This study examined the potential financial

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1 Impact of Dental Therapists on Productivity and Finances: II. Federally Qualified Health Centers Tryfon J. Beazoglou, Ph.D.; Howard L. Bailit, D.M.D., Ph.D.; Judy DeVitto, B.S.; Taegen McGowan, B.A., M.P.H.; Veronica Myne-Joslin, B.A. Abstract: This article estimates the impact of dental therapists treating children on Federally Qualified Health Center (FQHC) dental clinic finances and productivity. The analysis is based on twelve months of patient visit and financial data from large FQHC dental clinics (multiple delivery sites) in Connecticut and Wisconsin. Assuming dental therapists provide restorative, extraction, and pulpal services and dental hygienists continue to deliver all hygiene services, the maximum reduction in costs is about 6 percent. The limited impact of dental therapists on FQHC dental clinic finances is because 1) dental therapists only account for 17 percent of children services and 2) dentists are responsible for only 25 percent of clinic expenses and cost reductions are related to the difference between dental therapist and dentist wage rates. Dr. Beazoglou is Professor, Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut Health Center; Dr. Bailit is Professor Emeritus, Department of Community Medicine, School of Medicine, University of Connecticut Health Center; Ms. DeVitto is Administrative Manager, University of Connecticut Health Center Finance Corporation; Ms. McGowan is Research Assistant, Department of Community Medicine, School of Medicine, University of Connecticut Health Center; and Ms. Myne-Joslin is a data analyst, Cromwell, CT. Direct correspondence and requests for reprints to Dr. Tryfon Beazoglou, Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030; ; Beazoglou@nso1.uchc.edu. Keywords: access to care, federally qualified health centers, dental therapists, dentists, dental clinic finances, productivity Submitted for publication 10/12/11; accepted 5/2/12 This study examined the potential financial impact of dental therapists providing care to children within the four walls of Federally Qualified Health Center (FQHC) dental clinics. In some states, FQHCs can also deliver care to underserved patients in public settings such as schools and still receive their usual reimbursement rates. FQHC-operated, school-based dental programs are addressed in a separate article. 1 A detailed review of the dental therapy literature is available in the first article in this series. 2 FQHCs were established in the 1970s by the U.S. government (Health Resources and Services Administration, HRSA) to provide medical, dental, and behavioral health services to low-income and rural patients who do not have financial or physical access to the private delivery system. In part, FQHCs were established because in most states Medicaid fees are so low (for children and adults) that few dentists (or physicians) accept Medicaid-eligible patients. FQHCs are nonprofit organizations that receive prospective cost-based reimbursement (fee-per-visit) for the treatment of Medicaid patients. 3 For non- Medicaid, indigent dental patients (i.e., those unable to pay for all the care received), FQHCs charge a sliding scale fee-per-visit based on family income and size, following federal poverty guidelines. Part of the uncompensated care to indigent patients is covered by an annual 330 grant from the federal government. The contribution of the 330 grant funds to dental clinic revenues depends on the allocation of these funds among clinical divisions (e.g., medical, dental) within FQHCs. On average, the 330 grant pays for about 52 percent of all medical and dental services provided to indigent patients. The methods used to calculate the 330 grant awards are complex, and visit payment rates vary among FQHCs. Further, in some states the visit rate is dental-specific; others have one visit payment rate for all health services. Of the nation s 1,200 FQHCs, some 820 provide dental services (2009). These clinics employ 2,500 FTE (full-time equivalent) dentists and 1,120 FTE dental hygienists. 4 The literature on FQHC dental clinics is limited. All FQHCs are required to report to HRSA annually on their financial and clinical operations, but, for many important performance measures, medical and dental data are not presented separately. Some information is available from state studies of dental access disparities. The data suggest that most FQHC dental clinics have less than 1068 Journal of Dental Education Volume 76, Number 8

