Something to Smile About
On a warm August day, a small, red-haired woman climbs slowly into the chair at Apple Tree Dental, a nonprofit clinic in Madelia, Minnesota, 100 miles southwest of Minneapolis.
Life is not easy for Betresse Duggan, who is 44. She has chronic back inflammation and osteoporosis as well as heart problems. She lives on food stamps and $200 a month general assistance. “Things are pretty tough right now,” she says.
A woman wearing a dental smock named Jodi Hager asks Duggan about an upper tooth repaired a month earlier, then reviews the day’s plan and begins to fill cavities in two of Duggan’s teeth. Numb the gum. A shot of Lidocaine. Wait. Drill. Fix the first cavity. Polish. All the while, Hager and dental assistant Joanna Yanez work together seamlessly, passing instruments back and forth, suctioning, rinsing, draining.
With the first cavity done, Hager turns to the second. She expresses concern about this tooth, closer to the front of Duggan’s mouth, because the cavity is deeper than the first. Duggan is worried too, because her insurance won’t pay for either a root canal or a crown. “If the tooth can’t be saved,” she says, “it has to be pulled. I don’t have money for a crown.” In an effort to save the tooth, Hager applies two protective bases and then fills the tooth.
The appointment lasts 50 minutes. Though complicated by Duggan’s health problems, it is in almost every respect an ordinary interaction, played out daily in thousands of dental chairs across the United States.
But Jodi Hager is not a dentist. Rather, she’s what’s called an “advanced dental therapist.” And only in Minnesota, parts of Alaska, and now Maine is it legal for someone like her to treat cavities.
Dentists who employ dental therapists see them as members of a team of caregivers.
Hager is licensed by the state of Minnesota to provide preventive and routine restorative dental care, with a dentist’s supervision. Since 2003, “dental health aide therapists” have been allowed to work among native populations in Alaska, through the Alaska Native Tribal Health Consortium. Maine authorizes dental hygiene therapists to work under dentists’ oversight.
That Duggan found her way to Hager’s treatment chair is itself a ringing endorsement of Minnesota’s unusual approach to oral health care. Insured through the state’s version of Medicaid, Duggan had tried to find a dentist in New Ulm, a town 20 miles to the north that is six times larger than Madelia. “Every dentist I called said the same thing. They either weren’t taking new patients or they didn’t take my insurance,” she says. Finally, she heard about Hager through a social worker. She knows Hager is not a dentist, but she doesn’t care. She is grateful to have found a clinic that will treat her. Without dental therapists like Hager, it would be much harder for Duggan to find care.
Dentists who employ dental therapists see them as members of a team of caregivers, able to treat the most common disease in children and the elderly: tooth decay. Trained to perform less than 20 percent of the procedures that dentists can perform, dental therapists have lower salaries. This can allow the dentists who hire them to serve more underserved patients. Michael Helgeson, the dentist who is executive director of Apple Tree, which employs five dental therapists in six offices across the state, estimates that each therapist saves his organization $50,000, compared with the cost of hiring a full-time dentist—a savings that he says “allows us to add chairs, reduce waiting lists, and treat thousands of additional patients.” Other nonprofit clinics, such as Children’s Dental Services in Minneapolis, have seen even higher savings.
At Children's Dental Services in Minneapolis, many patients live in low-income neighborhoods that the federal government has identified as having a shortage of dentists.
In 2007, a 12-year-old Maryland boy named Deamonte Driver died after his mother was unable to find a dentist who would treat him and bacteria spread from an infected tooth to his brain. “That was a rallying cry for us,” says Jane Koppelman, Pew’s research director for children’s dental policy. “Something was very wrong with our dental care system.” Four years later, an Institute of Medicine report catalogued in detail the failures of this system: One-third of Americans had no dental insurance; many dentists were not accepting the low reimbursement rates Medicaid offered, leaving millions of people to scramble for a limited number of providers; dental care costs were rising and out of reach for many Americans; and dentists were poorly distributed across the country, leaving large swaths of rural and inner-city areas with shortages. Unsurprisingly, these failures were disproportionately affecting the most vulnerable citizens: low-income individuals, children, racial and ethnic minorities, and the disabled, who suffer from disproportionately high rates of dental disease. So Pew began work to expand access to dental care, with the W.K. Kellogg Foundation supporting research to document the benefits of dental therapists.
There are more than 50 countries around the world—including the United Kingdom, Australia, and other Western democracies—that authorize some type of oral health professional other than a dentist to provide routine care such as filling cavities. More than 1,000 studies of dental therapists working in these countries, as well as in Alaska, share the same findings: that dental therapists provide safe and effective care.
Momentum is building in support of dental therapy as a way to expand access to care in the United States. Pew worked with Minnesota legislators in 2008 to pass the authorizing legislation there. In April 2014, Maine became the second state to create a new type of oral health practitioner when Governor Paul LePage (R) signed legislation authorizing dental hygiene therapists. Legislatures in Connecticut, Kansas, Missouri, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, Vermont, and Washington, among other states, have considered similar legislation.
Mark W. Eves, a Democrat who is speaker of the Maine House of Representatives, sponsored the bipartisan legislation signed by Gov. LePage in response to what both leaders call Maine’s “oral health crisis.” All but one of the state’s 16 counties are federally designated dental health professional shortage areas.
Research suggests links between poor oral health and diseases, such as diabetes and heart disease, as well as poor outcomes in pregnancy.
