[Senate Hearing 112-898]
[From the U.S. Government Publishing Office]
S. Hrg. 112-898
DENTAL CRISIS IN AMERICA: THE NEED TO EXPAND ACCESS
SUBCOMMITTEE ON PRIMARY HEALTH AND AGING
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
EXAMINING DENTAL CRISIS IN AMERICA, FOCUSING ON THE NEED TO EXPAND
FEBRUARY 29, 2012
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
BARBARA A. MIKULSKI, Maryland MICHAEL B. ENZI, Wyoming
JEFF BINGAMAN, New Mexico LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington RICHARD BURR, North Carolina
BERNARD SANDERS (I), Vermont JOHNNY ISAKSON, Georgia
ROBERT P. CASEY, JR., Pennsylvania RAND PAUL, Kentucky
KAY R. HAGAN, North Carolina ORRIN G. HATCH, Utah
JEFF MERKLEY, Oregon JOHN McCAIN, Arizona
AL FRANKEN, Minnesota PAT ROBERTS, Kansas
MICHAEL F. BENNET, Colorado LISA MURKOWSKI, Alaska
SHELDON WHITEHOUSE, Rhode Island MARK KIRK, Illinois
RICHARD BLUMENTHAL, Connecticut
Daniel E. Smith, Staff Director
Pamela Smith, Deputy Staff Director
Frank Macchiarola, Republican Staff Director and Chief Counsel
Subcommittee on Primary Health and Aging
BERNARD SANDERS, Vermont, Chairman
BARBARA A. MIKULSKI, Maryland RAND PAUL, Kentucky
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina ORRIN G. HATCH, Utah
JEFF MERKLEY, Oregon LISA MURKOWSKI, Alaska
SHELDON WHITEHOUSE, Rhode Island MICHAEL B. ENZI (ex officio)
TOM HARKIN (Iowa (ex officio)
Ashley Carson Cottingham, Staff Director
Peter J. Fotos, Minority Staff Director
C O N T E N T S
WEDNESDAY, FEBRUARY 29, 2012
Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health
and Aging, opening statement................................... 1
Mikulski, Hon. Barbara A., a U.S. Senator from the State of
Franken, Hon. Al, a U.S. Senator from the State of Minnesota..... 27
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico. 44
Rockefeller, Hon. John D., IV, a U.S. Senator from the State of
West Virginia, prepared statement.............................. 51
Edelstein, Burton L., D.D.S., MPH, Professor of Dentistry and
Health Policy and Management, Columbia University, New York, NY 4
Prepared statement........................................... 6
Gehshan, Shelly, MMP, Director, Pew Children's Dental Campaign,
Pew Center on the States, Washington, DC....................... 9
Prepared statement........................................... 11
Whitmer, Grant, MSM, Executive Director, Community Health Centers
of the Rutland Region, Rutland, VT............................. 15
Prepared statement........................................... 17
Folse, Gregory J., D.D.S., President, Outreach Dentistry,
Lafayette, LA.................................................. 20
Prepared statement........................................... 22
Fogarty, Christy Jo, RDH, MSOHP, Licensed Dental Hygienist,
Licensed Dental Therapist, Children's Dental Services,
Farmington, MN................................................. 27
Prepared statement........................................... 29
Statements, articles, publications, letters, etc.:
Academy of General Dentistry (AGD)........................... 53
American Academy of Pediatric Dentistry (AAPD)............... 55
American Dental Association (ADA)............................ 62
American Dental Hygienists' Association (ADHA)............... 71
Hispanic Dental Association (HDA)............................ 76
DENTAL CRISIS IN AMERICA: THE NEED TO EXPAND ACCESS
WEDNESDAY, FEBRUARY 29, 2012
Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions,
The committee met, pursuant to notice, at 10:03 a.m. in
Room 430, Dirksen Senate Office Building, Hon. Bernard Sanders,
chairman of the subcommittee, presiding.
Present: Senators Sanders, Mikulski, Bingaman, and Franken.
Opening Statement of Senator Sanders
Senator Sanders. I'm Senator Bernard Sanders, chairman of
the Subcommittee on Primary Health and Aging, and the hearing
that we are going to be holding today deals with an issue that,
in my view, does not get the kind of attention that it needs.
We talk a whole lot about the health care crisis in America and
the 50 million people who have no health insurance, and the
people who die because they don't get to a doctor, and the high
cost of health care, and all of those issues are enormously
But when we talk about health care, it is also important to
talk about dental care and the great crisis that we have in
this country with regard to the high cost of dental care and
the lack of access to dental care, and that's what the topic of
this hearing is about.
So let's start off by talking about the nature of the
crisis. Today in America, 130 million Americans have no dental
insurance. One-quarter of adults age 65 or older have lost all
of their teeth. Many of them have dentures. Some of them don't.
Only 45 percent of Americans age 2 and older had a dental visit
in the past 12 months, and more than 16 million low-income
children go each year without seeing a dentist.
Lack of dental care, dental access, is a problem all over
this country, but it is a serious, serious problem for low-
income Americans, for racial or ethnic minorities, for pregnant
women, for older adults, for those with special needs, and for
those who live in rural communities. Simply put, which is often
the case in terms of social services, the people who need the
services the most are the ones who get them the least.
Over the last couple of months, I have been asking people
in the State of Vermont and throughout this country to write to
us, to tell us the stories of what it is like struggling
without dental care. We have received over 1,200 separate
stories, and you have the feeling that people wanted to finally
have an opportunity to vent, many from Vermont, but many from
all over this country, and those stories are available on our
Web site, www.sanders.senate.gov.
When we talk about dental care, what we should be careful
in terms of understanding, we're not just talking about a
pretty smile. What we're talking about is people going
throughout their lives experiencing severe pain. We should be
aware that a major cause of children's absenteeism from school
is dental pain, toothaches. We should be aware that when we
talk about dental problems, we're really talking about health
problems, because if your teeth are in bad shape, you're not
chewing your food properly, you're going to have nutritional
problems, you can have higher risk of diabetes, heart disease,
digestive problems, and poor birth outcomes. And as I think
Senator Mikulski will talk about in a moment, you can talk
about death. People have died when they have serious and
neglected tooth problems.
What we also have to understand is that if we are going to
address the dental crisis in this country, in my view Congress
is going to have to act, and it's going to have to act boldly.
Let me just talk about some of the problems out there in terms
of how we do dental care.
First, we need more dental providers. Simply stated, we
don't have enough dental providers. We are seeing more dentists
retire than we are seeing younger dentists graduate from dental
school. But even that is only half of the problem, because you
can have more dentists, but those dentists are not going to the
areas where we need them the most. Most dental practices are in
middle class, upper middle-class neighborhoods, not in the
areas where we need them the most.
So we have to be thinking about expanding the dental
workforce above and beyond just dentists. I know that we have
some of the panelists who will be talking about the proper role
that folks like dental therapists can be playing.
Second, we have to understand that only--and this is a very
important fact--only 20 percent of the Nation's practicing
dentists provide care to people with Medicaid. Most dentists do
not take Medicaid or only take a few Medicaid patients, and
only an extremely small percentage devote a substantial part of
their practice to caring for those who are under-served.
So it's not simply a question of bringing in more dentists
if those dentists are not going to treat the people who need
dental care the most.
Third, we need to expand Medicaid and other dental
insurance coverage. One-third of Americans do not have dental
coverage. Traditional Medicare does not cover dental services
for the elderly, and States can choose whether their Medicaid
programs provide coverage for dental care for lower-income
adults. Children with Medicaid or CHIP are required to have
coverage for dental services, but insurance alone does not
guarantee access. Only 38 percent of kids with Medicaid in the
United States see a dentist during a year.
Now, I've given you some bad news. Let me give you some
good news. Then we're going to hear a little bit about that
today. I happen to believe that one of the ways that we can
make progress in gaining access for dental care for low- and
moderate-income people is through the expansion of community
health centers, and that is something that Senator Mikulski and
I and others work very, very hard on.
In my State of Vermont, in the last 5 or 6 years, we have
significantly expanded dental access by opening up beautiful
clinics, state-of-the-art clinics all over the State of
Vermont, and now we have a situation where almost 25,000 people
in the State of Vermont are getting their dental care through
community health centers, and these community health centers
are providing wonderful care in beautiful, new facilities. So
in Vermont we are making some progress. I think that progress
is taking place around the rest of the country, but we'll want
to discuss that issue in greater depth in a little while.
I'd like to now give the microphone over to Senator
Mikulski, who has been interested in the issue of dental care
and health care for many, many years.
Senator Mikulski, thanks for being with us.
Statement of Senator Mikulski
Senator Mikulski. Thank you very much, Mr. Chairman. I'm
going to thank you for holding this very important hearing on
oral health and seeing it as part of primary care. Your own
commitment and vigor in ensuring universal health care for all
Americans is well-known, well-appreciated by many of us, and we
can't do a lot of this without you.
I come to this subcommittee not only as a member of yours
but as someone who chairs the Subcommittee on Children and
Youth. And a particular and unique need is the access to
dentists for children, and also those children with very
special needs that need unique ways of delivering dental care.
We in Maryland, Senator Cardin and myself, feel a very
poignant and compelling responsibility in this area because 5
years ago a little boy named Deamonte Driver, living in Prince
George's County, within the shadow of the capital of the United
States, died because of an infection that he incurred because
of the failure to have access to timely dental care, and also
to generalized health care. We couldn't believe it. We couldn't
believe that in the United States of America, a little boy, a
little boy would die because he couldn't have access to a
doctor, and it wasn't a rare doctor. It wasn't a doctor with--
it wasn't neurology. It was dentistry.
And at that time we were debating the SCHIP, and we made a
commitment, and with the help of great colleagues like Senator
Sanders, we went to work to make sure that dental care was
The legacy of Deamonte continues to be with us, and we feel
the best way to honor that little boy's memory is to continue
to fight so that no little boy, no child in America goes
without universal health care and goes without access to dental
Senator Sanders last week had an excellent hearing in
Maryland chaired by our dear colleague, Congressman Cummings,
in which we examined some of the issues and the progress made.
We were pleased that Dr. Edelstein and Shelly Gehshan was there
at that time. We looked over many of the points that were
covered because we said in those 5 years, how has the situation
improved, has it improved at all, and how can we improve access
and improve the delivery systems? Because we don't want access
to be a hollow opportunity.
Often when we provide access, we wanted to be sure that we
looked to what did the dentists say their handicaps are in
providing care. We all know that the issues of reimbursement
often range from skimpy to spartan. But for many of them, they
say that's not the only problem. It's the failure to keep
appointments. It's when they come, all of the social service
needs that people come with. It's beyond the capacity of
dentists who often practice all by themselves with the help of
a single or two dental hygienists. So they said help us so we
can get out there and help the kids.
We're proud of what we've done in SCHIP, and we're proud of
new innovations and new models. We listened to new thoughts,
like Dr. Kaplan, who heads up the Oral Health Impact Project,
where they take dental care to students. They actually set up
clinics in school auditoriums and make sure that they go to
where the kids are.
But we also heard very compelling problems from a mother
who was the mother of autistic twins and how she was rejected,
how she was rebuffed, nobody wanted to treat these girls, and
often if someone comes with a physical handicap or the
challenges of intellectual disabilities or other emotional
childhood diseases, it's beyond the scope often of a small
dental practice to know what to do and how best to do it.
So we've got big challenges, and though we've passed SCHIP,
a really big step forward, though we've passed the Affordable
Care Act, another giant step forward, we have a long way to go,
and I look forward to listening to the testimony today for the
best ideas on how we can move ahead, and I congratulate you
because in the United States of America, for all those Deamonte
Drivers--you know, Mr. Chairman, had he lived, he would be
getting ready to think about what school he wanted to go to. He
might even be thinking about the University of Maryland and the
School of Dentistry, but we'll never know. But we do know about
the other children in America.
Thank you, and let's get on with it.
Senator Sanders. Senator Mikulski, thank you very, very
Let's begin our panel with Dr. Burt Edelstein, who is a
board-certified pediatric dentist and Professor of Dentistry
and Public Health at Columbia University. Previously, Dr.
Edelstein practiced pediatric dentistry in Connecticut and
taught at the Harvard School of Dental Medicine for 21 years.
He is the founding director of the Children's Dental Health
Project, and authored the child section of the U.S. Surgeon
General's Report on Oral Health in America.
Dr. Edelstein, thanks very much for being with us.
STATEMENT OF BURTON L. EDELSTEIN, D.D.S., MPH, PROFESSOR OF
DENTISTRY AND HEALTH POLICY AND MANAGEMENT, COLUMBIA
UNIVERSITY, NEW YORK, NY
Mr. Edelstein. Thank you, Senator Sanders, and thank you,
Senator Mikulski, for the opportunity to again raise this issue
and to highlight what has already been accomplished and what
has yet to be done. I was kindly asked by your staff to address
the problem and to describe what is known in the context of
oral health disparities, dental care disparities, and the
consequences of these disparities.
This hearing does address exactly what the Surgeon General
called upon in identifying oral health problems as a hidden
epidemic, and that Healthy People has highlighted by indicating
that oral health is one of the leading health indicators in the
United States. The disparities are manifest, and I thought I
would summarize my written testimony by raising five questions
and seeing if I can answer them in brief.
The first is, as you've already mentioned, Senator Sanders,
is there, in fact, a problem? Well, yes. Reliable, objective
Federal data reported by Healthy People 2020, by the Institute
of Medicine, by the U.S. Surgeon General, all confirm profound
disparities, as you mentioned, in relation to race, ethnicity,
income, disability, education, virtually every indicator of
It's a problem that's well recognized by the public, but
only when the public is asked, and I thank you and congratulate
you on asking the public. Generally, when asked about health
issues, people don't respond about oral health unless it's
prompted. But as soon as they do, oral health issues rise to
the top of their concerns.
It's certainly well-known to people that work in emergency
rooms, in FQHCs, in the safety net, work in dental schools,
work everywhere, including now, thanks to your efforts, here on
Is the problem significant? According to relevant Federal
agencies that would include CDC, NIH, IHS, HRSA, CMS, the
Agency for Children and Families, Department of Agriculture
with its WIC program, the problem is large, and the problem is
Which brings me to question 3: Does it matter? If it really
didn't matter, then there wouldn't be reason for this hearing,
there wouldn't be reason to take action. But the mouth is an
essential body organ, essential to eating, breathing,
communicating, sensing and protecting our bodies. It has
specialized tissues, and when they're not healthy, the impact
is both immediate in pain and infection and chronic in the
exacerbation of medical conditions, as you've mentioned.
Oral diseases impact function, appearance, employability,
school performance, and even military readiness. It stresses
families and it presses community services, and on this
anniversary of Deamonte's death--thank you for putting us in
that context, Senator Mikulski--it certainly does drive home
the point that it can have even dire consequences.
But let's get to the two more important questions. Is it
fixable? And what is the role of the Federal Government?
Is it fixable? Yes. Fixing the problem of disparities is
complex. It's complex because it involves both the delivery
system and the people who utilize that system. It involves
workforce public and private systems, research and
demonstrations, prevention, alignment of incentives, public
education. It involves a host of issues. And I am so pleased to
report, with clarity, that the U.S. Congress has taken action
to put each of these elements into an orderly, sensible,
reasoned and carefully developed set of policies that exist
across Federal legislation, particularly in the CHIP
reauthorization of 2009 and in the Affordable Care Act of 2010.
Taken together, the nearly two dozen provisions that are in
those two laws bring us to what one person has characterized as
getting us to third base. We are almost home, but we're not the
rest of the way home because those authorizations become
meaningless until appropriations and enactment and appropriate
regulatory action and congressional oversight take us the rest
of the way.
I'm pleased to say that while the problems are complex in
that they involve both the consumer and the delivery system,
that has been carefully analyzed over a long period of time, by
this committee in particular, by the HELP Committee and by the
Finance Committee in the Senate, by the comparable and
appropriate committees in the House, and those laws now provide
an exquisite framework for addressing solutions to the problem.
So what is the Federal role? The Federal role is powerful
because it involves not only authorization and then moving that
authorization, but there are provisions that are direct from
the Federal Government, the FQHC programs, Head Start programs,
WIC programs. There are programs that are less direct but have
a Federal role, workforce training, support of research into
best practices so that we prevent the diseases we're talking
about, because we cannot drill and fill our way out of these
problems--public education campaigns, oral disease
surveillance--but most important of all is coverage.
Now, while Congress has ignored coverage for adults--
Medicare doesn't include it, Medicaid barely covers it, it
certainly leaves it up to State option, and ACA ignores it--
Congress has been terrific on attending to children's coverage.
As of the passage of ACA, combined with CHIPRA and Medicaid,
virtually every child in America will have access to dental
coverage. Now the question is how do we move the other pieces
of the puzzle so that that coverage translates into prevention,
disease management to really limit the disease burden, and then
subsequently into actual services for those children.
I look forward to your questions and I hope that we can
focus particularly on what Congress has already done and how
that sets the stage for what has yet to be done. Thank you.
[The prepared statement of Mr. Edelstein follows:]
Prepared Statement of Burton L. Edelstein, D.D.S., MPH
Senator Sanders, Senator Paul, and members of the subcommittee.
I am Dr. Burton Edelstein, professor of dentistry and health policy
at Columbia University and founding president of the Children's Dental
Health Project (CDHP), a DC-based independent non-profit organization
committed to eliminating disparities and achieving equity in oral
In these professional roles and in my role as a commissioner of the
Medicaid and CHIP Payment and Access Commission, I seek to objectively
analyze and understand the oral health disparities, the dental care
disparities, and the consequences of these disparities that your
hearing today addresses. I thank you for your concern over what Surgeon
General Satcher described as a ``hidden epidemic'' of oral disease and
what Healthy People 2020 has identified as a ``leading health
indicator'' for the Nation.
According to Healthy People 2020 (http://healthypeople.gov/2020/
Health.aspx) there are ongoing, impactful, and addressable oral health
disparities at all ages that require the Nation's attention in order
for the U.S. population to enjoy better oral health and associated
general health. Among these are:
population-wide inadequate use of dental services with
fewer than half of all Americans obtaining dental care in a year.
disparities in dental care by race, ethnicity, income,
educational attainment, and disability status.
disparities in dental care by insurance-coverage with more
privately insured people than publicly insured or uninsured obtaining
care in a year.
disparities in dental care by place with people living in
cities and suburbs having more care than those in rural areas.
In and of themselves, these disparities would not be of concern to
Congress were it not that people with characteristics associated with
these disparities--minority status, low income and education,
disability, public insurance or no insurance, and rural residence--also
have higher rates of oral diseases and that oral diseases are impactful
on people's ability to, in the words of Healthy People 2020, ``speak,
smile, smell, taste, touch, chew, swallow, and make facial expressions
to show feelings and emotions.'' Oral diseases cited by Healthy People
2020 include dental caries, periodontal disease, congenital
malformations like cleft lip and palate, oral and facial pain
disorders, and oral and pharyngeal cancers. Importantly, most of these
conditions and their significant consequences in pain and dysfunction
are preventable and prevention requires use of dental services.
The Medicaid and CHIP Payment and Access Commission employs a
schema to understand and investigate access to health care. This model
has two parts: (1) the availability of services to answer the question,
``Are healthcare facilities and providers available?'' and (2) the use
of services to answer the question, ``Do people use services when they
are available?'' This formulation recognizes the complexity of
understanding access issues like dental care because it incorporates
both concerns about providers of health care and concerns about
consumers of health care.
The issues surrounding access to healthcare are many and complex,
including myriad considerations of workforce--its adequacy, competency,
makeup, distribution, and integration; delivery systems--both safety
net and private; and coverage and financing--employer sponsored,
individual market, Medicare, Medicaid, and CHIP. These are as true for
dental care as other health services. I wish to focus particularly on
coverage issues today as coverage is a significant driver of access and
contributes to shaping workforce and delivery systems. Coverage issues
apply equally to care accessed in the private sector as in the safety
net, including the growing network of Federally Qualified Health
Centers (FQHCs) that offer dental services.
Medical and dental coverage are inherently different in design,
availability, and use. Nonetheless, dental coverage is an
overwhelmingly significant component of access to care, particularly
for Americans of modest or low incomes. I cannot stress enough that
Congress, in its decisions about coverage, has only very recently
recognized that dental services are essential to basic, primary, health
care--and then only for children.
The record is clear that Congress considers dental care to be an
``optional'' service for adults. For adults, it is missing in Medicare,
largely absent in Medicaid, and unaddressed in health reform.
As a result of the Medicare exclusion of dental coverage,
millions of baby boomers will be moving out of employer-sponsored
dental coverage that they have enjoyed for decades and into no dental
coverage at all. Unlike many of their predecessors, they have benefited
from dental care and have retained their teeth. They will need ongoing
and regular basic primary dental care which is increasingly priced out
of reach for the uninsured.
As a result of Congress determining in Medicaid that
dental care is ``optional'', it is up to the States to elect adult
dental coverage. According to tracking data from the American Dental
Association, in 2009 23 States limited their coverage only to emergency
relief of pain and infection (n = 16) or offered no dental coverage at
all (n = 7). Since that time, additional States have cut adult dental
programs as a cost savings measure. The outcome is that pregnant women,
the disabled, those in long-term care, and other very vulnerable
individuals that rely on Medicaid for their medical care have very
limited access, if any, to dental care.
