Access, Access, Who's Got Access?
No one who studies the issue denies that too few Americans are getting good oral healthcare. More than one quarter of US children aged 2-5 years and one half of those aged 12-15 years have tooth decay, and those rates are double in children from low-income families.Some ethnic minorities, particularly indigenous people, and those living in remote rural areas also suffer disproportionately from dental disease.
A Question of Capacity
The problem is not a lack of education about the importance of dental care, said Lawrence Hill, DDS, MPH, executive director of CincySmiles Foundation, a nonprofit clinic in Cincinnati, Ohio. Public dental clinics in Ohio have often had waiting lists of more than 1000 patients waiting to be seen, he said. "We have a real capacity issue as well as a funding issue," he said.
Dr. Hill and other advocates say that midlevel providers -- practitioners with duties between that of hygienists and dentists -- could help bring dental care to these underserved groups.
Because they spend less time in school than dentists, midlevel providers graduate without the crushing debt that the average dental school graduate carries. Education requirements range from 2 years after high school for dental health aide therapists in Alaska to 6 years for advanced dental therapists in Minnesota. Needing less income, these therapists can make their services more affordable.
Filling Positions and Teeth at Lower Cost
Dr. Hill estimated that he could hire a dental therapist for about $60,000 a year to do the work that he would have to pay a dentist $120,000 a year to do -- if dental therapists were licensed in Ohio. "They are not the only answer, but they have the potential to be a big part of it," he said.
The lower education requirements can also make it easier to recruit candidates who might not be able to afford dental school. This can be an important factor in training the practitioners who come from the communities with the most dental disease.
"Rural areas have tremendous problems filling positions," said Dr. Hill, who has visited Alaska twice to investigate the dental therapist program there. "In Alaska, they are selected from their communities with a commitment to go back to their communities," he said.
Advocates consider this important because cultural and economic differences between practitioners and patients can pose additional barriers to care.
Improving Dental Health With Prevention and Education
The ADA argues that better ways can be found to deal with the problem. "Nobody disputes the fact that parts of this country have access issues," said ADA President William Calnon, DDS. "But we do not agree with the idea that by putting more treatment there -- especially what we regard as lesser-trained providers -- you are going to improve disease management."
In the first place, he says, the best way to improve dental health is through prevention and education.
The ADA has lobbied to expand Medicaid and other government subsidies to dental care for indigent persons. The ADA has supported programs in which dental student loans would be forgiven for dentists who agree to practice in underserved areas, and it has pushed for community water fluoridation and public education about oral health.
In addition, the organization has advocated for a new profession of its own design: the community dental health coordinator. These workers would not treat dental disease but would teach people from communities with high rates of disease about how to improve their own health, help them communicate with dentists, and help them negotiate the healthcare system. "It's a medical model that has been used for years," said Dr. Conlan.
The ADA also supports expanded functions for dental assistants and hygienists who work under the supervision of dentists. More and more states are allowing expanded-duty dental assistants to place restorations. The ADA does not oppose this trend, said Dr. Conlan, as long as the assistants don't prepare teeth or do any other irreversible procedures.