Dental Therapy: Evolving in Minnesota's Safety Net

Karl Self, DDS, MBA; David Born, PhD; Amanda Nagy, MPH

Disclosures

Am J Public Health. 2014;104(6):e63-88. 

In This Article

Abstract and Introduction

Abstract

Objectives. We identified Minnesota's initial dental therapy employers and surveyed dental safety net providers' perceptions of dental therapy.

Methods. In July 2011, we surveyed 32 Minnesota dental safety net providers to assess their prospective views on dental therapy employment options. In October 2013, we used an employment scan to reveal characteristics of the early adopters of dental therapy.

Results. Before the availability of licensed dental therapists, safety net dental clinic directors overwhelmingly (77%) supported dental therapy. As dental therapists have become licensed over the past 2 years, the early employers of dental therapists are safety net clinics.

Conclusions. Although the concept of dental therapy remains controversial in Minnesota, it now has a firm foundation in the state's safety net clinics. Dental therapists are being used in innovative and diverse ways, so, as dental therapy continues to evolve, further research to identify best practices for incorporating dental therapists into the oral health care team is needed.

Introduction

Dental therapy has evolved as a way to address specific oral health care needs. In New Zealand and Australia, dental therapy began as a way to address poor oral health in children. High levels of untreated disease coupled with a workforce shortage led the UK government to supplement dental care with dental therapists as new members of the health care team. In Canada and for people served by the Alaska Native Tribal Health Consortium, an important factor in the creation of dental therapy was the opportunity to extend care to native communities that were often geographically isolated.[1]

In the United States, many barriers impede access to oral health care for the nation's most vulnerable populations, including lack of dental care coverage, an inadequate supply of dental providers (particularly in rural communities and inner cities), and the limitations of the dental Medicaid program.[2–4] These concerns are mirrored in Minnesota.[5] According to 2011 data from the Minnesota Department of Health, 56 of the 87 Minnesota counties are designated in whole or in part as dental health professional shortage areas.[6] Populations living in health professional shortage areas have less access to routine primary care than do populations living in areas with an adequate health care workforce.[7] Only one fourth of Minnesota dentists practice in rural areas. The current Minnesota dental workforce is also aging: 47% of dentists are older than 55 years, and 42% plan to retire within the next 10 years.[8]

Additionally, Department of Human Services data reveals that 862 000 Minnesotans were enrolled in a Minnesota Health Care Program (MHCP) in 2012 (MHCPs include Medical Assistance [Minnesota's Medicaid program] and MinnesotaCare).[9] Our October 2013 analysis of historical Minnesota Department of Human Services data shows that the number of Minnesotans eligible for dental care through Medical Assistance increased 59% from 2004 to 2012.

It is hard to estimate the number of individuals who have problems accessing routine dental care in Minnesota. A 2012 Robert Wood Johnson Foundation publication reported that whereas 80% of insured Minnesotans had a dental visit in 2010, only 58% of uninsured Minnesotans had a visit.[10] The unmet oral health need is also conveyed by the high number of emergency department visits for preventable dental-related problems. Davis et al.[11] found that in a single year patients made more than 10 000 emergency department visits to 5 major hospital systems in the Minneapolis–St. Paul metropolitan area. These patients incurred total charges of $5 million for dental issues such as toothaches and abscesses.

People who are enrolled in an MHCP and other underserved populations often turn to safety net providers to receive their oral health care. Although previous literature conveys the impression that the "dental safety net" has no single definition, the American Dental Association describes the safety net as the

sum of the individuals, organizations, public and private agencies and programs involved in delivering oral health care services to people who, for reasons of poverty, culture, language, health status, geography or education, are unable to secure those services on their own. [12(p2)]

Although safety net clinics provide a small portion of overall health care, they are an important resource for groups that face access barriers.[13] Not surprisingly, safety net clinics have many challenges, including difficulties in recruiting and retaining dentists.[4] Perhaps because of their staffing challenges, Minnesota's safety net providers helped lead the way when the state began an initiative to create a midlevel dental provider to address the growing oral health concerns of the state. In 2009, Minnesota became the first state to establish licensure of dental therapists with an additional process for certification as an advanced dental therapist to extend oral health care to underserved populations. The legislation limits dental therapists to practice primarily in settings that serve low-income, uninsured, and underserved populations or in a dental health professional shortage area.[14]

In response to the state mandate, the Minnesota Board of Dentistry simultaneously approved 2 programs for educating licensed dental therapists. The University of Minnesota School of Dentistry dental therapy education program was designed to educate dental therapy students alongside dental and dental hygiene students in a team environment. This collegial approach to education will facilitate the delivery of a single standard of care to all Minnesota patients regardless of provider type.[15] The program, initially designed to educate students to the licensed dental therapy standards, has since been modified to educate its students to also be eligible for advanced dental therapy certification. The other approved program was initiated as a collaboration of 2 institutions in the Minnesota State Colleges and Universities system formally designated the state college system.

The Minnesota State Colleges and Universities system developed a dental therapy program for Minnesota licensed dental hygienists, offering them the opportunity to become dual licensed, both as a dental hygienist and as a dental therapist. This program was designed from its inception to educate dental hygienists to become licensed dental therapists and to become eligible for advanced dental therapy certification. As of October 2013, 28 individuals have been licensed as dental therapists in Minnesota.[16] Nationally, there is interest about where these providers are practicing and what is known about the early adopters who employ the dental therapists. An earlier survey the University of Minnesota conducted in 2010 with Minnesota general dentists revealed a negative attitude toward dental therapy.[17] However, in light of the legislative mandate that therapists primarily treat underserved populations, it is not surprising that safety net clinics, rather than traditional private practices, have become the predominate employer of dental therapists in these early years. Thus, the attitudes of safety net clinic dental directors and administrators are of particular relevance. To better understand early adopters' attitudes toward and motivations for hiring a dental therapist, we undertook a survey in July 2011 to assess Minnesota's dental safety net providers' prospective views on dental therapy employment options.

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