Now as States set up coverage expansion through health
reform, Congress has obligated them to cover only pediatric dental
care, again ignoring the importance of oral health to adults, including
the most vulnerable.
This consistent record of exclusion is equivalent to arbitrarily
excluding a limb, an organ, or an essential biological function from
health coverage. It inherently suggests that dental care is not primary
care, not essential care, and something that people can do without.
In sharp contrast to Congress' approach to adults, it has
increasingly recognized the importance of dental care for children. I
applaud Congress for its passage of historic policies that not only
assure that children have extensive access to coverage but that go
further by addressing prevention, public education, workforce,
training, early intervention, research, quality, and accountability. It
is my sincere hope that your subcommittee's work serves to further
catalyze Congress--as well as the State and Federal Governments--in
assuring that oral health provisions in existing law (e.g. the Safety
Net Improvement Act of 2002, the Children's Health Insurance Program
Reauthorization Act of 2009, and the Affordable Care Act of 2010) are
moved from congressional intent to meaningful care for America's
Since the original enactment of S-CHIP in 1997, our Country has
made meaningful strides in ensuring that oral health is attended to for
children in Federal health programs. Head Start and WIC are attending
to children's oral health. Multiple Federal agencies have active
pediatric oral health initiatives. Countless reports, including many by
the Government Accountability Office at congressional request and
others by the Institute of Medicine have been published. A number of
congressional hearings have been held, dozens of bills introduced, and
key legislation enacted. Many States have similarly undertaken notable
oral health initiatives.
Sadly, the catalytic tragic event that awakened many policymakers
to the seriousness of poor oral health was the death of 12-year-old
Deamonte Driver 5 years ago this week. In fact, the day Deamonte's
death was reported in the Washington Post, the Children's Dental Health
Project was attending a long scheduled meeting with the Senate Finance
Committee. The purpose of our meeting was to ask the committee to
support inclusion of a mandatory dental benefit in the CHIP
reauthorization. Our efforts to date had not resonated but that
morning, the tragedy of this child's death transformed our
conversations with policymakers forever. It became painfully clear what
had long been known and well-documented but not fully recognized in
policy: that oral health is essential to overall health and that poor
oral health has significant and yes, sometimes tragic, consequences on
our health and well-being.
Just a few weeks after that conversation, the Senate Finance
Committee accepted a bipartisan amendment to add a dental benefit to
the reauthorization of CHIP. Today, all 50 States are required to offer
dental benefits to children enrolled in Medicaid and CHIP and States
are now planning the provision of dental care for children through
their Exchanges. The question now is, what needs to be done to make
these provisions real for families across the country?
At this point, it is critical that the provisions of CHIPRA and ACA
are implemented effectively and that States have the appropriate
guidance and flexibility to create a coordinated health care system
that truly incorporates oral health care. Continued congressional
interest and oversight is required to ensure that these laws' common
sense provisions are maximally implemented as, together, they inform
the public about risks for oral disease in children, provide targeted
and timely information to new parents, advance the science of disease
management, enhance training for dentists and dental hygienists,
promote accountability through disease surveillance, and encourage the
piloting of creative new workforce models including a new
paraprofessional concept built on principles of social work--the
Community Dental Health Coordinator, as proposed by the American Dental
Let me highlight two of these many opportunities that focus on
advancing oral health through cost-effective prevention:
ACA establishes a National Oral Health Literacy Campaign
that can raise public awareness about prevention and encourage
appropriate use of dental services. Recognizing current budget
constraints, we encourage that this campaign, authorized at $100
million, be initiated with a $5 million investment in Federal fiscal
The CDC is primed to address the very high rates of
ordinary tooth decay in America's youngest children. CDC reports that
more than 1 in 10 2-year olds, 2 in 10 3-year olds, 3 in 10 4-year
olds, and 4 in 10 5-year olds has visible cavities and that three-
quarters of affected children are in need of dental repair. The Surgeon
General reports that these rates are five-times greater than childhood
asthma, the next most prevalent chronic disease of U.S. children.
Because prevention is cost savings and improves quality of life, we
encourage support for $8 million in expanded funding in fiscal year
2013 to support CDC demonstrations of early childhood caries prevention
Arguably, the most important of CHIPRA and ACA dental provisions
are the requirements that States cover pediatric oral health care.
Regulatory guidance is needed to assure that dental coverage
established by CHIPRA meets covered children's needs and that the
CHIPRA dental benefit can serve well as a benchmark for the pediatric
dental benefit in ACA. ACA appropriately establishes pediatric dental
care among the 10 Essential Health Benefits that must be covered. As
you are well aware, however, there is a heated debate at both the
Federal and State levels about how these benefits should be defined,
how they will be accessed in the State Exchanges, and how consumer
protections will apply. Because these critical issues are particularly
nuanced for dental coverage, it is important that the details be
attended to with care. I urge you to look closely at these technical
issues as their resolution will determine how meaningful the dental
benefit will be to children and their families and how they will
contribute to access.
To address the problem of inequitable access through coverage
reform, it is critical that every dental plan certified by the State or
Federal Exchanges requires the same substantive level of consumer
protections. Whether dental coverage is obtained through a qualified
health plan or a limited-benefit stand-alone dental plan, consumers
need to be assured of choice, affordability, network adequacy, and
quality. Exemption of these requirements for dental plans but not
qualified health plans would be at the expense of children and their
parents. Congressional intention needs to be clearly communicated to
State legislatures and Exchange Boards as they establish their own
policies. An amendment by Senator Stabenow adopted by the Senate
Finance Committee clarified that intention. It stated that ``. . .
standalone dental plans must . . . comply with any relevant consumer
protections required for participation in the Exchange.'' This language
was reiterated in a September 22, 2011 colloquy with Senators Baucus
and Bingaman when Senator Stabenow stated,
``I intended for standalone dental plans to fully comply with
the same level of relevant consumer protections that are
required of qualified health plans with respect to this
The dental benefits created by CHIPRA and ACA must also be designed
to respect differences among our Nation's children in their level of
risk for tooth decay. We encourage Federal and State policymakers to
adopt best practices in coverage and care as suggested by the American
Academy of Pediatric Dentistry (AAPD). AAPD calls for ``risk-based''
care that provides the most intensive clinical care to children with
the greatest level of disease and risk for ongoing disease. A
pediatric-only dental benefit should follow AAPD's guidance and thereby
promote allocation of care according to individual children's needs. By
preventing dental disease at an early age and managing the disease as a
chronic condition when it does occur, we can significantly reduce the
cost of care and improve the quality of life for our children while
setting them on a path toward lifetime oral health.
Many of you and your colleagues have a long history of
extraordinary leadership in the Congress on health issues. On behalf of
children who do have coverage through your actions, advocates and
families now look to you for follow through on CHIPRA and ACA that will
assure full implementation of the oral health provisions. Doing so will
save money, improve patient experience, and improve the Nation's oral
health. There is much yet to be done and we look forward to working
with you to reach the goal of equitable oral health and dental care for
That concludes my testimony. I am happy to answer any questions you
Senator Sanders. Dr. Edelstein, thanks very much.
Our second witness is Shelly Gehshan, director of the Pew
Children's Dental Campaign at Pew Center on the States. Last
year she served on the Institute of Medicine's Committee on
Oral Health Access to Services, which made recommendations for
how the United States could improve access to dental care.
Prior to joining Pew, she spent nearly 20 years working for
State policymakers, including work as a senior program director
at the National Academy for State Health Policy.
Ms. Gehshan, thanks very much for being with us.
STATEMENT OF SHELLY GEHSHAN, MMP, DIRECTOR, PEW CHILDREN'S
DENTAL CAMPAIGN, PEW CENTER ON THE STATES, WASHINGTON, DC
Ms. Gehshan. You're welcome. Thank you, Mr. Chairman, and
thank you, Senator Mikulski, for inviting me here today to
testify, and thank you both for your leadership on oral health
My name is Shelly Gehshan. I am the director of the Pew
Children's Dental Campaign, and we released a big report
yesterday. I'd like to start with talking about that, and then
talk a little bit about the Institute of Medicine panel that I
served on last year.
Numerous reports have found limited access to dental care,
so if you ever hear otherwise, we have a wealth of data that
asserts and describes the problem that we are discussing here
We released a Costly Dental Destination yesterday that
documents the problem of people showing up in emergency rooms
for dental care. It is a symptom of a failing system, and it is
a huge waste of money. And although there have been many State
reports, no one has ever collected them all together, and this
was the first time that national data was made available on
The report estimates that in 2009, there were more than
830,000 ER visits nationwide, which is a 16 percent increase
over 2006. So we're going in the wrong direction. These are the
wrong services in the wrong setting at the wrong time for
desperate people who have no other alternative. We can really
do a better job than this. There are a number of State examples
I'm happy to describe later if there's time.
The Institute of Medicine looked at this quiet crisis in
access to dental care for about a year, and we issued a report
last July, and I'm going to describe several of the 10
recommendations that the IOM made.
The first one I'd like to describe is prevention, because
these are largely preventable problems, and that's the cheapest
and most humane way to attack the issue. Sealants and water
fluoridation are key, but in 23 States sealant programs reached
less than a quarter of high-risk children, and we have 74
million people in this country who don't have access to
fluoridated water, more if you count those who have well water.
The IOM committee recommends that Congress ensure that all
50 States receive infrastructure funding so that they can mount
effective, proven prevention efforts in their States. The IOM
also recommended that the Title 5 Maternal and Child Health
Block Grant be used to augment that funding and ensure that all
States have infrastructure.
On financing, as Burt mentioned, access to care is greatly
dependent on the ability to pay, and way too few people have
dental coverage. Since States are not required to provide
dental coverage for adults, most do not. It ebbs and flows over
time based on the economy, but that's a big driver for what
makes people end up in emergency rooms to begin with, is that
they have no way to pay for care. If they had a dentist, they'd
go to one, but no one will accept them.
The Institute of Medicine recommended that Congress move
toward expanding dental benefits to all Medicaid beneficiaries,
as well as ensuring that Medicaid reimbursement rates are
higher than they are now, and that administrative processes be
The IOM also recommended several strategies to expand
access to dental care at community health centers, which form
the backbone of the safety net in this country, including
ensuring that they can use a broader array of providers than
they have now, and that there's money available from Congress
to both recruit and retain providers.
And then finally the IOM addressed the issue of workforce
shortages, because we have got to do something about workforce
shortages. Forty-seven million Americans live in areas that are
federally designated as having a shortage of dentists, and at
this point more than a dozen States are looking at developing
new types of providers to expand the dental team and work under
the supervision of a dentist to reach more people, because
roughly we have about a third of the population left outside of
the current system, and that's just too many.
In terms of the new types of providers, there are dental
therapists who have worked effectively in other countries for
years. There are also approaches where States would add
training for dental hygienists or dental assistants or health
The IOM examined all studies done of alternative
practitioners, both in this country and abroad, and looked also
at the issue of whether or not they could safely provide
restorative care or drilling and filling cavities, and
concluded that all available evidence points to the safety and
quality of these providers being allowed to join the dental
So the IOM recommended that Congress, foundations, and the
Federal Government research how to use them to expand access,
and urged Federal funding to support demonstration projects to
study how those providers would be used to reach people who are
left outside the system now.
So to conclude, I think my two points would be I think it's
really critical for Congress to ensure that all States have
infrastructure funding to mount prevention efforts, and that
Congress pay more attention to innovations that are necessary.
In all my years in Washington and all the issues that I
have worked on, I have never been in a field with fewer
consumer choices and less innovation. There's just not much
known about how to do a better job of reaching people left
outside the system.
So thank you very much, and I look forward to answering any
questions you may have.
[The prepared statement of Ms. Gehshan follows:]
Prepared Statement of Shelly Gehshan
Mr. Chairman, Ranking Member Paul, and members of the committee,
thank you for holding this hearing and for the opportunity to testify.
My name is Shelly Gehshan, and I am the director of the Pew Center on
the States' Children's Dental Campaign. I am pleased to join my
colleagues in appearing before you today. The Pew Children's Dental
Campaign works to improve children's dental health through advocating
for more prevention, adequate funding for care, and ensuring there is a
sufficient workforce to care for low-income children.
ACCESS TO DENTAL CARE
Numerous reports have found that limited access to dental care is a
growing problem nationwide. I will focus today on two such reports: an
issue brief the Pew Center on the States released yesterday on wasteful
spending on dental care in emergency rooms, and a report outlining the
recommendations of the 2011 Institute of Medicine panel on how to
In 2009, the last year for which complete data are available, more
than 16 million American children went without dental care.\1\ There
are several factors contributing to this access crisis, such as lack of
insurance and inability to pay, and geographic and transportation
barriers in rural areas. Furthermore, about 47.8 million Americans live
in areas federally designated as having a shortage of dentists.\2\ Many
families face another kind of shortage, as they struggle to find
dentists who participate in the Medicaid program. Fewer than half of
the dentists in 25 States treated any Medicaid patients in 2008.\3\
\1\ U.S. Department of Health and Human Services, Centers for
Medicare and Medicaid Services, ``Medicaid Early & Periodic Screening &
Diagnostic Treatment Benefit--State Agency Responsibilities'' (CMS-
Topics/Benefits/Downloads/2009-National-Data.pdf (accessed February 27,
2012). This figure counts children age 1 to 19. Data from the 48
reporting States and the District of Columbia were supplemented with
reports obtained directly from Michigan and Oregon.
\2\ U.S. Department of Health and Human Services, Health Resources
and Services Administration, Designated HPSA Statistics Report,
``Health Professional Shortage Areas by State,'' February 24, 2012,
HPSA_SCR50_Smry&rs:Format=HTML3.2. (accessed February 27, 2012).
\3\ U.S. Government Accountability Office, ``Efforts Under Way to
Improve Children's Access to Dental Services, but Sustained Attention
Needed to Address Ongoing Concerns'' (November 2010). http://
www.gao.gov/new.items/d1196.pdf. Note: the GAO analyzed data from 39
This access problem has serious consequences. For example, research
from California and North Carolina shows a clear link between poor oral
health and students' ability to attend school and perform well.\4\ In
California alone, more than 500,000 children were absent at least one
school day in 2007 due to a toothache or other dental problem.\5\
\4\ S.L. Jackson, et al., ``Impact of poor oral health on
children's school attendance and performance,'' American Journal of
Public Health (October 2011), http://www.ncbi.nlm.nih.gov/pubmed/
\5\ N. Pourat and G. Nicholson, Unaffordable Dental Care is Linked
to Frequent School Absences (Los Angeles, CA: UCLA Center for Health
Policy Research, 2009) 1-6, http://www.health
policy.ucla.edu/pubs/publication.aspx?pubID=387 (accessed September 2,
HOSPITAL ER ADMISSIONS RELATED TO DENTAL CARE
This lack of access to dental care has led to more and more people
entering hospital emergency rooms (ERs) with preventable dental
conditions. The brief the Pew Center on the States issued yesterday,
``A Costly Dental Destination,'' \6\ estimates that in 2009,
preventable dental conditions were the primary diagnosis in more than
830,000 visits to ERs nationwide, a 16 percent increase from 2006.\7\
These ER admissions impose a significant and unnecessary burden on
State budgets. A 2006 national study found that treatment during
330,000 decay-related ER visits cost nearly $110 million.\8\
Furthermore, hospitals are generally unable to treat conditions such as
dental abscesses and toothaches, as few ERs have dentists on staff or
clinicians who have the training to treat the underlying issues.\9\
Many patients who leave without the underlying dental problem addressed
often return to the ER later as their condition deteriorates, for care
costing far more than services provided in a dental office or clinic.
\6\ ``A Costly Dental Destination: Hospital Care Means States Pay
Dearly,'' (February 2012).
\7\ Agency for Healthcare and Quality (AHRQ), ``Healthcare Cost and
Utilization Project (HCUP)--The nationwide Emergency Department Sample
for the year 2009 and 2006.'' AHRQ, Rockville, MD. http://
hcupnet.ahrq.gov/ accessed February 7-8, 2012. The Pew Children's
Dental Campaign identified preventable dental conditions using the
International Classification of Diseases (ICD-9) codes of 521 and 522.
These codes were chosen in consultation with Dr. Frank A. Catalanotto,
DMD, Professor and Chair of the Department of Community Dentistry and
Behavioral Science at the University of Florida's College of Dentistry.
Primary diagnosis is defined as visits in which one of these codes was
listed first on a patient's discharge record. One of these two ICD-9
codes was the primary code for 717,032 ER visits in 2006 and for
830,590 visits in 2009, which constituted a 15.8 percent increase over
this 4-year period. These figures do not include emergency dental
visits for which these codes were listed as a secondary code. One of
these codes (521 and 522) were listed as either a primary or secondary
code for 1,116,569 ER visits in 2006 and for 1,357,217 ER visits in
2009, which constituted a 21.6 percent increase. Secondary diagnosis
codes are of interest because the first diagnosis listed for an ER
visit may not always coincide with the primary or only reason why the
patient was treated.
\8\ Of the 330,757 ER visits for dental-related causes, 330,599
(99.9 percent) did not require a hospital stay. See: R. Nalliah, V,
Allareddy, S. Elangovan, N. Karimbux, V. Allareddy, ``Hospital Based
Emergency Department Visits Attributed to Dental Caries in the United
States in 2006,'' Journal of Evidence Based Dental Practice (2010),
Volt. 10, 212-22, http://www.jebdp.com/article/S1532-3382(10)00183-1/
\9\ P. Casamassimo, S. Thikkurissy, B. Edelstein, and E. Maiorini,
``Beyond the DMFT: The Human and Economic Cost of Early Childhood
Caries,'' Journal of the American Dental Association 140 (2009): 650-
In this brief, the Pew Center on the States examines hospital data
from 24 States showing the frequency and cost of dental-related ER
visits. Data on ER visits related to dental care are not available in
the majority of States. While the report highlights this growing
problem in States for which there are data, it significantly
underestimates the nationwide scope.
In California alone, there were more than 87,000 ER visits related
to preventable dental conditions in 2007,\10\ and Maine data from 2006
show that dental problems were the leading reason why Medicaid
enrollees and uninsured young people visited the ER that year.\11\
\10\ California HealthCare Foundation, ``Emergency Department
Visits for Preventable Dental Conditions in California,'' (2009),
accessed October 13, 2011, http://www.chcf.org//media/
\11\ B. Kilbreth, B. Shaw, D. Westcott, and C. Gray, ``Analysis of
Emergency Department Use in Maine,'' Muskie School of Public Service,
(January 2010), accessed October 3, 2011, http://muskie.usm.maine.edu/
INSTITUTE OF MEDICINE RECOMMENDATIONS ON IMPROVING ACCESS TO CARE
Persistent lack of access also led the Institute of Medicine (IOM)
to study the issue and release its recommendations last year. I had the
privilege to serve on the IOM's Committee on Oral Health Access to
Services, and I am pleased to share the recommendations with you today.
Included in all of these recommendations are the cost-effective and
research-based approaches identified in the Pew issue brief as ways to
prevent dental-related ER visits.
Prevention is the most cost-effective way to improve dental health.
Recognizing this, the committee recommended that the Centers for
Disease Control and Prevention (CDC) and the Maternal and Child Health
Bureau (MCHB) collaborate with States to ensure that they have the
infrastructure and support necessary to perform core dental public
health functions.\12\ This infrastructure is critical for States to
implement evidence-based prevention programs.
\12\ Institute of Medicine. Improving Access to Oral Health Care
for Vulnerable and Underserved Populations, 14 (July 2011).
We have a long way to go to ensure these essential dental public
health programs reach those who need them. Dental sealants--clear
plastic coatings that are applied to molars--have been proven to
prevent 60 percent of tooth decay at less than one-third the cost of
filling a cavity.\13\ Yet, in the 2009-10 school year, sealant programs
reached fewer than one-quarter of the highest-need schools in 23
States. In addition, seven States had no school-based sealant programs
at all.\14\ Community water fluoridation reduces decay rates for
children and adults by between 18 and 40 percent, and for most cities
every dollar invested in fluoridation saves $38 in dental treatment
costs.\15\ However, the most recent Federal data show that more than 74
million Americans on public water systems lack access to fluoridated
\13\ Recommendations on Selected Interventions to Prevent Dental
Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial
Injuries,'' Centers for Disease Control and Prevention Task Force on
Community Preventive Service, Am J Prev Med 2002;23(1S), http://
www.thecommunityguide.org/oral/oral-ajpm-recs.pdf; American Dental
Association. 2011 Survey of Dental Fees. (2011), 17. National median
charge among general practice dentists for procedure D1351 (dental
sealant) is $45 and national mean charge for procedure D2150 (two-
surface amalgam filling) is $144.
\14\ ``Making Coverage Matter,'' Pew Center on the States (May
\15\ ``Cost savings of Community Water Fluoridation,'' U.S. Centers
for Disease Control and Prevention, accessed March 30, 2011 at http://
\16\ Centers for Disease Control and Prevention, ``2008 Water
Fluoridation Statistics,'' (October 2010), accessed December 9, 2010,
Currently, only 20 States receive CDC infrastructure grants, but
those that do have been able to strengthen oral health programs,
collect crucial data on the scope of their challenges, and implement
prevention activities.\17\ These relatively small, cost-effective
investments have the potential to improve the dental health of
communities, improve access to care, and reduce decay--and therefore,
costs. These grants are needed in all 50 States.\18\
\17\ Centers for Disease Control and Prevention, ``CDC-Funded
States: Cooperative Agreements, September 20, 2011'', http://
/index.htm, accessed February 24, 2012.
