Dental Therapists Can Improve Access to Dental Care for Underserved Communities
By Lydia Mitts, Sinsi Hernández-Cancio,
11.28.2016
Millions of people in this country face significant barriers to obtaining the basic dental care they need to achieve good oral health. As a result, more than half of people in the U.S. go without any dental care each year, and many struggle with untreated dental disease that can have far-reaching, serious effects on their overall health.
Untreated dental disease can have serious consequences for people’s health. One reason some people can’t get access to timely dental care is the shortage of dental providers in many areas. These shortages hit some communities especially hard, particularly rural areas, and low-income neighborhoods, where people of color are more likely to live.
Adding dental therapists to the dental workforce is an important step states can take to improve access to dental care in underserved communities.
This burden of untreated dental disease disproportionately falls on communities of color, who already struggle with other serious health inequities, some of which could potentially be exacerbated by poor oral health.
In addition, unmet dental care needs exact an avoidable cost on the health care system each year as millions of dollars are spent on preventable dental-related emergency care each year.
People in the United States face many, often interrelated barriers to getting access to the dental care they need when they need it. For many, one serious obstacle to care is the fact that there aren’t enough dental providers near where they live. In fact, the Health Resources and Services Administration (HRSA) has identified nearly 5,000 dental provider shortage areas across the country (areas where there aren’t enough dentists to meet the needs of the community).
Shortage areas affect communities of all incomes, all racial and ethnic backgrounds, and all levels of urbanization. However, they are most common in rural areas and lower-income neighborhoods.
Communities of color are especially affected by dental provider shortages. On average, they are more likely to live in low-income areas where provider shortages are more likely to exist. Layered on top of this, certain racial and ethnic minorities are vastly underrepresented in the dental workforce. While black non-Hispanics, Hispanics, and American Indian/Alaska Natives together make up 32 percent of the U.S. population, they account for barely 10 percent of dentists in this country. This makes it incredibly challenging for these communities of color to access care from providers who are best suited to meet their cultural and linguistic needs.
Dental therapists are part of a dentist-led team. They educate patients about oral health and prevention, perform dental evaluations, give fluoride treatments, place sealants, clean teeth, place fillings and perform simple extractions.
Like nurse practitioners and physicians assistants in the field of medicine, dental therapists expand the reach of dentists and free them to perform more advanced treatments.
Expanding and diversifying the dental workforce to meet the needs of all communities is a critical component to improving access to timely, culturally competent care and to addressing health disparities. Addressing dental workforce shortages and improving timely access to dental care can also improve the overall quality and cost-effectiveness of care.
Adding dental therapists to the dental workforce is one strategy that states should use to improve access to timely dental care and to diversify the dental workforce to better meet their communities’ needs. States that want to expand their dental workforce to include dental therapists must pass legislation that authorizes dental therapists to practice in their state and determine the scope of practice for these providers.
What’s the problem?
Dental Provider Shortages Are a Major Barrier to Obtaining Timely Care
For many people, a major barrier to getting timely dental care is that there aren’t enough appropriate providers to go around. Nearly 49 million people live in oral health professional shortage areas. Shortage areas are most common in rural areas and in low-income communities, where people of color are more likely to live.
In the United States, dental provider shortages are only one of many interrelated factors that prevent people from getting the dental care they need to maintain good oral health. Not having comprehensive dental coverage and being unable to afford the cost of dental care are other major impediments to getting access to care.
Even when people do have dental insurance, they might not be able to find a provider in their network who is taking new patients.
In addition, there are multiple broader socio-economic barriers to obtaining dental care including lack of transportation, not having sick leave, limited understanding of how our health system works, low health literacy, and distrust of the system and of providers based on prior negative experiences or discrimination.
In addition, there are even fewer dentists who accept Medicaid. A 2010 study found that fewer than half of the dentists in 25 states accepted any Medicaid patients at all. This can make getting access to dental care particularly difficult for people on Medicaid, even outside of shortage areas. In 2014, on average, more than half of children across all states’ Medicaid and CHIP programs went without any preventive dental care. The shortage of dentists who accept Medicaid is a particular problem for low-income communities and people of color, who are more likely to rely on Medicaid to get the care they need.
Dental Care Disparities are Particularly Acute in Communities of Color.
The immense disparities in access to dental care across the country disproportionately affect racial and ethnic minorities. In particular, non-Hispanic blacks, Hispanics, and American Indians and Alaskan natives have the poorest oral health of the racial and ethnic groups in this country.
Among adults ages 20-64: Hispanics are 50 percent more likely to have untreated tooth decay than non-Hispanic whites; Non-Hispanic black adults are two times as likely to have untreated tooth decay as non-Hispanic whites. Non-Hispanic blacks and Hispanic adults are also nearly 50 percent more likely to have gum disease than non-Hispanic white adults.
» Non-Hispanic black and Hispanic adults are significantly more likely to go without any dental care in a year compared with nonHispanic white adults.
» Non-Hispanic black and Hispanic children ages 2 to 8 are twice as likely to have untreated tooth decay as non-Hispanic white children.
» American Indian and Alaska Native children ages 3 to 5 are four times more likely to have untreated tooth decay as white non-Hispanic children.
Dental Provider Shortages in Communities of Color are Exacerbated by Limited Provider Diversity
For care to be truly accessible, high-quality, and patient-centered, it must meet people’s cultural and linguistic needs and be grounded in an understanding of the communities in which they live.
