Crystal Ann Baker isn’t a dentist, but she fills cavities, pulls teeth and even performs children’s root canals.
Baker, who treats low-income patients in St. Paul, Minn., is among the nation’s first dental therapists — an innovative and controversial health position intended to fill socioeconomic and geographic gaps in dental care.
With nearly 17 million children nationwide lacking dental care and health reform expected to increase demand, California and other states are exploring similar models to expand the dental workforce, setting the stage for a series of battles with dentist organizations that warn that patient safety is at stake.
The American Dental Assn. argues that dental therapists lack the training and education needed to perform irreversible surgical procedures and to identify patients’ other medical problems.
The California Academy of General Dentistry argues that high school graduates with a few years of training could end up performing delicate procedures with permanent consequences. “Imagine how you would feel if your children were being taken care of by these people,” said Sun Costigan, president of the organization.
But advocates and researchers counter that concerns about insufficient training and substandard quality are unfounded.
Therapists would be properly educated and would help close vast gaps in care that can lead to costly emergency room visits for dental problems, said Shelly Gehshan, director of the Children’s Dental Campaign for the Pew Center on the States. Nationwide, 830,000 emergency room visits in 2009 were due to preventable dental problems, according to the center.
Many of the children lacking care don’t have insurance, live in areas without enough dentists or can’t find doctors who accept Medicaid. Problems accessing dentists could grow in 2014, when 5 million more children are expected to get dental insurance under the federal healthcare reform law.
“We need more qualified people to expand the reach of the dental system,” Gehshan said.
Dentists’ concerns about competition also are unwarranted, she said. She said therapists wouldn’t “threaten dentists’ identity, their control over the profession or their incomes.”
In 2005, Alaska became the first state to try out the new dental care model, when therapists began treating native populations. Minnesota authorized the new tier of practitioner in 2009, and the first graduates of dental therapy programs began practicing last year.
Now, California, New Hampshire, Oregon and Connecticut are among the states considering the creation of new classes of care providers to address the access problem.
Legislation pending in Sacramento would authorize a study to test workforce models for the state’s underserved children. The bill would also create a statewide office of oral health charged with assessing the state’s needs and addressing them.
California’s situation is different from some other states’. The ratio of dentists to patients is higher than the national average. The 37,631 licensed dentists are enough to serve the population, but they are not evenly distributed across the state, said Nadereh Pourat, director of research at the UCLA Center for Health Policy Research.
In 2009, Pourat found Alpine County did not have any licensed dentists. Imperial County had one of the worst ratios, at 4,166 people per dentist. Los Angeles County had about one dentist per 1,515 people, but in San Francisco, there was one dentist for every 820 residents.
“In some parts of the state we have a surplus of dental offerings and some parts of the state there is a clear deficit,” said state Sen. Alex Padilla (D-Pacoima), who wrote the bill calling for a review of California’s dental workforce. The state needs to do a better job at matching up dental services and patient needs, he said.
Taxpayers will benefit from more cost-effective care that reduces trips to the hospital, he said. Better dental care also could improve school attendance. More than half a million children missed school in 2007 because of dental problems, according to a UCLA study.
The proposed California study should look at treating children in schools, using technology to expand care and developing two- or three-year training programs for dental workers, said Jenny Kattlove of the Children’s Partnership.
Proponents of dental therapists say evidence is mounting that the model works. The W.K. Kellogg Foundation released a report last month concluding that research worldwide shows dental therapist care is both safe and effective.
But the American Dental Assn. called the study an “advocacy document.” The association’s president, Bill Calnon, said dentists are concerned about safety, not competition.
“This is not about dentistry or dentists protecting dentists,” he said. “This is about dentists doing what they feel is the absolute best for the American public … and doing it in a way that maintains the highest level of quality care possible.”
Improving training for hygienists or dental assistants and emphasizing prevention is a better approach, he said.
“Putting more treaters in the field, no matter what level of education or training, is not going to solve the problem,” Calnon said. “Prevention and education are the absolute keys.”
The California Dental Assn. is open to an academic study focused on whether dental therapists or other workers would be safe, cost-effective and efficient, said Dan Davidson, the group’s president. If therapists are added to the care system, they should only work under the close supervision of dentists, he said.
That’s what Baker does at HealthPartners in St. Paul, where she divides her time between educating patients and treating them. Many of her patients show up only when tooth pain becomes unbearable, or after they have already gone to the emergency room for help.
Baker, who earned a master’s degree in dental therapy at the University of Minnesota, said she sees plenty of room for both dental therapists and dentists. “We are not doing this to step on anybody’s toes,” she said. “We are simply hoping to make our profession of dentistry better.”