\18\ Institute of Medicine. Improving Access to Oral Health Care
for Vulnerable and Underserved Populations, 14 (July 2011).
The IOM committee also recommended that the MCHB use the title V
program to provide block grants and other funding for oral health. We
also recommended that private foundations and public agencies
collaborate on public education and oral health literacy campaigns
focused on prevention.\19\
financing of the oral healthcare system
Access to care is greatly dependent on ability to pay for services,
and individuals and families with inadequate insurance or no coverage
at all are those most likely to end up in the ER with dental problems.
While all States must provide comprehensive dental benefits to children
enrolled in the Medicaid program, there is no requirement for adult
dental coverage. Many State Medicaid programs that do cover adults only
do so for emergency situations.\20\
\20\ Ibid, 10.
In the IOM report, the committee recommended that the country move
toward including dental benefits for all Medicaid recipients. As a
first step, the IOM recommended that an essential dental benefits
package for adults in Medicaid be defined. Second, the IOM recommended
that the Centers for Medicare and Medicaid Services (CMS) fund State
demonstration projects that help us determine the best way to provide
oral health benefits within the Medicaid program.\21\
\21\ Ibid, 11.
To address the severe shortage of dentists accepting Medicaid, the
IOM committee recommended not only raising Medicaid reimbursement rates
for oral health services, but also reducing administrative barriers and
providing case-management assistance.\22\
Recognizing States' difficulty administering Medicaid dental
programs, the IOM suggested that Congress provide enhanced Medicaid
matching funds tied to efforts to reduce administrative barriers and
increase provider participation in State programs.\23\
\23\ Ibid, 12.
IMPROVING ACCESS THROUGH THE DENTAL EDUCATION SYSTEM
A key component to improving access to dental care is the education
of dentists. Recognizing this, the IOM committee recommended that
recruit more students from underrepresented minority,
lower-income and rural populations;
require all dental students to participate in community-
based rotations; and
recruit faculty who have experience with underserved
\24\ Ibid, 8.
To support these improvements, the IOM committee recommended that
the Health Resources and Services Administration (HRSA) use title VII
funds to expand community-based rotations for dental students, and that
State legislatures require at least 1 year of dental residency before
permitting a dentist to practice.\25\
\25\ Ibid, 9-10.
INTEGRATION OF THE MEDICAL AND DENTAL COMMUNITIES
There is a disconnect between dental health and overall health, so
the IOM made a recommendation to greatly enlarge the circle of
providers and find more opportunities to implement prevention
strategies. The IOM committee recommended that HRSA convene key
stakeholders to develop a core set of oral health competencies for
nondental health care professionals to be incorporated into medical
education programs.\26\ These core competencies would prepare them to
recognize the risk for oral disease, provide information and education
on oral health to patients, and make and track referrals to dental
health professionals. For example, education programs could include
training for obstetricians and gynecologists on oral health education
and prevention, or educate nurses and nurses' aides to provide
preventive services in nursing homes.\27\
\26\ Ibid, 5.
IMPROVEMENTS TO THE DENTAL WORKFORCE
Finally, there is a severe nationwide shortage, as well as a
geographic maldistribution, of dentists. Approximately 47.8 million
Americans live in areas federally designated as dental health
professional shortage areas.\28\ The IOM made a number of
recommendations to expand the number of dental providers, and better
use existing providers.
\28\ As of February 24, 2012, those 47.8 million Americans lived in
one of 4,461 dental health professional shortage areas. See ``Shortage
Designation: U.S. Department of Health and Human Services, Health
Resources and Services Administration, Designated HPSA Statistics
Report, ``Health Professional Shortage Areas by State,'' February 24,
3.2. (accessed February 27, 2012).
First, the IOM recommended that States amend their dental practice
acts to use dental auxiliaries to the full extent of their training,
and work in a wider variety of settings, using technology to foster
\29\ Institute of Medicine. Improving Access to Oral Health Care
for Vulnerable and Underserved Populations, 6 (July 2011).
Second, the IOM committee reviewed all available studies about new
types of providers and found no quality or safety concerns. The IOM
recommended that Congress, HRSA and other Federal agencies, and private
foundations conduct research to demonstrate how best to use new types
of dental providers to expand access--as well as how to measure quality
and access, and how to pay for performance. About a dozen States are
considering authorizing new types of dental practitioners to work in
underserved communities. Some of these practitioners are modeled after
dental therapists who have worked effectively for decades in countries
such as Great Britain, Canada, and New Zealand. Some would play a role
similar to that of nurse practitioners in the medical field. Another
approach is to train and license dental hygienists or assistants to
provide more services than they now can provide to patients. An
evaluation of dental therapists in Alaska found they were providing
safe, competent care that received high ratings of patient
\30\ Ibid, 12.
Additionally, Federally Qualified Health Centers (FQHCs) play a
critical role in providing health care, including preventive dental
services, to vulnerable and underserved patients. These health centers
provided dental services to more than 3.7 million patients in 2010.\31\
However, taken together, the safety net only reaches 7 or 8 million of
the more than 80 million who are underserved for dental care.\32\ The
IOM committee recommended that HRSA take several steps to expand access
to dental care at FQHCs. These include: developing a set of best
practices being employed by certain health centers that can be
replicated in other States; supporting the use of a variety of dental
providers; providing services outside the clinic at community settings;
and providing additional funding to recruit and retain providers.\33\
\31\ Health Resources and Services Administration, ``2010 National
Report,'' pg. 49 accessed December 12, 2011, http://bphc.hrsa.gov/uds/
\32\ Bailit, H., T. Beazoglou, N. Demby, J. McFarland, P. Robinson,
and R. Weaver. (2006) ``Dental safety net: Current capacity and
potential for expansion'' Journal of the American Dental Association
137 (6): 807-15.
\33\ Institute of Medicine. Improving Access to Oral Health Care
for Vulnerable and Underserved Populations, 15 (July 2011).
Lack of access to dental care has a pronounced impact on overall
health, and it is critical that we provide funding for States to
establish and maintain the infrastructure necessary for prevention and
comprehensive dental services. Innovation is also crucial to addressing
the dental workforce shortage, and steps must be taken to increase the
number and types of practitioners in underserved communities.
Thank you again for recognizing the importance of improving dental
health and increasing access to care. We appreciate the opportunity to
Senator Sanders. Ms. Gehshan, thanks very much.
Our third witness is Grant Whitmer. Grant is the executive
director of the Community Health Centers of the Rutland Region,
based in Rutland, VT. Mr. Whitmer has worked in various in-
patient and out-patient positions in the health care field over
the last 30 years as both a clinician and administrator. In his
current role, he oversees six medical facilities and one 8-
chair dental facility. He also serves on the Vermont Medicaid
Advisory Board and the Board of Bi-State Primary Care
Mr. Whitmer, thanks very much for being with us.
STATEMENT OF GRANT WHITMER, MSM, EXECUTIVE DIRECTOR, COMMUNITY
HEALTH CENTERS OF THE RUTLAND REGION, RUTLAND, VT
Mr. Whitmer. Good morning. I'd first like to thank Chairman
Sanders and Ranking Member Paul and members of the subcommittee
for highlighting the serious dental access challenges we're
facing and for inviting me to share experiences about how my
board and my health center are working hard to improve dental
access in our communities. My name is Grant Whitmer and I've
worked in the health care field for 30 years. I served as the
executive director of Community Health Centers of the Rutland
Region since 2006 when we became a Federally Qualified Health
Center. Currently, CHCRR operates six medical facilities where
we provide medical care to over 35,000 Vermonters annually.
CHCRR also operates an 8-chair dental facility which provides
comprehensive preventive and restorative oral health services,
and where we will provide approximately 12,000 dental visits to
roughly 4,000 individual patients this year.
Like other Federally Qualified Health Centers, our patients
are largely low-income and experience problems with access.
This is clearly reflected in our dental payer mix, which is
comprised of 47 percent Medicare, 44 percent uninsured, and
just 9 percent private insurance. That's 91 percent of our
patients are either covered by Medicaid or have no dental
While primary medical care is central to our mission and
represents the bulk of services we provide, there is an
increasing body of evidence that highlights the significant
impact of oral health on a patient's overall health and links
to other serious healthcare conditions such as heart disease,
arteriosclerosis, diabetes, poor nutrition, et cetera.
Dental care and equipment are a costly investment for a
health center. We do it because there's such a significant
need, it improves our patients' health, and because the
significant cost savings that we believe can be realized when
oral health care is provided in an appropriate setting. We
recently completed a study in our small community hospital that
revealed that in just 1 year, over 1,100 emergency department
visits were for dental pain or other dental conditions.
Treatment provided during the vast majority of these visits did
not treat the underlying dental condition, but instead provided
only symptomatic treatment of pain, sometimes an antibiotic,
and discharge advice to seek followup treatment by a dentist.
Because the underlying condition is not corrected, a
considerable number of these patients return multiple times to
the hospital ED for treatment of the same underlying oral
health condition. We are still analyzing the data, but our
initial analysis highlights two interesting facts. First, it
appears that adult patients covered by Medicaid are utilizing
the ED because they are unable to find a dentist who accepts
new adult Medicaid patients.
Second, and more surprising to us, is the fact that it also
appears that a significant number of patients covered by
private health insurance, but who lack dental coverage, are
using the ED for dental problems. They're doing this because
the cost of treatment in the ED is covered. But if they were to
seek treatment at a dentist's office, they would likely be
required to pay the full cost of treatment, often in advance at
the time of service, due to their lack dental coverage.
This creates a perverse circumstance whereby patients are
driven to utilize one of the most costly treatment venues, the
hospital emergency department, for symptomatic treatment of
oral health problems, often multiple times for the same
condition, instead of accessing restorative treatment in a
dental office to correct the problem at significantly reduced
In 2007, 1 year after becoming an FQHC, CHCRR initiated our
first dental service, a small 3-chair facility utilizing
donated equipment, and within the first 30 days it was
operating beyond maximum capacity.
During our first 4\1/2\ years of dental operations, CHCRR
has provided over 24,000 patient dental visits and over $1
million in free and discounted dental services. In April 2011,
CHCRR relocated its dental operations from the small 3-chair
facility to a new, expanded 8-chair facility, and as a result,
CHCRR has more than doubled our capacity, which will allow us
to provide at least 12,000 dental visits to approximately 4,000
individual patients, and over $350,000 in free and discounted
dental care each year.
CHCRR is committed to working with local dentists, schools,
our local community, local hospital, and the State to expand
dental access and increase the number of patients in our
service area who have a regular dental home and source of
dental care. Further details on these efforts were included in
my written testimony.
CHCRR is only one of many FQHCs in Vermont and across the
country who have demonstrated similar good work in expanding
access to needed dental services and improving the health of
the populations we collectively serve. FQHCs are structured
around an integrated medical home model and are able to orient
care in a manner that is tailored and appropriate for the needs
of the community and populations they serve. We believe that
FQHCs are uniquely qualified and well-positioned to be a
positive and useful vehicle to expand dental access in an
efficient and cost-effective manner.
Again, I'd like to thank the committee for your attention
to this issue and look forward to answering any of your
[The prepared statement of Mr. Whitmer follows:]
Prepared Statement of Grant Whitmer, MSM
Good morning. I would first like to thank Chairman Sanders, Ranking
Member Paul and the members of the subcommittee for highlighting the
serious oral health access challenges we're facing and for inviting me
to share my experiences about how my health center is working hard to
improve dental access in our communities.
My name is Grant Whitmer and I have worked in the healthcare field
for 30 years as a clinician and administrator in both the inpatient and
outpatient setting. I have served as the executive director of
Community Health Centers of the Rutland Region based in Rutland, VT
since 2006 when we became a Federally Qualified Health Center.
Currently CHCRR operates six medical facilities where we will provide
over 110,000 medical visits to over 35,000 Vermonters in 2012. CHCRR
also operates an eight-chair dental facility which provides
comprehensive preventive and restorative oral health services and where
we will employ three dentists and three hygienists in order to provide
approximately 12,000 dental visits to almost 4,000 individual patients
OUR NEED: THE NEED FOR DENTAL CARE IN RUTLAND
As an FQHC, CHCRR provides a full spectrum of primary care and
preventive services, we see all patients regardless of their income or
insurance status, and we are governed by a volunteer patient-majority
board. Like other Federally Qualified Health Centers, our patients are
largely low-income, many are on Medicaid or uninsured. Today in the
United States, there are over three times as many individuals without
dental insurance coverage compared to the number without health
insurance coverage. Additionally, dental coverage plans traditionally
come with significantly higher co-payment amounts (routinely 50
percent) for major dental procedures. Low-income patients even with
insurance struggle to come up with required co-payments that are
routinely required to be paid prior to beginning treatment. Patients
covered by Medicaid find it increasingly hard to find a provider who
will accept them due to reduced reimbursement levels.
In the CHCRR service area (Rutland County, VT) according to a
community needs assessment survey conducted by Rutland Regional Medical
Center and the Bowse Health Trust in 2011, approximately 71 percent of
practicing dentists are currently NOT accepting new Medicaid patients.
While primary medical care is central to our mission and represents the
bulk of services we provide, there is an increasing body of supporting
evidence that highlights the very significant impact of oral health on
a patients overall health and links to other serious healthcare
conditions to such as heart disease, atherosclerosis, diabetes, poor
nutrition, etc.\1\ \2\ \3\ \4\ \5\ In light of these facts it became
clear to CHCRR that we needed to expand dental access within our
community. We believe it keeps our patients and communities healthier,
makes good sense for the health center medical home, and ultimately
saves money by reducing overall healthcare expenditures. Several
studies suggest that every dollar spent on oral health returns overall
healthcare savings on the order of 3 to 10 times greater.
\1\ Journal of Periodontology 2 Jul 2008: 1501-02. Inflammation and
Periodontal Diseases: A Reappraisal.
\2\ American Journal of Cardiology and Journal of Periodontology
July 2009. Editors' Consensus: Periodontitis and Atherosclerotic
\3\ Warner, J (2004) The Web: ``Oral Health Score May Reveal Heart
\4\ American Academy of Periodontology The Web ``Gum Disease Links
to Heart Disease and Stroke'' http://www.perio.org/consumer/
\5\ Long, E (2006) The Web: ``Make Your Toothbrush a Weapon Against
Heart Disease'' [online] http://www.consumer-health.com/services/
Dental care is a large investment for a health center. However, the
return on investment is notable and we see the potential for enormous
cost-savings to overall health care spending by providing routine
dental care. One study showed that over a 3-year period, preventive
dental treatment provided in an office-based setting was nearly 10
times less expensive than care provided in the ER.\6\ A patient who
puts off (or who can't access) regular, preventive dental care is
likely to show up in an emergency room for treatment. We have seen this
in our local community hospital. We recently completed a study with our
local hospital that revealed that 3.4 percent or 1,116 of approximately
33,000 total annual visits to the Emergency Department were for
``dental pain'' or other dental conditions. Treatment provided during
the vast majority of these visits to the hospital ED did not treat the
underlying dental condition, but instead provided only symptomatic
treatment of pain, possibly a prescription for an antibiotic, and
discharge advice to seek followup treatment by a dentist.
Interestingly, since the underlying condition is not corrected, a
significant number of these patients return multiple times to the
hospital ED for treatment of the same underlying oral health condition.
We are still analyzing the data, but our initial analysis highlights
two interesting facts. First, it appears that adult patients covered by
Medicaid are utilizing the ED because they are unable to find a dentist
who accepts new adult Medicaid patients. Adult Medicaid reimbursement/
coverage in Vermont is capped at a maximum of $495 per year. Many of
these patients have not been to a dentist in many years and have
serious conditions that require extensive dental treatment, the cost of
which would exceed the annual cap. Second, and more surprising to us,
is the fact that it also appears that a significant number of patients
covered by private health insurance, but who lack dental coverage, are
using the ED for dental problems because the cost of treatment is
covered by their medical insurance instead of seeking treatment at a
dentists office because they would be required to pay the full cost of
treatment, often in advance at the time of service because they lack
dental coverage. This creates a perverse circumstance whereby patients
are driven to utilize one of the most costly treatment venues (the
hospital ED) for symptomatic treatment of oral health problems (often
multiple times for the same condition), instead of accessing
restorative treatment in a dental office to correct the problem at
significantly reduced cost. We are currently collaborating with the
hospital to develop better mechanisms to allow us to immediately see
and provide restorative treatment to these dental patients who present
to the ED at our new dental facility, which is just two blocks away
from the hospital. Once at our dental clinic, our intake staff work
with individual patients to help them identify and access available
services and develop a plan to insure the patient gets the dental
treatment they need. For instance, many times we find that patients who
may qualify for Medicaid have not applied because they are confused and
intimidated by the application process. In these cases our staff helps
these patients complete the application process and facilitates
enrollment in Medicaid. Our staff also works with patients to determine
eligibility for our sliding fee scale which is available to all
patients with household income below 200 percent of the Federal Poverty
Level. Additionally, our staff can arrange reasonable structured
payment agreements which are also based on household income. We expect
that by working together with the hospital, we will be able to
significantly reduce the current use of the hospital ED for dental
conditions and provide appropriate restorative and corrective treatment
to this population in an appropriate setting.
\6\ Children's Dental Health Project. ``Cost Effectiveness of
Preventive Dental Services.'' Policy Brief, February 2005, http://
CDHP_policy_brief.pdf, last accessed February 2012.
Prevention is even more cost-effective than timely treatment, and
multiple studies demonstrate the value and cost effectiveness of
preventive dental care. It is not by chance that a majority of private
dental plans cover the cost of routine preventive dental care at 100
percent without co-pays. One study showed that over a 3-year period,
preventive dental treatment provided in an office-based setting was
nearly 10 times less expensive than care provided in the ER.* For
children on Medicaid, the system-wide savings are realized nearly
immediately: research shows that low-income children who have a routine
dental visit by age one incur dental expenses at around half of the
cost level for children who don't have a routine visit until they are
older ($263 compared to $447).\6\ The cost-effectiveness of preventive
and routine dental care is undeniable--for children and adults.
OUR EXPANSION: SUCCESSES AND CHALLENGES
The following paragraphs provide a general overview of dental
services at CHCRR. In 2007, 1 year after becoming an FQHC CHCRR
initiated our first dental service in order to address the critical
need for oral health access in our area. CHCRR rented the office of a
retiring physician which was located in a ``remodeled'' residence over
100 years old. The layout of the facility was considerably less than
ideal, but utilizing donated equipment, CHCRR was able to open a
``quaint'' three-chair dental office staffed with three part-time
dentists who had recently retired from private practice. Our dental
experience was truly a case of ``if you build it they will come''--
evidenced by the fact that within the first 30 days of operation the
new clinic was operating beyond maximum capacity and schedules were
booked 3 months in advance. During the first full year of operations at
the small ``make-shift'' clinic, CHCRR provided 4,990 dental visits to
1,586 individual patients and provided $253,060 in free or reduced fee
dental services. Over the last 4.5 years, (mid-2007-11), CHCRR has
provided over 24,000 patient dental visits and a total of $1,062,249 in
free and discounted dental services. Additionally, CHCRR provides on
average $60,000-$70,000 annually in timely payment discounts to
patients without dental insurance.
Because even after opening the dental clinic the unmet need in the
community was so great, CHCRR sought ways to expand dental services
further. CHCRR was able to secure a mortgage for the purchase of a
3,500-square foot facility which is ideally suited for the location of
an expanded dental clinic. Additionally in support of our dental
expansion plans, CHCRR was fortunate enough to secure a combination of
grant funding totaling approximately $357,000 for the purpose of
purchasing necessary dental equipment and completing required
renovations to create a new expanded eight-chair dental facility. CHCRR
relocated its dental operations and began operating at this new
expanded facility in April 2011. The new facility has allowed us to
recruit additional dentists and hygiene staff in order to significantly
expand the volume and level of dental services we are able to provide.
In 2012 and each year going forward, CHCRR projects that it will
provide approximately 12,000 dental visits to almost 4,000 individual
patients and will provide free and discounted dental care in excess of
$350,000. CHCRR believes this represents good stewardship and a good
return on the grant funding used to support our dental expansion. CHCRR
truly is serving a population which has traditionally had significantly
reduced access to dental services. This is clearly reflected by our
patient-payer mix which is currently comprised of 46.7 percent
Medicaid, 44.3 percent Uninsured (91 percent Combined Medicaid &
Uninsured), and only 9 percent private insurance. We believe that by
providing expanded dental access to this population that we are making
a significant difference in the lives of patients, improving the
overall health of our community, and in the long run saving money for
our health care system. It is almost impossible to put into words the
truly life changing impact of something as simple as providing a set of
dentures (at a total cost of less than $500), to a patient who has gone
years without teeth which prevented them from eating regular food,
significantly diminished their self image, and made it more difficult
to get a job!
