How to reach patients in need

Drew Christianson grew up in a small town in Minnesota. It was so small, in fact, that it was common to see familiar faces popping up around the neighborhood.

“My dentist was my hockey coach,” Christianson remembers.

So when he attended the University of Minnesota’s dental school, he knew that he wanted that same sort of interaction with his future patients.

“I wanted to be personable with my patients,” he says. “I wanted to have that rapport and I wanted to make sure that my patients were as comfortable with me as I was with my dentist.”

That led Christianson, ultimately, to pursue a career as a dental therapist.

Serving a need

Dental therapists are licensed oral health care professionals who practice as part of a dental team, providing educational, clinical and therapeutic patient services. They are mid-level providers, akin to nurse practitioners on a medical team. Dental therapists provide preventive and restorative treatments for both children and adults, and they can also extract primary teeth, under the supervision of a dentist. They work primarily in settings that serve low-income, uninsured and underserved populations.

“What the dental therapist does is a basic level of restorative care and prevention,” says Dr. Karl Self, DDS, director of the division of dental therapy at the University of Minnesota School of Dentistry. “On the restorative side, they do direct filling. Anything that can be placed directly in a person’s mouth, they are authorized to do. They don’t do root canals. They don’t, by and large, do extractions, but some advanced dental therapists can do some sorts of extractions. They don’t do orthodontics. They don’t do periodontics or implants. They don’t do any of that higher level of care that patients require as the disease progresses.”

Dental therapy originated in New Zealand in the 1920s in response to the country’s lack of readiness for World War I-oral disease was rampant. The profession exists in 50 other countries around the globe, but didn’t come to the U.S. until it was introduced in Alaska in 2003.

In Alaska, however, dental therapists are called Dental Health Aide Therapists and only serve Native Americans. The profession started in Minnesota in 2009 and therapists are now present in two other states: Maine and Vermont. Eleven more are considering certifying the profession.

“There were not enough dentists to meet the need,” Dr. Self says. “We know for a fact that there were distribution issues such that there weren’t enough dentists in rural parts of the state, but additionally, they also weren’t seeing government program patients, so even in the urban areas there were a lot of underserved patients who were unable to access care.”

Differing opinions

But not everyone believes that dental therapists are effective team members.

“I understand that there are often success stories for dental therapists working in extremely isolated locations where dentists and patients are unable to coordinate visits,” says Dr. Kris Mendoza, DDS, a dental anesthesiology resident at UCLA and past president of the American Student Dental Association. “I do not deny that they are helping many people in these communities who are in dental pain; however, I do not believe that this model is applicable to 99.9 percent of the United States. I think there is a better way to deliver care to the population.”

Dr. Jane Grover, DDS, MPH, director of the ADA Council on Access, Prevention and Interprofessional Relations (CAPIR), says that dental therapists are not helping underserved areas as much as they are hyped.

“We’ve had three studies done, of those in Minnesota, and the majority are not in underserved areas,” Dr. Grover says. “I talked with a dentist just last week who has a therapist in his office and she’s working the front desk.”

Dr. Mendoza says that dental therapists may not be qualified to perform some of their more advanced procedures.

“One of the other problems I have seen is a lack of training and knowledge of human physiology and anatomy,” Dr. Mendoza says. “There are many complex disease processes that people come into the dental office with, and these dental therapists are not prepared to manage possible emergencies that occur with these patients.”

But Christianson-who, in addition to being a dental therapist, is also a clinical assistant professor at the University of Minnesota-disagrees, noting that at the University of Minnesota, dental therapists are trained side-by-side with dentists and hygienists. In fact, when it is time to take certification assessments, examiners do not know which career a candidate is pursuing.

“That’s the number one quality coming out of a provider is safety and quality assurance that everything is performed at the same level as a dentist,” Christianson says. “The program here at the University of Minnesota is all-encompassing in terms of allowing dental hygiene, dental therapy and dental students to all work together in the same classrooms and clinics. We do the same grading criteria in terms of restorative work or pediatric work, and it’s unbiased. You’re thrown in with all the students together, so it’s evaluated by the same criteria.

“When it comes to practice, since dental therapists have been practicing, there have been no safety issues that have come about,” he continues. “What’s nice about it is, and I say this loosely, the safety net of having the dentist there-that collaborative management agreement of what procedures you can perform and when you can perform them, and if situations do arise, there’ll always be a supervising dentist that should be available to you.”

