Access to dental care for low-income patients. Impact of Dental Therapists on Productivity and Finances: I. Literature Review

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1 Impact of Dental Therapists on Productivity and Finances: I. Literature Review Howard L. Bailit, D.M.D., Ph.D.; Tryfon J. Beazoglou, Ph.D.; Judy DeVitto, B.S.; Taegen McGowan, B.A., M.P.H.; Veronica Myne-Joslin, B.A. Abstract: This study examined the financial impact of dental therapists on Federally Qualified Health Center dental clinics (treating children) and on private general dental practices (treating children and adults). This article, the first of four on this subject, reviews the dental therapy literature and the dental access problem for low-income children. Dental therapists now practice in many developed countries, tribal areas of Alaska, and Minnesota. These allied dental professionals vary in their training and required dentist supervision, but all provide routine restorative and other related services to children and adults. The limited literature on the impact of dental therapists suggests that they work mainly in school and community clinics and some private practices, are well accepted by patients, provide restorations that are comparable in quality to those of dentists, expand the supply of services, do not increase private practices net revenues, and in school programs decrease the number of untreated decayed teeth. Of the approximately 33.8 million children enrolled in Medicaid and the Children s Health Insurance Program (CHIP), some 40 percent now receive at least one annual dental visit. To increase utilization for all children to 60 percent the rate seen in children from upper-income families another 6.7 million children need to receive care; dental therapists may help to accomplish that objective. Dr. Bailit is Professor Emeritus, Department of Community Medicine, School of Medicine, University of Connecticut Health Center; Dr. Beazoglou is Professor, Department of Craniofacial Sciences, School of Dental 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. Howard Bailit, Department of Community Medicine, School of Medicine, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030; ; Bailit@nso1.uchc.edu. Keywords: community health services, community dentistry, access disparities, access to care, low-income patients, dental therapy, dental therapists, dental practice Submitted for publication 2/13/12; accepted 5/2/12 Access to dental care for low-income patients (at <300 percent of the Federal Poverty Level) is a serious national problem. Most of those patients do not have adequate personal wealth or private or public dental insurance to purchase private sector dental care. As a result, they have relatively low utilization rates and high levels of oral disease morbidity and disability compared to middle- and upper-income populations. 1 One strategy for reducing access and health disparities is to lower the unit cost of providing services by substituting lower for higher cost labor. All things being equal, this should make care more affordable, increasing the demand for services and utilization rates. This is one rationale behind physicians use of physician assistants and nurse practitioners. Dentists also have a long history of increasing their efficiency by delegating tasks to dental assistants, expanded function dental assistants, dental hygienists, and laboratory technicians. Recently, a new type of dental mid-level provider has become part of the oral health care delivery system in some areas of the United States, so that dental health aide therapists now provide care in tribal areas of Alaska and in the state of Minnesota. 2 Internationally, dental therapists are practicing in many developed countries, including the United Kingdom, Australia, Canada, New Zealand, and the Netherlands. Although the training and roles of dental therapists differ among countries, all dental therapists extend the capacity of dentists, especially in underserved areas, primarily by providing common diagnostic, preventive, and restorative services. The goal of this study was to examine the potential impact of dental therapists treating children on the productivity and finances of delivery organizations and, in turn, on reducing access disparities. This examination includes the development of an economic model that community clinics and private practices can use to estimate the financial impact of dental therapists. The results are presented in four related articles published in this issue. This article, the first, reviews the relevant dental therapy literature and examines the magnitude of the access problem August 2012 Journal of Dental Education 1061

