New Curriculum Guidelines Published by AAPHD Offer States a Model for Training Dental Therapists

The American Association of Public Health Dentistry (AAPHD) recently published a compelling series of papers that established curriculum guidelines for the training of a new workforce model, dental therapists.

AAPHD is the nation’s largest membership organization of dentists, dental hygienists and others committing to improving the oral health of the public.  It believes that adding dental therapists as members of the dental team may help meet growing U.S. oral health needs, particularly among underserved populations.  The papers are the work of an academic panel whose 11 members were selected for their expertise, experience and in-depth knowledge of dental education.

For New Mexico, one of the states that is pursuing the dental therapist model, this means we have a template on which to build an education program that would produce quality dental providers who can meet the needs of our remote and underserved population.

This compelling series of papers also includes the following:

• Principles on which a dental therapy program should be based;
• Recommended length of training programs;
• Competencies required for graduates; and
• General curriculum content of such programs.

The proposed model curriculum is based on a two-year, post-secondary training program.  The panel reviewed the course of study for dental therapists in programs already in the United States (Minnesota and the Alaska Native Tribal Health Consortium/University of Washington program) and throughout the world.  The dental therapist designation is a professional, accredited position in 55 countries.

The entire collection of papers is available online and will be published in a special issue, June 2011 issue of peer-reviewed Journal of Public Health Dentistry.

In a guest editorial introduction to the special issue, panel convener Caswell Evans Jr., DDS, MPH, Associate Dean for Prevention and Public Health Sciences at the University of Illinois at Chicago, noted that the absence of a nationally recognized program of study for dental therapists could result in a “patchwork of responsibilities and varying scopes of practice for dental therapists that could lead to confusion by the public.”

The panel’s proposed curriculum should help to answer questions about the training and education for dental therapists and will likely become a model for other states, including New Mexico.

In addition, AAPHD President Diane Brunson, RDH, MPH, said that the recommendations will help establish “a career path for entering the profession to best serve the oral health needs of all populations.”

“We believe that the expert panel recommendations, used as a model to build on, will assure that curricula from school to school and state to state are consistent, of high quality and will pave the way for national accrediting,” she added.

Integrating Medical and Dental Care Can Improve Access and Health of New Mexicans

Oral health is essential to overall health. Yet, for decades, the medical and dental professions have practiced in their own separate spheres, rarely working together to coordinate to improve care for their patients.

My hope is that may be changing – at least here in New Mexico.

Recently, at the New Mexico Health Resources (NMHR) annual provider retreat in Taos, I was struck by how many presenters — medical and dental professionals alike — focused on opportunities for medicine and dentistry to work together in diagnosing and treating patients. I’m encouraged that we will see more action among healthcare professionals, provider groups, payers and others to collaborate on improving the health of all New Mexicans and expanding access to these necessary healthcare services.

Following is a quick summary of several key presentations from the retreat.

Diabetes Management & Treatment at the Dentist’s Office - According to Gary Cuttrell, MD, DDS, JD, University of New Mexico division chief for dental services, 60% of Americans see a dentist once a year. For many people, this is more often than they see their primary care physician. This presents a unique opportunity for dentists, hygienists and other dental professionals to use their training and education to provide basic non-invasive diabetes screenings for diagnosing, referring and helping patients manage diabetes.

Application of Fluoride Varnish In Primary Care Settings – Many presenters suggested that, with some additional training, health professionals in primary care medical practices could apply fluoride varnish to patients’ teeth to prevent further tooth decay and ultimately avert the long-term health problems of obesity, cardiovascular disease and diabetes that can be caused by poor oral health.

Perinatal Dental Care Coordination between Obstetricians and Dental Practices - Irene Hilton, DDS, MPH, presented compelling reasons for obstetrical and dental professionals to collectively reach out to and treat women early in their pregnancies. From the start, a pregnant woman passes on whatever dental disease she may have to her child. Ideally, a woman will have seen a dentist before she is pregnant, but, if not, she should see one within the first 10 weeks.