2 five operatories, two or fewer FTE dentists, and less than one FTE dental hygienist per dentist. 3,5-11 For FQHCs that provide dental care, dental patients account for about 10 percent of total FQHC revenues and expenses. In terms of dental clinic revenues, one study reported that 41.8 percent comes from grants, 6.5 percent from self-pay patients, 6.5 percent from private insurance, and 45.1 percent from public insurance (mainly Medicaid). 5 The dental safety net system (including FQHC dental clinics) has the capacity to treat about 8 to 9 million of the approximately 85 million people that have low incomes and limited financial access to dental services. 12 The safety net system consists of public and voluntary sector health facilities that care for the underserved. Besides FQHCs, the system includes local community dental clinics (non-fqhcs), dental schools, some hospitals, and public school clinics. Currently, FQHC dental clinics treat approximately 3.7 million people per year (2010). 4 Most patients (85 percent) have family incomes below 150 percent of the Federal Poverty Level (FPL), and about 50 percent of FQHC dental patients are children (eighteen years of age or younger). 5 Medicaid fee-for-service reimbursement rates are 30 to 70 percent below prevailing market fees in most states, and relatively few states provide more than emergency care for adults. As a result few private practitioners (i.e., <25 percent) accept Medicaid or indigent patients. 13 Nevertheless, private practices provide about two-thirds of the services to Medicaid patients (and substantial pro bono or reduced fee services for lower and middle-income patients). 14 Because of limited access to private offices and the limited size of the dental safety net, low-income patients have much lower utilization rates (approximately 30 percent of ever enrolled [one or more days] adults and children with annual visits) compared to those with private dental insurance or to people with family incomes 400 percent or above the FPL (approximately 60 percent). 10 Methods Economic Model FQHC dental clinics have excess demand for their services (represented by the horizontal lines in Figures 1 and 2). This is because of the large numbers of Medicaid and low-income patients (approximately 85 million), and because with low Medicaid fees, most private practices do not accept Medicaid patients. In addition, few Medicaid programs cover adults. In contrast, although limited in number and capacity (i.e., less than 4 million adult and child patients treated annually), FQHC dental clinics receive additional public funds to provide dental care to Medicaid and low-income patients of all ages. These are the primary reasons for excess patient demand. Figures 1 and 2 depict the supply and demand conditions in FQHC dental clinics where the prevailing price per unit of service is P 0 and the quantity demanded and supplied is Q 0. The introduction of a dental therapist entails the substitution of a higher price input (dentist time) by a lower price input (dental therapist time). This implies a shift of the supply function (S) to the right (S 1, Figure 2) along the demand function (D), other things being equal. The magnitude of the shift represents the cost difference between dental therapist time and dentist time used in the production of selected dental services. As the equilibrium shifts from point A to point B, the price per unit of dental services remains the same (P 0 ) and the quantity demanded and supplied increases to Q 1 (Figure 2). How much the utilization increases depend on the reduction in costs per unit of service (magnitude of shift of the supply) and the shape of the supply function. Level of training, scope of services, degree of supervision, and dental therapist wages determine changes in dental care costs. These interdependent dimensions are related to the productivity and efficiency of dental clinics employing dental therapists. In general, there is a positive relationship between the level of training (formal education or on-the-job), years of experience, and earnings. General dentists are trained for more years than dental therapists; dental hygienists are trained for more years than dental assistants; and it is assumed that dental therapists are trained for more years than dental hygienists. As a result, the wage rate of a dentist is expected to exceed that of a dental therapist and so on. For FQHC dental clinics to perform efficiently, each and all its resources (inputs) must be employed efficiently. This requires that, at the margin, the value generated by an input is equal to its remuneration (wage rate). Consider a dental service (e.g., a bitewing X-ray) that takes dentists, dental therapists, dental hygienists, or dental assistants the same time to perform. Efficient use of resources requires that the least costly input provides this service (i.e., dental assistants). Similarly, economic efficiency requires that dental hygienists rather than dental therapists or August 2012 Journal of Dental Education 1069

3 Price! S P0 A D 0 Q0 Quantity Demanded and Supplied Figure 1. FQHC dental clinic demand (D) and supply (S) without dental therapists Price S S1 P0 A C D P1 B 0 Q0 Q1 Quantity Demanded and Supplied Figure 2. FQHC dental clinic demand (D) and supply (S1) with dental therapists 1070 Journal of Dental Education Volume 76, Number 8