Many communities of color face added difficulty getting access to care from providers who are equipped to provide culturally competent care. If there are too few dentists to go around, there are even fewer dentists of certain racial and ethnic minorities. Non-Hispanic blacks, Hispanics, and American Indian/Alaskan Natives make up barely 10 percent of dentists, but more than 30 percent of the population. Further, only 8 percent of students in training to become dentists are black, Latino, or American Indian.
For care to be truly accessible, high-quality, and patient-centered, it must meet people’s cultural and linguistic needs and be grounded in an understanding of the communities in which they live. To be sure, providers don’t necessarily have to come from the same racial and ethnic background to provide high quality, culturally competent care, but sharing common experiences and language can help tremendously in reducing more intangible (but no less important) barriers to high quality care. These barriers include confusion about the health care system, cultural differences that interfere with communication, trust, and previous experiences of being treated with disrespect and even racism.
Diversifying the dental workforce is essential to improving people of color’s access to high-quality dental care. Not only are providers of color usually better able to provide culturally competent care to people of color, they are also more likely to choose to work in minority and underserved communities.
Improving cultural competency of care in this country is of paramount importance to improving the quality of care and health outcomes that our system delivers.
Emergency Rooms Are the Only Available Source of Dental Care for Some
The emergency room can be the only accessible source for dental treatment for people who struggle to get access to timely care. This means that many people are only able to obtain care once they face painful complications that could have been prevented if they had access to basic care. In 2009, more than 800,000 visits to the emergency room were related to preventable dental conditions.
These emergency room visits come at an immense cost to states and other health care payers: It is estimated that the average cost to Medicaid for inpatient emergency treatment of dental problems (for patients admitted to the hospital from the emergency room) is almost 10 times more than the cost of providing preventive dental care. The cost of outpatient emergency room care is nearly three times more than the cost of preventive care.
Improving access to timely, preventive dental care and routine treatment in more cost-effective outpatient settings is critical to preventing more serious dental problems. It also helps improve communities’ overall oral health. This, in turn, can help reduce the need for dental-related emergency room visits and the corresponding costs to the health care system.
Unmet Dental Care Needs Can Contribute to Other Health Disparities
Untreated dental disease can have far-reaching consequences for people’s overall health and wellbeing. Without access to necessary care, dental infections can spread throughout the body and affect other areas of people’s health. Growing research has found that untreated dental conditions can put people at greater risk for other health concerns. These include conditions where there are already significant racial and ethnic health disparities.
Diabetes is a prime example. Racial and ethnic minorities are more likely to have diabetes and are at increased risk for complications from diabetes, such as blindness and kidney disease. While there are a number of factors that contribute to these disparate outcomes, there is growing clinical evidence that shows access to dental care may be one piece of this puzzle. There is strong evidence that untreated gum disease can raise blood sugar levels, and, in turn, increase the risk of related complications. In addition, people with diabetes who are unable to meet their blood sugar targets are at increased risk of developing the very gum disease that can place them at higher risk for further diabetes complications.
Timely dental care is therefore one of a number of types of care and resources that patients need to effectively manage their diabetes. Recent studies have found that treating gum disease in diabetic patients can actually help improve their diabetes management outcomes.
Premature birth is another example of a health issue where there are significant racial and ethnic disparities and where access to dental care could make a difference. Non-Hispanic black women have significantly higher rates of preterm birth compared to non-Hispanic white women. And preterm birth is the leading cause of death for black infants, who are twice as likely to die before their first birthday as non-Hispanic white babies.
A growing body of research suggests that untreated gum disease is one of many factors that can increase a woman’s risk of giving birth prematurely.
Given the growing evidence that dental disease can have a far-reaching impact on other clinical conditions, it is important to consider how disparities in access to dental care may contribute to disparities in other clinical areas.
A Strategy That Addresses This Problem: Adding Dental Therapists to the Workforce
Why States Are Considering Adding Dental Therapists to their Workforce
As states, advocates, and community leaders work to improve the value of health care and address broader health disparities, these efforts must include strategies to reduce disparities in access to timely dental care for communities of color.
To improve access to dental care for communities of color and other underserved communities, states must develop strategies to expand the dental workforce and increase the capacity of dental practices to serve more people in these communities. One option for achieving this goal is for states to pass legislation that grants licensing to mid-level dental providers, called dental therapists, to provide care.
Dental therapists work as additional members of a dentist-led team. They provide health education; preventive care (including sealants that protect teeth from cavities); and limited, non-surgical restorative dental services, such as fillings, crowns, and tooth extractions. Each state determines the full scope of services that dental therapists are allowed to provide through “scope of practice” laws and regulations.
Dental therapists are not a new type of provider. More than 50 countries have thriving dental therapy programs that have been shown to improve access to high-quality care. In the United States, there are a growing number of places in which activity is underway to bring dental therapists into the oral health workforce.
» In Indian country, a growing number of tribes and Indian health boards are employing dental therapists to serve their American Indian/Alaskan Native communities. In 2003, the Alaska Native Tribal Health Consortium created a Dental Health Aide Therapist (DHAT) Initiative, which added dental therapists to the care teams serving Alaska native villages state-wide. The Swinomish tribe in Washington began employing dental therapists in early 2016. In 2016, The Coquile Tribe and the Confederated Tribes of Coos, Lower Umpqua, and Siuslaw Indians in Oregon also received approval for a pilot project to employ dental therapists under a state initiative aimed at expanding innovations in oral health care.
» In Minnesota, dental therapists have been providing care since 2011.
» Maine and Vermont have passed legislation to allow dental therapists to practice.
Close to a dozen additional states are currently considering legislation to allow mid-level dental providers to practice.