OUR FUTURE: CHALLENGES AND VISION
CHCRR is committed to working with the local private dentists,
schools, our local community, local hospital, and the State to expand
dental access and increase the number of patients in our service area
who have a regular dental home and source of dental care. We are
partnering with our local hospital and medical home pilot to decrease
inappropriate utilization of the hospital emergency room for dental
conditions and facilitate transfer of that care to an appropriate
dental provider. We are also incorporating annual dental screening
exams as part of regular medical health maintenance visits provided at
our medical clinics, and facilitating treatment for patients with
identified oral health conditions who do not have a regular source of
dental care. We are also developing a program to be initiated in 2012
whereby CHCRR will provide local schools with ``vouchers'' for a free
dental check-up and evaluation. These vouchers can be distributed by
appropriate school personnel to parents of children who are identified
by the school as being in need of dental services or a regular dental
home. The voucher can be used at the CHCRR dental clinic for a
comprehensive dental evaluation and cleaning, including x rays. As part
of their visit, CHCRR will work with these patients to facilitate their
enrollment in Medicaid or other programs for which they may be eligible
and will provide them with a regular dental home for ongoing preventive
and restorative dental care.
CHCRR believes that in terms of the number of individuals without
dental coverage compared to the number of individuals without medical
coverage (over three times as many individuals do not have dental
coverage compared to the number of individuals who do not have medical
coverage), that access to comprehensive dental services is in that
respect even more critical than access to medical care. Additionally,
our current system does not encourage the most appropriate and
efficient use of our precious and limited healthcare resources. The
current system results in many patients foregoing dental treatment. The
lack of dental coverage and out-of-pocket costs, actually drives a
large portion of dental treatment to the emergency room setting where
only symptomatic treatment is provided and at considerable added cost
to our healthcare system and the overall health of our community.
For the above reasons, CHCRR believes that there is a critical need
for increased access to comprehensive preventive and restorative dental
services in our service area and we are fully committed to doing what
we can to positively impact this situation.
CHCRR is only one of many FQHC's in Vermont and across the country
that have demonstrated similar good work in expanding access to needed
dental services and improving the health of the populations we
collectively serve. Because FQHC's are structured around an integrated
medical home model that provides a full range of primary care,
behavioral health and dental services, and because of the populations
they serve, FQHC's are able to orient care in a manner that is tailored
and appropriate for the needs of the community and populations they
serve. We believe that FQHC's are uniquely qualified and well-
positioned to be a positive and useful vehicle to expand dental access
in the most efficient and cost-effective manner.
Senator Sanders. Grant, thank you very much.
Our fourth witness is Dr. Gregory Folse, who is president
of Outreach Dentistry in Lafayette, LA. He has a mobile
geriatric dental practice and a comprehensive school-based
dental practice throughout the State of Louisiana. Dr. Folse is
also the current chair of Louisiana Oral Health Coalition.
Dr. Folse, thanks very much for being with us.
STATEMENT OF GREGORY J. FOLSE, D.D.S., PRESIDENT, OUTREACH
DENTISTRY, LAFAYETTE, LA
Mr. Folse. Thank you, Senator Sanders and members of the
subcommittee. With great joy I provide oral health services to
the vulnerable patients we're talking about today. On the
ground, the truth about oral disease and poor access to dental
care is clear and undeniable to me. Poor children, the aged,
blind and disabled adult Americans suffer needlessly with
painful and infected teeth and gums and other unhealthy
conditions. My staff and I have declared war on the diseases
that affect these patients, and we're dedicated to win it.
I have two delivery models. One is a vulnerable nursing
home, nursing facility model, and the other is treating
Medicaid-eligible children in schools.
In my geriatric model I personally provide comprehensive
portable dentistry in 24 different nursing facilities. Without
the fancy comforts of an office, I provide services from simple
denture adjustments to full mouth extractions and fillings. It
can be done.
I employ two hygienists, one assisting with the primary
triage of the patients and the other providing onsite hygiene
services and facility staff education. They are invaluable
professionals. Each have found and immediately referred
patients in serious health crises and saved lives in the
General supervision regulations in Louisiana allow this
model to work and allow hygienists to increase the entry points
of the dental delivery system for my patients.
In 2008, I started a vulnerable children's model, and using
15 dentists, part-time mostly, and 18 expanded-duty dental
assistants, we go into schools and provide care for children
and have seen over 20,000 children so far, during 43,000
successful patient visits. We provide comprehensive services.
This isn't a cherry-picking operation. I'm a doctor. We do it
I form partnerships with FQHCs, school-based health
centers, and nurses to assist me in emergency referrals of
these children, because a lot of the parents and families are
very hard to reach, and getting those emergency services is
In the old days when I started this practice, 68 percent of
my patients had no teeth, compared to 80 percent who have teeth
now, causing the emergency and cancer rates to skyrocket in my
practice. The tragic death of Deamonte Driver was not the first
oral health-related death that I've encountered. In 1995, I saw
Miss Mary, who died from oral disease. Others in my practice
that I've been associated with have, unfortunately, followed.
The burden of disease present when a patient enters a nursing
facility is profound. The lack of access to dental services
between retirement and facility admission is certainly a
Oral health is a life and death scenario in this vulnerable
population, yet many have no funding or no access to care. An
absolute all-hands-on-deck policy is needed to solve the access
to dental care problems in this great country. We need all
delivery models engaged, whether portable or mobile services,
or in bricks-and-mortar offices or non-profit clinics,
regardless of which trained oral health professional is
providing the care.
In Louisiana, we fought a ferocious battle over my delivery
models, but fortunately access to care won. This can be done.
I'm a dentist with a traditional staff who is going out and
doing it in untraditional locations. My patients value my
services. I don't hear ``I don't like the dentist'' like I used
to. They line up and wait for me in the nursing facility. Miss
Tammy tells me jokes. Miss Pam made me a bracelet. Miss Bonnie
reached in her purse and gave me this piece of bread she had
saved for herself folded in some foil. It was a special thing
that she did for me because of the value she put on the
Now, I didn't eat it. I don't know how long it had been
But what I do for them matters, and they know it.
Thirty percent of the patients that I serve in my nursing
facilities have no funding for care, so I donate significant
amounts of care every year. No one suffers. Although this works
for my patients and for me, it's not the answer. Today's
dentists and other dental care providers are burdened with
significant debt, and the infrastructure is not in place for
them to go out and do what I do.
The overwhelming surgical needs that I see in my practice
is really profound. I find many patients that live in pain
without my services before they come into the facility, for
sure. There are a couple of solutions out there.
One of the things that I've been able to access in my
practice is the use of incurred medical expense adjustments for
nursing home patients. This is a very little-known access
model, a funding mechanism. The American Dental Association has
recently published a really nice article, and I've got
references to it in my testimony that will show you how to do
The other issue I think that would be a great solution is a
bill that I've worked on for years, which is called the Special
Care Dentistry Act. This bill would provide services to the
most vulnerable patients, the aged, blind and disabled, who
don't currently even have funding in my practice.
I've heard for years ``it will never,'' ``they will
never,'' ``you'll never,'' ``we'll never.'' That's not true. I
believe in this country and believe that in my lifetime these
patients will one day have the infrastructure to access the
care that they so desperately need.
I thank you for your time.
[The prepared statement of Mr. Folse follows:]
Prepared Statement of Gregory J. Folse, D.D.S.
Thank you Senator Sanders, Senator Paul, and members of the
subcommittee for holding this hearing today. My Name is Dr. Gregory
Folse and it is with great joy that I come to you today as a provider
of oral health services to the vulnerable populations who typically
have poor access to dental care. I'm honored with the hope that by
sharing the details of my life's work with you, we can better the lives
of the patients I serve. On the ground, the truth for me about oral
disease and poor access to dental care is clear and undeniable. Poor
Children and Aged, Blind and Disabled adult Americans suffer needlessly
with painful and infected teeth and gums and other unhealthy oral
conditions. My staff and I have declared war on the oral diseases
making our vulnerable patients suffer and we're dedicated to win it.
I'm here to tell you we have helped them, we are helping them, and we
will continue to help them. We also routinely help others to do the
This endeavor will require, however, assistance from each of you to
make models like mine a replicable and viable professional choice for
So what are my models? I have two--one practice treating vulnerable
nursing facility residents and another mobile school-based dental
practice for Medicaid eligible children.
MY GERIATRIC MODEL
In my geriatric model I personally provide comprehensive, portable,
dental services in 24 nursing facilities to wonderful patients I
consider to be God's children. I've developed dental director position
in each facility. Without fancy equipment or the comforts of an office,
I can and do provide services from simple denture adjustments to full
mouth extractions and fillings. Patient autonomy and privacy,
instrument sterilization, use of universal precautions, and care
delivered to the same standards as in-office care can be, and are,
My practice staff includes two hygienists, one assisting with
preliminary triage assessments and completing the facility's Minimum
Data Set items on oral health for all residents while the other is
dedicated to providing actual onsite hygiene services and facility
staff education on prevention and provision of daily oral hygiene
services. They are invaluable professionals. Each have found and
immediately referred to me patients in serious health crises, and have
saved lives in the process. General supervision regulations in
Louisiana, which allow hygienists to see patients without a dentist
present, are critical to this model and help me insure patients get the
care they need. Without general supervision, which fully enables a
hygienist's abilities, I would not have a viable prevention model or
the ability to provide my patients access to comprehensive care.
Working with hygienists has increased the entry points of my patients
into the dental delivery system. This is a wining model for my
I do maintain a business office but no care is provided there. Two
people man this ship, my office manager and my patient relations/
billing manager. Both assist with normal office functions and
facilitate obtaining informed consent for the patients I treat.
I travel with one trained dental assistant who assists with the
treatment I provide. We have fun and do a lot of good.
All of my staff are god-sent!!!
MY VULNERABLE CHILDREN MODEL
In my vulnerable children model, I employ 15 dentists, 18 expanded
duty dental assistants, and an administrative service company to
provide comprehensive dental services to children in schools. Since
2008, some 275 schools have requested services and to date my teams
have treated over 20,000 children during 43,000 successful patient
visits. We provide comprehensive services and do not ``Cherry-Pick.''
With state-of-the-art modern technology, fillings, stainless-steel
crowns, x rays, baby tooth root canals, and some extractions can be
provided to the same standards as in an office setting. We refer
children to specialists when needed just as you would in an office.
Followup emergency care systems are in place as are emergency referral
sites. I've formed partnerships with school-based health center nurses
who assist me in emergency referrals as many families are extremely
hard to reach by phone. It has been reported that out of 1.6 million
phone calls to families in the poorest sections of East Baton Rouge
Parish school district only a 45 percent connection rate was achieved.
These data prove the use of a written general informed consent form is
the only way to assure access to the most vulnerable children--those
whose parents can't be reached by phone.
Breaking the cycle of oral disease and neglect is, again, a major
focus of my efforts for this population and oral health education is
the only way to do it. We give each child dietary counseling, teach
them about prevention of oral disease, and show them how to brush and
floss. Additionally, these efforts ease the child into a caring and fun
atmosphere which starts each visit off in a good way. The dentists who
work for me are continually amazed at how well the children behave and
HISTORICAL PRACTICE DATA
In the old days (1992) when I started my nursing facility practice,
68 percent of my patients had no teeth and comprehensive dental
services were only moderately in demand. As of September 2011, 80
percent have teeth, many more posterior teeth are present (harder to
keep clean and to restore), and patients and their families are
demanding preventive, restorative, surgical, and prosthetic services.
The greater numbers of teeth present, coupled with the lack of dental
care in the last season of life, have caused dental emergencies and
oral cancer rates to sky-rocket in my practice. The tragic death of
Deamonte Driver was not the first oral health death I've encountered.
In my vulnerable adult dental practice I'm aware of many patients who
have died and/or been sent to hospitals due to oral infections, sepsis
caused from oral infections, and oral cancer. In 1995, I was involved
with my first death due to oral disease patient, Ms. Mary. Others have
unfortunately followed. The burden of disease present when a patient
enters a nursing facility is profound. The lack of access to dental
services between retirement and facility admission is certainly a
Conversely, I've provided life-saving dental treatment to many
patients throughout the years who would have died without it. Treating
serious infections, diagnosing oral lesions in time for them to be
treated, and referring patients to specialists when needs exceed what I
can do in facilities are all part of my routine. Oral disease found in
vulnerable populations is, without a doubt, a life and death situation.
I've seen it.
If there is one health care policy that enjoys almost universal
support--and that's saying something in the contentious world of health
care policy--it is that improving access to health care professionals
is critical to improving health outcomes. Agreement on how to best
achieve the policy goal of improving access, however, remains elusive.
Fortunately, we now have empirical data sets from places like my home
State of LA that affirm two important points: (a) bringing oral health
professionals to the patients works and (b) there is no one delivery
model that by itself can solve the access to care crisis. An absolute
``all hands on deck'' policy is needed to solve access to dental care
in this great country. We need all the delivery models engaged, whether
by mobile/portable services or within bricks and mortar dental offices,
or non-profit clinics regardless of which properly trained oral health
professional is providing the care.
In LA we fought a ferocious battle, and used up a tremendous amount
of energy, over the basic question of utilizing the mobile/school based
model to increase access to underserved populations. Fortunately the
need for access to dental care won the day due to a terrific alliance
of health care professionals including Federal qualified health clinics
(FQHCs), school-based health centers, physician groups, hospital
groups, churches, and advocates from across the State. The lesson
learned is that the promotion of and use of Practice Administrators,
general, written, informed consents, and portable/mobile dental
services are all vital to oral health care reform if true access to
dental care is to be achieved.
THE GOOD NEWS
This can be done! I'm a dentist with a traditional staff who has
made a viable go of treating wonderful and needy vulnerable patients--
the patients we are all here today to serve. To me they are God's
children who greatly need and want what my staff and I provide. They
value our services and I'm blessed to serve them. I don't hear ``I
don't like the dentist'' like I used to. My patients line up and wait
for me to arrive. Sometimes they give me simple things in appreciation:
Ms. Tami tells me jokes, Ms. Pam made me a bracelet, Mr. George played
a song for me on his guitar and Mrs. Bonnie gave me a piece of bread
from her purse. Many can't speak or even thank me but those give me the
most joy of all--the joy of being their doctor and doing what is best
for them. I want others to know these joys so I travel around the
country and teach others to do what I do. There are providers using my
model, or parts of it, in 17 States now, and for that I am especially
pleased. Another great joy for me is knowing that I've helped others to
care for vulnerable populations, for treating them I feel is a gift
As you will see not all the patients I serve have access to funding
for care. I find it rewarding to donate services to them. Annually I
routinely provide tens of thousands of dollars of donated services
ranging from 10 to 16 percent of my gross production. Although donating
services works for my patients and for me it is not the answer. Today's
dentists and other dental care providers are burdened with significant
debt. They need an infrastructure in place that will allow them to make
a living while that debt is reduced. I will provide solutions to that
problem later in my testimony.
A DAY IN THE LIFE . . .
The need for surgical dental services in my practice is
overwhelming. As of September 2011, my practice managed oral health
services for 24 nursing facilities and some 2,500 residents. Of those,
2,000 have natural teeth (are dentate) and of the 2,000 dentate
patients--51 percent or roughly 1,000 needed extractions due to
abscesses and/or severe gum disease. Specifically, 50 percent of
dentate residents or 40 percent of the total resident population needed
surgical care. Additionally, one must also consider the resident
turnover rate of 30-40 percent. With 875 new patients per year and 51
percent needing surgical care, I must manage an additional 430 new
surgical patients/year. The total number of patients with surgical need
equals 1,430 residents per year.
I physically can't meet this overwhelming amount of need. But I
Additionally, the medical intricacies of this population are
complex to say the least. Most patients present with multiple medical
diagnoses and are taking a myriad of medications. Managing them pre-
and postoperatively is a daunting task requiring much time and effort.
I'm honored and blessed, however, to do it.
WHO ARE SPECIAL NEEDS PATIENTS?
To me, poor children, children and adults with intellectual and
developmental disabilities, disabled adults, the aged, frail elders,
medically compromised elders, and medically compromised adults are all
Special Needs Patients. From a governmental perspective, however, they
are defined as Medicaid eligible poor children and the aged, blind, and
disabled (ABD). For ABD adults oral health services are considered
It is a societal sin to deny oral health services to the aged,
blind, and disabled adults. How is it right for a poor developmentally
disabled child to lose dental benefits when they turn 21 years old? How
is it right for a poor grandmother with no money to be denied treatment
of dental infection? How is it right for a 45-year-old man with
intellectual disabilities and no family, who can't be treated in a
traditional setting, to suffer with dental pain and have no hospital
anesthesia services to cover his hospital needs?
I simply say ``It isn't right.''
According to Medicaid and Chip Payment and Access Commission
(MACPAC) report to Congress dated March 2011, in 2009 62.2 million
Medicaid eligible existed and, of those, 17.4 million, or 28 percent
were Aged and/or Disabled (AD). Amazingly to some, the total medical
expenditures for only that AD population were $223 billion or 2/3 of
the total Medicaid expenditures (plus Medicare expenditures).
Specifically, 28 percent of the Medicaid population accounted for 66
percent of the total Medicaid expenditures. This doesn't surprise me at
all. Half of these patients in my practice are infected, needing
surgical intervention. Many live in pain and without my services would
stay in pain. Their mouths teem with bacteria and disease. That
bacteria gets into their bloodstream and lungs. That bacteria decreases
their quality of life and often their life-span.
AVAILABLE DENTAL BENEFITS FOR THE AGED, BLIND, AND DISABLED ADULT
So what is actually available? Medicare covers virtually nothing.
Private insurance is very rare and the first to go at retirement age
and in the 20 years of my geriatric practice I've had eight patients
with dental insurance. As already detailed, Medicaid benefits are
optional to each State although Medicaid does cover prisoner oral
health services, boil and bedsore treatments, any medical infection,
and heck--Medicaid will even cover a penile implant. I doubt, however,
the patients receiving these implants will ever get to kiss anyone with
a mouth full of decayed teeth and gum disease.
ACTIVE SOLUTIONS #1--IME ADJUSTMENTS
A special dental access mechanism is available for nursing facility
residents. Incurred Medical Expense regulations can help most nursing
facility residents who are enrolled in Medicaid to pay for dental care.
A great article entitled How-to guide for IME By Stacie Crozier, ADA
News staff and a corresponding document Incurred Medical Expenses
Paying for Dental Care: A How-To Guide were written and published by
the ADA. To find the article go to http://www.ada.org/news/6295.aspx
and for the document click on the word document on the first page of
the article. The article gives the reader an understanding of the law
and what IME can do whereas the document details how to use IME
adjustments from dental office, patient, and Medicaid Case Worker
perspectives. In 20 years of practice no funding mechanism has allowed
more access to dental care in my practice.
Unfortunately, IME adjustments are only allowed for Medicaid
eligible nursing facility residents with a social security or pension
income. Those without those income sources have no access to care
through this system. Ironically, the most vulnerable residents, those
who never worked like intellectually or developmentally disabled
adults, have no funding for services through this system. I donate
services to them routinely.
ACTIVE SOLUTIONS #2--SPECIAL CARE DENTISTRY ACT
The Special Care Dentistry Act of 2010 is near and dear to me as it
seeks to create a national Medicaid Infrastructure for ABD adults. The
bill supports State Medicaid oral health services for ABD adults with
Federal dollars and is strongly supported by the dental profession and
advocacy organizations across the country. If enacted, no poor,
vulnerable population will be left without coverage and for the first
time oral health services would be ensured for our most vulnerable
adult population, aged blind, and disabled adults. With the rampant
disease detailed in the ABD population, providing dental services to
this population should prevent unnecessary medical procedures and
expenditures. If passed, as infrastructure develops, and as the
existing or new workforce is engaged we can better train the profession
while the aged, blind, and disabled get care. The bill ensures age
appropriate procedures as well as deeming that oral health services are
``medically necessary.'' Fiscally it makes sense too. The bill doesn't
require coverage for the entire adult Medicaid population, a costly
proposition, only the most vulnerable citizens within it.
For years I've heard ``It'll Never, You'll Never, They'll Never,
and We'll Never.'' I believe in this country and know that in my
lifetime these patients will one day have the infrastructure for access
to dental care that they so desperately need.
WHAT HAPPENED TO DENTAL EDUCATION AND VULNERABLE PATIENT TREATMENT
Early in the 1980s Federal and State governments began cutting
financial support to dental schools resulting in today's dental schools
that must be self-funded. For schools to stay financially viable a
significant amount of resources must come from the students and patient
pools paying for dental services. Unfortunately, the most vulnerable
aged, blind, and disabled patients can't pay, dental schools can't see
large numbers of them for free, and fewer are treated. Consequently,
since the dental students don't treat them in large numbers, they
aren't well-trained and are uncomfortable treating the aged, blind and
disabled population. As tuitions rise, the dental student debt has also
risen rendering many dental students fighting to make ends meet upon
graduation. This can obviously negatively impact their choice to treat
vulnerable patient populations.
ORAL HEALTH/GENERAL HEALTH CONNECTIONS--CDC
Poor oral health means poor health to me. Although some describe
how poor oral health is linked to many medical health problems, I see
it differently. You can't be healthy if you have poor oral health.
There is no division of the terms in my mind. Infected teeth and gums
are a significant detractor from quality of life. Patients of mine,
especially disabled patients, suffer orally and those sufferings add to
a host of medical complications such as the chance for infective
endocarditis, sepsis, complicated diabetes ramifications, the risk of
heart disease and stroke and stroke. Oral cancer is a significant
killer with a horrible death rate. With regular oral exams oral cancers
can be detected early when they are more easily treated. Unfortunately
for my patients many haven't seen a dental provider in years and when
my model finds a cancerous lesion it is rarely treatable. Death from
oral cancer is a horrible death. I've seen it too many times.
