By Anne Blythe
The words “dental therapy” might conjure images of nestling onto a therapist’s couch to find a remedy for teeth-gnashing fears of leaning back in a dentist’s chair.
But that’s not what oral health care’s newest profession is, as several dozen people discovered recently during a three-hour discussion organized by the John Locke Foundation, a conservative-leaning think tank that advocates for free-market policies.
Inside Marbles Kids Museum about a half mile from the General Assembly chambers where state lawmakers define the limits of practice for North Carolina dentists and hygienists, a dental therapist from Minnesota chronicled her path for the dentists, hygienists, oral health policy advocates and lawmakers in attendance.
Dental therapists are all about settling more people into dentist chairs, and they do it by providing some of the same care as dentists, especially in rural areas with oral health care provider shortages.
Christy Jo Fogarty, the country’s first advanced dental therapist, pursued the master’s degree and state license in Minnesota, a state which expanded the scope of practice allowing her to do some of what a dentist does — extracting loose and diseased teeth, drilling cavities and placing temporary crowns on teeth.
“Our scope of practice is about 12 percent of what a dentist can do,” Fogarty said. “But in that scope of practice, we are trained to the level of a dentist.”
Lessons from another state
In 2009, Minnesota became the first state to authorize licenses for dental therapy. The first licenses were issued in 2011. As of April, 10 states allow dental therapists.
In Minnesota, where there are just over 3,400 dentists and 93 dental therapists, the dental therapy program grew from concerns about care shortages in some areas and an effort to send mid-level providers to those places.
Fogarty became the first to receive the advanced therapist license in Minnesota’s two-tier system. That gives her the authority to provide care to patients even without a dentist present, while the therapists without that designation must have a dentist on site with them.
An advanced license can be attained only after 2,000 hours of dental hygiene experience and a 16- to 27-month higher education program mirroring some of the same training and classes given to dental students.
Then there are dental therapy board exams, which include being evaluated on work on a mannequin and fake teeth, as well as completing two fillings on actual patients.
Christy Jo Fogarty talks about her work. Video courtesy: the Pew Charitable Trusts
Once licensed, Fogarty went to work for Children’s Dental Services, a non-profit dental clinic with 200 sites and vans to help transport chairs and equipment to and from remote sites.
Forty-five minutes is all it takes to haul in the paraphernalia and get ready for patients. The therapists often set up at schools, community centers or hospitals and are there for several-day spans.
Fogarty touts her profession as one that extends oral health care to people and communities often underserved in part because many private practitioners have stopped taking Medicaid and public assistance patients, saying reimbursement rates caused them to lose money.
She shared a 2-year-old boy’s story to highlight her point.
At one site, a mother came in with her young child, a toddler with damaged front teeth.
They were on public assistance, and the mother had spent all morning calling local dental offices but none would see her son. Had Fogarty not been there, they might have gone to a hospital emergency room and gotten pain relief but not dental care.
“We were able to get his two front teeth out,” she said.
The next time Fogarty saw the pair, she worried there might be more crying as there had been at the first visit, but the toddler ran directly toward her.
“He just wrapped his arms around my legs,” Fogarty recounted. “The mom said, ’You’re the lady who took his pain away.’”
In Alaska, dental therapists, sometimes compared to nurse practitioners or physicians assistants, have been licensed to provide care on remote federal lands.
Other states are considering programs, too.
Fogarty acknowledged to dentists in the audience that adding therapists to the list of oral health careers in North Carolina would not eliminate all the problems the state has with access to care. But, she added, it might go a long way, as well as save some money on emergency room visits for oral health issues more appropriate for a dentist’s chair.
Jordan Roberts, the Locke Foundation’s health care policy analyst, opened the discussion by calling the model “a supply-side reform that has proven effective.”
But dentists in the crowd questioned whether it truly would allay the dearth of providers in many of North Carolina’s 80 rural counties, two of which have no dentist at all.
Limitations on hygienists
In North Carolina, there long has been a struggle between dental hygienists seeking to broaden their scope of practice and dentists who have shown little enthusiasm for budging some of the most restrictive laws in the country.
Louder calls for change have erupted in recent years with a heightened focus on the crucial connection between oral and general health and a dismantling of the wall between dentistry and medicine.
North Carolina has 165 areas with 2.5 million residents that, according to federal standards, have dental health professional shortages.
Michael Riccobene of Riccobene Associates Family Dentistry, which has 20 offices in Wake, Durham, Orange, Cumberland, Forsyth and Pitt counties, questioned whether therapists with many of the same financial challenges as dentists would open practices inareas with high numbers of Medicaid patients.
Dentists list low Medicaid reimbursements and the high student loan debt carried by new dental school graduates as challenges that limit where they choose to practice. They can make more money in urban areas that help allay debt, which, in North Carolina is just below the $287,000 national average.
“If we’re just replacing dentists with people who can do 80 percent less work and we have all the challenges of costs that were already there … then I’m not really sure this is the best solution,” Riccobene said.
In Minnesota, Fogarty said, the addition of therapists has opened opportunities for dentists to see more patients and actually improve bottom lines.
Since Fogarty is reimbursed at the same rate as a dentist, Gary Oyster, a longtime Wake County dentist, asked how dental therapy saves the state money.