4 dentists provide prophylaxes and preventive services. Thus, it is economically irrational and inefficient to employ dental therapists to provide services now done by lesser trained personnel. In this analysis, dental therapist services do not include those performed by dental assistants and dental hygienists. Children s dental services provided by dentists that dental therapists can deliver are listed in Table 1. To estimate the cost reductions from having dental therapists perform these services, it is necessary to estimate the value of children services, the dentist share of service costs, and the wage differential between dentists and dental therapists. Equation 1 shows the potential cost reduction of employing a dental therapist, and equation 2 shows the percent cost reduction in total clinic revenues: (1) Potential Cost Reduction = X * s * (W D W DT )/W D. (2) Percent Cost Reduction = (X / Y) * s * (W D W DT )/W D. In these equations, X is the market value of a subset of dental services currently produced by dentists that dental therapists could produce; s is the dentist s percentage share in the cost of these services (dentist salary/total clinic expenses); W D is the wage rate of the dentist; W DT is the wage rate of the dental therapist; and Y is the market value (total revenues) of dental services produced by an FQHC dental clinic. Data Sources and Variables The collection of FQHC data was part of a separate study of FQHC dental clinic finances that preceded the current project. Working in cooperation with the National Network for Oral Health Access (NNOHA), FQHC dental clinics from around the country were asked to participate in the study if they had twelve months of electronic record data (patient visits) available. FQHCs were solicited from the NNOHA website, specific FQHCs recommended by NNOHA leaders, national NNOHA meetings, and an NNOHA-sponsored webinar. The information requested from the FQHCs included patient visits (date, clinic, provider, patient numbers, patient age, dental services [American Dental Association, ADA, codes], payer, and charge/s per visit or per service); description of clinic operations (provider and staff types, number and annual hours, number of operatories, and clinic square feet); and clinic finances (revenues from grants, patient care by payer, other sources, and expenses by expense category). Table 1. Dental therapist services ADA Code Procedure 2140 Amalgam, one-surface 2150 Amalgam, two-surfaces 2330 Composite, one-surface anterior 2331 Composite, two-surface anterior 2391 Composite, one-surface posterior 2392 Composite, two-surface posterior 2930 Stainless steel crown, primary 3110 Pulp cap, direct 3120 Pulp cap, indirect 3130 Pulpotomy 7140 Extraction, elevation/forceps removal These data were used to estimate the parameters in Equations 1 and 2. The variables used in the economic model are the following: Market value of dental services (Y). FQHC dental clinics have three primary payers: Medicaid, patient self-pay, and private insurance. Clinics charge a fee-per-visit for Medicaid and self-pay patients. The per-visit fee is a cost-based prospective reimbursement for Medicaid patients. The same fee-per-visit is applied to self-pay patients on a sliding scale, based on family size and income. As a result, the implicit price of specific dental procedures varies, depending on the payer and services provided to patients per visit. To have a standard way of comparing the value of services across patients, payers, and visits, the market value of dental services produced by clinics was calculated by applying the 2005 National Dental Advisory Service Comprehensive Fee Report for each service times its frequency. 15 Market value of dental therapist services (X). The market value of children services that dental therapists produce substituting for dentists (see Table 1) was estimated using the ADA average fee for each service. Dentist share of service costs. Based on the FQHC financial and service data, the dentist s share of service costs ranged between 17 percent and 32 percent with a mean value of 25 percent. As an initial conservative estimate, 30 percent was used in the calculations. Dentist s wage rate (W D ). An average compensation of $80 per hour (wages and fringe benefits) was based on discussions with FQHC dentists. Dental therapists wage rate (W DT ). The average compensation rate for dental hygienists, $40 per hour (wages and fringe benefits), was used as an initial conservative value. Actual dental therapist salaries are expected to be higher. August 2012 Journal of Dental Education 1071