Pneumonia and lung diseases are especially worrisome. A study,
Reservoir Of Respiratory Pathogens For Hospital-Acquired Pneumonia In
Institutionalized Elders by All A. EL-SOLH, M.D., MPH, FCCP; et al.
detailed that of 46 patients in an ICU 28 had colonization of their
dental plaques with pathogens known to cause pneumonia. Of those
patients, 13 patients developed pneumonia. It was proven that 8 of the
13 patients had respiratory pathogens that matched genetically those
recovered from their dental plaques. Over half of the patients in this
study who got pneumonia got the bacteria that caused their pneumonia
from their dental plaque. I have no doubt that providing preventive
dental services to this population reduces the amount of oral bacterial
and thereby should reduce the incidence of life threatening and costly
We all agree that bacteria in the lungs is bad and reducing the
amount of oral bacterial is a primary must for aging and vulnerable
patients. So who is a major front-line offensive and defensive player
in my model? The dental hygienist. They help me keep my patients
healthy through patient and staff education and providing preventive
treatment. Unfortunately, without passage of a bill like the SCD Act,
these services aren't covered for the most vulnerable ABD patients.
PRACTICE CHANGING INNOVATIONS
I'd be remiss if I wouldn't mention several practice innovations
that have significantly enhanced my ability to treat poor children and
ABD adults. Physics forceps, the Nomad hand-held x ray machine, digital
x ray sensors, and portable dental units allowed me to provide a level
of care I could have only dreamed of when I started my practice in
Senator Sanders. Thank you very much, Dr. Folse.
Our final witness is Christy Jo Fogarty, and she is going
to be introduced by Senator Franken of Minnesota.
Statement of Senator Franken
Senator Franken. Thank you, Mr. Chairman. I'm very pleased
that Christy Jo Fogarty could join us today from my home State
Ms. Fogarty began her career as a dental assistant, and
after Minnesota became the first State in the Nation to license
mid-level dental providers, Ms. Fogarty became a dental
therapist. She went on to continue her education and became one
of the first in the country to complete advanced dental
therapist education and training.
She currently works at Children's Dental Services, a non-
profit dental clinic that serves pregnant women and children
under the age of 21.
Ms. Fogarty has served on the Farmington city council for
10 years and was appointed to the State Board of Soil and Water
Resources in 2009. She has also served as the chair of the
Farmington Economic Development Authority and has been active
on dozens of advisory committees in her community.
Thank you for joining us, Ms. Fogarty.
STATEMENT OF CHRISTY JO FOGARTY, RDH, MSOHP, LICENSED DENTAL
HYGIENIST, LICENSED DENTAL THERAPIST, CHILDREN'S DENTAL
SERVICES, FARMINGTON, MN
Ms. Fogarty. Thank you, Senator Sanders, and thank you,
Senator Franken and committee members, for this opportunity to
share Minnesota's story on expanding access to dental care
through the use of a new dental provider.
As Senator Franken said, my name is Christy Jo Fogarty.
I've been in dentistry for over 15 years, first as a dental
assistant and then over a dozen years as a dental hygienist,
and in June 2001 I graduated with a Master's in Science from
the Oral Health Practitioner Program in Metropolitan State
University in St. Paul. This 27-month, full-time Master's
program educates students who are already licensed dental
hygienists to practice advanced dental therapy.
The advanced dental therapist is a true mid-level
practitioner, a provider between a dentist and a dental
hygienist. It is similar to a nurse practitioner but in the
dental field. The advanced dental therapist is not a
replacement for a dentist. It is intended to extend the reach
of the oral health care delivery system so that it will be
easier and more affordable for under-served populations,
including children and the elderly, to obtain high-quality oral
health care services.
While Minnesota's Advanced Dental Therapy Program is the
first of its kind in the United States, more than 50 other
countries have educated and utilized mid-level dental providers
safely and effectively for decades. Interestingly, the push to
create a dental mid-level in Minnesota did not come from the
dental community alone but from community groups, safety net
programs, charities, hospitals, and all of the major medical
insurers. They pushed for a new dental provider because so many
people just couldn't find a dentist.
Emergency rooms in the Minneapolis-St. Paul area reported
10,000 visits related to oral health care problems. Only 17.5
percent of Medicaid children in Minnesota received dental
treatment for services in 2010, and only 5.5 percent of
Medicaid children in Minnesota received a sealant on a
permanent molar in 2010. An estimated 60 percent of Minnesota
dentists are expected to retire in the next 15 years.
In 2009, the Dental Practice Act in Minnesota was changed
to include two new practitioners, dental therapists and
advanced dental therapists, both of which are required to see
at least 50 percent public assistance or uninsured patients.
Dental therapists work under the indirect supervision of a
dentist, which means a dentist must be onsite but not in the
operatory with the therapist. This new provider--which in my
opinion doesn't do much to improve access to care for
vulnerable populations because of the requirement for a dentist
to be onsite--this was included in the legislation largely at
the urging of the Minnesota Dental Association and the
University of Minnesota, who educate dental therapists.
In contrast, advanced dental therapists, after completing
the Master's program, working 2,000 hours under the indirect
supervision of a dentist and passing a certification exam, can
then work in alternative settings without a dentist present but
in collaboration with a dentist.
I am now working on getting my needed 2,000 hours at
Children's Dental Services in Minneapolis. As Senator Franken
said, it's a non-profit dental clinic that sees children from
birth to age 21, as well as pregnant women.
I love my work. I provide all the preventive services of a
dental hygienist, as well as certain restorative procedures,
certain kinds of extractions, and I will have limited
prescriptive authority. I also know when I need to refer to a
dentist or a specialist. It's incredibly gratifying to restore
someone to good oral health and teach them how to maintain good
Most of the patients I see haven't been to a dentist ever
or in a very long time. I explain to every patient and the
patient's parents that I am not a dentist, and I explain my
background and education. I have yet to find one person to
I recently treated a little boy who, like most of my
patients, needed extensive dental work. He needed four 1\1/2\-
hour appointments to complete eight stainless-steel crowns and
several baby root canals or pulpotomies. After completing all
of this restorative work, I was also able to clean his teeth
and place sealants as a part of completing his treatment. This
little boy was not only pain free, but he and his mother were
well-educated on how to prevent future decay.
Another little boy I saw was only 2 years old. He had
recently fallen and hit his front tooth. After a week had gone
by with no dental care, the tooth turned black, was causing
pain, and the child was having difficulty sleeping. By the time
I saw the boy, the tooth was traumatized beyond repair and I
performed the necessary extraction to relieve the pain and
eliminate the infection. The boy's mother told me she had
called around for hours before she was able to get an
appointment in our clinic. She did not have insurance for her
little boy, and dental office after dental office turned her
away both because of lack of insurance and because of the boy's
age. She said we were the last call she was going to make
before she brought him into the emergency room. This would have
been a huge expense on the public health system, with no
What can be learned from the Minnesota experience? First,
mid-levels are offering safe, cost-effective care to people who
otherwise would struggle to find care. Second, no longer will
seeing a dentist be the only means of accessing dental care in
Minnesota. This means schools, nursing homes, community
centers, really anywhere with a power source can become a place
to receive dental care. And third, building on an already-
trained workforce of dental hygienists means a dental therapist
workforce can be achieved in a relatively short amount of time.
Please do whatever you can to make it easier to improve
access to care through the exploration and utilization of new
types of dental providers in Minnesota and across the Nation. I
look forward to your questions. Thank you.
[The prepared statement of Ms. Fogarty follows:]
Prepared Statement of Christy Jo Fogarty, RDH, MSOHP
Thank for this opportunity to share the Minnesota story on
expanding access to dental care through the use of a new type of dental
provider. My name is Christy Fogarty and I graduated in June 2011 with
a Masters in Science from the Oral Health Practitioner Program
administered jointly by Metropolitan State University in St. Paul and
Normandale Community College in Bloomington, MN. This program, which
educates students who are licensed dental hygienists already holding a
baccalaureate degree, to practice as Advanced Dental Therapists.
Advanced Dental Therapists provide all of the services of a dental
hygienist by virtue of dual dental hygiene and dental therapy
licensure, all of the services of a basic dental therapist, and
additional services including oral evaluation and assessment,
formulation of an individualized treatment plan, extractions of
permanent moderately to severely mobile or ``loose'' teeth and
provision, dispensing and administering antibiotics, analgesics and
anti-inflammatories. The Advanced Dental Therapist is a true mid-level
provider--a provider between a dentist and a dental hygienist--and is
similar to the nurse practitioner who works under general supervision
but in the dental field. The Advanced Dental Therapist is not a
replacement for a dentist but is intended to extend the reach of the
oral health care delivery system so that it will be easier and more
affordable for underserved populations, including children and the
elderly, to obtain high quality oral health services. An estimated 60
percent of Minnesota dentists may retire in the next 15-20 years. (UMN-
Academic Health Center, Educating Minnesota's future health professions
Workforce: 2008 Update) the dental workforce in rural areas has a
larger percentage of dentists over the age of 59, magnifying the loss
of dentists due to retirement in the near future. Twin Cities
(Minneapolis/St. Paul metro area) emergency rooms reported 10,000 ER
visits related to oral health problems at a cost of more than 4.7
million in 2005 (Davis, Deinard, and Maiga, 2005). In addition, only 42
percent of those on Minnesota's public health programs receive dental
care, leaving low-income adults and children without needed dental
care, even though every $1 spent on preventative care saves about $4 in
dental costs (DHS, March 2007 and the National Institute of Dental
Research). While Minnesota's Advanced Dental Therapy program is the
first of its kind in the United States, more than 50 other countries
have educated and utilized mid-level dental providers safely and
effectively for decades.
A STRONG FOUNDATION IN PREVENTION
How did I begin my journey? I have been in dentistry for over 15
years, first entering the field as a dental assistant. Shortly after
beginning dental assisting school I fell in love with the field of
dentistry and knew I wanted to do more. Before completing dental
assisting school I applied for dental hygiene school. After competing
with over 300 applicants for 30 spots, I was accepted at Normandale
Community College's dental hygiene program. While in dental hygiene
school, I took courses that included anatomy, physiology, biology, bio-
chemistry, psychology, radiology, and pharmacology. In addition we
spent hundreds of hours providing direct patient clinical care. We also
spent time with patients teaching them how to prevent gum disease and
tooth decay. After graduation I spent 2 years working with a private
practice dentist who was very dedicated to giving back to the community
and accepted a high percentage of public assistance patients. It was
there I saw first hand the difficulty many people face in accessing
dental care and learned how very challenging this population can be to
treat. Although dental disease is almost 100 percent preventable, I saw
patients with rampant untreated decay. In this practice I was able to
hone my skills in prevention and disease treatment, collaborating with
the dentist on treatment planning and realistic outcomes. I then moved
forward with my career and began work as a temporary for hire
hygienist. I was able to work in dozens of practices in the urban core
of the Minneapolis/St. Paul metropolitan area, the suburbs, and the
more rural areas of our State. For 7 years I witnessed private practice
offices unable or unwilling to serve people with public assistance
insurance, the uninsured, and people with special needs and the
homebound. I have often heard that the access issue has more to do with
a maldistribution of dentists and not a lack of dentists. I have
witnessed firsthand many areas where people cannot enter the dental
system and receive care and I saw that it has nothing to do with the
availability of dentists in the area. It was at this point in my career
that I heard of the big push in Minnesota to create a mid-level
practitioner to improve access to dental care, and I knew I had to be a
part of this new program.
MINNESOTA ENACTS LEGISLATION TO IMPROVE ACCESS TO DENTAL CARE THROUGH
THE CREATION OF TWO NEW TYPES OF DENTAL PROVIDERS: THE DENTAL THERAPIST
AND THE ADVANCED DENTAL THERAPIST
Interestingly the push to create a dental mid-level did not come
just from the dental community but from a large cohort of community
groups including safety net programs, Health Partners, Regions
Hospital, the United Way, and all of the major medical insures. In
fact, over 45 organizations supported creating a mid-level point of
entry practitioner (appendix A) http://www.adha.org/
governmental_affairs/downloads/restorative_chart.pdf. The opposition
came only from organized dentistry. In 2009 the dental practice act in
Minnesota was changed to include two mid-level practitioners, dental
therapists and advanced dental therapists. Dental therapists work under
the indirect supervision of a dentist, which means a dentist needs to
be present in the office and aware of what procedures are being
completed by the dental therapist, but the dentist does not need to be
in the operatory with the dental therapist. This new provider, which in
my opinion, doesn't do much to improve access to care for vulnerable
populations because of the requirement for a dentist to be onsite, was
included in the legislation largely at the urging of the Minnesota
Dental Association and the University of Minnesota that educates dental
therapists. The other mid-level practitioner created is the advanced
dental therapist who after 2,000 hours of working under indirect
dentist supervision can work in alternative settings without a dentist
present, but in collaboration with a dentist.
It is important to note that currently there is no requirement in
the legislation that a dental therapist or an advanced dental therapist
need to be a dental hygienist prior to licensure. However, the only
advanced dental therapy program in Minnesota, which I graduated from,
requires that all applicants be licensed dental hygienists with
extensive dental hygiene work experience. I chose to attend
Metropolitan's program because I feel the foundation in preventive care
afforded by a dental hygiene education is critically important for
treating this vulnerable population. By virtue of their dual dental
hygiene and dental therapy licensure, graduated from Metropolitan
State's program work as Advanced Dental Therapist to provide a full
range of preventive oral health care services in addition to
administering restorative services, performing extractions of ``baby''
teeth and very mobile permanent teeth and having limited prescriptive
authority. This broad range of primary care services will enable me to
improve access to care for rural and underserved populations and
increase entry points into the oral health care delivery system.
Working with a collaborative management agreement with a dentist, I
will also refer patients to a dentist when they need the services that
only a dentist can provide.
BECOMING AN ADVANCED DENTAL THERAPIST
I was in the first class of advanced dental therapists but getting
there wasn't as easy as it may seem. I learned that despite having over
a dozen years of experience as a dental hygienist I still needed more
training to even be accepted into the program. While I had the required
2,000 hours of dental hygiene experience, I also had to be licensed to
administer both local anesthetic and nitrous oxide, and be certified as
an REF or restorative expanded function hygienist. This certification
allows licensed dental hygienists to place both silver and tooth-
colored fillings, and place stainless steel crowns after a dentist has
removed the decay and prepared the tooth to be restored. Note that 14
other States allow dental hygienists to provide these types of
restorative services, illustrating that many States are expanding the
role of non-dentist providers to increase access to dental care
(appendix B) http://www.health.state.mn.us/divs/orhpc/pubs/workforce/
dent08.pdf. I then had to go through an extensive application and
interview process. Once accepted into the accredited, 27 month, full-
time masters program I started very challenging coursework. This
included clinical coursework that taught us the new skills we would be
We were taught these skills, within the scope of our practice, to
the same level as a dentist. In other words our training to prepare
teeth, remove decay and fill teeth was taught in the same matter dental
students learn it across the country everyday. In addition, we took
coursework in advanced pharmacology, epidemiology, managing patients
with special needs, and pediatric dentistry (appendix C) http://
page_name=master_science_oral_health_practitioner.html. While learning
new skills is always challenging my background was very useful in
learning treatment planning, assessments, and prevention education as
these were critical thinking skills I had used for over a decade as a
dental hygienist. In our clinical training I was able to see dozens of
uninsured patients in our home clinic allowing me to restore hundreds
of teeth before ever officially entering the field of dental therapy.
We also were able to do rotations through Community Dental Clinic,
Hennepin County Medical Center in their pediatric and oral surgery
departments, the VA nursing home and Children's Dental Services. These
experiences allowed us not only more clinical time with patients but
allowed us to work directly with experts in the field to expand our
critical thinking skills.
While completion of this master's level education was the most
significant requirement for licensure in Minnesota there were still
several additional requirements I had to complete prior to being
allowed to practice dental therapy in Minnesota. I had to complete a
clinical exam on both a typodont or ``fake'' teeth, and I had to
complete two fillings on actual patients. The patient portion of the
exam was taken with dental students from the University of Minnesota
and other dental students from across the country. The evaluators in
this process did not know which patients were being treated by a dental
student or an advanced dental therapy student, again this shows that in
our scope of practice, we are trained to the level of a dentist. After
passing the dental boards I then had to find employment in order to
gain the 2,000 hours of experience as a dental therapist before being
eligible to take the certification exam that will certify me as an
Advanced Dental Therapist. Finding work was not challenging as
Children's Dental Services was eager to hire an advanced dental
therapist. In fact, they have another licensed hygienist currently in
the program they intend to hire.
Children's Dental Services is a non-profit dental clinic that sees
children from birth to age 21. And because education of new mothers on
how to take care of their children's gums and teeth is so critically
important, we also see pregnant women to not only improve their oral
health, affecting their overall health, but to educate them on
preventive care for their children. Children's Dental Services also
does mobile dentistry, bringing care to over 150 metro site including
schools, community centers and hospitals. Statewide we have over 200
sites allowing us to bring much-needed dentistry directly to the
children who most need care. We also see children with special needs,
having taken our mobile units over an hour and a half away to treat
deaf and blind children in their schools. We also offer translators in
almost a dozen languages. This helps to remove language as a barrier to
dental care, and increases our ability to educate patients and parents
on preventive oral care. The final piece to being able to practice
dental therapy in Minnesota was to find a dentist to collaborate with.
Again this was not as challenging as I thought it might be. The
dentists I work with at Children's Dental Services were very supportive
quite frankly because they knew and trusted me because of my work as a
dental hygienist. As a result I have not just one but five dentists I
am in collaboration with, with several more willing to sign with me.
EFFECTS ON ACCESS DENTAL THERAPY IS HAVING TODAY
As a practicing dental therapist, I see firsthand every day the
difference I make in opening access to dental care. As a full-time
dental therapist I see anywhere from 6-10 patients a day. For example,
in the month of January alone I saw 57 patients who needed numerous
restorative procedures. In addition to referrals and triaging I did 4
space maintainers, 5 pulpotomies (root canals on baby teeth), 11
stainless steel crowns, 17 extractions and 47 fillings. I also saw 12
emergency patients that could have otherwise ended up in the emergency
room where they would have been given antibiotics and pain medications
and told to find a dentist. There really is no dental emergency room. A
medical emergency room simply isn't able to provide oral health care
services but only to administer palliative treatment to alleviate the
pain and prevent infection.
On one occasion I saw a 2-year-old boy who had fallen and hit his
front tooth. After a week had gone by without dental care, the tooth
had turned dark and was causing him pain, making it difficult for him
to sleep. By the time I saw him, the tooth was traumatized beyond
repair and I performed the necessary extraction to relieve the pain and
eliminate the infection. The boy's mother told me she had called around
for hours before she was able to get an appointment with our clinic.
She did not have insurance for her little boy and dental office after
dental office turned her away because of the lack of dental insurance
and because her little boy was under the age of 3, which is the
standard age most private dental practices in Minnesota begin to see
children. She said we were the last call she was going to make before
she brought him to the emergency room. This would have been a huge
expense on the public health system, with no conclusive treatment. When
I become an advanced dental therapist, after completing 2,000 hours as
a dental therapist, I will become even more effective as a point of
entry into dental care. I will have the ability to work in schools,
community centers, nursing homes, virtually anywhere that dental needs
are going unmet.
PUBLIC ACCEPTANCE IN MINNESOTA OF NEW DENTAL PROVIDERS
From my vantage point, the acceptance level of dental therapy is
nothing short of amazing. Every patient I see I explain to them that I
am not a dentist and that I am a dental therapist. Once I explain to
them that a dental therapist is much like a nurse practitioner in
medicine they are comfortable with me treating their children. I have
never once had anyone say they would prefer to see a dentist. In many
cases, because I am a licensed dental hygienist, I have also cleaned
their teeth so the parents are already comfortable with me, and I have
developed trust with them. In fact, there was an 8-year-old boy I saw
recently who had never been to the dentist before for several reasons
including struggling with finding a dental office who would take their
public assistance insurance. Unfortunately, as is the case with the
vast majority of the population I see, this little boy needed extensive
dental work. He needed four 1\1/2\ hour appointments to complete eight
stainless steel crowns and several baby root canals, or pulpotomies.
After the first appointment with me the mother said, ``I don't care if
you're a dentist or not I want my son to see only you.'' After
completing all of this restorative work, I also was able to clean his
teeth and place sealants as a part of completing his treatment. This
little boy was not only pain free but he and his mother were well-
educated in how to prevent future dental decay.