According to Dr. Hilton, pregnant women are more open to seeking care and following a care plan. This is a good opportunity, for the obstetrician and dentist to collaborate on reinforcing good oral health habits for the mother, who hopefully will instill them in her child. Unfortunately, some women may not see a dentist until the end of their pregnancy and, as a result, they may fail to get all the treatments they need. This is particularly problematic for women covered by Medicaid, because once they give birth, they no longer have their own dental coverage.

I am encouraged by these discussions, and I’m sure there are other opportunities for medical and dental professional to work together for the benefit of their patients.  Let’s break down those silos, so that all New Mexicans can enjoy good health!

In a Dental Emergency, Kids Insured by Medicaid Frequently Can’t Get Care

Kids in need of emergency dental care stand a poor chance of getting it if they are covered by Medicaid, according to a new study published online in the journal Pediatrics.

Posing as mothers of a 10-year-old boy with a fractured front tooth, six research assistants phoned 85 dental practices in Cook County, Ill., twice, four weeks apart, requesting an appointment.  Each time they told the same story, with one difference:  health insurance.  In one call, the boy was covered by Medicaid; in the other, Blue Cross.

In Illinois, even non-enrolled dentists can be reimbursed by Medicaid for providing emergency dental care.  Still, the disparities in access were startling.  While nearly all (95.4 percent) of kids with Blue Cross insurance got an appointment, only about a third (36.5 percent) of Medicaid-covered children did.  Even among dental practices enrolled in Medicaid, children with Medicaid were still 18.2 times more likely to be denied an appointment than their counterparts with private insurance.

The study authors note that the scenario they came up with – of a boy with a fractured upper front tooth and pain after falling off a bike – was chosen by a pediatric primary care provider and dental consultants “as a common dental condition warranting timely treatment to optimize outcomes.”  A crown fracture of a permanent front tooth – which the reported symptoms indicated – “requires urgent dental care, ideally within 24 hours,” the authors observe.

That nearly two-thirds of Medicaid kids in this situation were denied care is distressing.  Another concerning finding:  One-fifth of calls to Medicaid-enrolled practices on behalf of children covered by Medicaid resulted in appointments requiring cash payment – even though Illinois prohibits dentists from collecting cash for services rendered to Medicaid patients.  Doing so is a violation of the dentist’s contract with the state dental administrator.

What’s clear here is that Medicaid coverage is no guarantee that a child with a dental emergency will get the care he needs.

So what’s the answer?

The study authors conclude:  “Although removing provider barriers may not eliminate all oral health disparities, finding dental providers willing to accept public insurance and serve children from low-income families is arguably the first vital step toward improving the oral health of our nation’s children.”

Organized dentistry says the solution is to increase Medicaid reimbursement.  Raising Medicaid rates for dentists can help, especially in states where payment rates are far too low.  When paid appropriately for their services, dentists are more likely to accept Medicaid patients.  However, higher reimbursement rates are not a fix-all.  And, in the current economy, it is unlikely that states will raise their reimbursement rates.

We need to make it easier for dentists to treat more Medicaid enrollees.  Interestingly, a 2010 report by the Pew Children’s Dental Care Campaign shows that, by bringing in new types of dental care providers – such as a dental therapist or a hygienist-therapist – most private dental practices could serve Medicaid patients without sacrificing their profits.  In fact, according to Pew, solo private practices, where most dentists work, could even increase their profitability while expanding access to dental care.

In New Mexico, not only do we have a major shortage of dental care providers, but very few dentists treat significant numbers of Medicaid patients as part of their practice.  Less than half our Medicaid-covered kids get any dental care at all in a given year.  I hate to think what might happen to any of them in a dental emergency.

A dental therapist model could help solve this problem.  Employed at half the cost of a dentist and able to provide some of the most commonly needed dental care services, dental therapists could make Medicaid financially feasible for many dental practices.  Plus more kids would get the dental care they need.

That’s a win-win all around.

I welcome your thoughts.

This Los Angeles Times story provides some more background on the study. You can also read the study abstract on the Pediatrics web site.