Opinion

OPINION | DONALD M. BERWICK

Proper dental care should be a human right

hands of dentist holding his tools during patient examination isolated on white background; Shutterstock ID 274735031; PO: oped

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In Alaska, scores of tiny Alaska Native villages dot the landscape, some with only a few hundred inhabitants and many accessible only by bush planes. They may be short on some amenities, but many have superb dental care. That’s thanks to a program called Dental Health Aide Therapist, or DHAT, which the Alaska Native Tribal Health Consortium started in 2004. DHATs, analogous to physician assistants in medicine, are trained to do dental evaluations, administer preventative services like fluoride treatments, fill cavities, and extract badly diseased and loose teeth. They remain in communication with supervising dentists through phone, email, shared health records, and teledentistry.

DHAT care is first-rate. A 2012 panel sponsored by the W. K. Kellogg Foundation reviewed over 1,100 studies and reports on such programs, focusing on 26 of the 54 nations that use them. The panel concluded that they “… have consistently found that the quality of the technical care provided by dental therapists (within the scope of their competency) was comparable to that of a dentist and in some studies was judged superior.” Detailed independent evaluations of the Alaska DHAT program arrive at similar conclusions. DHAT care now reaches over 40,000 children and adults in Alaska.

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But tens of thousands of people in Massachusetts are not so lucky. According to a recent review by the Massachusetts Health Policy Commission, only 53 percent of low-income children and youth and 56 percent of low-income adults in the Commonwealth saw a dentist in 2014. Kids on Medicaid visited emergency departments for preventable oral health problems six times more often than commercially insured children; for MassHealth adults, the figure is seven times. Over half of the residents in Massachusetts nursing homes have untreated dental decay. In 2014, low-income seniors in Massachusetts were seven times as likely to have lost all their teeth as those with means. Nearly a third of adults with special needs are missing six or more teeth.

Tooth decay does not make headlines, but the downstream consequences of poor dental care are severe, such as poor nutrition, serious infections, degraded school performance, and acute and chronic pain. And, like poor or delayed medical care, missing dental care is costly. Those emergency room visits are far more expensive than the dental office care that could have averted them.

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The problem is largely one of supply. Only a minority of Massachusetts dentists accept public insurance. In 2014, just 35 percent of Massachusetts dentists saw even one MassHealth patient, and only 26 percent billed MassHealth more than $10,000. The distribution of dentists is geographically lopsided. One-tenth of our population lives in federally designated dental health professional shortage areas. Our state has made stunning progress in assuring health care as a human right, but, across the board — from low-income children and minorities to individuals with disabilities and seniors in long-term care — we are failing to provide even basic dental health care to those who can least afford to pay for it themselves.

Thankfully, there’s a solution on the table that would expand dental care and reduce costs.

State Representative Smitty Pignatelli and Senate Majority Leader Harriette Chandler have introduced legislation that would bring a DHAT-like resource to our state, creating a new class of mid-level dental professionals called “dental hygiene practitioners.” If approved, Massachusetts would join Minnesota, which has increasingly begun relying on mid-level providers to help serve vulnerable populations in community health centers, schools, and nursing homes. Like Alaska, Minnesota has found that clinics employing mid-level providers are able to serve more people, reduce travel times for patients, and remove financial and logistical barriers that underserved patients too often face. Maine has authorized mid-level practitioners as well. A similar bill in Vermont has been approved by the legislature and is awaiting the governor’s signature. And with California and Colorado recently passing legislation authorizing state Medicaid programs to reimburse for teledentistry services, the trend is quickly moving into the mainstream.

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The evidence is that dentists, too, benefit from the extra volume that dental therapist programs can bring into their practices. Dr. R. Bruce Donoff, dean of the Harvard School of Dental Medicine, writing in support of the Pignatelli-Chandler bill, noted that the US Commission on Dental Accreditation, with members from the American Dental Association, the American Dental Education Association, and the American Dental Hygiene Association, voted in 2015 to implement standards that further legitimize dental therapy as a profession. He takes this as a “significant signal that dental mid-level providers are safe, are meeting the needs of the public, and are sought after by dentists.”

Proper dental care is as much a human right and as smart an investment as is proper medical care. By passing the Dental Health Practitioner legislation, Massachusetts now has a chance to add access to dental health to its list of proud commitments.

Dr. Donald M. Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement, is commissioner on the Massachusetts Health Policy Commission.
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