Access to Care
Breaking Down Barriers to Oral Health for All Americans: The Role of Workforce
- Dr. Raymond F. Gist

Raymond F. Gist, DDS, President, American Dental Association

Barriers to Oral Health Care

Smile Alabama! (Medicaid) Service Improvements Under New Rate Structure

Actual and Projected Number of Applications and Graduates

Actual and Projected Numbers of Dentists

In recent years a variety of stakeholders have proposed new models for expanding the delivery of oral health care, based largely on their interpretation of the size, location, and composition of the dental workforce.

Certainly, an adequate dental workforce, located where it is needed and sufficiently funded to carry out its mission, is critical to improving the nation's oral health. This includes having sufficient numbers and types of allied personnel available to support the dentists who ultimately are responsible for diagnosing, planning treatment, and delivering those services that only they, as doctors of oral health, are appropriately educated and trained to perform.

ADA policies on workforce are too numerous to mention here, but they all derive from basic principles.

  • All Americans deserve access to oral health care provided by fully educated and trained dentists and the teams that support them.
  • While innovative use of existing and some new dental team members shows great promise, only dentists should diagnose disease, develop treatment plans, and perform surgical/irreversible procedures.
  • Dentists, in cooperation with appropriate governing bodies, should determine the scope of practice of allied dental personnel with an eye to (1) which functions and procedures can be delegated, (2) what degree of supervision is appropriate for those procedures and personnel, and (3) which cannot be delegated to someone who lacks the knowledge and skill of a dentist.
  • Everyone who provides oral health care must have completed appropriate education and training, and must meet any additional criteria needed to assure competence within the scope of practice approved by authorized licensing bodies.

A consistent refrain among supporters of so-called midlevel practitioners is that there are not enough dentists to care for a major influx of indigent patients. They further argue that baby-boom dentists will retire in such numbers as to further diminish what they maintain is an already inadequate dentist population. In fact, studies conducted by the ADA and the American Dental Education Association (ADEA) indicate that the number of dental schools and graduates will increase steadily through 2030 and that the number of professionally active dentists also will increase from its current level of approximately 180,000 to as many as 200,000 over the same period. The real problem is where the dentists are in relation to underserved populations. Access disparities can be greatly reduced by finding new ways of getting dentists to the people and getting people to the dentists.

The National Health Service Corps, the Indian Health Service, and the loose network of Federally Qualified Health Centers use various combinations of incentives to place dentists in underserved areas, most focusing on student loan repayment. Some states also offer tax incentives or scaled reimbursement for practitioners working in underserved areas or providing care under public assistance programs such as Medicaid. Some dental programs join forces with schools or social service entities to provide transportation and other support services to help patients keep appointments. Even under chronic funding constriction, imaginative people have maximized available resources and leveraged natural allies to dramatically improve the abilities of existing programs and systems to deliver care where it is most needed.

Administrative and reimbursement reforms to the Medicaid dental programs in Michigan (Healthy Kids Dental), Tennessee (TennCare), and Alabama (Smile Alabama!) have substantially increased dentist participation and patient utilization. In Brattleboro, Vermont, Head Start, the state health department, school officials, and hospital administrators collaboratively established a fee-for-service, for-profit dental center to address the needs of the underserved in a rural community.

All of these initiatives wrought significant, positive change through relatively minor funding increases combined with improvements in administration. They did so with little or no change in the population of dentists. Unfortunately, unlike Brattleboro's small-scale program, none of the statewide systems provide care to adults in any meaningful way.

Multiple groups have offered new workforce models intended to provide clinical services—including surgery—to underserved populations. Their proponents cite various dental therapist programs in other countries, in which non-dentists perform such surgical procedures as extractions, restorations, and even pulpotomies. But the midlevel programs in these countries differ so dramatically in scope of practice, populations served, and degree of dentist supervision that referring to them en masse is misleading at best.