2 for low-income children since these two issues apply to all delivery systems. The second article examines the relevant outcomes for dental therapists providing care to children in Federally Qualified Health Centers (FQHCs). The third article looks at these same issues in FQHC-operated school-based delivery systems, and the final article estimates the impact of dental therapists employed in private general practices, providing care to children and adults. Dental Therapists Training, Supervision, and Services In the Alaska program, dental therapists were formerly educated in the New Zealand Dental Nurse program, but now they spend a year in coursework at the University of Washington School of Medicine DENTEX program and a second year of clinical training in a tribal dental clinic in Bethel, Alaska. At the end of the two years, they are required to complete a supervised clinical preceptorship for three months or 400 hours. Graduates are then eligible for certification as a dental therapist. 3 Minnesota has established three types of dental therapy training programs. The University of Minnesota School of Dentistry offers both a four-year baccalaureate and a three-year master s program. The bachelor s degree program is designed for students who have at least one year of college (included in the forty-month program). The master s program is for students with a B.A. or B.S. degree. In addition, in its Advanced Dental Therapist Program, Metropolitan State University (located in Minneapolis and in affiliation with Normandale Community College) offers a two-year master s degree for students with a B.S. or B.A. degree in dental hygiene. 2,3 The latter program allows dental therapists to provide a modestly broader scope of services and to work in a collaborative arrangement with dentists. In Minnesota, dental therapists are required to primarily provide care to underserved adults and children. The Alaskan dental therapists and advanced dental therapists work under general dentist supervision. That is, the supervising dentist is not physically present in the same location but is available electronically. The two types of therapists trained at the University of Minnesota work under indirect supervision, i.e., the supervising dentist is present in the same facility but not necessarily the same room. The services provided by the three types of dental therapists are similar and include examinations, preventive services, local anesthesia, restoration of deciduous and permanent teeth, and extractions. Dental therapists are not allowed to scale below the gum line. A detailed list of services for each type appears in Table 1. 3 Evaluation The literature on the impact of dental therapists on the quality of care, patient satisfaction, and practice/clinic finances is limited. Indeed, there are no randomized controlled trials comparing dental therapists and dentists in terms of these and other outcomes in the United States. For that matter, few studies have examined these issues for U.S. private or public sector dentists. Most research data on dental therapists come from other countries. In New Zealand, Great Britain, and Australia, dental therapists started working in publicly run school clinics, but now are also employed in private practices and hospitals. In the latter facilities, they treat both children and adults and usually work under indirect or general dentist supervision. The total numbers of dental therapists in Great Britain, Australia, and New Zealand are estimated to be 700, 1,300, and 700, respectively. 4,5 These countries have far fewer dental hygienists per dentist than in the United States and Canada. 4 Previous articles have reviewed the history of dental therapy programs in these and other countries, including the United States Other research has reported the following: the majority (57 percent) of the public would allow dental therapists to restore their teeth; 15 patients treated by dental therapists and dentists were equally satisfied; dental therapists reported being underutilized by dentists (e.g., they can treat more complex patients); dental therapists often worked part-time in multiple private practices; 17,19-22 many dental therapists feel underpaid, especially relative to dental hygienists; 17,19,22-24 and dually qualified hygienists and therapists working in private practices appear to spend most of their time providing hygiene services, making it difficult for them to maintain their therapist skills. 19,20,22,24 Studies conducted in Australia and New Zealand have compared the technical quality of restorations placed by dental therapists and dentists and reported no statistically significant differences Preliminary results from the Alaskan dental therapists experience also found high patient and commu Journal of Dental Education Volume 76, Number 8

3 Table 1. Scope of practice for dental therapists in Alaska (AK) and Minnesota (MN) AK Dental Health MN Advanced MN Basic Aide Therapist Dental Therapist Dental Therapist Evaluation and Preventive Services Examination/assessment/inspection yes yes no Dental radiography yes yes yes Provide, dispense, administer select medications no yes no Counseling yes yes yes Cleaning above the gum line yes yes polish Fluoride application yes yes yes Sealant placement yes yes yes Cleaning below the gum line (scaling) no no no Space maintainers yes yes yes Basic Restorative Services Temporary restoration/art technique yes yes yes (general supervision) Isolation yes yes yes (general supervision) Injection of local anesthetic yes yes yes Tooth preparation (drilling primary and permanent teeth) yes yes yes Tooth restoration (filling primary and permanent teeth) yes yes yes Primary tooth SSC (preformed cap) yes yes yes Primary tooth pulpotomy (a nerve treatment) yes yes yes Surgical Services Extract primary teeth (uncomplicated) yes yes yes Extract permanent teeth (conditional uncomplicated) yes yes no Other surgical care no no no Advanced Restorative Services Periodontal treatment (gums) no no no Endodontic treatment (root canals) no no no Fixed prosthodontic treatment no no no Removable prosthodontic treatment no no no Orthodontic treatment no no no Adjunct Services Community level oral health programming and promotion yes yes yes Care coordination yes yes yes Population assessment no yes yes Research no yes yes Note: Level of supervision for AK Dental Health Aide Therapist and for MN Advanced Dental Therapist is general/collaborative. Level of supervision for MN Basic Dental Therapist is indirect except as noted. Source: Edelstein B. Training new dental health providers in the U.S. W.K. Kellogg Foundation, At: Accessed: September nity satisfaction and comparable (to dentists) technical quality of restorations and patient records. 