We are encouraged by the interest and support of so many individuals and organizations in the evaluation released this week of Alaska’s dental therapist program. The evaluation conducted by RTI International assessed the work of the first cohort of dental therapists practicing in the U.S., the experiences of more than 400 patients and the performance of dental therapists on hundreds of procedures. Using criteria derived from examination standards for assessing U.S. dental school graduates, the evaluation clearly demonstrates the safety, competence and appropriateness of care provided by dental therapists practicing in Alaska. It is but the latest link in a long chain of evidence-based research and experience from more than 50 other countries supporting the dental therapist model as a way to provide necessary oral health care services in underserved communities.
It is important to understand what this evaluation is – and what it isn’t.
The evaluation assessed the performance of half of the newly practicing dental therapists in five Alaska communities over a period of more than two years. It is an intensive examination of how the dental therapist program in Alaska is being implemented. It clearly demonstrates that it is being implemented well, and that dental therapists are providing safe, competent and appropriate care.
This evaluation was never intended to be a study of the impact of Alaska’s program on access to dental care or on overall oral health. Alaska Natives have some of the most severe oral disease in the country. This young but thriving program, which started in 2005, has not had enough time yet to make a measurable impact on oral health, but it shows incredible promise.
We are delighted with the findings of this evaluation, which was guided by a National Advisory Committee and an Alaska Tribal Coordinating Council. Members of these two committees are dental program directors, dental educators, national policymakers and representatives from tribal health boards and leading national dental organizations.
Oral Disease: The Nation’s “Silent Epidemic”
Alaska is similar to the rest of the country in that many communities don’t have enough dentists: an estimated 10,000 dental professionals are needed to eliminate severe dental care shortages across the nation. We believe that other states should strongly consider the dental therapist model as a way to expand access to good, safe oral health care services.
In 2000, the Surgeon General’s Oral Health in America report described the “silent epidemic” of oral disease that affects our most vulnerable citizens. The epidemic has not abated. Ten years later, nearly 50 million Americans live in areas without enough dentists and many more simply cannot afford care. As a result, too many children and adults live in pain, miss school or work, and, in extreme cases, face life-threatening medical emergencies from consequences of dental infections. The Kellogg Foundation supports efforts to change these very systems and conditions that result in millions of children and families being left out of the quality oral health care loop.
Although many solutions have been proposed to address serious dental care shortages, none has made significant inroads toward eliminating the serious access problems that still plague so many vulnerable children and families.
Some, for example, have called on states to increase their Medicaid payment rates as a way to increase participation by dentists in Medicaid, which currently is very low. Currently, only one in four dentists participates in Medicaid, and most of these dentists accept only a few Medicaid patients. While raising Medicaid payment rates can help, particularly in states where rates are too low, it won’t solve the shortage problem because it won’t put more dentists in underserved communities. And during times of severe economic stress, such as we are experiencing now, it is unlikely that many states will increase their Medicaid rates. Indeed, it is incumbent on all of us to find more cost-efficient solutions to our access problems.
Similarly, providing free or discounted care for low-income patients is a valuable service to the community but is not a long-term solution, given both the magnitude of the need and the fact that people need care on a regular basis. Charity dental care treats just 7 million people per year, yet tens of millions lack adequate access to dental care. It is clear that a more comprehensive approach is needed to bridge this divide.
Dental Therapists as Part of the Solution
Dental therapists are trained to work in underserved communities and in fact often come from such communities. Dental therapists cannot replace dentists but can extend their reach by providing services in places where there aren’t enough dentists to meet the need.
We recognize that dental therapists alone cannot solve our nation’s serious oral health problems. In fact, the W.K. Kellogg Foundation has long supported a range of community-driven solutions for addressing oral health access issues among vulnerable children and families. We believe that prevention, oral health literacy and a strong public health infrastructure are critical to good oral health, as is access to basic, regular dental care for preventing serious problems and identifying and treating problems early when they do occur.
Improving oral health will require a multifaceted approach that includes treatment, prevention and promotion strategies to address the various determinants of oral health. Several organizations are exploring new workforce options that could provide valuable services such as educating patients about good oral hygiene and the importance of seeking regular dental care. But we also need providers who can deliver that care and address the range of oral health needs among underserved populations.
It will take a long time to see an impact – much longer than the four short years that Alaska’s promising dental therapist program has had so far. But based on Alaska’s experience and the experiences of many other countries, we believe that dental therapists can be part of the long-term solution – as well as a model for other states to consider.
Established in 1930, the W.K. Kellogg Foundation supports children, families, and communities as they strengthen and create conditions that propel vulnerable children to achieve success as individuals and as contributors to the larger community and society. Grants are concentrated in the United States, Latin America and the Caribbean, and southern Africa.