5 Implicit Assumptions The assumptions underlying the analysis are the following: dental therapists are seamlessly integrated into FQHC dental clinics with no training costs; dental therapists are perfect substitutes for general dentists and provide all the services that they are legally able to provide; dental therapist cost reductions do not include costs associated with dentist supervision of dental therapists; dental therapists do not provide services currently performed by dental assistants and hygienists; and part-time dental therapist employment does not cause management inefficiencies related to patient scheduling, staff training, etc. These assumptions result in an upper boundary estimate (i.e., maximum impact possible) of the cost reduction for substituting dental therapists for dentists. Finally, sensitivity analyses were used to assess the relative impact of differences in dental therapist and dentist wage rates, dentist s share of total FQHC dental clinic expenses and share of children s services, and supply elasticity (the percent change in quantity supplied relative to the percent change in price). Results Cost Reduction and Utilization Increase The results are based on data from Connecticut and Wisconsin FQHCs. The Connecticut FQHC has seven dental clinic sites, and the Wisconsin FQHC has five large sites. These FQHCs were selected because of their size and data quality. Table 2 presents the annual number and market value of dental therapist-provided children services. All dental therapist services, mainly restorations and extractions, account for about 17 percent of children services, valued at 37 percent of total children services. Table 3 presents the potential upper boundary cost reductions from using dental therapists in FQHC dental clinics. Children services account for 26 to 37 percent of total FQHC dental revenues. The dentists contribution (i.e., wages) to the latter value is 30 percent. The absolute cost reduction from dental therapists under ideal conditions is up to $10,400 per dentist. As a percentage of child and total clinic service values, dental therapist cost reductions are about 5.6 percent and 1.6 percent, respectively. The expected increase in FQHC clinic dental services, given the estimated cost reduction from using dental therapists depends, on the elasticity of supply (percent change in utilization/percent change in costs). Since elasticity estimates are not available, a supply elasticity of 0.5 is assumed; this means that the percentage increase in utilization is equal to one-half the percentage reduction in costs. In this case, the increase in utilization is 1.9 percent to 2.8 percent. A less plausible supply elasticity is 1.0, which increases the estimated utilization increase by the same percentage reduction in costs. Sensitivity Analysis Based on Connecticut data, Table 4 shows the percentage and absolute dollar effects, respectively, of various dental therapist wage rates (ranging from $25 to $60 an hour) and dentist s share of FQHC dental clinic expenses (ranging from 20 to 40 per- Table 2. Mean number and value of annual dental therapist dental services provided to children (under age nineteen years) by FQHCs from Connecticut and Wisconsin Connecticut Wisconsin Value Value Services Number (000) Number (000) Restorations 5,427 $794 5,682 $1,103 Stainless steel crowns 121 $ $28 Pulp caps, pulpotomies 254 $ $23 Extractions 1,021 $ $84 Subtotal 6,823 $1,000 6,571 $1,138 Total children services 39,951 $2,660 55,259 $3,826 Total services, all patients 167,691 $9, ,091 $14, Journal of Dental Education Volume 76, Number 8

6 Table 3. Percentage and absolute annual cost reductions from substituting dental therapists for dentists treating children within the four walls of FQHCs from Connecticut and Wisconsin Connecticut Wisconsin Total value of all services (Y) $9,217,500 $14,562,737 Value of child services $2,660,020 $3,826,340 Value of child services provided by dentist (X) $999,604 $1,002,964 Dentist s share value of child services replaced by dental therapist (X*s) $299,881 $300,889 Number of FTE dentists Dental therapist absolute cost reduction (X*s*(WD-WDT)/WD) $149,941 $150,445 Dental therapist cost reduction per dentist $10,412 $7,918 Dental therapist percent cost reduction 5.6% 3.9% Dental therapist percent cost reduction for total services 1.6% 1.0% Note: The symbols for formulas 1 and 2 are in parentheses. Table 4. Effects of dental therapist wage differentials and dentist share of FQHC revenues on percent cost reductions Dentist Dental Therapist Dentist Dentist Dentist Dentist Dentist Wages Wages/Hr Share Share Share Share Share (W D ) (W DT ) (W D -W DT )/W D 20% 25% 30% 35% 40% $80 $ $80 $ $80 $ $80 $ $80 $ $80 $ $80 $ $80 $ cent). As the dental therapist wage rate increases, cost reductions per dentist are reduced from $9,432 (dentist s share 25 percent) to $3,430. When the dentist s share is 40 percent, the cost reductions per dentist decline from $18,865 to $6,860. As expected, cost reductions decline with increasing dental therapist wages and increase as the percentage of dentist share in the production of services increases. That is, the financial advantage of dental therapists decreases with increasing dental therapist incomes (relative to dentist incomes) and increases if dentists account for a larger share of total clinic production costs. The sensitivity analysis for the number of children per delivery site is shown in Table 5 (data from selected FQHC sites in Wisconsin and Connecticut). Actual data are presented for five FQHCs of different sizes (dentists, chairs, etc.) and numbers of children seen per year. For example, clinic A treats 359 children per year and clinic E treats 2,463 children per year. As