“I don’t save money for the state,” Fogarty said. “Who I do save money for is my employer. It expands the number of children they can see.”
Oyster said later that he and other dentists were not collectively ready to come out against dental therapy in North Carolina, but he was not yet persuaded the financial models were that different.
“Unless it’s propped up by government or corporations, I don’t see how it’s going to work,” he added.
Some questioned whether sending therapists to poorer regions might set up an equity and justice problem, where those with deeper pockets would get to see a dentist with more education and training and those with less wealth would see therapists.
“I just want everyone to have dental care,” Fogarty responded.
Unlikely fast-tracking in NC
At least half a dozen state lawmakers were in the crowd, and none offered much promise for swift change in North Carolina.
Sen. Jim Davis, a Republican from Franklin and a dentist for 40 years, noted a recent legislative battle over attempts to amend scope of practice changes to allow hygienists to administer anesthesia.
“We are behind in North Carolina,” Davis said.
To get more dentists in shortage areas, Davis suggested increasing the number of dental students admitted to and graduated from the UNC-Chapel Hill and East Carolina dental schools, as well as education models that leave them with less debt.
But the lawmakers were mum on one dentist’s suggestion of increasing the Medicaid reimbursement, two-thirds of which is provided by the federal government.
Sen. Jim Perry, a Republican and retired Kinston businessman who has also worked in the corporate side of dentistry, was appointed to the legislature in January and was a panelist at the Locke Foundation event.
He urged therapy advocates to hold more conversations and try to build a coalition of support.
“When you have warring factions it tends to freeze things up,” Perry said.
Republish our articles for free, online or in print, under a Creative Commons license.
I’ll be interested to see how managed care influences this discussion. As oral health / dental care are currently carved out of managed care, but oral health outcomes are a part of the contractual obligations of managed care companies, will they be incentivized to lead the charge to increasing access to a basic level of oral health care?
In addition to rural areas, people with disabilities are especially affected by the lack of dental providers who accept Medicaid in NC. While NC has great penetration rates among physical health providers in the Medicaid program, the same cannot be said for dentists. Much of this is a rate issue, and will not be solved until that is addressed, or, a tiered rate structure is created to create dentist extenders (similar to PAs / NFPs) and encourage broader access.
Including oral health care in the current Medicaid transformation to managed care could have provided flexibility to flex rate structures at the health plan level. When we talk about whole-person care as a primary driver for our system improvements, leaving oral health out of the mix seems nonsensical, and people with disabilities suffer as a result.
Great piece about dental therapy, an evidence based, high quality, cost effective and safe member of the dental team. They are working well in Minnesota and Alaska & 8 other states have passed legislation. With respect to comments by Dr. Riccobene, dental therapists would work for dentists, but have much lower overhead costs- salary/supplies/lab costs. They have fewer loans since they take less time to educate. If recruited from rural areas that is where they are more likely to work as evidenced in MN. With respect to Dr. Oyster’s comments, they save money, pain and suffering. Low cost preventive & restorative care by a dental therapists keeps children and adults healthy, in school or work, and saves costs of emergency room visits for preventable dental problems. Yes, they get the same reimbursement as dentists because they deserve that. BUT they will also be less expensive for FQHCs to hire them. And NO, it is not necessary for extra government support. Remember, when a dentist criticizes dental therapy, ask him/her for evidence, ie publications and reports that supports their concerns/opinions. Then wait for a response. You will hear nothing except LIES and MISREPRESENTATION. All the published evidence supports, quality, safety and efficacy of dental therapists.
Why do people who advocate for poor people receiving dental care from people who are not dentists present themselves as heroes? Plenty of dentists in our state accept Medicaid. Patients have transportation issues and other problems. Also, some patients break their appointments and only show up when they have pain. How are dentists the blame for these issues? There are health departments FQHC’s who are treating children at their schools and who are focused on oral health education making a difference everyday. I for one take offense to treating people on public assistance programs like they are a nuisance.
While the dental therapist is one solution to access to oral health care and oral health inequity in North Carolina it is not the only solution and may not be the best for our State. A broad group of oral health advocates, including private foundations, public health dentists, State Medicaid officials, Dental Hygiene and Dental Assistant representatives, UNC and ECU faculty representatives and practicing Dentists was convened by the North Carolina Dental Society in the Summer of 2018. These diverse advocates came together to form a new Council on Prevention and Oral Health whose objective was to recommend and implement sustainable and cost-effective solutions to improve the oral health of citizens of North Carolina. This Council carefully has evaluated evidenced-based data and recently has recommended an innovative solution. This solution engages a public-private partnership to provide oral health services to Title1 schools and special needs facilities. In addition to on site preventive services a dental home will be provided to all participants. Private dental entities including FQHCs will contract with county health departments to allow practice staff to function as “public health” providers. Important changes to the rules that control hygiene practice currently are being promulgated by the North Carolina Board of Dental Examiners. Our goal is to empower an already existing pool of well-trained Dental Hygienists to extend oral health service to underserved populations. With the inclusion of teledentistry and the use of agents such as silver diamine fluoride our Council believes that we can have a significant impact on oral disease in a relatively short time period of time.
Frank Courts, DDS
Chair NCDS Council on Prevention and Oral Health