Dr. Self says that much of the opposition to dental therapy is misunderstanding how they are best used.

“Initially, there was a lot of resistance to dental therapy,” Dr. Self says. “My opinion is that the dentists didn’t have a good understanding how a dental therapist was educated and how they could be utilized in their practices to increase access to care for underserved patients. What we’re finding, seven years later, is that there is a growing acceptance of dental therapy. It’s being driven, I believe, by more information we’ve been trying to get out and share with dentists what this is really all about, and that’s helped understanding. The dentists who have hired dental therapists and are sharing that information with their peers have helped acceptance and understanding.”

Tale of two providers

The ADA recommends its Community Dental Heath Coordinator (CDHC) model over dental therapists.

CDHCs, which are active in nine states, are community health workers with dental skills that focus on case management, navigation, oral health education and promotion, motivational interviewing and community mapping. They are able to link patients with available, but underutilized, dental care.

“They address the upstream determinants of dental disease,” Dr. Grover says. “They work with families that are within the community to navigate them into care. If their state practice act allows, they may perform clinical preventive procedures, again because they’re dental assistants who were dental hygienists, so they’re working within their state practice act to not only balance clinical and community duties, but they also spend most of their time in the community.”

Dr. Grover was a clinician at a federally qualified health center for 12 years before coming to the ADA.

“In an integrated setting, as health centers are, you can have a gorgeous clinic, you can have multiple chairs, you can have skilled clinicians standing by, but if patients aren’t aware of where those clinics are, and patients are not case managed into those clinics, if we don’t have integrated care, if you don’t have that kind of connection between a dental delivery setting and the community, you’re not really providing access to care,” Dr. Grover says. “I saw it in Washington, D.C., a couple of months ago-a new dental clinic, beautiful setting, nine chairs, three dentists and no patients. Getting the word out is not enough. It’s important to make that connection, and that’s what community dental health coordinators do-they make that connection for patients.”

“In the traditional model, dental therapists serve as a bandage instead of a solution,” Dr. Mendoza says. “Instead of trying to patch our wounds, we need to prevent the metaphorical bleeding from ever occurring. The root of the problem is oral health literacy and access to care. If we can bridge the gap between the patient and the dentist, we can begin to solve this problem. It is up to the dental community to find a solution to this problem.”

Outlook

Dental therapy is still a somewhat new and unfamiliar part of the dental team. How are things looking? Pretty good, Dr. Self says. Applications for the University of Minnesota program seem to be on the rise.

“Like every program, it varies from year to year, but I would have to say we had one of our strongest applicant pools this year for the class that will start in September 2017,” Dr. Self says. “There seems to be growing interest in it, especially for a program that only started seven years ago.”

The University of Minnesota’s program has evolved since 2009. Initially, there were two programs: a bachelor’s and master’s degree. Then the program changed to an all-master’s degree, but the program has since evolved to dual licensure-dental therapist and dental hygienist. The latest permutation gives graduates even more marketability.

“The appeal to applicants has been higher because of the amount of schooling you get and the licensure you get at the end,” Christianson says. “We had a lot more inquiries throughout the year than in the past because things are starting to change.”

And doctors seem to be embracing dental therapists.

“Around these parts, I would say it’s becoming more of a regularity,” Christianson says. “More people know what it is, and if you think it’s interesting to you and you wanted to try in, people are doing it.”

“When I started working back in 2014, there were some dentists that were really on board with me working and helping them with their restorative patients, but there was one dentist that really didn’t want me to be there,” Christianson says. “In a work environment, that can be really harsh. At the same time, I just showed my work and my patient rapport at the clinic. Over three months, the patients that I got most were from the doctor that didn’t want me there.”

Minnesota isn’t alone. Since approving dental therapists in 2009, Maine added them in 2014 and Vermont followed suit in 2016.

“There are pilot projects going on in Native American communities in the states of Washington and Oregon,” Dr. Self observes. “There’s legislation in many different states that is being discussed, including North Dakota, Maryland and Massachusetts.”

“I know that I am making a difference with patient care,” Christianson says. “I have patients that will routinely see me. I see their whole families for the restorative work or their assessments when they come in. And just the ‘thank you’ that I get and the praise for the quality of work that we do and the time and effort that we put in to know our patients. That allows me to know that I am making a difference.”