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    Would dental therapists in school-based clinics improve kids’ access to primary dental care?

     

    Given the gaps in dental care in this country, particularly in children, some advocates are pushing for the introduction of a midlevel provider called a dental therapist who would do most of the basic work a dentist does.

    Less than half of children on Medicaid received a preventive dental visit in 2008, according to a 2012 Mathematica Policy Research report.

    Alaska and Minnesota already have dental therapists practicing. Although there are a variety of midlevel provider models that states are investigating, Oregon, Michigan, and Connecticut are considering or authorizing pilot projects; 8 states have pending legislation; and there are expressions of interest in other states, according to Shelly Gehshan, director of children’s dental policy at Pew Charitable Trusts, which is a key advocate for the change.

    In an extensive overview of the literature last year, the Kellogg Foundation said that dental therapists are now used in 54 countries, including the United Kingdom and Canada, and their use in New Zealand goes back to 1921. They work in school-based programs in most countries, the report said.

    “We are right where the country was in the 1960s with the development of nurse practitioners. . . . In 10 or 20 years everybody will have them,” states Gehshan. As with medical care in the 1960s, she said, dental care has too few providers, even as more people are getting insurance coverage.

    Requirements for supervision of dental therapists by a dentist may vary from state to state, Gehshan says, although Pew does advocate for that supervision. On the other hand, she believes remote supervision has proved safe and effective in Alaska and Minnesota and with computers and phones it will happen elsewhere.

    However, many people in dentistry don’t agree with the effectiveness or cost-effectiveness of creating a dental therapist profession. Dueling reports have flown back and forth for some time. The American Dental Association said last year, “To the extent that workforce additions can help us break down some of the barriers . . . allowing nondentists to perform irreversible surgical procedures is not the way to go.”

    Paul Casamassimo, DDS, MS, of the American Academy of Pediatric Dentistry (AAPD), says his group’s position is that “there is insufficient evidence to show that a dental therapist will improve access to care for children.” If AAPD received compelling evidence that they do, “then we would reconsider our position,” he said.

    Many in the dental profession recognize “that under certain circumstances the therapists can provide care with adequate training,” said Casamassimo, who is director of the AAPD Pediatric Oral Health Research and Policy Center. Yet there are studies indicating that dental therapists don’t pay for themselves. He noted that a dentist must be involved in the care and a dental practice must be large enough to generate enough of the procedures that dental therapists do.

    Many dentists are saying that Medicaid payments cover only a fraction of usual dental charges, so their question is why not adequately fund the current system rather than rebuilding it, said Casamassimo. With the nation training more dentists, he said, it’s hard to tell how the economic model will work out.

    On the other hand, a review in the September 2013 American Journal of Public Health argues that if the United States had publicly funded, school-based clinics staffed by dental therapists, primary dental care would be available to nearly all children and cost less.

    The cost of capitalizing such a school-based system using dental therapists could be recovered rapidly by the savings, note the researchers, including Kavita Mathu-Muju, who is with the faculty of dentistry at the University of British Columbia. They also point out, “In the United States, no studies on the quality of care provided for children by dentists are available.”



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