WHAT CAN BE LEARNED FROM MINNESOTA
Minnesota is the first State to take the mid-level practitioner and
fully integrate it into dentistry and many things can be learned from
what we are doing. First, mid-levels are offering safe, cost-effective
care to people across the State, opening up access to dental care to
people who otherwise would have struggled to find care. I myself am
seeing over 50 patients a month. Second, no longer will seeing a
dentist be the only means to entering the dental system. Traditionally
the only way a patient could seek dental treatment was to first see a
dentist but with Minnesota's legislative changes it is now possible for
advanced dental therapists to assess and treat dental pain without the
patient first having to see a dentist. This means schools, nursing
homes, community centers, really anywhere with a power source can
become a place to receive dental care. Advanced Dental Therapists are
also able to assess and refer not only to our collaborating dentist but
also to specialists if the needed treatment is outside our scope of
practice. This enables the patient to get needed treatment faster and
more efficiently. Third, utilizing an already trained workforce of
dental hygienists means getting a dental therapist workforce can be
achieved in a relatively short amount of time. In fact in Minnesota
there are over 5,300 licensed dental hygienists. This is an incredible
and largely untapped resource that can help open access to dental care
not only in Minnesota but across the country. At the same time we have
this large dental hygiene workforce where we are looking at a shortage
of dentists in the very near future with nearly 18 percent of the 3,300
practicing dentists in Minnesota planning to retire in the next 5 years
(appendix D). http://www.mnsafetynetcoalition.org/
For over 50 years nurse practitioners have provided quality, safe,
effective medical care to people across the country, opening up a new
entry point into the medical care delivery system. It is time to do the
same for dentistry. Too many people struggle to enter the dental system
and mid-level providers can be that additional entry point and help
access desperately needed dental care. In addition to opening access,
mid-level dental providers can also help decrease costs. Mid-level
advanced dental therapists are paid far less than dentists therefore
employment at places like Children's Dental Services can decrease costs
and provide safe, quality, effective dental care for those most in
Frankly, it has been tough slugging in Minnesota. I have faced
delays in credentialing, struggles with processing insurance claims,
and as a I work toward my 2,000 hours needed to become an ADT, the
Minnesota Board of Dentistry is still working a process to test dental
therapists to allow licensure as ADT's. Despite the challenges in
becoming and working as a mid-level dental provider but I am proud to
be persevering and so gratified to see the result of our work with
patients suffering from the pain of untreated dental decay and look
forward to continuing to serve those who would likely not have had
access to needed dental care without me. Please do whatever you can to
make it easier to improve access to care through the exploration and
utilization of new types of dental providers in Minnesota and across
Appendix C--Advanced Dental Therapy Courses
This course focuses on the fundamentals of epidemiology and the
application of this knowledge to interpreting scientific research
related to health and disease at the population level. The scientific
principles and conceptual framework of epidemiology are presented.
Through the course, the student gains an understanding of epidemiology
as the science of public health and community health nursing and dental
therapy/advanced dental therapy by examining the range of health
problems and diseases affecting diverse cultures, races, and ethnic
Theories and Explorations: Community-Based Intercultural Communication
Theories and Explorations in Community-Based Intercultural
Communication has a global perspective while engaging students in
community-based projects and topics. Theories are learned to help
students develop their ability to apply a comparative perspective to
cross-cultural communication episodes in interpersonal interactions.
Students research topics of interest that evolved out of their own
communities to better understand the social, economic, religious and
political values and practices of a specific immigrant/refugee group.
Through reading and textbook students learn the knowledge and theories
of Intercultural Communication; through library research students learn
in depth about one specific culture's belief system; and students
practice and learn skills needed to engage in respectful and sensitive
communication with others whose beliefs, values, and attitudes are
different than their own through their community-based project.
Health Policy and Leadership
Students achieve a contextual understanding of selected health care
systems, focusing on social, cultural, economic, and political
variables. The U.S. population-based, market-driven system is studied
in depth. Federal, State and local health policy areas of
responsibility are explored. Nursing and dental therapy/advance dental
therapy leadership roles including client advocacy and political
activism are studied. An experiential component includes lobbying an
elected official and exploring nursing and dental roles and issues
related to health policy with an advanced practice nurse or dental
therapist/advanced dental therapist.
Designing for Quality in Health Care (Formerly Research)
This course focuses on clinical and operational excellence and
continuous improvement of quality and safety from the leadership
perspective. Topics include process improvement philosophies and
approaches, process design for quality results, system analysis for
error prevention, program evaluation, measurement and use of data,
responding to less than perfect results, critical communications, and
current topics inpatient safety and quality in health care delivery.
Health Assessment and Oral Diagnostic Reasoning
This didactic and clinical course focuses on the significance of
systemic and oral diseases and their connection to dental patients.
Oral Health Care Practitioner student skills in dental therapy/advanced
dental therapy patient evaluation, assessment, treatment planning
within the context of dental collaborative management agreements, and
consultations/referrals will be emphasized. This course develops a
comprehensive, patient-centered, problem-solving approach to clinical
evaluation, assessment and treatment planning stressing the development
of critical thinking and clinical judgment. Socio-cultural, familial,
environmental, and developmental influences across the life-span will
be considered. In addition, emphasis is on health promotion, disease
prevention, and the management of common oral health problems.
Pharmacological Principles of Clinical Application
This didactic course prepares the Oral Health Care Practitioner
student to provide proper care for patients who are taking medications
and to administer medications as outlined in MN Statute 150A.106 that
complement clinical dental therapy/advanced dental therapy care
delivery. Providing, dispensing, and administering analgesics, anti-
inflammatories, and antibiotics within the context of advanced dental
therapy scope of practice and collaborative management authorization is
a course focus.
Management of Dental and Medical Emergencies
This didactic and laboratory-based course reviews common medical
and dental emergencies that may be seen by dental therapists/advanced
dental therapists in the dental setting, as well as, management
protocols and prevention strategies for emergencies. This course
illustrates the relationship between accurate data collection and
achieving successful outcomes in the management of dental and medical
emergencies. Emphasis is placed on gathering, analyzing and processing
information to develop appropriate action plans.
Community-Based Primary Oral Health Care I
This lecture and laboratory-based course is the first in a series
of courses taught throughout the curriculum that provides learning
opportunities leading to competency in dental therapy/advanced dental
therapy practice. In a simulated setting the course emphasizes
operative dentistry techniques that restore form, function, and
esthetics to faulty teeth with the purpose of contributing to both oral
and general health. The basic principles of tooth preparation and
restoration, and the appropriate selection and application of direct
restorative materials, are emphasized. Focus is on theoretical and
laboratory principles of operative dentistry utilizing direct placement
restorative materials in the permanent dentition.
Community-Based Primary Oral Health Care II
This lecture and laboratory-based course builds upon the concepts
and skills learned in Community-Based Primary Oral Healthcare I. The
laboratory emphasis of the course is restorative dentistry for the
pediatric and adolescent patient in a simulated setting. Course
concepts and strategies include behavior and trauma management;
management of the developing occlusion; oral evaluation, assessment,
and treatment planning within the context of collaborative management
agreements; preventive strategies; and restorative care for the
pediatric and adolescent patient within the dental therapist/advanced
dental therapist scope of practice. Collaborative management agreements
and indications for professional referral/consultation to provide
comprehensive patient care are also a course focus.
Community-Based Primary Oral Healthcare III
Community-Based Primary Oral Healthcare III consists of lecture,
laboratory, and clinical components. The lecture component of the
course is a continuation of previous coursework preparing the master's
student for dental therapy/advanced dental therapy clinical
experiences. The laboratory component provides simulation and dental
laboratory experiences with complex, direct restorative procedures,
repair of removable oral prostheses, and fabrication of preventive,
removable oral appliances. The clinical component of DENH 660 provides
initial experiences in the delivery of dental therapy/advanced dental
therapy services and patient management in the clinical setting.
Implementation of professional referrals and consultations to ensure
comprehensive care is also emphasized. All course components are under
direction of licensed dentists.
Community-Based Primary Oral Healthcare IV
Community-Based Primary Oral Healthcare IV consists of lecture,
laboratory, and clinical components. The lecture component is a
continuation of the curriculum preparing the student for the scope of
practice as a dental therapist/advanced dental therapist. The didactic
and laboratory components provide students with the theoretical and
applied skills addressing the dental therapy/advanced dental therapy
scope of practice related to exodontia and brush biopsies. The clinical
course component offers MS: OHCP students the opportunity to develop
skills in providing primary oral healthcare to underserved patients
across the life-span while under direction of licensed dentists. The
development of professional referrals and collaborations are also
emphasized to manage comprehensive patient care.
Community-Based Primary Oral Healthcare V
This seminar and clinically based course provides the MS: OHCP
student with opportunities to further develop and refine their skills
in providing primary oral healthcare to underserved patients across the
life-span under supervision of licensed dentists. Additional
development and refinement of skills and concepts necessary for the
delivery of dental therapy/advanced dental therapy primary oral health
care services is the course focus. In the clinical setting ethics,
responsibility, and self-evaluation and self improvement continue to be
emphasized, as well as, professional referrals and consultations to
provide comprehensive patient management.
Advanced Specialty Clinic
This seminar and practicum-based course provides the MS: OHCP
student with practical experiences in delivering dental therapy/
advanced dental therapy primary oral healthcare services to special
needs patients in extended campus clinical settings while under the
supervision of a licensed dentist. Patient groups encountered with
special needs may include: pediatrics, geriatrics, medically
compromised, patients with genetic and/or acquired disabilities and
financially or motivationally impaired patients.
Advanced Community Specialty Internship
This seminar and practicum-based course offers in-depth experiences
providing primary oral health care services to a special needs patient
population of the Masters in Science in Oral Health Care Practitioner
student's choosing. Emphasis will be placed on providing dental
therapy/advanced dental therapy primary oral health care dental
services under the guidance of a supervising dentist for one of the
following underserved populations: pediatric; geriatric; medically,
mentally, or psychologically compromised patients; financially and/or
motivationally impaired patients. Competent, professional dental
therapy/advanced dental therapy treatment requiring consideration
beyond routine approaches and the comprehensive management of patient-
centered dental problems is a focus.
Comprehensive Competency-Based Capstone
This course is the culmination and synthesis of the educational
experiences of the Masters in Science of Oral Health Care Practitioner
student. Integration and application of independent critical thinking
and problem solving skills, professional attitudes, ethics, sound
clinical judgment, and primary oral health care skills are essential to
dental therapy/advanced dental therapy practice success and will be
demonstrated through clinical practical experiences. A final scholarly
paper and poster presentation focuses on a topic relevant to dental
therapy/advanced dental therapy practice and will demonstrate the
writing and communication skills necessary for the Master of Science
Senator Sanders. Thank you very much, Ms. Fogarty.
We've been also joined, in addition to Senator Franken, by
Senator Bingaman, who has long been interested, I know, in the
issue of dental care, and we appreciate him being here.
Let me start off by being provocative, if I might. We have
heard from all of you, I think, and everybody here on our side,
that we have a crisis in this country, that we have millions of
people who don't get to a dentist when they should. We have
people who are suffering. We have people who get ill because of
In your judgment, and I'll start off with Dr. Edelstein and
go on down the line, has the American Dental Association or
State dental societies been aggressive in standing up and
saying we have a problem and, as the professionals dealing with
this issue of dentistry, we're going to solve this problem? Has
the American Dental Association or State dental societies
stepped up to the plate and done what they have to do to
protect the dental needs of the American people?
Who wants to start off on that one? Dr. Edelstein or anyone
Mr. Edelstein. My personal involvement in public policy to
address the issues that you've raised began after working as a
Senate staffer on the original SCHIP legislation, and I noted
at that time the absence of attention by my associations to the
issue of access equity and the consequences thereof.
As a member of the American Dental Association who receives
their publications on a regular basis, I can't help but notice
the tremendous increase in attention that the organizations
bring to their members about the problem. I think we have
turned the corner on organized dentistry's recognition that
there is a significant issue.
There certainly has been collaborative effort by multiple
organizations, child health organizations, health
organizations, hospital organizations, safety net
organizations, and dental associations in addressing some of
these issues through legislation, in particular a terrific
coalition that was created around the enactment of the CHIP
reauthorization, and I want to recognize Senator Bingaman for
his tremendous leadership in these oral health provisions.
In direct answer to your question, I would say that there
is a tremendous increased awareness and much work to be done.
Because we need the dentists to deliver the services so often--
again, we can't work without the dentists--it's critical that
they be actively engaged.
Senator Sanders. Any other comments on that?
Ms. Fogarty, in Minnesota, have you had the cooperation of
Ms. Fogarty. If I may, I'm going to speak very candidly.
Senator Sanders. Please.
Ms. Fogarty. The Minnesota Dental Association, and the
American Dental Association for that matter, have been
staunchly opposed to mid-level providers. And in Minnesota
particularly, when we were fighting to get this legislation
passed, the American Dental Association, instead of funneling
thousands of dollars into trying to find solutions into the
access to care issue, they funneled thousands of dollars in
Minnesota to fight mid-level practitioners, particularly dental
The original legislation was actually intended to be, just
as I am, founded in prevention, founded from hygienists, and we
wanted to create an advanced practice dental therapist or
dental hygienist, which was the original title. Many
compromises were made, as whenever you're doing new legislation
there is, and ``therapist'' was what we came up with for a
final title. But the only reason that we have dental therapists
and not exclusively advanced dental therapists who also have
licensure as dental hygienists is because of the dental
association and the University of Minnesota.
And I think that foundation in prevention, as you heard
from everybody on this panel, prevention is where we want to
get so we're preventing disease and not just treating it. And
if you create a practitioner who only treats diseased teeth,
you're missing a great big piece of that picture, and it was
organized dentistry who fought to make sure that we had
practitioners who had no foundation in prevention.
Senator Sanders. OK. Dr. Folse, do you have any thoughts on
Mr. Folse. Yes. As I mentioned, there was a ferocious fight
in my State over the mobile portable care that I provide in
schools. There was even a bill that was backed by the Louisiana
Senator Sanders. Say that again. The dental society opposed
a mobile dental clinic for low-income children?
Mr. Folse. Yes. They opposed my portable dental practice in
Louisiana that goes into schools and treats patients that
actually don't have dentists. I researched the Medicaid rolls
and made sure that they don't have a dentist of record for the
last 12 months.
From that fight, however, we learned a lot of things. They
are not prepared to continue fighting those access models and
have re-engaged with me to some degree in helping me to do it.
The Louisiana Dental Association did promise a plan to address
the same things that I'm doing, which hasn't occurred.
While I was fighting in Louisiana on the ground level to be
able to continue to provide services, the bill actually banned
the practice of dentistry on school grounds. While I was
fighting there to do that, the American Dental Association on
the other hand, on a national level, was looking into what I
was doing and backing me. They brought me up to a Medicaid
symposium as an expert. I presented on my program, and it's
been recommended as a viable model to go across the State.
So you've got some differences there in the philosophies. I
don't think that we'll see another battle like we had in
Louisiana anytime soon.
There is one other thing that goes on, though, that's of
major importance, and that are the dental regulatory boards. A
dental board can set up regulations that will stop this access
to care. Right now, to get informed consent on all of these
patients, which is a major issue, if I have to call all of the
families of the children that we treat, I'm looking at a 40 to
45 percent connection rate to the family. That's not talking to
a parent to get consent. That's connection rate. So the most
vulnerable children, those families that don't have phones,
that the parents don't answer the phone call, if you require a
phone conversation with that family, you'll never treat the
What we use is a general written informed consent that the
family signs, and it's got all the medical documentations that
we need, and it allows care to the most vulnerable children
that are out there. A board can regulate that out and stop me
from seeing the most vulnerable.
Senator Sanders. Thank you very much. My time is over. Let
me give the mic to Senator Mikulski.
Senator Mikulski. Well, I want to thank you all, each and
every one of you, for what you're doing every day to make sure
the needs of vulnerable populations are taken care of. We've
talked about children. We've talked about people in nursing
homes. We've talked about the blind. We've talked about special
needs. These aren't the lucrative, prosperous and pampered
patients that are looking for cosmetic super-whitening. Nothing
wrong with that, but you really obviously are very duty-driven
people, and we want to thank you for what you do.
Dr. Edelstein, we talked in Baltimore, so I'm not going to
ask you questions. I really want to go to Ms. Fogarty and Dr.
Ms. Fogarty, what you're talking about really sounds like
an innovative way to support the dentist. The dentist will
perform certain procedures that only a dentist can do, but not
everything the dentist does can only be performed by a dentist.
And doesn't this parallel pretty much the battle the nurse
practitioner/physician assistant movement went through 40 years
Ms. Fogarty. Yes, same battle 40 years later, a different
part of medicine.
Senator Mikulski. And yet in any modern practice,
clinicians value what a nurse practitioner or a physician's
assistant can do, and it hasn't resulted in the loss of
prestige, power, or income to doctors. Is that correct?
Ms. Fogarty. Right. In fact, I've heard many doctors say
they don't know what they would do without their nurse
Senator Mikulski. So I would hope that as for you and your
efforts, there are lessons learned from winning those battles,
and for the American dental establishment to take lessons
learned from this incredible workforce social movement.
Now, what States license your level of practice?
Ms. Fogarty. Minnesota is the only State. Well, I shouldn't
say that. Minnesota is the only State that has this type of the
advanced dental therapist. Alaska does----
Senator Mikulski. Are you licensed to do this?
Ms. Fogarty. I am licensed to do dental therapy currently.
I'm completing my 2,000 hours so I can become an advanced
Senator Mikulski. What I need to know is this. I know what
a nurse practitioner is.
Ms. Fogarty. Yes.
Senator Mikulski. And you have a license to be a nurse. A
person can get a nurse practitioner, OK?
Ms. Fogarty. I'm licensed to do dental therapy in the State
Senator Mikulski. But tell me, is this the mid-level care?
Ms. Fogarty. Yes.
Senator Mikulski. I don't want to get lost, because people
won't know the distinction between dental therapy and dental
hygienist. It's a very confusing terminology.
Ms. Fogarty. Correct.
Senator Mikulski. That's not a negative comment. But if
we're going to be advocates, we've got to speak in plain
English to win the support of the people.
Ms. Fogarty. Correct.
Senator Mikulski. We're never going to win the support of
the establishment until the establishment knows it can benefit
their practice and their pocketbook. You solve those two
problems, you solve their willingness to support you.
Ms. Fogarty. I carry both a license as a dental hygienist
and as a dental therapist. I have dual licensure.
Senator Mikulski. So what I'm looking for is--so Minnesota
is the only one. So other States who might want to adopt this,
you're the only one. Or if we wanted to have Federal
encouragement in this area, Minnesota is the only one?
Ms. Fogarty. Correct.
Senator Mikulski. And is that because of this stymieing
from the establishment?
Ms. Fogarty. I can't speak to other States. I just know in
Minnesota it was quite a battle against organized dentistry.
Senator Mikulski. So where did you get your training? At
the dental school? Where did you get your training?
Ms. Fogarty. I got my training at Metropolitan State
University in collaboration with Normandale Community College.
The University of Minnesota has a different type of program for
a different type of licensure.
Senator Mikulski. So is this a universally recognized
Ms. Fogarty. It's an accredited program, yes.
Senator Mikulski. Which can be duplicated and replicated in
Ms. Fogarty. Absolutely, absolutely.
Senator Mikulski. Well, Mr. Chairman, I think my time is
really almost up on this. The reason I pursued this was there's
not going to be enough dentists to go around, and no matter
what models we adopt, and there are several here, we're looking
at the community public health. If you live in a food desert,
your only access is to cupcakes and fried chicken, you're going
to have other issues, for children or adults. So we have to
look at other models.
This is a promising model, and we have lessons learned from
the nurse practitioner/physician's assistant that as a movement
became programs that I think have really helped, particularly
in the area of primary care.
Senator Sanders. Yes.
Senator Mikulski. I would hope that we could look at
lessons learned, talk with you about how we can encourage this,
and encourage dental schools and so on to do it. And for our
dental establishment, I would hope they would look at what
other modalities benefited from practitioner physician's
assistant, because it did not affect their power, it did not
affect their prestige, it did benefit patients which we're sure
every clinician is connected to, and it didn't shrink their
Ms. Fogarty. Correct.
Senator Mikulski. Isn't that kind of what it is?
Ms. Fogarty. That's exactly what it is.
Senator Mikulski. Thank you. Dr. Folse, what you're doing
really warmed my heart. When you talked about your patients,
you can see you clearly love them, and that's why they love
you. But you show them love every day with your big smile and
making sure they have one, and that's true of everybody here.
And by the way, if I could tell the rest of the story about
Deamonte, his mother was a woman of modest means, but after the
tragedy of Deamonte she made sure she got her education. She's
a dental hygienist today.
Senator Sanders. Is that right?
Senator Mikulski. Isn't that a sweet ending to the story?
So let's have more sweet endings with big smiles.
Senator Sanders. Thank you, Senator Mikulski.
Statement of Senator Bingaman
Senator Bingaman. Thank you very much, Mr. Chairman.
Let me ask Dr. Folse, I'm very interested in your children
model, vulnerable children model. How are you reimbursed for
those services in schools?
Mr. Folse. Through Medicaid.
Senator Bingaman. Medicaid in Louisiana provides a level of
reimbursement. Is it an adequate level of reimbursement to
cover your costs, or not?
Mr. Folse. It is an adequate level of reimbursement. It's
gone down the last couple of years, but we're still making a
viable go of it.
Senator Bingaman. Are you the only one in Louisiana doing
this in the schools with a mobile unit?
Mr. Folse. There were more before the issues occurred, but
now there are, I believe, three other FQHCs that are providing
portable care. I think there are 12 portable permits that have
been applied for and given by the State Board of Dentistry.
Senator Bingaman. And what about in other States? Do the
FQHCs in other States do this as well? I'm not familiar with
this kind of a mobile unit going into the schools on a regular
basis in my State.