18,28,29 Limited information is available on the economic impact of dental therapists, and the published research is not rigorous methodologically. In Great Britain, reports have noted that dental therapists do not generate surplus net income for private practitioners Multiple studies of nurse practitioners and physician assistants employed in medical practices and clinics reported no consistent change in net revenues. 33,34 In contrast, a privately published economic modeling exercise estimated that one dually qualified dental hygienist-dental therapist can increase the annual net income of solo general dental practitioners by 52 percent (from $337,242 to $511,446). 35 In terms of impact on oral health, some data are available from New Zealand, where dental therapists provide most care to children up to twelve years of August 2012 Journal of Dental Education 1063

4 age in a voluntary school program. 36 Teenagers receive free care in contracted private offices and the school system. Adults (eighteen years and above) obtain care in the private practice system. At age twelve to nineteen years, the decayed, missing, and filled teeth (DMFTs) are similar (around 2.0) in New Zealand and the United States. For children aged six to eleven years, the prevalence of untreated coronal decay is significantly lower in New Zealand (2.7 percent) than in the United States (7.7 percent). 37 Also, the prevalence of untreated oral diseases among New Zealand children with different family incomes is not statistically significant. In contrast, large oral health disparities are seen in children in the United States. The prevalence of edentulousness in the elderly is modestly higher in New Zealand (34.6 percent) than in the United States (27.6 percent), and so is the prevalence of untreated coronal decay in adults thirty-five to forty-four years of age (37.5 percent in New Zealand vs percent in the United States). The New Zealand school-based care system appears more effective in treating caries and reducing oral health disparities. The advantages of New Zealand s child care system are not seen in the adult population. Access Problem As of 2009, 33.8 million children in the United States were enrolled in Medicaid and the Children s Health Insurance Program (CHIP), but with the recent economic downturn, this is probably an underestimate of the current number. 38 Another 5.4 million low-income children are eligible for Medicaid benefits but are not enrolled in the program. Also, in several states, Medicaid eligibility standards are so restrictive that a large percentage of poor children are not eligible for the program. The bottom line is that the number of children who should be Medicaid/ CHIP-eligible is probably close to 40 million. All states are required to provide dental care to Medicaid-enrolled children. Nationally, utilization rates (one or more visits to a dentist per year) average 40 percent but vary by state. 39 Generally, states with relatively high Medicaid fees (relative to market fees) have higher utilization rates. For example, Vermont Medicaid dental fees are in the 50 th percentile of market fees, 90 percent of dentists participate in the program, and over 50 percent of eligible children have a dental visit annually. 39 In most states, Medicaid dental fees are 30 to 50 percent of market fees. 40 In large part, this accounts for the relatively low dentist Medicaid program participation (25 percent) and, in turn, low Medicaid patient utilization rates. 41 Economic barriers are not the only access problem. There are also social barriers that limit access to oral health care. In the state of Michigan, Medicaideligible children from fifty-two rural counties were enrolled in a private insurance plan that paid dentists market-level fees. While more dentists accepted these special Medicaid patients, utilization rates have not exceeded 53 percent (versus 66 percent for privately insured Michigan children). 42 Such factors as level of caregiver education, language, and transportation also impact utilization rates. These social barriers need to be addressed to increase Medicaid utilization rates. The appropriate target utilization rate for Medicaid-eligible children is an open question and is a social and political rather than a scientific issue. Is it the 66 percent seen for privately insured children; the 46 percent reported in national studies for children from middle-income families; or 56 percent, the utilization rate reported for children from upper-income families? 