce
  • Working With Midlevel Providers: Dentists’ Perspectives
  • States Stalled on Dental Sealant Programs
  • Expanding the Dental Team: Increasing Access to Care in Public Settings
  • In Search of Dental Care: Two Types of Dentist Shortages Limit Children’s Access to Care


The Pew Charitable Trusts is driven by the power of knowledge to solve today’s most challenging problems. Pew applies a rigorous, analytical approach to improve public policy, inform the public, and invigorate civic life.


  1. Allareddy V, Rampa S, Lee MK, Allareddy V, Nalliah RP. Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. J Am Dent Assoc. 2014;145:31–317.
  2. Early and Periodic Screening, Diagnostic, and Treatment. Available at: Accessed September 22, 2015.
  3. Holt K, Barzel R. Oral health and learning: when children’s health suffers, so does their ability to learn. Available at: Accessed September 22, 2015.
  4. United States General Accounting Office. Oral Health: Dental Disease Is a Chronic Problem Among Low Income and Vulnerable Populations. Available at: Accessed September 22, 2015.
  5. American Dental Association Health Policy Institute. Emergency Department Use for Dental Conditions Continues to Increase. Available at: HPIBrief_0415_2.ashx. Accessed September 22, 2015.
  6. US Department of Health and Human Services, Health Resources and Services Administration. Health Professional Shortage Areas Designation Population Statistics. Available at: shortageAreas.aspx. Accessed September 22, 2015.
  7. US Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. National and State-Level Projections of Dentists and Dental Hygienists in the US 2012-2025. Available at: Accessed September 22, 2015.
  8. Nash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Int Dent J. 2008;58:61–70.
  9. The Pew Charitable Trusts. Expanding the Dental Team: Studies of Two Private Practices. Available at: Accessed September 22, 2015.
  10. The Pew Charitable Trusts. Expanding the Dental Team: Increasing Access to Care in Public Settings. Available at: Accessed September 22, 2015.
  11. National Black Caucus of State Legislators. Health and Human Services: Resolution HHS-15-24. Available at: html. Accessed September 22, 2015.
  12. National Foundation for Women Legislators. Resolution: In Support of Calling Upon the United States Congress to Provide Full Funding for the Alternative Oral Health Workforce Providers Demonstration Program. Available at: Accessed September 22, 2015.
  13. National Dental Association. Position on Access to Care and Emerging Workforce Models. Available at: Accessed September 22, 2015.
  14. American Association of Public Health Dentistry. AAPHD Publishes Proposed Curriculum Guidelines for Training Dental Therapists. Available at: Accessed September 22, 2015.
  15. Vujicic M. Where have all the dentist visits gone? J Am Dent Assoc. 2015;46:412–414.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental HygieneOctober 2015;12(10):30–31.

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