03/11/2009 - Mr. Chair and Members of the Committee. My name is Shelly Gehshan and I am Director of the Advancing Children’s Dental Health Initiative for the Pew Center on the States. The Pew Center on the States (PCS) is a division of The Pew Charitable Trusts that identifies and advances effective policy approaches to critical issues facing states. By researching emerging topics, PCS highlights innovative policy approaches to complex problems for states. The Children’s Dental Health Initiative is a five-year project to advance state policies that will dramatically improve children’s lives.
Dental care is the most prevalent unmet health need among children. Dental problems impair children’s ability to learn, play, and interact with their families and peers. Enduring dental pain from untreated cavities is unimaginable to most of us for even a day, let alone for weeks or months, but that is the reality for many low income children. Some problems may be intractable. This one is not.
The legislation you are considering would create a new primary care dental professional similar to those used in Alaska and 53 countries around the world. This professional would strengthen dental care just as nurse practitioners and physician assistants have strengthened general medical care. The safety, quality, and effectiveness of these professionals is well-established. Rigorous research shows they perform their duties as competently as dentists. The educational levels being contemplated in this legislation exceed what other countries require, but the net result would be the addition of a competent, trusted member of the health professions that would greatly increase the level of dental care in Minnesota. The intent in developing new workforce models is not to supplant dentists but to round out the dental team.
A mid-level practitioner would help bolster the capacity of community health centers, thereby expanding access to quality dental care for children and other vulnerable underserved populations. These new providers could be trained to do about 25 to 30 percent of the services that dentists are trained to do, such as cleanings, filling cavities, and pulling teeth, but could perform many of the services that children commonly need. Dentists will be needed for complex patients and procedures, but could delegate routine work to these new providers.
The Challenge of Children’s Dental Care
Access to dental care for low income children has been a vexing and persistent problem. Dental caries, or tooth decay, is the most common childhood disease, affecting 59 percent of children nationally. By comparison, asthma, the second most common childhood disease, affects 11 percent of children. Surveys show that 50 percent of children have cavities by the time they enter kindergarten.
Overall, the problem of poor dental health falls disproportionately on the poor—80 percent of pediatric dental disease is concentrated in 25 percent of children, primarily those from low-income and minority households. Although some level of decay in children may be unavoidable, the short- and long-term costs of failing to treat it are not. Nationwide, 31 percent of poor preschoolers have untreated cavities, compared to only 6 percent among children whose family incomes exceed 300 percent of the poverty level.
Why New Providers are Needed
There is no real safety net for dental care. There are no dental emergency rooms. The bedrock of the dental safety net is community health centers, but nationally only about 1 in 10 people who lack access to dental care can get that care from a safety net provider. Almost 20 percent of positions for dentists and hygienists in community health centers are vacant because dentists or hygienists are not willing or able to practice in these clinics. The vacancy rate is nearly 30 percent in rural areas. These new professionals could work with dentists and hygienists to treat patients at community health centers who lack sufficient numbers of providers.
In all states, there is a shortage of dentists who can treat young children. Across the country, there are way too few dentists in rural areas, low income urban areas, and who will accept Medicaid and SCHIP. The pressure to look for workforce models to improve access is large and growing. Many states have acknowledged they have an overall shortage of dentists and looking for solutions. Clearly more needs to be done, and the expansion of the dental health team in Minnesota is a step in the right direction.
Support for a New Dental Provider
I want to spend a minute to describe the international workforce picture. In 53 countries around the world, including Great Britain, Australia, New Zealand, and Canada, there are primary dental care providers called “dental nurses” or “dental therapists.” They complete a rigorous two-year training program that is basically the same as the last two years of dental school. In practice, they focus on patient-centered care for children, in schools, clinics, and private practices. To compare, dental school is roughly two years of basic science, and two years of clinical training. Around the world, some countries are moving towards an “Oral Health Practitioner” model that is a three-year program that combines dental therapy with dental hygiene. The legislation you are considering today would create a new primary care dental provider as well. The educational levels exceed what other countries require, and will increase the cost of education, and reimbursements unnecessarily. A lower level of education would produce excellent results and be more cost effective for states. But regardless of the education level, new providers would help improve access for children and other vulnerable groups.