the number of children increases, the absolute value of dental therapist cost reductions increases, but not the percent cost reductions. Also, the largest FQHC (E) does not have sufficient volume to employ a full-time dental therapist. That is, the range of dental therapist annual hours required in these clinics varies from 171 to 1,034. Since a full-time dental therapist is expected to work 2,000 hours per year (forty hours times fifty weeks), clinic E does not have sufficient volume of children services to employ a full-time dental therapist. Hence, to employ dental therapists full-time, they must work in multiple FQHC dental clinic sites. National Impact The estimated increase in utilization is 3 percent. This upper bound estimate is based on an expected maximum percent saving reduction of about 6 percent and an assumed supply elasticity of 0.5. In 2010, FQHC dental clinics treated 3.7 million patients, and 50 percent were children (1.85 million). Hence, the maximum estimated increase in utilization is 55,500 children (1.85 million times 3 percent). Based on 237 hours of dental therapist time per FTE dentist and 2,500 FTE dentists employed in FQHCs, August 2012 Journal of Dental Education 1073

7 Table 5. Dental therapist cost reductions in FQHC dental clinics of various sizez (A-E) Variables A B C D E Revenue/gross billing $816,890 $1,126,004 $1,885,304 $2,838,192 $4,059,469 Expenses $635,074 $1,048,240 $1,673,709 $3,203,895 $3,704,006 Chairs FTE dentists FTE dental hygienists FTE dental assistants Patients 1,503 3,593 4,872 4,793 7,315 Visits 5,321 7,814 12,597 11,505 17,596 Children (18 and under) 359 1,432 2,912 1,709 2,463 Visits for children 929 2,320 5,742 3,686 5,465 Value of children services $128,003 $263,086 $774,374 $688,658 $1,024,327 Value of dental therapist services $48,869 $57,376 $306,163 $163,080 $255,885 Dentist share value of child services $14,661 $17,213 $91,849 $48,226 $76,765 Dental therapist services ,067 1,139 1,668 Dental therapist hours per year , Dental therapist savings $7,330 $8,606 $45,924 $24,462 $38,383 % savings 5.73% 3.27% 5.93% 3.55% 3.75% 285 FTE dental therapists are needed to generate this increase in utilization. This estimate assumes that all FQHCs employ dental therapists; that dental therapists provide all restorative and other services legally allowed; that they average thirty-minute appointments; and that dentists do not spend any time supervising them. This estimate does not take into account broken appointments, sick leave, and related issues that reduce patient visits. Because some assumptions are problematic, the actual impact of dental therapists on access within the four walls of FQHCs is unknown but is likely to be substantially less. Discussion This study suggests that dental therapists providing care to children within the four walls of FQHCs will have a very modest impact on dental clinic finances and utilization. Specifically, dental therapists will generate a cost reduction of no more than 6 percent of total children costs. For the average FQHC, the absolute dollar cost reduction will be in the vicinity of $10,400 per dentist. The absolute cost reduction (but not the percentage) increases with more dentists. Extrapolating these data nationally, FQHCs have the capacity to employ about 285 dental therapists within their four walls. Under ideal conditions, these dental therapists have the potential to treat an additional 55,500 children. These are maximum estimates, and actual cost reductions and utilization are likely to be substantially lower. The primary reasons for the relatively limited impact of dental therapists on FQHC clinic productivity and finances are the following. First, the majority of children are reasonably healthy and do not require many dental therapist-level services. Based on Connecticut and Wisconsin data, about 70 percent of children services are diagnostic and preventive and only 17 percent restorative and extractions. Together, dental hygienists and dental therapists can provide about 95 percent of the care required by children treated in FQHCs. Second, most diagnostic and preventive services should be provided by dental hygienists, since they are trained to provide these services and presumably will have a lower wage rate than dental therapists. Third, dentists account for 25 percent or less of clinic operating costs. Seventy-five percent of expenses are related to other staff (e.g., dental hygienists, dental assistants, administrators), facilities, equipment, supplies, etc. These expenses continue whether dentists or dental therapists provide services. The cost reductions are mainly related to the difference in wage rates between dental therapists and dentists. These findings are in agreement with published reports from the United Kingdom that general dental practitioners who employ dental therapists do not generate an increase in net practice revenues and, in fact, may not cover dental therapist overhead costs. 16,17 The negative impact of dental therapists on 1074 Journal of Dental Education Volume 76, Number 8

