The American Academy of Pediatric Dentistry Is Wrong About Dental Therapy

This article is in response to the piece by Dr. Michael Davis published in Dentistry Today about the American Academy of Pediatric Dentistry’s (AAPD) rebuke of the HRSA Advisory Committee for the Training of Primary Care Medicine and Dentistry (ACTPMD) recommendations in support of dental therapy. The National Coalition of Dentists for Health Equity (NCDHE) welcomes the opportunity to respond to the myths and misinformation discussed by both Dr. Davis and AAPD.

The Mission of the NCDHE is to unite dentists in support of evidence-based, high quality, and cost-effective oral health services including disease prevention and treatment, and care delivery models. Our membership includes private practitioners, former dental school deans, the former editor of the Surgeon General’s report on oral health, dental educators, former members of the ACTPMD, and current and former members/consultants of the Commission on Dental Education.

The American Academy of Pediatric Dentistry is wrong about dental therapy. (Photo from PxHere)

We are a group of dentists who are pursuing oral health equity and we strongly support dental therapy as one of the evidence-based solutions to the access problems in this country.

In this article, the NCDHE will provide specific references to the AAPD comments below but a large body of the evidence can be found on the websites for the NCHDE, the National Partnership for Dental Therapy, the Minnesota Department of Health, Community Catalyst, and the Pew Trusts Dental Campaign.

DISCUSSION

The first thing we observed is that the AAPD did not provide any evidence for their myths and opinions.

• AAPD Statement – “The AAPD believes that oral health services to our nation’s highest-risk children should not be provided by non-dentists with less education and experience, especially when there is no evidence-based research to support the safety, efficiency, effectiveness or sustainability of such an approach.”

NCDHE Response – While it is true that dental therapists, by design, have less total education than dentists, they have a significantly smaller scope of practice than dentists, thus needing less education. More importantly, for those procedures they provide, they are trained to the same standards as dentists and have taken part in educational programs approved by the Commission on Dental Accreditation. In addition, they must pass the same state licensing examinations as dentists, limited to those procedures in their scope of practice.

In all the legislation passed thus far, dental therapists must be supervised by dentists.

With respect to the sentence “there is no evidence-based research to support the safety, efficiency, effectiveness or sustainability of such an approach,” this is simply not true. Some of the safety and quality studies were reviewed in a 2019 publication in the Journal of Dental Education (1); note that the editor of JDE chose this paper as one of the ten best published that year.   A 2020 report about Appletree Dental clearly documented the cost effectiveness of dental therapists in providing dental care to underserved populations (2).

• AAPD Statement – “Every child in our nation deserves the same high quality of oral health services delivered in the safest way possible. The most vulnerable children should not be treated by the least trained, and certainly not under the guise of promoting ‘equity.'”

NCDHE Response – There are numerous reports documenting the quality and safety of oral health services provided by dental therapists, including this one published in the Journal of The American Dental Association (3), and several others (4,5).

Other references about quality of care are in the websites cited above.

• AAPD Statement – “There is no clinical or ethical justification for children with more severe oral health needs to receive lesser care.”

NCDHE Response – Repeating statements such as “the least trained” and “lesser care” is misrepresenting the education of dental therapists. As stated above, dental therapists are educated in CODA approved educational programs and must pass state licensing examinations and they must be supervised by licensed dentists. We have already responded above to the false claims about “lesser care.” The AAPD’s repetition of this myth language does not make it any truer.

• AAPD Statement – “Dental therapists receive significantly less education and training than dentists. (General dentists attend four years of dental school after college; pediatric dentists spend an additional two or more years beyond dental school.)”

NCDHE Response – Again, repeating this mischaracterization does not make it true.  Yes, they have less education because they have a smaller scope of practice. To repeat, for those procedures in their scope of practice, CODA requires that they be educated to the same standards as dentists. See comments above.

• AAPD Statement – “The knowledge to perform specific dental procedures does not mean that the providers have the ability to determine whether or when various procedures should be performed, or to safely manage the full range of a child’s oral healthcare.”

NCDHE Response – This is a problematic myth to counteract, similar to trying to prove a negative. The AAPD does not support this statement with any evidence.

