Excerpt from Dr. Jack Mooney, Past-President of CSDA About Dental Therapists
Dr. Jack Mooney has testified in front of his state's legislature and active for many years in the Connecticut State Dental Association. This email he wrote to the ADA clearly describes the issues and has been reprinted with his permission.
"In short the argument for Dental Therapists is that there simply are not enough dentists to fulfill the access to dental care of the population. (Pro-Dental Therapist organizations) assert that the creation of another level of provider is a necessity, as well as stating that opposition to this provider based on the evidence is unethical. Going through this I’m reminded of the Theory of Relativity, in other words through what or whose lens does one view Access, Public Oral Health and what are the factors that are irreducible to affecting Access in a positive manner while concurrently positively affecting the oral health of any given population.
It’s pretty clear to me that (Pro-Dental Therapist organizations are) looking at the issue through a myopic lens. Alaska and Minnesota have demonstrated only one evidence based fact that Dental Therapists can operate safely and competently. In my opinion it is not a violation of our ethical code if we do not support the creation of a new provider based on the other irreducible factors that impact Access. When looking at evidence based data, it behooves us to examine all of the evidence. Furthermore when considering expanding scope or creating a new provider one has to look deeper than simply creating. Any designed system demands two irreducible criteria. First is adequate funding and the second is adequate infrastructure. Without these, any system will fail and interestingly enough, even when all of the criteria are met, it doesn’t necessarily mean the system will succeed in its mission.
So here is my lens which I believe is a bit clearer and looking at the issue from 10,000 feet not from any one particular side. Background is important, I heard a lot about New Zealand and how well Dental Therapists were doing there. New Zealand is a fascinating case for many reasons. First they truly do have a shortage of dentists and they actually started Dental Therapy way back in 1922. By the year 2000, Dental therapists were in every school district which eliminated many of the traditional barriers to care. Cost, travel, time of day etc. were eliminated. What’s surprising are two findings. First, not every child was treated. The highest utilization rates were 90% in some regions while most ranged between 70-80%. One region stands out at 65%. That means that even with no traditional barriers to care patients will still not completely utilize care. To my knowledge there has not been a good study about why people who can get care for no cost, do not utilize that care. An anecdotal finding I have made is, the poorer the group the less the utilization, even when there is no cost for care. The second observation, which is disconcerting from a Public Health perspective is that despite having no barriers, relatively high utilization rates for school aged children, this group lags far behind their western counterparts in oral health measurements. In other words even having unfettered Access and care, school aged kids still suffered disproportionately from caries.
The next viewpoint is from the state of Connecticut. In 2008 after a very long lawsuit the General Assembly agreed to finally raise fees while at the same time the Connecticut State Dental Association agreed to actively pursue a provider base of 600 providers. Those fees were raised to the 55 per centile for children, adults were also covered at half of the child fees. There was also a shift to one plan administrator which alleviated a substantial amount administrative headaches. In short, the child dental Medicaid plan was radically simplified for both patients and providers. This simplification would eventually result in a provider base of 1800 and child utilization rates of around 62%. In the course of five years, no Medicaid child goes more than 24 hours with a toothache and treatment times for routine care is less than 10 days. Every child now has at least two providers within a couple of miles of their home. The most impressive statistic was the apparent improvement (this effect still needs to be studied) in the oral health of the child Medicaid population. Initially, there was a surge of restorative treatment done, but over a five year period we witnessed a shift from a restorative paradigm to one of routine prophylactic care. The data seems to indicate that the oral health of this group has improved, quite a contrast to New Zealand or Alaska/Minnesota.
The beauty of the Connecticut experience is that it offers a different perspective from the “Innovate crowd”. While there is no denying that the thousands of patients that have been competently treated by Dental Therapists in Alaska and Minnesota have indeed benefitted, the impact on overall oral health has been negligible. Connecticut (not by initial design) took advantage of its existing dental care infrastructure versus spending time effort and money on innovating with a new provider. The positive impact in Connecticut happened without any substantive change to the existing dental workforce and in my opinion is proof that innovation should only be considered if and when that workforce is overwhelmed. Even when overwhelmed, society/government needs to make a commitment fiscally and infrastructure wise to support the creation of a new provider. As we are witnessing in Minnesota, creating a new provider is no guarantee that the targeted population will get care and furthermore that the care will cost the patient or society less money.
I argue that the Connecticut experience has provided anevidence based ethical approach wherein government, in partnership with the profession, can fund providers, recruit providers and take advantage of the existing dental delivery infrastructure to provide access and improve the oral health of a targeted population. Comparing with the happenings in Minnesota versus Connecticut reinforces this argument. While Minnesota has at best meandered forward, Connecticut went from one of the worst performing child Medicaid states to now the best. Given the different approaches and evidenced based outcomes I argue that it is more ethical to try the Connecticut path first, then innovate if you fail. Pushing the ethical argument further I argue that pushing for Dental Therapists before education and fully utilizing the existing dental delivery infrastructure is unethical because it takes away from the other important elements that must come together in order to positively affect oral health. If we indeed buy into the “low oral health literacy” argument then does it not behoove both sides to address this one specific issue before wasting valuable time money and resources supporting a provider that the evidence shows to have limited positive outcomes relating to oral health? Connecticut shows that it is more timely and cost effective to use what you have before innovating. Again how much time effort and money spent trying to create (which needs education, competency testing and regulation) when simple steps can be taken to affect a larger amount of patients in a timely fashion? And finally ethically are we not bound to do this in this sequence versus creating and hoping for an outcome?
It is a shame that the Foundations and our profession have not joined and started building oral health from the bottom up. Low oral health literacy demands education. Adequate funding for Medicaid demands collaboration in the legislative arena. Creating adequate provider panels, demands cooperation with the existing professional organization. And when necessary, when the system is overwhelmed, it will demand the creation of a new provider. Simple evidence driven, ethical actions."
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