43 If the goal were to increase Medicaid/CHIP utilization rates to 60 percent a midpoint among the three levels for children from other socioeconomic groups then 20.2 million of the 33.8 million enrolled children need to have at least one annual dental visit. Currently, about 40 percent or 13.5 million Medicaid/CHIP-enrolled children access dental care each year. To achieve a 60 percent utilization rate, another 6.7 million children need to be provided with dental care. A related issue is the oral health of low-income Medicaid/CHIP-enrolled children. In many states, children from families up to 250 percent of the Federal Poverty Level (FPL) are eligible for enrollment. The key issue is what percentage of these children have untreated carious teeth. According to data from the NHANES study, 37 no more than 12 percent of children ages six to eleven years and 27 percent of those ages twelve to nineteen years have untreated carious permanent teeth (Table 2). Some unknown percentage of children require other dentist services such as extractions and pulpotomies, and some younger children have untreated decay in deciduous teeth. As a reasonable estimate, perhaps 35 percent of children require dentist-level services. Therefore, of the additional 6.7 million children targeted for care, perhaps 2.2 million require dentist or dental therapist services. The remaining 65 percent can be cared for by dental hygienists under the supervision of dentists Journal of Dental Education Volume 76, Number 8

5 Table 2. Percentages of children with untreated caries in permanent teeth by Federal Poverty Level (FPL) and age, Age Less Than 100% FPL 100% to 199% FPL 200% or Greater FPL 6 11 years 11.7% 11.9% 3.5% years 27.1% 27.0% 12.8% Source: Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in oral health status: United States, and Vital Health Stat 2007;11(248). Discussion Our literature review suggests that dental therapists are providing routine dental services to adults and children in many developed countries and have been introduced in the United States. Overall, the evaluation literature is limited, and the few studies available report on a convenience sample of a small group of dental therapists or delivery settings that employ dental therapists. Much more research is needed on the operation of public and private sector dental care delivery systems and the role of dental therapists and other personnel. The major contribution of dental therapists appears to be providing dental services to children in school-based dental care systems and community clinics. Indeed, in New Zealand and some areas of Australia, dental therapists in school-based clinics provide most of the oral health care that children receive. In several countries, dental therapists work in private practitioner offices, but so far, the number employed in this setting appears limited. The reasons for this are unclear, but some research has indicated that private dentists find it difficult to cover dental therapist-generated practice expenses. In Australia and Great Britain, many dental therapists are also qualified as dental hygienists, and at least in private practices, they appear to mainly provide hygiene services. Studies of the impact of nurse practitioners and physician assistants have indicated that they increased the supply of medical services but had little or no impact on reducing the unit cost of care. Dental therapists are just getting started in the United States. They are mainly employed in frontier areas of Alaska that are difficult to staff with dentists. The employment of dental therapists in Minnesota is in an early stage of development, and it is premature to come to any conclusions on the organizations that will employ them and their impact on access and expenditures. The access disparity problem for children indicates that enrollment in Medicaid and CHIP is now about 33.8 million and there are perhaps another seven million low-income children who are eligible but not enrolled in Medicaid/CHIP. Only 40 percent of Medicaid-eligible children are receiving dental visits annually; in large part, this appears related to low reimbursement rates. National oral health survey data indicate that low-income children have more untreated decayed teeth than children from wealthier families. Still, only 35 percent of poor children appear to need dentistlevel services. Most low-income children who do not have untreated decayed teeth can be managed by dental hygienists who provide periodic screenings and preventive services. To reach utilization rates seen in middle- and upper-income families, another 6.7 million children need to receive care. The key questions are these: What impact will dental therapists employed in community clinics, school-based programs, and private practices have on reducing access disparities, and will employment of dental therapists reduce per patient expenses? These issues are addressed in the next three articles Acknowledgments This study was supported by a grant from the Pew Center on the States. We appreciate the significant contribution to this project from the members of the Pew Advisory Committee (Drs. Norman Tinanoff, Gregory Nycz, Beth Mertz, Scott Wetterhall, Jack Brown, and Wayne Cottam) and Dr. William Maas. We also recognize the significant time and effort that Ms. Shelly Gehshan and Mr. Andrew Snyder put into reviewing drafts of the report to the Pew Center on the States and this article. Their comments and suggestions were helpful. August 2012 Journal of Dental Education 1065

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