While the NCDHE has provided evidence of safety, quality and cost effectiveness in the above references, there has been no study of the ability of dental therapists to determine whether or not various procedures should be performed. However, we remind all that dental therapists are trained to consult for difficult cases; our members have spoken with many dental therapists on numerous occasions and they all respond similarly to this question; they are trained to refer when necessary.

As one further example, we know that in the past year, while there have been 116 complaints against dentists brought to the Minnesota Board of Dentistry, there have not been any complaints brought against dental therapists (Personal Communication September 6, 2022, Bridgett Anderson LDA, MBA, Executive Director of Minnesota Board of Dentistry), nor have there been any reported complaints in Alaska as of 2 years ago (Personal Communication, Dr. Mary Williard).

• AAPD Statement – “Although the few limited studies on the technical quality of procedures performed by dental therapists have found that the resulting work is comparable to that produced by dentists, there is no evidence to suggest that they deliver expertise comparable to a dentist in such fields as diagnosis, pathology, trauma care, pharmacology, and care of special needs patients.”

NCDHE Response – This is just a repetition of the prior myth-based statement. We would refer to the previous response we made.

• AAPD Statement – “While nurse practitioners are not allowed to perform major irreversible surgeries, dental therapists with less training would be allowed to perform irreversible surgeries on child patients.”

NCDHE Response – First, ”major irreversible surgeries” is a phrase frequently used by opponents of dental therapy to scare the public and legislators. What we are talking about is tooth preparation for a restoration with a high-speed dental drill or the extraction of primary or adult mobile teeth.

There is NO evidence that dental therapists cannot perform these procedures safely and with high quality. Second, physician assistants can perform numerous “irreversible surgical procedures” such as intracranial pressure monitoring/placement, cardiac catheterization on patients with heart conditions, Pleural Tap/Thoracentesis, Endotracheal intubation, Lumbar Puncture/Spinal Tap, and others (6).

Finally, the AAPD letter ignores the principle that dental therapists are part of a team that includes dentists. Like PAs and nurse practitioners, dental therapists participate in the care of patients that are under the general supervision of the dentist or physician. Pediatric dentists should have learned from their orthodontic colleagues about how to create a robust team to care for frequent and complex diseases such as dental disease.

The NCDHE believes that dentists at the head of a team including dental therapists would create a far better future for all patients.

• AAPD Statement – “Despite 14 states having some form of dental therapy on the books, Minnesota is the only state with any practicing dental therapists, with the exception of one in Maine (which has no training program). There are no data—none—that suggests that oral health outcomes, access to care, or cost of care improve in any place where dental therapists have practiced. That includes Minnesota, as well as prior tribal pilot programs in Oregon and Washington. Independent assessment of the data on the Minnesota dental therapy program found it has not yet been proven to be as effective as promised. Patient access to care was not meaningfully increased, nor did care become more affordable. Minnesotans continue to experience the same barriers to obtaining good oral health.”

NCDHE Response – First, the AAPD knows very well that dental therapists have been practicing in Alaska for over 15 years. Second, a thorough Pub Med search would have been easy for AAPD to perform. There are quite a few publications that counter this myth. Just a few are included (7-12), all demonstrating improved health outcomes. Further, if AAPD is suggesting that improved health outcome studies are important, we would respectfully ask AAPD to provide references documenting improved health outcomes from patients cared for by pediatric dentists.

We cannot find any such outcomes publications.

• AAPD Statement – “Evidence from Canada and Minnesota shows dental therapists often do not locate in underserved areas. For example, about 3 out of 5 dental therapists licensed in Minnesota were working in the Twin Cities metro area as of April, 2016. Only 8 dental therapists were located in the 70 percent of Minnesota’s counties fully or partially designated as Health Professional Shortage Areas.”

NCDHE Response – First, there is no language in the Minnesota legislation requiring dental therapists to practice in rural areas. However, there is language requiring dental therapists to spend at least 50% of their effort on Medicaid or otherwise underserved patients; thus, no matter where they practice, they are providing care to the populations in need. It is also important to remember that during the time cited by the AAPD, there were only about 100 dental therapists in the state.

Further, in Minnesota, over a quarter of the state’s dental shortage areas—home to more than 260,000 Minnesotans—are in the Twin Cities area.