Mr. Folse. I'm not the one to ask that about FQHCs. I've
heard of others in other States doing it, but I don't have data
Senator Sanders. Mr. Whitmer, did you want to respond to
Senator Bingaman. Yes, please go ahead.
Mr. Whitmer. I can add some comment to that. In Vermont,
there are five FQHCs that have banded together and operate a
mobile van. They receive some funding to help from the Ronald
McDonald House, and the van pretty much travels around to the
different communities and schools throughout the area providing
services where it's needed.
Senator Sanders. Senator Bingaman, without taking your
time, I would also point out that in Vermont we now have four
school-based clinics where we have chairs in schools, in the
schools, not mobile clinics, and they're working phenomenally
Senator Bingaman. That's great. As part of the service that
you provide in the schools--I was briefed at one point on some
type of a sealant that is put on kids' teeth at a certain age,
and this was something that some States were trying to do for
all of their 3d graders or all of their 6th graders or
something. Is that anything that's gone on in Louisiana,
anything you're involved in, Dr. Folse?
Mr. Folse. Yes. In my practice we provide sealants, age
appropriately, on all the children that we see. Additionally,
we do fillings and stainless-steel crowns and baby tooth root
canals and little extractions. It's a comprehensive dental
program. In the space of this table, I can set up a dental
office and do great dentistry for children.
There are sealant programs that are run by the Department
of Health in-hospital as well, and we work in conjunction with
them where we go into a school and are doing the comprehensive
care. They don't do the sealant programs there. We make sure
that we don't--there's plenty of work for everybody to do, and
so we work together on those issues.
Senator Bingaman. I guess one obvious question is where is
the initiative coming from to get these services provided in
the schools? Is it something that the State of Louisiana
decided, OK, we're going to do this, and let's find some
dentists who want to participate and got in touch with you, or
is this something you initiated?
Mr. Folse. In the State, I initiated it and approached
different school districts with the idea. At first I didn't
know if it would be a viable model, and the response was pretty
overwhelming. We're in the New Orleans area, the Baton Rouge
area, and the Shreveport area and surrounding parishes, and
weekly different schools are calling us, asking us to go in.
My limiting factor is manpower in having enough dentists
working for me. Roughly 15 dentists work part-time. Some work a
day a week. I think I have three full-time dentists now.
Senator Bingaman. It does seem as though if you're looking
for cost-effective ways to provide useful health care, this
kind of a program for kids in schools, where you could line up
the kids and provide the services to a lot of kids at one time,
it would seem like this would qualify.
Mr. Folse. It's a wonderful program, and I think the most
important part of it, besides the oral health education that we
do for each child, is that we're treating the vulnerable, those
that aren't going to get seen elsewhere. And when you can focus
on that population, you've really done something.
Senator Bingaman. Thank you very much. My time is up.
Senator Sanders. Thank you, Senator Bingaman.
Senator Franken. Thank you, Mr. Chairman, for inviting me
to attend this important hearing today. I'm very proud that my
home State of Minnesota is the first in the Nation to create a
license for mid-level dental providers called dental
It's my understanding that most other developed countries
have dental therapists. Is that right? Does anybody want to
jump in on that?
Ms. Fogarty. Yes, that's true. The vast majority of Europe
has dental therapists--New Zealand and Australia. The dental
therapists that they have in Alaska are the dental aide
therapists. They were actually first trained in New Zealand.
Senator Franken. Right.
Ms. Fogarty. And they've been active----
Senator Franken. We had a hearing about them in Indian
Affairs, and they were doing remarkable work. In villages, in
Native villages in Alaska, these small villages, they would not
see a dentist for a year, and once a year a dentist would fly
in and do some dental work. Instead, through BIA, they trained
these dental therapists in New Zealand and then they went back.
These were Native peoples in Alaska, and it made a tremendous
difference because then your dental therapist could see the kid
in the store and say, ``Oh, brush your teeth every day.'' You
know what I mean? I mean, that's important, right? And it's
somebody they know. It's not the dentist that flew in.
Thank you, Ms. Fogarty, for coming into Washington to
The Institute of Medicine recently reported that many
Americans have trouble getting access to dental care,
particularly those in rural areas, children, older adults, and
racial and ethnic minorities. Just tell me how are dental
therapists such as yourself uniquely able to help meet the oral
needs of those often under-served and overlooked populations?
Ms. Fogarty. Well, the No. 1 thing that we're doing is
we're adding to the workforce. And it's been said again and
again, there aren't going to be enough dentists. We have to
find new modalities to be able to get access to care.
Currently, I am seeing probably about 50 patients a week.
Many of them I'm triaging and funneling into either hygiene or
doing the work myself, or if it's something beyond my scope of
practice, I'll get it referred to the dentist.
But much to the question Senator Bingaman said is our non-
profit organization at Children's Dental Services, we have over
150 offsite locations doing much of the same type of work in
the metropolitan area, and over 250 statewide. So we're going
into schools, into community centers, and for me, once I become
an advanced dental therapist, I can go to those schools and be
the primary caregiver for everyone in that school. There will
be very little in this population that I can't complete onsite
at a school without a dentist present. So if that's not opening
up access to care, I don't know what is.
Senator Franken. And you're an advanced dental therapist.
Ms. Fogarty. I'm training to be an advanced dental
therapist. I have to complete my 2,000 hours before I'm
licensed. Currently I am working with a dentist in the office.
But after 1 year of full-time work, I do work full-time, that
Senator Franken. Ms. Gehshan, same question. How are you
able to serve these under-served communities or people?
Ms. Gehshan. Well, I work for the Pew Center on the States,
and our project supports campaigns in a number of States to
help them develop new workforce models. We're currently working
in California, Maine, and New Hampshire, and we helped out in
Minnesota when the legislation was passed in 2009.
We don't advocate a one-size-fits-all answer, because the
needs are different in States and they have different resources
to build on. Some, for instance, have a shortage of hygienists,
so a hygiene-based model might not make sense. Some States lack
training programs. In New England, for instance, there may have
to be a regional approach to train new types of providers.
But it's very clear that new providers could augment the
care that the current dental system provides and are critically
necessary, and the evidence supports it. What we hope will
happen is that Congress will put funding into the Alternative
Workforce Demonstration Program that was created in the
Affordable Care Act. It would be the best way to get objective
evidence about how to use the new models to actually reach
those who are outside the system, not to compete with dentists
but to just make sure that everyone has access to quality care.
Senator Franken. I'm running out of time, but your
recommendation would be, and I kind of hear that the panel's
recommendation would be that in light of the fact that a lot of
dentists are going to be retiring and we're going to have a
workforce shortage in dentists, that this model of the middle-
level dental therapist, that every State do what Minnesota is
doing. Is that fair to say?
Mr. Edelstein. Yes. If I could, I'd like to put the
workforce issue in the context that we at the Children's Dental
Health Project have been working on for the last 15 years.
Recognizing that workforce is a critical element, we carry what
we call our five buckets. Workforce is one, the safety net is
another, coverage and financing a third, prevention a fourth,
and surveillance to find out what's working and what isn't a
So I would suggest that it is a multifaceted problem. It's
a systems delivery problem, and those are only on the delivery
side. There are also the issues of engaging families with
health education and motivation to participate in their own
care, but most of all to make sure that the benefit of
prevention really reaches people because, as I mentioned
earlier, the legislation is already there to address this
comprehensively. Workforce is an important piece of it, but
right now Congress is focused on the coverage piece, and the
coverage is essential if we're going to get people into chairs.
Senator Franken. Well, I think that's an impressive bucket
And I thank you, Mr. Chairman.
Senator Sanders. Senator Franken, I'm going to do another
round of questioning, and you're more than welcome if you have
Senator Franken. I think I have to go to Judiciary.
Senator Sanders. OK. Thank you.
Senator Franken. But thank you all. Thank you for all your
Senator Sanders. Thank you.
We have heard about the problems, and we have talked about
some solutions. Let me discuss one area where I think there's
great potential, and we're seeing it working out in the State
In recent years, we have seen a significant increase in the
number of Federally Qualified Health Centers. We've gone from
two to eight, and we now have nine FQHC dental practices in the
State. As I go around the State, including to Mr. Whitmer's
organization in Rutland, what we are seeing is just beautiful
state-of-the-art dental facilities that are taking a whole lot
of folks. In fact, in Vermont, a State of about 630,000 people,
we now have 25,000 people getting their dental care through
Mr. Whitmer, I've been down to Rutland on a number of
occasions, and I remember that small practice. Talk a little
bit about the need that you saw in Rutland County when you
opened the practice and what's happened since.
Mr. Whitmer. Well, it truly was a case of ``if you build
it, they will come.'' We certainly saw the critical need for
dental access, but as a new and fledgling FQHC, we didn't even
know what we didn't know about dental care at the time, but we
knew we needed to try to do something.
We actually got donated equipment, rented a retiring
physician's practice and really, I guess they would call it,
cobbled together a quaint dental practice, and I'm not
exaggerating the fact that within 30 days it was beyond
It was truly amazing because that initial clinic was
staffed with three recently retired part-time dentists, and all
of them, over the course of--after we'd been doing it for a
while, had remarked--I usually met once a month with all the
dentists, and they all remarked that it was some of the most
rewarding work that they'd done in their career, probably the
most rewarding time of their career, and the stories of
individuals that were just so grateful and thankful for the
care that they had received and the difference that it made in
I mean, you just can't over-state the impact of somebody
that has really gone without teeth, unable to really afford or
find a place to get dentures, and something that is as simple
as getting dentures that not only allows them to eat better--I
mean, if you eat without teeth, you have to eat certain kinds
of foods. You're not able to really even eat a balanced diet.
It has impact on nutrition and everything else.
But more than that, just the self-respect and image, the
change in their self-image that was evident in these patients
was truly, truly heartwarming, and it really was kind of the
genesis for us to really make the decision that we needed to do
whatever was necessary to expand the access; because, quite
frankly, the dental services have a net financial negative
impact on our practice, and we provide the service because
there is a critical need, and because we really do believe, as
has been said by others on this panel, our system, not only is
there an access problem, but our system is created so that, I
would call it--well, I don't want to say squandering, but we're
certainly not using the resources that are being spent toward
dental care in the most effective manner. And done in an
appropriate fashion, we could certainly do a better job and get
a lot more people healthy.
Senator Sanders. Now, I know that you have moved out of
your quaint old office into a new office with new chairs. Do
you have a waiting list there? Are people coming to that office
Mr. Whitmer. We've certainly expanded. We've more than
doubled the capacity in that clinic, and at this point our
limiting factor--we've talked about the workforce. Our limiting
factor is recruiting new additional dentists to be able to
provide those services.
Senator Sanders. OK. That takes us to another area which
I'd like to go. Generally speaking, dentists make a decent
living. I mean, their incomes are pretty high. Why is it that
we have actually a dental shortage in this country? Before we
even get to the issue of dental therapists, let me just start
off with dentists. Why do we not have enough dentists? I know
that in Vermont, and I suspect around the country, FQHCs
struggle to bring dentists in. We have tripled funding for the
National Health Service Corps. That's helped, but we've got a
long way to go.
So why do we have a shortage of dentists in this country?
Who wants to take a shot at that one?
Ms. Gehshan. I'll take a shot at that one. The supply of
dentists ebbs and flows over time. In the 1970s and 1980s there
was the biggest crop of new dentists trained and graduating and
entering the workforce, and they are the ones that are
beginning to retire now in larger numbers. But there also was a
recession back then which led to pressure to close a number of
those dental schools, and only now, because of how high the
incomes are for dentists, are there new dental schools cropping
The only thing that I would say about it, though, is that
there's no evidence whatsoever that shows that if you add more
dentists to the system, we're going to reach the one-third of
the population that's outside, because most of them are
practicing in good faith to the best of their ability but in
the system that they inherited, which largely takes care of
insured and private-pay patients who don't need very much.
And so where we need innovation and where we need the
alternative workforce demonstration programs is to think about
new delivery systems and a wider array of providers to reach
Senator Sanders. Well, you were very generous in what you
said. But the bottom line is, I think translated into hard
English, is you've got many dentists who are not treating low-
and moderate-income people. Is that what you're kind of saying?
Ms. Gehshan. Well, yes.
Senator Sanders. My understanding is, and somebody correct
me if I'm wrong, that just about 20 percent of dentists in this
country will treat people with Medicaid. That's a fact, is it
Ms. Gehshan. Senator, that's true. I do think that Medicaid
is something of a mess. I think everyone would admit that. The
rates are too low. Some of the policies that States adopt are
designed to make it hard for both providers and for patients to
get in, and case management would help enormously. There's
research that shows that if you pay for case management,
patients are less likely to not show up for an appointment.
But I think that many of those are policies that we could
really address. I mean, the Institute of Medicine recommended a
number of changes in dental education so that we start
producing different types of dentists who are more likely to
serve under-served patients.
Senator Sanders. Dr. Folse.
Mr. Folse. Yes. I'd like to address this in the context of
the aged, blind, and disabled, and the cost for me personally
when I started this practice back in 1992, with no funding from
Medicaid except for denture care, which I think was very low at
the time for a set of dentures. I suffered greatly for probably
15 years in this practice as far as income, probably the lower
10 percent of dentists as far as my income is concerned.
Without the infrastructure present, I would probably still
be doing it because I'm called to do this. This isn't really a
choice for me. The advent of my understanding of the incurred
medical expense allowances has finally put some income for the
services that my patients need. A recent graduate coming out of
dental school that wants to do this kind of care that doesn't
know about the IME is going to be facing the same things I
faced 20 years ago, and it's just a difficult thing. Without
that coverage for the aged, blind, and disabled patients, we
aren't going to get very much diversity no matter who is
providing the care.
So I think, looking at that, and again I talk about the
Special Care Dentistry Act because it focuses funding for the
true vulnerable in the country, the aged, blind and disabled
adult, and if we can get those covered, all the nursing home
patients would be covered, all of the intellectual disability
patients, developmentally disability patients, when they reach
that 21 years old where they've had coverage before and now all
of a sudden they're on the street as far as oral health is
concerned, that bill would take care of all of that and at
least allow us to develop the infrastructure to treat them.
Senator Sanders. Mr. Whitmer.
Mr. Whitmer. You said one comment. I think I'll use an
example that we were fortunate enough to recruit two new female
dentists right out of school this year, I mean wonderful
dentists. They're in it for the right reasons.
But quite frankly, and I was really astounded when I heard
this, and I think you were down there and heard it directly
from them, but each of those dentists graduated with over
$350,000 worth of debt, OK? And without the National Health
Service Corps and the loan repayment that it provides, they
would not--I mean, they really had a calling and were really
interested in serving this population. But without that loan
repayment assistance, they would not probably have been able to
go to an area to be able to serve this population.
I just wanted to give that feedback, that these people are
graduating with sometimes higher debt than physicians.
Senator Sanders. Yes.
Mr. Whitmer. And the National Health Service Corps really
has made a difference for us in being able to recruit those
Senator Sanders. Dr. Edelstein.
Mr. Edelstein. Senator, you've raised both FQHCs and
Medicaid, dentist participation in Medicaid. I wanted to
highlight a program that links the two together.
Because FQHCs become so quickly swamped with patients and
have to pedal hard to try to keep up with the volume, one of
the solutions that the Dental Health Project, working with HRSA
and CMS and the National Association of Community Health
Centers and the ADA, developed is contracting of dentists to
community health centers. This expands the availability of
services for the FQHC. The patient remains the responsibility
and the patient of record of the FQHC, but it introduces
patients who are vulnerable to private practitioners who may
not yet be Medicaid providers. So it has a number of solutions.
It introduces the Medicaid patient as a person who the
dentist can develop a relationship with on referral of the
FQHC, and it expands the FQHC capacity.
Senator Sanders. OK. Are there any brilliant questions that
I haven't asked that you would like to answer?
I would also mention that Senator Jay Rockefeller, who has
long been interested in this issue, has given us a statement
that we'll put into the record.
[The prepared statement of Senator Rockefeller follows:]
Prepared Statement of Senator John D. Rockefeller, IV
Mr. Chairman, I want to thank you for holding this hearing
on the dental crisis in this country, a crisis that has worried
me since my days as a 1964 VISTA volunteer in West Virginia
when we worked to bus school children to the dentist. At that
time, many of these children had never had dental care, and
although we have made great improvements, particularly for our
children, we have an uphill climb to get to where we should be.
Dental care is important to overall health--and that's as
true in adulthood as it is in childhood. But sadly, care for
adults and seniors has lagged behind. This is the reason that I
pushed for an amendment to the health reform legislation to add
dental services for Medicare patients--and, although we were
not able to succeed, it's why I'm working on legislation to
make affordable dental care for our seniors a reality once and
As you are well aware, the crisis in access to dental care
is even more pronounced in rural areas of our country such as
the State of West Virginia. Rural areas have fewer dentists per
capita, are less likely to have the preventive advantage of
fluoridated water supplies, and are less likely to have dental
insurance coverage as a benefit of employment.
Just this week, we learned that more Americans are turning
to emergency rooms for basic dental care. This drives up health
care costs and it means that pain and suffering are going
untreated. This backward system can result in tragedies such as
the death of 12-year-old Deamonte Driver 5 years ago. Health
care and dental care should not be a luxury. Let's all work to
raise awareness about the importance of oral health, starting
within the first few years of a child's life to see them grow
into strong, healthy adults.
Thank you, Mr. Chairman, for giving this problem the
attention it deserves.
Senator Sanders. Ms. Gehshan.
Ms. Gehshan. Senator, this is not a brilliant question, but
I do have one more thing to say, which is that one of the
functions of State dental directors, which are funded by the
Centers for Disease Control infrastructure grants that I
mentioned before, is to do planning for the State, and I think
it's really critical that that funding be available for all
States because that actually adds data to these discussions in
States about what the needs actually are and takes it out of
the political realm a little bit. It helps States move forward
on workforce as well as prevention.
Senator Sanders. This is an issue that this committee is
going to stay on because I think it's an issue of enormous
importance that does not get the kind of discussion and
attention that it deserves. And there's one other part of the
issue that we did not really go into, and maybe I'll ask that
as a last question, but I want to pursue it in the future, and
that is why dental care is so very expensive.
I mean, the truth of the matter is, if you trip on the
stairs and you knock out a couple of teeth, it's going to take
many, many thousands of dollars to replace those. Why?
Mr. Edelstein. The answer to the question relates also to
the prior question about the training of new dentists. The
reason that so many of those schools closed at that time was
because the colleges and universities found the cost of
providing dental care to be so high. Medical students are
trained in their medicine, basic medical knowledge in the
university, but they get their clinical training in the
hospitals. Dental students have both their basic training and
their clinical training inside the university. The costs are
tremendous for delivering that care, and as Mr. Whitmer
mentioned, it's hard to clear a profit even within the FQHC
model, although with efficiencies that are inherent in the
FQHC, they're doing well.
The same issue relates to the cost of dental care in the
private office. Each office is a complete surgical suite. And
so the tremendous infrastructure costs that accrue to hospitals
accrue also to offices. Now, there are ways around it.
Certainly, Dr. Folse has demonstrated that mobile approach.
There are efficiencies in larger offices. There's a strong
trend in America toward larger group practices. There are
efficiencies to be had.
But the way things are structured at the moment, the
delivery of care is itself very costly, and the demand high,
the supply low.
Senator Sanders. Well, let me just conclude by thanking all
five of you. I think your testimony was great. We're going to
shine a spotlight on an issue that is not talked about, and
we're going to do our best to solve this problem. So, thank you
all very much for participating.
Mr. Folse. Thank you, Senator.
[Additional material follows.]
Prepared Statement of the Academy of General Dentistry (AGD)
The Academy of General Dentistry (AGD) is a professional
association of more than 37,000 general dentists dedicated to staying
up to date in the profession through continuing education. Founded in
1952, the AGD has grown to become the second-largest dental association
in the United States, and it is the only association that exclusively
represents the needs and interests of general dentists. More than
772,000 persons in the United States are employed directly in the field
of dentistry. A general dentist is the primary care provider for
patients of all ages and is responsible for the diagnosis, treatment,
management and overall coordination of services related to patients'
oral health needs.
While patients who avail themselves of dental services in the
United States enjoy the highest quality dental care in the world, many
people are underserved presently. This raises the need to address both
access to care and utilization of care. Access to care refers to the
availability of quality care, and utilization of care refers to the
behavior and understanding necessary by patients to seek care that is
Illnesses related to oral health result in 6.1 million days of bed
disability, 12.7 million days of restricted activity, and 20.5 million
lost workdays each year.\1\ However, unlike medical treatments, the
vast majority of oral health treatments are preventable through the
prevention model of oral health literacy, sound hygiene and preventive
care available through the dental team concept.
\1\ U.S. Department of Health and Human Services. Oral Health in
America: A Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institutes of Health,
National Institute of Dental and Craniofacial Research, 2000. NIH
publication 00-4713. Available from www.surgeongeneral.gov/library/
The AGD believes the role of the general dentist, as leader of the
dental team, is of paramount importance in improving both access to and
utilization of oral health care services. The AGD believes that all
Americans deserve good oral health and oral care delivered by fully
Recognition of the important role oral health plays in an
individual's overall health continues to grow, as for the first time
the Department of Health and Human Services' ``Healthy People'' series,
Healthy People 2020, recognized oral health as a leading health
indicator in the Nation's overall health.