8 net private practice revenues may explain the limited number of dental therapists in the United Kingdom and Australia. 18,19 Presumably, if they generated significant increases in net income, the demand for dental therapists would increase, and more would be educated. In developed countries, most dental therapists are employed in school-based clinics. There are several other barriers to the effective use of dental therapists in FQHCs. First, most FQHC dental clinics have five or fewer operatories and will find it difficult to employ dental therapists within their four walls. With two full-time dentists per clinic, for greater efficiency four chairs should be used by the dentists. In addition, most clinics employ about.5 dental hygienists per dentist (versus 1.5 per dentist in private general practices). FQHCs have a significant opportunity to see more patients and generate greater net revenues by employing more dental hygienists. This will require additional operatories and will further constrain the employment of dental therapists. Second, beyond facilities, dentists and other clinical and administrative personnel need formal training to work with dental therapists. These training programs do not exist (other than the one under development at the University of Minnesota), and currently, dental schools provide students and residents with minimal didactic and clinical experience working with dental hygienists and dental assistants. The exception is when students and residents rotate through community clinics and private practices. Third, based on the current structure of FQHC dental clinics, most will have to employ dental therapists on a part-time basis. Even the largest FQHC in this study with over four FTE dentists did not have enough child patients needing restorations and extractions to employ a full-time dental therapist. For FQHCs employing dental therapists part-time, they will have to schedule patients needing restorations and extractions on specific days and times. This will be a management challenge since clinics often have high broken appointment rates. Fourth, clinics have many other options to increase their capacity to see more patients and generate higher net revenues besides using dental therapists. As already noted, large increases in output can be expected from providing dentists more operatories, employing more dental hygienists and other staff, and, of course, improving basic management processes. Fifth, dental therapists are only legal in one state, and it may take ten to twenty years before the majority of states legalize this new occupation. Also, FQHCs have the capacity to employ relatively few dental therapists (285), so the value of starting new dental therapist training programs, regulatory mechanisms, etc. for this small number is questionable. There are situations in which dental therapists could be a significant advantage to community clinics. A good example is small frontier communities in Alaska, since it will always be difficult to recruit dentists, and especially culturally competent dentists, to these isolated tribal areas. Also, for clinics that have at least one full-time dentist and are unable to recruit additional dentists, dental therapists may offer an alternative. A 2006 study reported that 26 percent of rural clinics had open dentist positions. 20 A more recent investigation reported that 39 percent of surveyed clinic directors had open dentist positions. 21 However, these studies were completed before the current economic downturn, and now dental students are graduating with $200,000 or more debt. For both reasons, FQHCs offer new graduates the opportunity to significantly reduce their debt and at the same time make a reasonable salary. As such, FQHCs may have less difficulty recruiting and retaining dentists now than in the past. A related issue is the large increase in dental school graduates expected in the next ten years. Another possible opportunity is to have dental therapists provide care to adults. This issue needs further investigation, but at face value this option is unlikely to increase dental therapist cost reductions substantially. Adults have relatively less need for simple restorations and extractions than children. Also, most Medicaid programs do not cover adult dental care or adequately reimburse FQHCs for treating adults. The value of training dental therapists for more than 2.5 years is problematic. As seen in Table 4, this will lead to higher dental therapist salaries and decreased FQHC cost reductions. Also, since dental therapists and dental hygienists can provide 95 percent of children services, it is unlikely that more years of training and a wider scope of practice will have much impact. This may not be true with regard to treating adults, but it is unclear what percentage of adult services can be provided by dental hygienists and dental therapists. As part of this study, a model was developed that FQHCs can use to estimate the economic impact of employing dental therapists within their four walls. The data needed to make the estimates should be available to any FQHC that has an electronic dental record system. August 2012 Journal of Dental Education 1075

