Reflections from Minnesota

While working as a National Association of Public Interest law clerk in Minnesota more than 20 years ago, I had a supervisor ask if I’d heard of the dental crisis. I had no idea what she was talking about. My supervisor showed me an article from the local newspaper about a young girl insured by Medical Assistance (MA) who was unable to get dental treatment until she landed in the emergency department with an abscessed tooth and systemic infection. Thus began my education about access-to-care issues and the long list of barriers to professional oral health care, including poverty, language, immigrant status, and cost.

Six years later, I joined Children’s Dental Services (CDS) in Minnesota as executive director. I was surprised to see nothing much had changed in improving access to dental care in Minnesota since 1995. If anything, access to care appeared more challenging. I found a deeply committed public health dental community in Minnesota, hampered by a lack of tools for addressing the dental crisis. Together this community explored innovative initiatives to address this problem, such as creating a pathway for licensing foreign-trained dentists (which lasted about 1 year due to administrative oversight concerns) and seeking parity for Minnesota’s MA reimbursement rate for dental services (largely unsuccessful over the past 17 years, with Minnesota falling to the 47th lowest of all states for MA dental reimbursement).¹ While resources for improving dental access waned in Minnesota, there has been a three-fold increase in foreign-born residents since 1990, including many with high dental needs.² Census data also showed that while income has generally grown for Minnesotans, racial gaps persist, particularly among Black, Hispanic, and American Indian populations.³

ADVENT OF DENTAL THERAPISTS

These conditions precipitated the introduction of legislation for a midlevel dental practitioner in Minnesota in 2008, which passed into law in 2009. As executive director of a nonprofit targeting dental care to Minnesota’s most vulnerable children, I regarded this legislation as presenting a critically needed opportunity for oral health care reform. At its core, Minnesota’s dental therapy law strives to improve access to quality preventive and restorative dental services for low-income and underserved communities. CDS hired the first licensed Minnesota dental therapist in 2011, subsequently employed 18 dental therapists either part- or full-time, and offers its clinics as a training ground for Minnesota dental therapy students. The impact of integrating dental therapists into CDS practice has been nothing short of remarkable. On average, CDS’ dental therapists have production rates in the top half of all restorative providers when pooled with dentists. Since December 2011, CDS’ advanced dental therapists (ADTs) have provided care to more than 30,000 patients; 47% have been served in portable, satellite sites, and 32% in rural settings. During this time, there have been 12 requests to see a dentist instead of a dental therapist and two complaints of poor patient experience by an ADT. During the same period, there were six complaints of poor experience by dentists and two complaints with dental hygienists. No complaints made to the Minnesota Board of Dentistry relating to care provided by Minnesota dental therapists have been substantiated. Overall, appointment wait time at CDS has decreased by 2 weeks and overall patient time with a provider has increased by 10 minutes. Among survey respondents, 97% state they were satisfied or very satisfied with the quality of care provided by an ADT, compared with 92% satisfaction with dentists and 97% satisfaction with dental hygienists. Finally, the total cost savings gained by using a dental therapist for restorative services is $1,200 per week or $62,400 per year. CDS has used this savings to hire additional providers, including both dentists and dental therapists, to expand access to dental services for its target communities. Furthermore, CDS dentists are now focusing their unique skills on hospital and endodontic care, resulting in a three-fold increase in the number of patients CDS serves in hospital-based settings and the inception of its endodontic care program. The integration of dental therapy at CDS has cumulatively improved access to services for not only the greater than 30,000 additional patients served by dental therapists, but 10,000 more patients receiving advanced restorative treatment from dentists.

Like the first day I learned of the crisis in access to dental care, I continue to regard dental access as a social justice issue. While struggles certainly remain and dental therapy is only one of the many tools required to address this deep and longstanding challenge, the advent of dental therapy in Minnesota is the most important and impactful strategy I have witnessed in making quality dental care available to all.

REFERENCES

1. Gupta N, Yarbrough C, Vujicic M, Blatz A, Harrison B. Medicaid fee-for-service reimbursement rates for child and adult dental care services for all states, 2016. Health Policy Institute Research Brief. American Dental Association. April 2017.
2. Minnesota Compass. Immigration. Available at: mncompass.org/immigration/overview. Accessed September 13, 2017.
3. United States Census Bureau. Quick Facts: Minnesota. Available at: census.gov/quickfacts/fact/table/MN/PST045216. Accessed September 13, 2017.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2017;4(10):39-40.