These models share, however, some basic flaws. They overload midlevel providers with more responsibility than they should be expected to bear. Their proponents consistently refer to certain procedures, including extractions, as "simple," saying that of course more complex cases will be referred to dentists. However, we believe that midlevel providers' training—some models call for as little as 18 months—cannot adequately prepare them to distinguish between "simple" and "complex" cases. We further question a midlevel's ability to distinguish between teeth that cannot be saved and should be extracted from those that could be saved by restorative methods beyond the midlevel's training. For these and other reasons, the ADA opposes unequivocally models that call for non-dentists to perform surgical/irreversible procedures, often with little or no direct supervision by fully trained dentists.

Midlevel proponents either imply or assert that care from these providers will be less expensive than that delivered by dentists, because they will earn less than dentists. But the difference between the salary of a dentist and that of a therapist or advanced hygienist would likely be offset by a therapist's lesser productivity compared with that of a fully trained dentist and would have a minimal effect on the overall cost of delivering care.

The ADA is piloting a new dental position, the Community Dental Health Coordinator (CDHC), that represents a completely different philosophy. Modeled on the community health worker, which has proven extraordinarily successful on the medical side, CDHCs function primarily as oral health educators and providers of limited, mainly preventive clinical services. They also help patients clear the red tape, find dentists, book appointments, and assist with critical logistical support such as securing child care, transportation, and permission to miss work in order to receive treatment. A public health system based on the surgical intervention in disease after disease has occurred is inherently flawed. Rather than focusing strictly on treating disease, the CDHC provides the education and preventive services that ultimately can contain an epidemic by preventing it.

In some communities, dental clinics, whether government funded, private, or nonprofit, may be the only resource available for dental care, and they often are overwhelmed. Many dentists who dedicate their careers to working in them do so out of a powerful sense of social responsibility. But the system cannot sustain itself relying solely on doctors who, upon completing grueling years of education and training, to say nothing of attempting to repay the cost of completing their education, choose such selfless career paths. These positions must pay competitively. Equally important, clinics must find new ways to partner with private practitioners, who can adjust to varying caseloads and confer a degree of efficiency beyond the capabilities of clinics under their current administrative and compensation structures.

Dental school clinics and off-site training programs also can be instrumental in providing needed care to patients who otherwise could not afford it. A prime example is the collaboration between the NYU College of Dentistry and Henry Schein Cares, which places dental students, faculty, residents, and hygienists in diverse clinical settings caring for disadvantaged patients. In addition to the obvious benefits of providing care to underserved populations, such programs bring students into direct contact with people whose oral health needs are profound, and teach students the real impact they can have in serving these communities.

Untreated dental disease in America is a national disgrace. What Surgeon General David Satcher famously called a "silent epidemic" of untreated oral disease owes in part to a failure to speak up. Dentists have carried the burden of advocating and caring for the underserved for decades, with only limited success. Perhaps most frustrating is that real change is within reach. The system of clinical care is essentially in place, one that has proven to be a model for the larger sphere of health care—patient education, focused prevention, and, when needed, early intervention to restore optimal health. When brought into this system, patients are empowered to be stewards of their own health.

Innovations in the dental workforce, such as expanded function dental assistants, oral preventive assistants, and patient navigators like the Community Dental Health Coordinator, can greatly improve the system's efficiency and capacity. But addressing workforce issues while ignoring other major determinants such as education, prevention, administration, and, most importantly finance, is the policy equivalent of digging a hole in the ocean.

That other sectors of society are becoming increasingly vocal and passionate about the need to improve America's oral health can only help. Disagreement is natural and ultimately healthy. But attempts to end the epidemic of untreated dental disease that do not position dentists as leaders and guides are doomed to fail. The people we all want to help deserve better—everyone deserves a dentist. The 156,000 members of the American Dental Association stand ready to continue working, aided by our new allies, toward our common goal of a healthier, more productive nation.

Addressing workforce issues while ignoring other major determinants such as education, prevention, administration, and, most importantly finance, is the policy equivalent of digging a hole in the ocean.