9 The major limitation of this study is that it is not based on empirical information from the actual operation of dental therapists working in FQHC clinics. Instead, using data from a small convenience sample of FQHC dental clinics, estimates are provided on the likely financial and utilization impact of dental therapists. Although basic information is available on the number and types of children services, there are many unknowns on how FQHCs will use dental therapists. Conclusions This study is an initial effort to examine the impact of dental therapists on FQHC productivity and finances treating children. The analysis suggests that dental therapists will have a modest effect on reducing costs and increasing utilization. Acknowledgments This study was supported by a grant from the Pew Center for the States. We want to thank the FQHCs that provided data for this study; the Board of the National Network for Oral Health Access, which was a strong supporter of this effort; and the many people who reviewed drafts of the project report and papers, including Drs. William Maas, Norman Tinanoff, Wayne Cottam, Gregory Nycz, Scott Wetterhall, Tim Brown, and Beth Mertz. We also recognize and appreciate the significant time and effort that the Pew staff, Ms. Shelly Gehshan and Mr. Andrew Snyder, put into all phases of this study. REFERENCES 1. Bailit HL, Beazoglou TJ, DeVitto J, McGowan T, Myne- Joslin V. Impact of dental therapists on productivity and finances: III. FQHC-run school-based dental care programs. J Dent Educ 2012;76(8): Bailit HL, Beazoglou TJ, DeVitto J, McGowan T, Myne-Joslin V. Impact of dental therapists on productivity and finances: I. Literature review. J Dent Educ 2012;76(8): Beazoglou T, Bailit H, Drozdowski M. Federally qualified health center dental program finances: a case study. Public Health Rep 2010;125: McFarland J. Presidential address at the annual National Network for Oral Health Access conference, Washington, DC, September 24, Ruddy G. Health center s role in addressing the oral health needs of the medically underserved. National Association of Community Health Centers, At: com/client/documents/issues-advocacy/policy-library/ research-data/research-reports/oral-health-report- FINAL.pdf. Accessed: November Beazoglou T, Heffley D, Lepowsky S, Douglass J, Lopez M, Bailit H. Dental safety net in Connecticut. J Am Dent Assoc 2005;136: Byck G, Cooksey J, Russinof H. Safety net dental clinics. J Am Dent Assoc 2005;136(7): Glassman P, Subar P. The California community clinic oral health capacity study: report to The California Endowment, At: sources/documents/pacific_communitycapacitysurvey- CAEndowmentReport pdf. Accessed: November Edelstein B. Update on disparities in oral health and access to dental care for America s children. Acad Pediatr 2009;9(6): Bailit H, D Adamo J. Improving access to oral health care for vulnerable and underserved populations. Unpublished paper prepared for Institute of Medicine consensus report: improving access to oral health care for vulnerable and underserved populations. 11. Institute of Medicine. Improving access to oral health care for vulnerable and underserved populations, At: to-oral-health-care-for-vulnerable-and-underserved- Populations.aspx. Accessed: September Bailit H, Beazoglou T, Demby N, McFarland J, Robinson P, Weaver R. Dental safety net: current capacity and potential for expansion. J Am Dent Assoc 2006;137(6): Borchgrevink A, Snyder A, Gehshan S. The effects of Medicaid reimbursement rates on access to dental care. Washington, DC: National Academy for State Health Policy, Beazoglou T, Bailit H, Myne V, Roth K. Supply and demand for dental services: Wisconsin Unpublished report to the Wisconsin Dental Association, national dental advisory service comprehensive fee report. 23 rd ed. Milwaukee: Yale Wasserman, D.M.D., Medical Publishers, Williams S, Bradley S, Godson J, Csikar J, Rowbotham J. Dental therapy in the United Kingdom: part 3. Financial aspects of current working practices. Br Dent J 2009;207: Harris R, Burnside G. The role of dental therapists working in four personal dental service pilots: type of patients seen, work undertaken, and cost-effectiveness within the context of dental practice. Br Dent J 2004;197: Nash DA, Friedman JW, Kardos TB, Kardos RL, Schwarz E, Satur J, et al. Dental therapists: a global perspective. Int Dent J 2008;58(2): Friedman J. The international dental therapist: history and current status. J Calif Dent Assoc 2011;36(1): Rosenblatt R, Andrilla H, Curtin T, Hart LG. Shortages of medical personnel at community health centers. JAMA 2006;295: Bolin KA. Survey of health center oral health providers. National Network for Oral Health Access. At: www. nnoha.org/goopages/pages_downloadgallery/download. php?filename=13902.pdf&orig_name=nnoha_salary_ survey_report_final_1210.pdf&cdpath=/nnoha_salary_ survey_report_final_1210.pdf. Accessed: December Journal of Dental Education Volume 76, Number 8