Dental care is the greatest unmet health need among children. More than 16 million U.S. children go each year without seeing a dentist. A number of factors are associated with increased difficulty in receiving care, including location, family income and insurance, race and ethnicity and age. The nationwide shortage and maldistribution of dentists, as well as low Medicaid reimbursement rates, fuel the problem of accessing routine care.
Expanding the current dental workforce is one component of a larger effort to help states find cost-effective policies to ensure that underserved Americans receive timely and quality dental care. Pew supports state efforts to expand the dental team to serve children who lack access to care. This FAQ from the children's dental policy project addresses key questions about expanding the oral health care workforce.
Q: I thought everyone had a dentist. Who isn’t receiving care?
A: Part of the access problem can be attributed to the shortage and uneven distribution of dentists across the country. Children who live in rural areas remain chronically underserved. Overall, the proportion of dentists to population is shrinking—in 2010, that ratio was at its lowest level in nearly 100 years. Limited access is a particular problem for poor children. Kids aged 2 to 11 whose families live in poverty are twice as likely to have untreated decay as their more affluent peers. While all states offer dental coverage for low-income children, it can be difficult to find a dentist to serve Medicaid enrollees. In fact, in most states that reported data on access, a majority of dentists did not treat a single Medicaid patient.
Q: Why don’t dentists accept Medicaid?
A: In a number of states, Medicaid reimbursement rates are too low to cover the actual cost of providing care. There are also administrative barriers associated with the program. For instance, dentists often have to get pre-approval before performing certain procedures. Furthermore, signing up to be a Medicaid provider and verifying patients’ eligibility can be very cumbersome. Frequent no-shows by Medicaid recipients also deter dentists from participating.
Q: If states raised Medicaid reimbursement rates for dentists, would that solve the access problem for low-income children?
A: States could encourage more dentists to serve low-income patients by ensuring their Medicaid rates are high enough to cover the cost of providing care. Yet higher reimbursement rates alone are not enough. There is still the problem of the lack of dentists operating in rural and underserved areas. Alaska, Arizona, Connecticut, Delaware and Maryland have the five highest reimbursement rates of all 50 states, yet most of their Medicaid-enrolled children did not see a dentist in 2009.
Q: Can’t community health centers address this problem?
A: It’s true that millions of people rely on community clinics and dental school clinics to access services. However, our current dental safety net is simply not able to serve all of the people in need of care. One study estimates there are 82 million underserved people from low-income families, a need that far exceeds the safety net’s capacity to care for 7 to 8 million people.
Q: Are there ways that new or existing dental providers could provide quality, routine dental care?
A: Yes. States are exploring new models to expand the dental team and serve more people who are left out of the system. One approach is to provide additional training to expand the scope of services offered by existing dental professionals, such as hygienists and dental assistants, so that they are able to perform more procedures. Also, nondental professionals, such as pediatricians, can be trained to incorporate preventive oral health services in their practices. A third approach is to train and license a new type of dental health professional.
Q: What do you mean by a “new type of dental health professional”?
A: One proposed new dental health professional is the Community Dental Health Coordinator (CDHC), whose role can be likened to a social worker that focuses on oral health needs. CDHCs would provide a small set of preventative services but no restorative procedures (such as fillings). A number of states are also considering licensing new professionals whose role in the dental field would be similar to how nurse practitioners work in the medical field. One example is an Advanced Dental Hygiene Practitioner (ADHP), a hygienist with extra training. An ADHP would be able to do both preventive and restorative care, and work in a variety of settings. Dental therapists are another example of a new type of oral health practitioner. These professionals have worked for several decades in countries such as Australia, Canada, Great Britain, and New Zealand. These are primary care dental professionals who can perform quality, routine care as part of a team led by a dentist. Dental therapists can offer a subset of the services performed by dentists. For example, dental therapists can clean teeth, fill cavities and extract primary teeth. These new members of the dental team could be deployed in rural and other high-need areas of a state, and care for underserved patients, such as low-income children and the elderly.
Q: How do we know that dental therapists can provide quality, safe care? Have they ever been trained and employed in the U.S.?
A: The existing research indicates that dental therapists both here and abroad deliver safe and effective care. An Institute of Medicine report found no evidence to support concerns about the quality or safety of care provided by new types of dental providers. This report encouraged states to explore new types of providers that can improve access. Dental therapists are currently deployed in Minnesota and Alaska, and a 2010 study concluded that dental therapists in Alaska deliver safe, competent care within their scope of practice. Research also shows that dental therapists in Alaska are working effectively under the general supervision of dentists. No research, either internationally or in the U.S., has ever found problems with the care provided by dental therapists.
Q: What’s the advantage of utilizing these new types of providers?
A: The biggest advantage of an expanded workforce would be to increase access to dental care for millions of children. These new types of oral health professionals could potentially work in clinics and schools, providing greater numbers of children with preventive, routine dental care. Where more serious problems are uncovered, dental therapists refer children to a dentist. Using these new practitioners could also allow dental offices to work more efficiently, freeing dentists to do the more complex tasks that only they are trained to provide.
Q: Some dentists are concerned that authorizing dental therapists or other new providers could negatively affect their businesses. Would that happen?
A: Research shows that private-practice dentists who hire a new dental team member can serve more patients and significantly improve their financial bottom line. In addition, this research shows that hiring auxiliaries will enable many practices to treat more Medicaid patients while increasing their profits. For example, a solo pediatric dentist who hires one hygienist-therapist would be able to devote up to 20 percent of the practice to serving Medicaid-enrolled patients and still increase their income by 30 percent.
Q: Do current providers support new types of oral health practitioners?
A: Yes and no. For example, the American Dental Association only supports modest changes in the dental workforce. The ADA backs the creation of Community Dental Health Coordinators, but these individuals would not be trained to fill or extract teeth. In contrast, the American Association of Public Health Dentistry supports state efforts to explore new types of providers and has developed a model curriculum for training dental therapists, and the American Dental Hygienists Association supports state efforts to create new providers. While many dentists opposed a new Minnesota law to train and license two kinds of dental therapists, some dentists publically supported this legislation. As additional states adopt new types of providers, more dentists are likely to recognize the positive impact that these new members of the dental team could have on closing the access gap.
Q: How do Americans feel about new providers?
A: Recent polls show that the general public supports adding additional members to the dental team to improve access to care. A national poll found that more than 75 percent of respondents were in favor of training new providers. In addition, 78 percent of Maine residents support the creation of a new dental provider.
Q: How difficult would it be for states to train these new kinds of professionals?
A: Within the space of two years, Minnesota passed a state law to license new providers and recently graduated its first class of dental therapists. Training dental therapists has proven to be cost-effective. A Canadian study of four consecutive graduating classes showed that dental therapists paid for themselves, on average, in only three-and-a-half years.
Q: Prevention efforts have proven effective in the fight against tooth decay. Shouldn’t we simply focus on expanding these services?
A: This is not a case of either or—we need to provide both preventative and restorative care. There are still many children who lack access to dental sealants and fluoridated water, which are cost-effective prevention strategies. Only 72 percent of people on community water systems have access to optimally fluoridated water. Only 9 states have sealant programs in high-risk schools that reach even half of its children. Prevention is important, but regular dental care is also critical. An untreated cavity is not like a cold or flu that goes away with time and bed rest. As the August 2010 death of a young Ohio man reveals, a cavity needs to be treated before it becomes a serious and potentially life-threatening problem. We need more prevention as well as more access to dental care.