Dentistry is unlike medicine in that there are far fewer types of providers. In medicine, there are registered nurses, nurse practitioners, physician assistants and physicians, to name just a few. The educational requirements for these positions vary and they are quite different from each other by design. A registered nurse has a different function and scope than a physician. Nurse practitioners are not considered second tier physicians, but separate types of providers with a different function in the delivery system.
Training for Practitioners
Developing a new training program will take time, but it has been done before and can be done here. In a survey of 36 state oral health coalitions that I did at my last job, 12 states in addition to Minnesota were looking at creating new providers. Minnesota schools could work with other states and the Commission on Dental Accreditation (CODA) to develop uniform standards to accredit the new training programs. Accreditation is a voluntary process, and CODA can issue interim accreditation until a school graduates its first class. States should also consider establishing uniform standards, so a national certification process can be used. Physician assistants across the country take one national exam for certification that is then used by states as one of the main criteria for state licensure or certification.
State Regulation of the Health Professions
As you know, regulation of the health professions falls squarely on the shoulders of state policymakers. The goal of state regulation is to ensure the safety of the public AND to ensure the public has access to care. Each decision you make has to balance costs and benefits. The first question to answer is, how will these new providers be used and how will they fit into the health care system? If they are to be used in underserved areas, then they can function in a hub and spoke system, with supervising dentists at the hub, and the new providers a phone call and internet hook-up away from a real-time consult. This is 2009, when technology means that supervision doesn’t have to be on-site to work. My recommendation is that there should be general supervision under standing orders. This is not a safety issue, and will in no way put patients at risk. Under general supervision, these new providers will have specific instructions about what cases they can take, what treatment they can provide on their own, which cases they can’t take, and a requirement to get approval for any case they are not sure of.
Around the world, dental nurses and therapists with two years of training, and dental health aid therapists in Alaska, practice with either no on-site supervision or under general supervision, and the research has shown no harm whatsoever to patients. Quite the opposite. These families are obtaining quality care they would otherwise not be able to access. Minnesota’s children do not have different mouths or teeth than children elsewhere. Nor do Minnesota’s children deserve lower standards for care provided. If it works there, it will work here.
Scope of Services
Dentists are business owners and leaders of their dental teams, but they do not deliver all dental services. They rely on other providers, and referrals to other dentists. Most discussions about workforce begin with an assumption that dentists can do anything that their patients require, and can do it better than any non-dentist could. But in other countries, the two-year dental therapist or nurse program includes 760 hours of clinical training on treating children. By comparison, dental students have much less experience with children, receiving an average of only 171 hours in pediatric dentistry.
Dental schools teach students how to do root canals, periodontal surgery, and orthodontics, yet few general dentists perform them, preferring instead to refer to patients to specialists. Further, while dentists are trained to clean teeth, 77 percent of general practitioners and 88 percent of periodontists prefer to hire hygienists to clean their patient’s teeth. According to the American Dental Association (ADA), 43 percent of patient visits are for hygiene services. That means in today’s private practices, the first provider who does a diagnosis and provides treatment (in this case cleaning) is usually the hygienist. Ultimately, new oral health professionals will become a major source of patient visits via referral, and will allow clinics and private dental practices to see more patients, improve efficiency and devote more time to more complex procedures.
There are many research studies from other countries, and the United States, that show that providers other than dentists can be taught in short periods to pull teeth and fill cavities with quality and consistency that is equal to that of dentists. The question about scope of services is, what are the needs for underserved patients who are not served by private practices? If you can teach students who become dentists to perform those services safely, then you can teach students who become dental therapists or oral health practitioners to perform them safely.
Private practice dentists deliver nearly 90 percent of the care in this country, and the safety net delivers 10 percent. These new primary care providers will bolster the 10 percent—to increase the number of patients who can be cared for in underserved areas. These are vulnerable, low income children and adults whom private dentists do not treat. This new position provides a common sense safety net solution to deliver high quality care to people who otherwise cannot get it. Mid-level providers will never replace dentists. Dentists will be needed for complex patients and procedures, but dentists could delegate routine work just as physicians do to nurse practitioners and physician assistants. When the field of dental hygiene was created, it took nearly 40 years for all states to license them. But now dental practice is unimaginable without them. I urge you to enact legislation that creates new providers. I, and Pew Center on the States, stand ready to assist you and the committee with your work on dental health issues, so please feel free to contact me in the future with any questions you may have. Thank you.