Dental therapists in these urban areas are fulfilling their mission of treating low-income and underserved populations.

Further, dental therapists are geographically distributed in proportion to the state’s population: 55% of Minnesotans live in the Twin Cities metro area, where 59% of working dental therapists are employed; 45% of Minnesotans live outside the Metro area, where 41% of working dental therapists are employed.

In the most recent report from Minnesota, this number has decreased to 39% which is still excellent (13,14).

• AAPD Statement – “Dental Therapy programs are incredibly expensive to start, with little to show for it. Vermont has spent over $2.4 million since 2016 to start a program, including a $1.6 million federal grant, a $400,000 HRSA grant in 2018, and an additional $400,000 from the state. Not a single dental therapist is training or practicing in Vermont.”

NCDHE Response – While it is true that Vermont has had some startup difficulties due in part to costs, the programs in Alaska, Washington, and Minnesota (now 3 programs) are all functioning well.  More importantly, the start up and annual maintenance costs for dental therapy programs are still considerably less than those costs for dental schools; annual budgets for dental schools are easily in the $60,000,000 a year cost range.

Dental school tuition is much higher than tuition at dental therapy educational programs and dental therapists are much lower in salaries than the salaries of dentists.

While these figures are out of date, we would point out two facts:

1) In 2016, federal funds to dental education schools neared $36 million.

2) In 2016, state and local government funding to dental schools totaled more than $445 million (15, 16).

• AAPD Statement – “Studies from other countries that purport to justify the dental therapist experiment overstate their conclusions and lack adequate data to substantiate them. For example, there has not been a reduction in caries in these countries.”

NCDHE Response – The Nash study provided an excellent review of the 100+ year utilization of dental therapy. It documents quality, safety, and cost effectiveness (12).

At least two other studies, one in Alaska (7) and one in Canada (10) demonstrate decreased dental disease.

• AAPD Statement – “Although advocates argue that dental therapy model will reduce costs, dental services cost the same amount to the patient – and the state – no matter who performs them. For example, Minnesota Medicaid offers identical reimbursement rates for dentists and dental therapists. Essentially, dental therapy creates a new layer of bureaucracy without delivering any new service or savings to patients.”

NCDHE Response – Dental therapy advocates carefully say that care by dental therapists reduces the costs of delivering dental care to patients. That is what has allowed organizations such as Appletree Dental and Children’s Dental Services to significantly expand their missions, primarily with underserved patients; the same could be said for FQHCs, which use sliding fee scales for underserved patients.

We would need a better definition of what AAPD means by a “new layer of bureaucracy” to respond to that myth but ALL studies cited by all the references NCDHE has provided show increased dental services to patients. We also believe that the AAPD does not have any data to support the claim that patients seen by dental therapists in private dental practices do not pay any lower fees; that would be totally up to the discretion of the practice owner.

• “AAPD Statement– There is no shortage of dentists in the United States – and no shortage of care available for children. The number of pediatric and general dentists is growing faster than the child population and the demand for dental services, a trend expected to persist through 2040. It is not dentists that are lacking, but adequate reimbursements in Medicaid. Despite these challenges, over the past 20 years there has been a near doubling of the pediatric dentist workforce and a significant expansion in children dentally uninsured and receiving treatment under Medicaid and CHIP. It certainly can be improved, but dental therapists are not the answer.”

NCDHE Response – Over 60,000,000 people living in DHPSAs would disagree with the first part of this statement (17). The shortage of affordable dentists is easily manifested in the high number of patients that seek dental care for pain and infection in hospital emergency departments because they cannot afford to go to a dentist office (18).

While the NCDHE would agree that raising Medicaid reimbursement rates would be a fair and appropriate thing to do, there is no consistent evidence that raising Medicaid reimbursement rates will significantly increase access to dental care for Medicaid recipients and this solution is very expensive (19). Nor does raising Medicaid reimbursement rates do anything for those middle-income families who simply cannot afford dental care in traditional private practice settings.

Finally, we would also suggest that this is not just about the numbers of dentists. Forbes Magazine and even the American Dental Association Health Policy Institute both think that the dental care system in this country is broken and that there are solutions that are not just increasing the numbers of dentists (20,21). Finally, while there may in fact be a lot of pediatric dentists, for most families, according the American Dental Association Health Policy Institute, affordability of dental care in private practice settings is the problem (22).

