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'Dental therapy' takes root where dentists are scarce in Minnesota

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Dental therapy student
Megan Becker, a second-year dental therapy student, works with Dr. Gail Park at the 3M Foundation Dental Simulation Clinic, Oct. 8, 2013, at the University of Minnesota in Minneapolis. Minnesota is one of a handful of states that license dental therapists.
MPR Photo/Jeffrey Thompson

A new, mid-level dental profession is slowly taking root in Minnesota.

Over the past two years universities have trained, and the state has licensed, 28 dental therapists, practitioners who perform many basic dental procedures that previously only a dentist would do. They work in places where dentists won't go, or are unwilling to accept Medicaid coverage.

Minnesota is one of just two states that are using the new profession to reach underserved patients.   

Among the field's pioneers is Christy Jo Fogarty, of Farmington, who holds dental therapist license number 2 in Minnesota.

Fogarty, 43, also was the first person in the state to be certified as an advanced dental therapist -- an even higher level of training that gives her the freedom to work independently at mobile dental clinics in schools, Head Start programs and community centers.

"I work under general supervision, which means a dentist does not need to be on site with me," she said. "And I can do anything within my scope of practice."

That means Fogarty can perform a lot of basic dental procedures. 

"I can do any kind of fillings -- that's on children and adults; white fillings, silver fillings. I can do stainless steel crowns -- that's both on children and adults. I can do extractions of baby teeth."

Her patients are primarily low-income children and pregnant women. They usually have no dental insurance or their coverage is provided through the government's Medicaid program. That plan includes dental care, but many private dentists won't accept Medicaid's low reimbursement rates.

Working on a mannequin
Dental therapy students train on mannequins at the 3M Foundation Dental Simulation Clinic, Oct. 8, 2013, at the University of Minnesota in Minneapolis. Minnesota is one of a handful of states that license dental therapists.
MPR Photo/Jeffrey Thompson

Fogarty's nonprofit employer accepts Medicaid, even though the payments don't cover all of its costs. Children's Dental Services in Minneapolis likely would have been forced to cut back on its services by now, if dental therapists hadn't come along, Executive Director Sarah Wovcha said.

"This really has been a lifesaver for us," she said.

Wovcha said the new, lower-paid practitioners have helped her organization stretch its dollars. Wovcha pays dental therapists approximately $45 per hour, compared to an average of $75 per hour for a dentist.

"So that has a huge impact on our ability as a safety net provider to maintain our financial solvency," she said.

Children's Dental Services still employs dentists. Wovcha has not cut any positions and she doesn't plan to because she finds it hard to fill dentists jobs and needs dentists to perform root canals and other complicated procedures. Besides, Wovcha said, dental therapists can't legally work in Minnesota without a dentist's supervision. 

That requirement has made it challenging for some dental therapists to find work. In 2009, many dentists strongly opposed the legislation that created the dental therapy profession, and some of those dentists haven't changed their minds about the need for these mid-level practitioners. 

Emily Eggebrecht, a dentist at Children's Dental Services, was in dental school while the debate over dental therapists raged at the Capitol. 

"I know there was that kind of fear from the dental world that the care wouldn't be of the same level, but I really do think it is," she said.

While some dentists were convinced that the care would be substandard, Eggebrecht said others were worried that dental therapists could take business away from them. 

So far, that isn't much of an issue with only 28 licensed dental therapists in the state compared to 4,200 dentists. But as dental therapists increase in number, many already understand that the success of their careers depends in part, on their relationship with dentists. 

Cavity preparation training
Kaitlin Gebhart, second-year dental therapy student, works on cavity preparation training at the 3M Foundation Dental Simulation Clinic, Oct. 8, 2013, at the University of Minnesota in Minneapolis. Minnesota is one of a handful of states that license dental therapists.
MPR Photo/Jeffrey Thompson

"There's days where it's scary just because there's the unknown," said Kaitlin Gebhart, who will graduate next year from the University of Minnesota's dental therapy program.

Gebhart, a 23-year-old from Elkton, S.D., assumes she'll be able to find a job. But she said it is a little unnerving to follow such an uncharted career path. 

"Is it going to be successful? Are people going to be accepting of this? There's times when you run in to people that aren't accepting of it and you have to learn how to handle it," she said. The U of M has graduated 18 dental therapists so far. Fourteen are employed, two have moved out of state and two other graduates have not found work yet.  

It will take time to figure out what the demand is for dental therapists, said Karl Self, who directs the university's Division of Dental Therapy. So far, safety-net providers have been some of the profession's biggest supporters. But Self said there's a growing interest from dentists too.

"We do have a dental therapist out in Montevideo in a small, one-dentist, private practice office," he said. "There's dental therapists up north in Deerwood, Minnesota. We've had inquiries from people in the St. Cloud area, Duluth, Rochester."

Some dentists have told the University that they're most interested in hiring practitioners who can cover for them if they're sick or need a vacation.

Dental therapists can't do that. So the U of M is seeking permission from the Minnesota Board of Dentistry to change its training program to allow its dental therapists to be eligible for certification as advanced dental therapists, who can work independently.

Metropolitan State University and Normandale Community College already offer an advanced dental therapy program. 

Marshall Shragg, the dentistry board's executive director, said it's not surprising that educators and employers are still figuring out the best way to move the new profession forward. He views the effort as a strong sign that dental therapy has a place in dentistry.

"I would think that within ten to twenty years that this will be a profession that we look back on and say, 'didn't we always have this?' because it will be part of a team that is just exactly what we accept and expect," Shragg said.

Currently dental therapists educated in Minnesota can only practice in Minnesota. There is no comparable profession in any other state, except Alaska. But a number of states are considering creating mid-level providers to expand access to dental care. If that happens in a coordinated way, Minnesota's dental therapists may one day be able to practice anywhere in the country.