Dental therapists bridge gap

Laura Dvorak had never heard even heard of a dental therapist until she showed up at a St. Paul clinic last week to get three cavities filled.

But after spending more than an hour in the chair with Crystal Ann Baker, a newly hired dental therapist at HealthPartners' Midway Clinic, Dvorak says she's a fan.

"I was very satisfied with her work and her bedside manner and her training," said Dvorak, 35, of Maple Plain. "If you hadn't told me she wasn't a dentist, I would have assumed she was."

Dental therapists span the divide between the hygienist and the dentist, similar to the way a nurse practitioner or physician assistant works in a medical setting. They practice under a dentist's supervision and are trained to do such things as fill cavities, place crowns, give local anesthesia and, in some cases, pull teeth.

A year after the first cohort of dental therapists began practicing in Minnesota, the new and controversial breed of dental worker is showing early signs of acceptance.

"We're kind of setting the model," said Baker, who was hired by HealthPartners in March. "There's still a lot of resistance. Not because people are worried that we're ill-qualified; it's more about how do we incorporate this new profession into our practice?"

While the state has licensed just 15 dental therapists, their arrival comes at a time of growing need. Under the federal health care law, as many as 5 million more children will be covered in 2014, and nationwide attention is turning to dental therapists as one way to help more disadvantaged people get dental care at a lower cost.

"We've got dental therapist grads in rural areas, community clinics and now at HealthPartners," said Dr. Karl Self, director of the University of Minnesota's dental therapy program. "We're starting to be able to get the employers together and talk about best practices, about what's working."

Baker, a Jacksonville, Fla., native, graduated from the U with a master's in dental therapy. She said her arrival at the HealthPartners clinic has gone smoothly, aside from "little kinks" in scheduling, such as getting assigned a root canal, which is beyond the scope of her training. When that happens, she switches procedures with her supervising dentist, Dr. Kevin Nakagaki.

"We cooperate real well," Baker said. "We identify them early in the huddles, so the whole day isn't chaotic."

HealthPartners, one of the state's largest health plans, operates 16 dental clinics. It cares for the largest number of patients enrolled in state programs, the target population for dental therapists.

Baker is the company's first dental therapist, but Dr. David Gesko, director of HealthPartners' Dental Group, said he plans to add more.

Demand for services

Public health officials say the vast majority of dental disease is preventable, yet nearly 17 million children fail to see a dentist every year, according to the Pew Charitable Trust.

In Minnesota, Medicaid provides dental coverage to about 390,000 low-income or disabled children, yet only about 42 percent of them get dental care each year, according to federal data. About 60 percent of the state's children with private insurance get dental care.

Regions Hospital in St. Paul said five people a day came to the emergency room for dental issues in 2011.

"There's a crisis," said Sarah Wovcha, executive director of Children's Dental Services in Minneapolis. "We don't currently have enough dentists who are able -- or willing -- to provide care to low-income people. Even insured people are having a harder time finding a dentist."

"We're seeing the same quality and the same or better productivity, while paying 30 percent less an hour to do the same restorative procedures," Wovcha said.

While a dentist might get $75 an hour, a dental therapist receives about $45. Fogarty's work during the past year has more than kept pace with the dentists, Wovcha said. Out of 17 providers, she ranked fourth in productivity.

Fogarty previously spent 12 years working as a hygienist and is on track to become the state's first advanced dental therapist. After logging the required 2,000 hours of clinical experience, the certification by the state Board of Dentistry will allow her to take on more complex procedures, such as removing adult teeth. More important, she will be able to do more work without the on-site supervision of a dentist, giving her flexibility to practice in such places as nursing homes, Head Start clinics, homeless shelters or emergency rooms.

Fogarty said and the nine dentists she works with have "a nice rhythm."

"We're not a silver bullet," she said. "We're one more tool."

Dentist opposition

The American Dental Association has taken a strong stance against dental therapists in Minnesota and nationally, arguing that only a dentist has the skills to pull teeth or engage in other permanent or invasive procedures. The group is spending millions in federal and state efforts to repeal parts of President Obama's health care law, according to campaign finance groups.

The Minnesota chapter sees low reimbursement rates as the bigger issue.

"I get $12.09 for an exam. My hygienists gets $26 for cleaning," said Dr. Michael T. Flynn, president-elect of the Minnesota Dental Association. "That's affordable care ... but it's not sustainable in my practice."

Flynn runs a practice in Lewiston, a southeastern Minnesota city of about 1,400, where he has spent decades as the only dentist for miles around. Medicare doesn't cover seniors' dental care, and the state Medicaid reimburses him just 30 cents on the dollar, he said. That has forced him to lay off workers and limit how many poor or uninsured patients he sees.

With more than 82 million Americans struggling to get access to oral health care, other states are looking to the experience of Alaska and Minnesota with dental therapists, said David Jordan, director of Dental Access Project at Community Catalyst in Boston.

Oregon passed a pilot program last year to use the mid-level providers, and legislation has been proposed in several other states, including California, New Hampshire, Maine, Vermont, Kansas and New Mexico.

Minnesota is moving slowly to get more dental therapists trained. The U and Metropolitan State are the only schools to offer degrees, though a partnership between Metro State and Normandale Community College may attract more entry-level students. Metro State has just four students enrolled and on track to graduate in 2013.

"Little by little, it's catching on," said Ann Leja, acting dean of health sciences at Metro State. "Our grads have had no trouble getting jobs."