“For me, what stood out was the frustration of people trying to access a dentist—particularly those on Medicaid,” says Eves. “You hear stories of parents calling desperately, across a wide region, trying to do the right thing, and dentists say they can’t afford to treat Medicaid patients. The step we took last year gives dentists another way to expand their care to those patients.” This August, the Commission on Dental Accreditation—the federally sanctioned accreditation agency for dental education programs—issued final standards for dental therapy education programs. According to the guidelines, an accredited program must include at least three academic years of full-time instruction, with the opportunity to give advanced standing to individuals already trained as dental assistants and dental hygienists. Leon A. Assael, a dentist who is dean of the University of Minnesota School of Dentistry—one of the first U.S. schools to develop a dental therapy training program—describes the release of the new standards as “a tremendous achievement. The Commission has now accepted dental therapy as a profession worthy of being accredited.”
But many dentists remain unconvinced. The American Dental Association reiterated its opposition earlier this year, saying it “remains firmly opposed to allowing non-dentists to perform surgical procedures” such as treating cavities.
The push to expand access to dental care comes amid increasing recognition that oral health is vital to overall health. “Oral disease is so ubiquitous that people accept it as part of being human,” says Assael. “They expect teeth will fail and they will end up with dentures.”
But poor oral health, he points out, has cascading effects, on both children and adults. Healthy teeth are essential to healthy eating, to digestion, to sleep, to breathing, to self-esteem. It’s difficult to sleep with a toothache; without sleep, it’s hard to concentrate in school or at work. More broadly, research suggests links between poor oral health and diseases, such as diabetes and heart disease, as well as poor outcomes in pregnancy.
“People ask, ‘Why is my mouth important?’ I say to them, ‘Why is your arm important?’” says Assael. “The oral cavity is a human organ system, very much like your stomach or intestines. It has profound effects on other organ systems. When the structures of the mouth are destroyed by disease, such as tooth decay, the effects are profound and severe.”
Children are disproportionately affected by the lack of access to dental care, along with low-income individuals, certain ethnic minorities, and the disabled.
Minnesota is, in some respects, an unlikely pioneer. On overall measures of access to dental care, the state does well, ranking 17th nationally in the number of dentists per capita. But a disproportionate number of those dentists work in major cities, and more than 70 percent of the state’s 87 counties—including Watonwan County, where Madelia is located—are partially or entirely designated by the federal government as having a shortage of dentists. In both Minneapolis and St. Paul, the federal government has also identified substantial low-income neighborhoods as having a shortage of dentists.
Minnesota first enacted legislation authorizing two types of dental therapists to work statewide in 2009. Licensed dental therapists are allowed by law to provide preventive and restorative care under the supervision of a dentist. Advanced dental therapists have additional training in dental therapy and 2,000 hours of clinical experience. Advanced therapists are allowed to provide additional services, such as oral assessments, and can practice in sites other than where their supervising dentists are located, though they still must work under a collaborative management agreement with a dentist—who must, for example, review treatment plans.
By Minnesota law, at least 50 percent of dental therapists’ caseloads must be underserved patients.
Minnesota’s first dental therapists—Hager among them—began practicing in 2011. She qualified as an advanced dental therapist in summer 2013. As of July 2015, the state Board of Dentistry had licensed about 50 dental therapists, including nine advanced therapists, to practice in the state.
On the day that she saw Duggan, Hager did consult a dentist. A 25-year-old woman new to Apple Tree arrived at the clinic at around 1:45 p.m. with an emergency: She had not been able to open her mouth for nearly 23 hours. She had visited an urgent care clinic, where she was told to see an oral surgeon. But in order to do that, she needed a referral from a dentist. And, like many Apple Tree patients, the woman had state-subsidized insurance—Medicaid, usually not accepted by any oral surgeon closer than the University of Minnesota in Minneapolis, more than 100 miles away.
After consulting her supervising dentist, Hager called an oral surgeon in Mankato, about 30 miles away. When he came on the line, Hager briefly explained the situation and began to relay his questions to the young woman, who responded in a barely audible voice. When did the problem begin? Had she eaten anything at all? What had she had to drink? When? Could she get to Mankato by 3? Is there someone who can drive her home?
The conversation lasted a few minutes. After hanging up, Hager told the young woman she had a 3 o’clock appointment with the oral surgeon, who would take her insurance. “That’s huge,” Hager says, relief in her voice.
Hager quickly gave the woman instructions and advice—don’t drink anything, even water; be sure to call the oral surgeon if running late; remember to schedule follow-ups—then sent her off.
Hager left the clinic just before 4, after a nearly eight-hour day. She had seen a total of 15 patients, 11 of them children, two-thirds of them insured by Medicaid. She treated nine cavities and conducted 11 oral assessments, mostly squeezed between appointments after a hygienist had cleaned the person’s teeth.
One of the patients was a young boy from Pipestone, a two-hour drive away. Hager grew up there, near the South Dakota border; she knows on a visceral level that it’s a long way to drive for dental care.
Scheduled to repair two cavities, Hager had noticed that the boy badly needed to have his teeth cleaned. Rather than ask the boy’s mother to bring him back another day—at least a five-hour task—Hager rearranged the schedule so the youngster could also get a cleaning.
“For low-income people, trying to make multiple trips—taking days off from work, paying for gas, and arranging child care—are huge barriers,” says Helgeson, Apple Tree’s executive director, who loves the new opportunities for care that his clinics now provide. “A patient who would otherwise wait weeks or months may not wait at all, or wait only an hour or two.”
Frank Clancy is a Minneapolis-based writer whose work has appeared in The New York Times Magazine and numerous other publications.