Dental therapists are a proven way to improve access to care for those with affordability problems; see specific references cited in this letter.

• AAPD Statement – “The best way to provide needed dental care to underserved children is through a Dental Home – the existing model of a dental team working together with the direct supervision (or physical presence) of a dentist.”

NCDHE Response – AAPD provides no evidence to support this claim. NCDHE supports the concept of a dental home. All dental therapists are supervised by a dentist, thus providing a dental home, albeit, the patients might be served with portable equipment in a distributed care system.

• AAPD Statement – “Children will be best served by protecting the financial support of dental Medicaid, which will encourage access to care through current providers already prepared to serve, and by expanding loan repayment assistance programs that have the proven result of placing dentists in designated Health Professional Shortage Areas”

NCDHE Response – As stated above, there is little evidence to document consistent and significant increases in Medicaid utilization after raising reimbursement rates (19). In addition, there is little evidence that loan repayment assistance programs have any long-term effects on dentists practicing in DHPSAs.

There is a short-term effect but these programs are very expensive (23).

CONCLUSION

The bottom-line of the AAPD’s message is that if states and the nation pay dentists more, then the underserved would be served.

That is the ultimate solution from their perspective.

We propose that this implies that the solution is to pay a King’s ransom to meet the urgent care needs of America’s poor and underserved children. If this indeed is the solution, then it is more likely that the need will never be met.

However, if a solution were to include innovations that lower long-term costs and increase access to levels of care that meet urgent needs, then many would favor that option. The answer has to be somewhere in the middle ground, and that is why the ACTPMD made the recommendation in favor of dental therapy. This was not in any way to undermine dentistry, but to enhance it…much as modern medicine and healthcare has added newer workforce models and technology to extend their impact and accessibility.

It’s health equity that is addressed by extending the dental team.

We would also point out that the NCDHE is not the only organization supporting the implementation of dental therapy.

Over 100 other bipartisan organizations have signed on to support actions of the National Partnership for Dental Therapy (24).

Disclaimer: The opinions expressed in this paper do not necessarily reflect the official opinions of any organizations which with the authors are associated.

