Improve Care, Increase Revenue: The Case for Midlevel Providers by Leon A. Assail, DMD, and John Powers, DDS

Dental decay remains the most untreated disease in our society. A recent American Dental Association study highlighted 2009 government findings that more than 60 percent of people in the United States did not visit a dentist in the previous year.1 While that presents a real challenge to those of us who lead the dental team, it also presents a much larger opportunity.

In the February 2015 issue of the Journal of the American Dental Association, a new commentary brought attention to a two-year-old systematic review of oral-health outcomes produced by dental teams incorporating midlevel providers, sometimes referred to as dental therapists.2 The results, released by the ADA's Council on Scientific Affairs, add to the growing body of evidence in support of expanding the dental workforce. Simply put, dental-care teams that employ midlevel providers can reduce the rate of untreated decay more than teams that employ only dentists.

Our experience as researchers, educators, and providers demonstrates that this is true in practice—not just in theory.

According to Dr. Timothy Wright, one of the lead researchers and past chair of the American Dental Association's Council on Scientific Affairs, the results of studies indicate that appropriately trained midlevel providers are capable of providing high- quality services, including restorative care.

Dental therapy students and graduates from University of Minnesota School of Dentistry focus on the treatment of dental caries. Integrated-care teams in the school are able to evaluate, plan and provide initial caries treatment during their first visit to the school's clinic. The care team includes the dentist faculty member as the head of the team, as well as students from the doctor of dental surgery, dental hygiene, and dental therapy programs.

In this environment, future oral-health professionals learn to work together toward the goal of more effective treatments for patients with high levels of untreated decay. Reducing rates of untreated decay has always been a central goal of dentistry and a core activity of dentists. Much of the burden of dental disease—pain, missed school and work days, and lower academic achievement—is not due to the presence of decay, but due to untreated decay that has progressed to the point of causing significant harm.

One study found that in 2010, approximately $2.1 billion was spent on emergency-room visits for dental conditions—costs that could mostly have been avoided with earlier, routine care.3 A similar study uncovered that from 2008-2011, 101 people died in hospitals due to preventable dental disease.4

At Main Street Dental Care, a solo practice in rural Minnesota, staff watched the number of Medicaid patients treated increase by 50 percent in the first year after hiring a dental therapist. New patients come from as far as four hours away, many of whom haven't been able to see a dentist in years because too few accept state-based insurance.

At the same time, not having to focus so much on routine fillings allows time for more exams and complex procedures. At the Minnesota practice this included 555 more exams, 55 more root canals, 12 more implant procedures, 110 more surgical extractions, and 88 more removable prosthodontic procedures.

The practice's net profits increased after employing a dental therapist and serving an additional 234 Medicaid patients—despite Minnesota having one of the lowest Medicaid reimbursement rates in the country. Expanding the dental team to include midlevel providers has been so successful that the practice recently hired a second dental therapist.

What about the 60 percent of Americans who did not see the dentist? Employing midlevel providers is an opportunity to extend our care to more of that huge group, including those on Medicaid or those with limited personal resources for health care, while still increasing practice profits.

In one example, dental therapists bill $150,000-$250,000 per year more than the cost to employ themselves and their assistant.5 Because of the lower cost of employing a midlevel, it also offers an opportunity provide high-quality care at an affordable cost to those who pay out-of-pocket. On a basic level, it's a chance for all of us, as leaders of the dental team, to do more for the communities we serve.

While dental therapists are certainly not the best option for every dentist and every practice setting, they are a remarkable resource to practices in areas that have high levels of untreated disease, where there are patients who will not be seen or cannot be seen because of the high-unit cost of care.

There is no question that we should work toward preventing decay, and there are several strategies proven to do so, such as fluoridating more community water supplies, applying fluoride varnish to very young children's teeth, brushing daily with fluoride toothpaste, and providing dental sealants. However, we must also recognize that we are not doing our jobs as health-care providers if we do not make prevention accessible to a much greater segment of our society, and provide care when prevention fails. Midlevel dental providers can help on both fronts.

  1. Vujicic M. "An Analysis of Dentist's Income: 1996-2009," JADA 2012: 143(5): 452-460.
  2. Wright J.T., Graham F., Hayes C., et al. "A Systematic Review of Oral Health Outcomes Produced by Dental Teams Incorporating Midlevel Providers," JADA 2013: 144(1): 75-91.
  3. Wall T, Nasseh K. American Dental Association, Health Policy Institute. "Dental-related emergency visits on the increase in the United States." May 2013.
  4. Allareddy V. et al. "Hospital based emergency department visits involving dental conditions: predictors of poor outcomes and resource utilization," JADA 2014; 145(4): 331-337.
  5. 5. The Pew Charitable Trusts. "Expanding the Dental Team: Increasing Access to Care in Public Settings." June 2014.

Dr. Leon A. Assael is dean of the University of Minnesota's School of Dentistry in Minneapolis, Minnesota.

Dr. John T. Powers is the owner and sole dentist at Main Street Dental Care in Montevideo, Minnesota.


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