Expand Access to Dental Care in Maryland

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With greater access to routine dental care, Deamonte Driver, a 12-year old from Prince George’s County, Maryland, may still be alive. Deamonte’s untreated dental problems spurred a chain reaction, leading to his tragic death in 2007.

The barriers that Deamonte faced are similar to those facing thousands of children across M
aryland, the root of which is access: only 39% of Maryland children received any dental service in the previous year. Access to dental care is likely to become worse under the Affordable Care Act as 224,000 individuals are expected to gain Medicaid coverage in Maryland.

The problem of access to dental services, while multi-faceted, begins with limited availability of dental providers. One way to increase capacity for dental services is by authorizing a new class of dental providers in the state, known as “dental therapists.” Several states, including Alaska, Maine, and Minnesota have leveraged dental therapists to fill gaps in dental care and increase access to dental services. These mid-level professionals serve in a capacity similar to nurse practitioners or physician assistants. Studies have shown that dental therapists provide high quality care, primarily serve low-income patients, achieve high patient satisfaction ratings, and reduce emergency room visits for oral health-related issues. No problems have been reported with respect to quality of care from dental therapists.

Thus, the state legislature should consider legislation which authorizes a new class of providers, dental therapists, as one way to increase access to affordable, high-quality dental care for all Maryland children.

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6 Responses to “Expand Access to Dental Care in Maryland”

  1. kkline5 Says:

    This is a very interesting argument about expanding dental care in low-income communities. I had no idea that “dental therapists” were being used as mid-level providers in the United States! Expanding access to dental care is clearly a critical issue in many places, whether or not using dental therapists is the best strategy to accomplish this.

  2. deepskhanna Says:

    The blog contains a great suggestion of introducing Dental Therapists in low income states but it also makes me wonder if dentists can be replaced with the therapists just an a physician can not be replaced by a physician assistant.There are certain procedures which dentists are exposed to and hence licensed to perform.Recruiting dental therapists would not totally solve this problem rather if the government can have a policy of mandatory rotations of final year dental students and dentists sitting for state licencing exam to work for a minimum of 6 months in these states may suffice this issue.In developing countries like India where doctors do not want to work in rural cities,the government has made laws -called mandatory rural postings only after which a dentist is given his degree.

  3. visa9 Says:

    This raises one of the major gaps with the current health reform changes because currently dental and medical care insurance is separate in the majority. While dental coverage is required as of Jan. 1, 2014, under the ACA for children, it is not required of adults. Dental ‘extenders’ would be an ideal resource to meet the dental need of the population especially in communities with poor access to dentists.

  4. ekravinsky Says:

    This is a very interesting blog, thank you. In terms of communications, it is an example of the way that isolated terrible events, such as the death of Deamonte Driver, can be used to bring attention to public health issues such as oral health that are otherwise under appreciated. For more background there are some good resources on the Kellogg Foundation website: http://www.wkkf.org/what-we-do/healthy-kids/oral-health/oral-health-resources. The first is an IOM report on Improving Access to Oral Health Care for Vulnerable and Underserved Populations which notes that reimbursement rates for MA and CHIP need to be increased, dental schools should increase training opportunities in community-based settings for those with “complex oral health care needs”, and then that “states should examine and amend state practice laws to allow healthcare professionals to practice to their highest level of competence”, which seems to be a very discrete way of endorsing the use of dental therapists. I think that the recommendation for increasing dental students’ training in complex care in community settings speaks to the need for dentists as well as dental therapists, given the likelihood that dental problems in persons with a history of low access ( as well as poor nutrition and probable deprivation in other areas) may be more likely to need complex dental care as well as basic care. The site also includes a Pew (and others) report: The State of Children’s Dental Health: Making Coverage Matter” from 2011 which addresses other issues important for children’s oral health, including sealants and fluoridation, school-based services, fluoridating water, and improved dada collection. I think these reports suggest that increasing utilization of dental therapists is important, but should be done in conjunction with other measures for maximal effectiveness.

    On another note, it is interesting that dental care is not mandated for adults under the ACA., although dental coverage is available for adults in some markets. This seems to reflect lack of appreciation for the importance of oral health to health in general. I wonder if there was a battle over this in the development of the ACA? I can’t seem to find info on this, if anyone knows, please advise.

  5. mdavid24 Says:

    This is very interesting. More interesting to know that pediatric oral healthcare is not under the ACA?? But, I agree with the post that “dental therapists” is one strategy to treat more patients. Is the issue that there is not enough providers? Or not enough coverage to obtain care under these providers.

    Another point…I am a PA and although my education did not jump into the deep depths of biochemistry, I have a lot of practical experience that allows me to adequately manage “routine” care, as well as be trained on specialty procedures, to the point that I receive referrals from and train physicians (bone marrow aspirations). I have run practices with physicians that have doubled who they see in an hour with just 1 PA in the office (on top of being able to take days off etc), so I do agree that these “dental therapists” will be helpful in at least providing baseline routine care for patients and increasing workload for each dental office. The bottom line is that there is not a lot being done to improve oral health care, which can lead to death, in these children, and I think strategies, such as what you have discussed need to be continually brought forth before an unexpected epidemic occurs.

  6. ericamckeonhanson Says:

    This is a topic that I am very passionate about and I thank you for the blog post. In addition to being the mother of two children who have suffered from severe dental decay in part due to the lack of access to dental care, I have also spent the past twelve years working on two different American Indian Reservations in rural Montana where community members suffer from dental health disparities at an alarming rate. Among the American Indian/Alaska Native (AI/AN) populations in the United States (US) the rate of early childhood caries (ECC – tooth decay among children under age 6) is five times the US average. In my faculty position at our local tribal college, I have lead NIH funded research to establish baseline data which produced staggering numbers of young AI children suffering from severe ECC in our community. We are now at the beginning stages of two NIH funded community based participatory research intervention projects, one focused on an oral health literacy campaign and the other to introduce a community oral health worker very similar to the dental health therapist.
    As we have worked over the past several years to determine why our community AI/AN children suffer from ECC at such a high rate, we have discovered it is a multifaceted issue. Two of the significant contributors to this health disparity are lack of caregiver knowledge about proper dental care and lack of access to care. Although the rural area in which we live is served by a dental unit of Indian Health Service, it is often understaffed and underfunded leaving many of the community dental needs unmet. Alaska has been successful at increasing access to dental care for many of their tribal villages through Dental Health Aide Therapists (DHATs) The DHATs are recruited from the rural communities and villages in which they live and will eventually be placed. After receiving training, the DHAT returns to their home and provides mid-level care often times in the absence of a dentist. Although the DHAT does not have the level of training of a dentist, they are able to provide dental care, including minor restorations, to patients who would otherwise go untreated. This has had a tremendous impact in the communities with DHATs and prevented such severe complications as seen in the case of Deamonte Driver. The American Dental Association (ADA) has also developed the curriculum and endorsed the training of a similar member of the dental team called the Community Dental Health Coordinator (CDHC). The ADA has recognized the important role these CDHC’s can play in rural and urban populations with limited access to dental care. As mentioned in the original post, only a few states allow the practice of these mid-level providers. There has been push back from dentist groups in other states opposed to this endeavor for reasons such as patients being able to see a dental therapist for a cheaper cost than seeing a dentist for routine care. The dental therapist is an intervention that has the potential to make a real difference in undeserved populations and needs to be supported in every state.

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