REFERENCES

1. Catalanotto, FA, In Defense of Dental Therapy: An Evidence Based Workforce Approach to Improving Access to Care, J Dent Educ. 2019 Feb;83(2 Suppl):S7-S15. doi: 10.21815/JDE.019.036. PMID: 30709933
2. Langelier M, Surdu S, Moore J. The Contributions of Dental Therapists and Advanced Dental Therapists in the Dental Centers of Apple Tree Dental in Minnesota. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany; August 2020. https://www.chwsny.org/wp-content/uploads/2020/09/CHWS_Contributions_of_DTs_ADTs_at_Apple_Tree_Dental_2020.pdf
3. Wright, JT Do midlevel providers improve the population’s oral health? Journal of the American Dental Association Volume 144, ISSUE 1, P92-94, January 01, 2013 https://jada.ada.org/issue/S0002-8177(14)X6025-3 
4. Scott Wetterhall, James D. Bader, Barri B. Burrus, Jessica Y. Lee, and Daniel A. Shugars, “Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska,” RTI International (RTI Project Number 0211727.000.001) (October 2010), http://www.rti.org/sites/default/files/resources/alaskadhatprogramevaluationfinal102510.pdf
5. Dental therapists: evidence of technical competence. Phillips E, Shaefer HL.J Dent Res. 2013 Jul;92(7 Suppl):11S-5S. doi: 10.1177/0022034513484333. Epub 2013 May 20. PMID: 23690358 Review.
6. https://www.flrules.org/gateway/ruleno.asp?id=64B8-30.012
7. Chi et al, Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta, Journal of Public Health Dentistry ISSN 0022-4006, 78 (2018) 175–182
8. Provider and community perspectives of dental therapists in Alaska’s Yukon-Kuskokwim Delta: A qualitative programme evaluation. Chi DL, Hopkins S, Zahlis E, Randall CL, Senturia K, Orr E, Mancl L, Lenaker D. Community Dent Oral Epidemiol. 2019 Dec;47(6):502-512. doi: 10.1111/cdoe.12492. Epub 2019 Aug 29. PMID: 31464356
9. Supply of care by dental therapists and emergency dental consultations in Alaska native communities in the Yukon-Kuskokwim delta: a mixed methods evaluation. Chi DL, Mancl L, Hopkins S, Randall CL, Orr E, Zahlis E, Dunbar M, Lenaker D, Babb M. Community Dent Health. 2020 Aug 31;37(3):190-198. doi: 10.1922/CDH_00022Chi09. PMID: 32673470
10. Mathu-Muju, KR, Friedman, JW and Nash, DA, Saskatchewan’s school-based dental program staffed by dental therapists: a retrospective case study. Journal of Public Health Dentistry 77 (2017) 78–85
11. Brickle, CM, Self, KD, Dental Therapists as New Oral Health Practitioners: Increasing Access for Underserved Populations September 2017 Supplement ■ Journal of Dental Education
12. Nash, D et al, A review of the global literature on dental therapists, May 2013Community Dentistry and Oral Epidemiology 42(1) DOI:10.1111/cdoe.12052.
13. Pew Charitable Trusts analysis using DHPSA data by county, accessed January 24, 2019, https://data.hrsa.gov/hdw/tools/DataByGeography.aspx
14. Minnesota Department of Health and the Minnesota Board of Dentistry, “Dental Therapy in Minnesota, Issue Brief,” 2018, https://www.health.state.mn.us/data/workforce/oral/docs/2018dtb.pdf.
15. HRSA Justification of estimates for appropriations committees, FY 2018, https://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-2018.pdf.
16. American Dental Association, “Dental Education, Report 3: Finances, Table 1 a. Fiscal Statistics for All Dental Schools, FYE 2006 to 2016,” https://www.ada.org/en/science-research/health-policy-institute/data-center/dental-education.
17. https://www.kff.org/other/state-indicator/dental-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
18. https://www.dentistrytoday.com/emergency-room-visits-for-dental-problems-cost-2-billion-a-year/
19. Ben Johnson et al., “The Cost-Effectiveness of Three Interventions for Providing Preventive Services to Low-Income Children,” Journal of Community Dentistry and Oral Epidemiology 45, no. 6 (2017): 522, doi: 10.1111/cdoe.12315; T. Buchmueller et al., “THE EFFECT OF MEDICAID PAYMENT RATES ON ACCESS TO DENTAL CARE AMONG CHILDREN,” NBER Working Paper 19218 (July 2013), https://www.nber.org/papers/w19218.pdf.
20. https://www.forbes.com/sites/robwaters/2016/12/12/owww-if-you-think-the-u-s-medical-care-system-is-broken-take-a-look-at-dental-care/?sh=415bfe947648
21. Vujicic, M , Our dental care system is stuck. And here is what to do about it. JADA 149(3) n http://jada.ada.org n March 2018
22. Gupta, N and Vujicic, M, Main Barriers to Getting Needed Dental Care All Relate to Affordability – https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpibrief_0419_1.pdf
23. Werts M, Amah G, Mertz E. How Evidence-based Is US Dental Workforce Policy for Rural Communities? Rensselaer, NY: Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany; September 2020
24. National Partnership For Dental Therapy, https://www.dentaltherapy.org/join         

ABOUT THE AUTHORS

Dr. Frank Catalanotto is a former dean and currently Professor at the University of Florida College of Dentistry. His professional interests include social responsibility, oral health inequities and racial equity. Dr. Catalanotto’s current advocacy efforts are focused on new emerging oral workforce models. He is a Vice-Chair of the National Coalition of Dentists for Health Equity and a Co-Chair of the National Partnership for Dental Therapy. He is a founding member of Floridians For Dental Access.

Dr. Lawrence Hill is the executive director of the American Association for Community Dental Programs and currently serves on the Governing Council of the Ohio Public Health Association and the Board of Directors of Universal Health Access Now-Ohio. He served as the dental director for the Cincinnati Health Department and volunteer executive director for a United Way partner dental care nonprofit organization for over 30 years, during which he developed one of the largest community based dental programs in the country.