The statement for the record of the hearing submitted by the
American Dental Association provides an excellent discussion of the
many barriers to optimum oral health in this country. AGD will take
this opportunity to focus on two issues: oral health care for children
and the role of the dental team.
ORAL HEALTH CARE FOR CHILDREN
A number of States are working to improve access to dental services
for the underserved. Nowhere is the dental crisis more evident than the
children in underserved populations. While all children covered by
Medicaid and the Children's Health Insurance Program (CHIP) have
coverage for dental services, ensuring access to these services remains
a concern. The AGD is committed to identifying and implementing
strategies for increasing participation by general dentists in
providing oral health services to children enrolled in Medicaid and
Increased participation by general dentists is an integral part of
a national strategy for increasing access to care for children and
their families. Efforts to improve access must include initiatives
designed to address the barriers to bringing more general dentists into
the Medicaid and CHIP programs. In order to increase participation,
there first is a need to better understand the barriers to
participation before strategies for overcoming these barriers can be
developed. A part of this process is to facilitate a robust discussion
between those who currently participate in providing Medicaid and CHIP
services and those who either do not or do so on a very limited basis.
To better understand the role of general dentistry in these
programs, AGD, in 2011, surveyed the members of the Pennsylvania
Academy of General Dentistry (PAGD). The respondents were asked about
their participation or lack of participation in Medicaid and CHIP. The
survey also asked about incentives that might encourage greater
participation in either or both programs.
Based in part on the survey results, AGD is exploring a possible
collaboration with the Centers for Medicare & Medicaid Services (CMS)
to explore strategies that can be adapted by the States to increase
participation by general dentists and strategies for use by AGD and CMS
to urge greater participation by dentists.
The ability of a dentist to participate in State Medicaid/CHIP
plans is based primarily on the quality of the State plan and adequate
reimbursement rates for dental Medicaid and CHIP programs. According to
research published in the July 12, 2011 edition of the Journal of the
American Medical Association, ``higher Medicaid payment levels to
dentists were associated with higher rates of receipt of dental care
among children and adolescents.''
There are other strategies that if adopted, could increase
participation rates by dentists. Case management (making appointments
for children in the dental office for full exams and assisting
caregivers in overcoming family-related obstacles to care) and
addressing the broad range of issues that dentists have with payors,
for example, would signify huge steps forward.
Additional factors influence dental utilization and access for both
children and adults, including:
Economic barriers, such as a lack of Medicaid coverage for
dental services for adults and an inability to pay for services by
those who do not have dental insurance;
Cultural barriers, such as a lack of knowledge about the
importance of preventive dental care; and
Individual barriers, such as lack of transportation or an
inability to get time off from work.
With the Pennsylvania results in hand, AGD is undertaking a
national survey of AGD members with the same purpose of gaining a
better understanding of the factors that determine whether a general
dentist participates, and to what extent, in Medicaid, CHIP, and other
pro bono services. AGD will also inquire into other practice strategies
being used by general dentists to reach low-income populations and
identify successful involvement by general dentists.
There is a strong cohort of AGD members who provide dental care
through Medicaid and CHIP. We are confident that by working together,
AGD and CMS can increase the size of the cohort and increase the number
of children who regularly see a dentist.
THE DENTAL WORKFORCE
The existing dental workforce model is a proven delivery system.
Comprised of fully trained and licensed dentists, dental hygienists and
dental assistants (expanded function dental assistants in some
States)--the existing dental workforce model is adaptable to virtually
We often hear that there is or will be a shortage of dentists, but
recent studies project that the number of dental school graduates will
steadily increase through the year 2030. The real issue to be addressed
is the staggering cost of a dental education. According to the American
Dental Education Association, upon graduation from dental school, the
new dentist will have student loan debt in excess of $200,000. This
level of debt impacts the individual's career path and limits choices
upon graduation. Many are forced by economic necessity to practice in a
corporate setting rather than going into private practice or practicing
in underserved areas.
Congress should consider expanding and protecting the National
Health Service Corps Loan Repayment Program, by providing recently
graduated, licensed dentists with a cost-of-living stipend and
educational loan forgiveness in exchange for practicing in underserved
communities, lowering interest rates for educational loans, and
creating more general practice and pedodontic residencies to help those
living in underserved areas.
Many groups have offered models intended to provide clinical
services--including surgery--to underserved populations. However, there
is no empirical evidence, other than studies that reach preconceived
conclusions, to support the economic feasibility of training
independent mid-level providers, such as dental therapists, to perform
irreversible, surgical procedures. In fact, it raises significant
concerns about the quality and safety of the resulting dental care
provided to underserved populations. This questionable model has the
strong potential to lead to the establishment of a two-tiered oral
health care system where the poor--especially the minority poor--and
the geographically disadvantaged would be subjected to second-class
care from inadequately trained oral health providers.
To advocate for independent mid-level providers to provide
unsupervised care to underserved patients is not only economically
unfeasible but also ill-advised as it works against the prevention
model. Because underserved patients often exhibit a greater degree of
complications and other systemic health conditions, the use of lesser-
educated providers risks jeopardizing the patients' health and safety.
This approach will provide lesser-quality care to the poor.
The independent mid-level provider model is often compared to
physician assistants or nurse practitioners, generally omitting the
significant differences among those models.\2\ Physician assistants and
nurse practitioners require up to 6 years of post-high school
education, not the 2 years or less suggested for many dental therapist
models.\3\ Surgical procedures are not part of the scope of practice of
medical mid-levels, in stark contrast to the proposed dental mid-level
\2\ American Academy of Physician Assistants. ``What is a PA?''
Retrieved March 7, 2012. http://www.aapa.org/the_pa_profession/
\3\ U.S. Congress. Senate Health, Education, Labor, and Pensions
Committee Subcommittee on Primary Health and Aging. ``Dental Crisis in
America: The Need to Expand Access.'' (Date: 2/29/12). Text from:
American Dental Association Statement for the Record. Available from:
Are we really ready to give up on bringing underserved populations
into the existing dental care system based on the dental team? We are
concerned with the near-obsessive focus on independent mid-levels as
the ultimate solution to access problems. The solution should not be
the creation of a sub-level tier of unsupervised, non-dentists, who
practice outside of the dental team, to diagnose, drill and perform
other dental procedures on the poor or geographically disadvantaged.
This approach would be a disservice to the poor and disadvantaged
There is no single solution that will resolve all barriers, but
progress is being made. As documented by the American Dental
Association in their statement for the record for this hearing,
dentists working with their State and community leaders have been
successful in helping to alleviate barriers. For example, dentists in
Maryland have secured an expansion of dental Medicaid, bringing care
within reach for more of the State's citizens. After the tragic death
of Deamonte Driver, the Maryland Department of Health and Mental
Hygiene convened a Dental Action Committee (DAC). The DAC developed a
dental action plan that included recommendations such as increasing
reimbursement levels, developing a culturally appropriate oral health
message for the target population and training dental and medical
providers to provide oral health risk assessments, among others.
According to data reported to CMS, dentists' participation increased
from 743 in July 2008 to 902 in February 2010 and utilization rates
increased for children enrolled in the program from 31 percent in 2007
to 36 percent in 2008.\4\
The dental team concept provides the patient with a dental home for
continuity of comprehensive care with a focus on prevention and
treatment to forestall or mitigate the need for cost-ineffective
critical care. It also best ensures that the patient will receive
appropriate, competent and safe care.
The AGD believes the role of the general dentist, as leader of the
dental team, is of paramount importance in improving both access to and
utilization of oral health care services.
The AGD is willing and able to work with other communities of
interest to address and solve disparities in access to and utilization
of care across the Nation. We should work together to ensure that all
Americans receive the very best in comprehensive dental care to achieve
optimal dental health and overall health.
Prepared Statement of the American Academy of Pediatric Dentistry
The American Academy of Pediatric Dentistry (AAPD) is pleased to
offer comments to the subcommittee on this important topic. The AAPD
appreciates the subcommittee's focus on this issue and its concern for
improving the oral health of America's most vulnerable children.
Founded in 1947, the AAPD is a not-for-profit membership association
representing the specialty of pediatric dentistry. The AAPD's 8,000
members are primary oral health care providers who offer comprehensive
specialty treatment for millions of infants, children, adolescents, and
individuals with special health care needs. The AAPD also represents
general dentists who treat a significant number of children in their
practices. As advocates for children's oral health, the AAPD develops
and promotes evidence-based policies and guidelines; fosters research;
contributes to scholarly work concerning pediatric oral health; and
educates health care providers, policymakers, and the public on ways to
improve children's oral health. The AAPD's reference manual of clinical
guidelines is the most extensive of any organization in dentistry, and
is the benchmark for promoting the highest quality of clinical oral
health services for America's children. The AAPD wants to ensure that
the best interests of children come first and foremost in any
strategies to address access to oral health care.
Pediatric dentists care deeply about access to care and are
currently serving those with the greatest needs. The AAPD is strongly
committed to improving the oral health status of America's children,
through a variety of advocacy, service, and public education
Pediatric dentists provide a disproportionately greater amount of
care to Medicaid children. According to a recent AAPD survey, over 70
percent of AAPD members are Medicaid providers. This is supported by a
recently published survey which found that pediatric dentists devote
close to 20 percent of private practice delivery to children qualifying
for public assistance programs.\1\ Given the data, one can extrapolate
that 20 percent of the 4,396 average total patient visits provided per
year by the Nation's 5,300 active private pediatric dental
practitioners equals an estimated 4.66 million Medicaid visits per
year. This does not include the significant amount of free care that is
provided by pediatric dentists who find the administrative burden of
Medicaid participation to be too onerous and expensive to be feasible.
Additionally, many pediatric dentists participate in free-care events
such as Give Kids a Smile and Missions of Mercy.
The pediatric dentist workforce is growing and diversified. The
AAPD for the past 15 years has advocated an increase in the number of
pediatric dentists; thanks to congressional support for health
professions training funds (Title VII of the Public Health Service Act)
for primary care dental training, the number of first year residency
positions in pediatric dentistry has increased by 200 over this
timeframe. Nearly 60 percent of trainees are female. A 2008 article
``The Impact of Title VII on General and Pediatric Dental Education and
Training'' presented a comprehensive review of the impact of the title
VII program on general and pediatric dental training.\2\ The main
conclusion was that the program has been important in the growth and
expansion of residency training in pediatric and general dentistry, by
facilitating a more diversified dental workforce and providing outreach
and service to underserved and vulnerable populations. Furthermore,
``As the need for more pediatric dentists and general dentists with
advanced training is expected to continue, title VII's role in
expanding workforce capacity, and in supporting [general dentistry and
pediatric dentistry] curricula, will remain important in the
foreseeable future.'' \3\
The AAPD made significant progress in establishing dental homes for
children in Head Start during the 2007-10 AAPD-Head Start Dental Home
Initiative. Our Regional Oral Health Consultants, State Leaders and
project staff successfully implemented strategies to meet the goals of
the initiative--that every Head Start and Early Head Start child across
the country have a dental home and that Head Start staff and parents
have the information they need to ensure that every child in Head Start
has optimal oral health. Hundreds of new providers were recruited to
provide dental homes to Head Start and Early Head Start children across
the country. New collaborative partnerships were developed at the State
and local level in States that launched the initiative, sometimes
bringing Head Start, dentists, Medicaid representatives and other
stakeholders to the same table for the first time. Most importantly,
families that have struggled to obtain dental care were able to access
a true dental home.\4\ Unfortunately, the Office of Head Start decided
to fold this program into a larger center for health grant and
significantly reduced funding for the dental home initiative. Now, the
agency is back to their prior failed approach of providing
informational resources to Head Start personnel to pass along to
parents/guardians, rather than linking directly with the practicing
community to ensure that Head Start children have access to a dental
AAPD members contribute funds, time and other resources personally
to help disadvantaged children obtain dental care as well as through
our charitable foundation. More than 25 percent of AAPD members have
given to Healthy Smiles, Healthy Children: the Foundation of the AAPD
(referred to as HSHC) at least once during the last 3 years, allowing
the foundation to provide Access to Care grants which have helped over
1.6 million children nationwide to date. HSHC Access to Care grants are
part of a pilot initiative launched in 2009 to provide matching and
challenge grants of up to $20,000 to support local initiatives
providing care to underserved or limited-access children. Originally
established as a complement to the AAPD's Head Start Dental Home
Initiative, the Access to Care grants represent the centerpiece of the
Academy's social responsibility and outreach efforts. HSHC will award
10 additional Access to Care grants in the spring of 2012, totaling
$196,000, and hopes to double the number of grants awarded in 2013.
These Access to Care grants are funding programs such as:
Homeless Children's Oral Health via Herman Ostrow School
of Dentistry University of Southern California
Geisinger Health System Foundation Every Smile Counts (PA)
The Dental Foundation of Oregon The Tooth Taxi Mobile
Indiana Dental Association Born to Smile Program
The Ohio State University Nisonger Center Johnstown Road
Access to Care
Illinois Chapter, American Academy of Pediatrics Bright
Smiles From Birth: An Oral Health Education and Technical Assistance
The AAPD is committed to improving oral health literacy. The
American Academy of Pediatric Dentistry is a proud partner with the Ad
Council and distinguished members of the Partnership for Healthy
Mouths, Healthy Lives coalition that is about to launch a 3-year oral
health literacy campaign. The Ad Council, known for such iconic public
service advertising campaigns as Smokey the Bear ``Only You Can Prevent
Forest Fires'' and McGruff the Crime Dog's ``Take A Bite Out Of
Crime'', will conduct a national campaign to improve children's oral
health. The goal of the 3-year campaign will be to raise awareness and
educate parents and caregivers about the value of good oral health for
their children and how it can be achieved. Additionally, the AAPD has
produced oral health informational resources such as brochures and
videos that are available to anyone at no cost through our Web site.\5\
AAPD members have contributed to the development of statewide
initiatives that have increased access to care. An excellent example of
this is the Access to Baby and Child Dentistry (ABCD) program in
Washington State. A pediatric dentist in each ABCD county or region--or
a general dentist in areas without a pediatric dentist--has been
selected and trained by the University of Washington to identify,
recruit, train and mentor local dentists for the program. These dental
champions are essential partners in ensuring that dentists are well-
trained and valued partners in meeting the needs of low-income young
children in their communities. Almost 1,600 dentists, dental students
and pediatric dental residents have been trained since 1995 to provide
ABCD's early pediatric dental techniques and preventive services to
young children across Washington State. ABCD providers receive enhanced
Medicaid reimbursement for providing family oral health education and
selected preventive procedures, including oral evaluation, fluoride
varnish application, and certain restorative procedures.\6\ AAPD vice
president Dr. Joel Berg was instrumental in the development of this
Additional examples of successful State initiatives include Into
the Mouths of Babes in North Carolina \7\ and the Michigan Healthy Kids
Dental \8\ and Points of Light programs.\9\ Healthy Kids Dental is
available to Medicaid-eligible children in 65 Michigan counties, has
over 300,000 enrollees. Nearly 91 percent of dentists who treat
children in those counties participate in HKD.
Pediatric dentists care for our country's medically fragile
children. Pediatric dentists often treat patients who present special
challenges related to their age, behavior, medical status,
developmental disabilities, intellectual limitations, or special needs.
Caries, periodontal diseases, and other oral conditions, if left
untreated, can lead to pain, infection, and loss of function.\10\ \11\
\12\ \13\ Children with significant childhood illnesses like cancer,
heart disease, and craniofacial abnormalities have treatment
compromised by poor oral health. The role of the pediatric dentist in
private practice and in the Nation's children's hospitals is to provide
dental care to allow life-saving treatment for these children. This is
why in addition to the title VII primary care dental training program,
the AAPD also supports continuation of Children's Hospitals GME
The AAPD recognizes the disparities in oral health across ethnic
minorities and low-income children, and applauds the subcommittee for
shining a spotlight on the issue. The AAPD believes that every child
deserves a healthy start on life, but when it comes to oral health,
many children face significant challenges. Young children in low-income
families tend to have higher rates of tooth decay and have greater
difficulty accessing ongoing dental care. Tooth decay is the most
common chronic childhood disease--five times more common than asthma.
According to data collected for CMS's Early Periodic and Screening,
Diagnostic and Treatment (EPSDT) benefit, only about 38 percent of
Medicaid-eligible children received a dental service in 2008, below the
Healthy People 2010 goal of 56 percent of children having a dental
visit within a year. This is reflected in the October 2010 CDC Fact
Sheet, Medicaid/CHIP Oral Health Services, which states,
``Despite considerable progress in pediatric oral health care
achieved in recent years, tooth decay remains one of the most
preventable common chronic diseases of childhood. Tooth decay
causes significant pain, loss of school days and may lead to
infections and even death.''
More than one-third (36.8 percent) of poor children ages 2 to 9 have
one or more untreated decayed primary teeth, compared to 17.3 percent
of non-poor children. Additionally:
Uninsured children are half as likely as insured children
to receive dental care.
Untreated dental decay afflicts one-fourth of children
entering kindergarten in the United States.
Low-income and minority children have more dental cavities
than other children.
Less than one of every five poor children enrolled in
Medicaid receives preventive dental services in a given year, even
though Medicaid provides dental coverage for enrolled children.\14\
A study by Larson and Halfon,\15\ using a large national sample,
confirms that those who suffer the most from disease, including dental
caries, have a host of often intractable social issues that would make
consistent provision of established preventive services, by any dental
provider, difficult and in some cases impossible.
A healthy mouth contributes to good overall health. Associations
have been found between oral infections and diabetes, heart disease,
stroke, and low-birth weight babies. Poor dental health damages
children, affecting their development, school performance and behavior.
In extreme cases, poor dental health and its treatment can lead to
serious disability and even death. In finding access to care and
managing chronic pain and its consequences, families experience a
diminished quality of life.\16\
The dental home provides the best dental care. Research indicates
that the oral health care of children is best managed within the
context of a dental office, or ``dental home.'' According to the AAPD
Policy on the Dental Home,
``The dental home is inclusive of all aspects of oral health
that result from the interaction of the patient, parents, non-
dental professionals, and dental professionals. Establishment
of the dental home is initiated by the identification and
interaction of these individuals, resulting in a heightened
awareness of all issues impacting the patient's oral health.''
A dental home:
Is an ongoing relationship between the patient and the
dentist or dental team that is coordinated/supervised by a dentist.
Provides comprehensive, coordinated, oral health care that
is continuously accessible and family-centered.
Is an approach to assuring that all children have access
to preventative and restorative oral health care.
The benefit of dental services delivered within the context of a
dental home is highlighted by Drs. Paul Casamassimo and Art Nowak in
the Journal of the American Dental Association:
``Children who have a dental home are more likely to receive
appropriate preventive and routine oral health care. Referral
by the primary care physician or health provider has been
recommended, based on risk assessment, as early as 6 months of
age, 6 months after the first tooth erupts, and no later than
12 months of age. Furthermore, subsequent periodicity of
reappointment is based upon risk assessment. This provides
time-critical opportunities to implement preventive health
practices and reduce the child's risk of preventable dental/
oral disease.'' \18\
Pediatric dentists provide quality dental care with a high level of
efficiency. Pediatric dentists, on average, spend approximately 92
percent of their time in the office treating patients.\19\ In-office
visits per pediatric dentist average 3.9 visits per hour, 123.9 visits
per week and 5,794.3 visits per year (3.0 patients per hour, 93.4
patients per week, and 4,395.9 patients per year excluding hygiene
visits).\20\ This compares quite favorably with the full-time dental
therapist from Minnesota, who testified before the subcommittee that
she only sees anywhere from 6-10 patients a day.\21\
The AAPD has long advocated for effective dental Medicaid programs.
Medicaid dental programs that reimburse at market-based rates will
succeed in meeting children's oral health needs. The goal is to obtain
high levels of provider participation and patient utilization, with an
increased focus on early intervention and prevention. As noted above,
pediatric dentists have even gone so far as to support litigation
against State Medicaid dental programs that are not meeting Federal
requirements for access. The AAPD believes the Federal Government can
do a great deal to assist the States in improving their programs by
1. The formation of public-private partnerships at the State level
with Federal grants, with CMS making the promotion of such partnerships
a high priority.
States that have been most successful in participation by dentists
and utilization by patients have one thing in common--their efforts
began with a public-private partnership. These partnerships have
addressed the specific barriers to access in each State's program and,
ultimately, to improvement in access to dental services for enrolled
children and adults. This was critical to the success of the ABCD
program in Washington State that was noted above, which involved a
collaboration included the Washington State Dental Association, the
University of Washington School of Dentistry, the Washington Dental
Service Foundation, local health jurisdictions, and others. Since its
inception in 1995, ABCD has more than doubled the percentage of
Medicaid-enrolled babies, toddlers and preschoolers who receive dental
care in Washington State--to more than 4 out of 10 children today.\22\
2. Initiatives to bring many more private sector dentists into the
dental Medicaid program, such as an enhanced Federal medical assistance
percentage (FMAP) to States that make needed changes to their dental
Medicaid programs as provided in the '``Essential Oral Health Care Act
of 2009'' H.R. 2220. This would result in much higher utilization and
the formation of dental homes for a great many more Medicaid
Over 90 percent of all practicing dentists are in the private
sector and--unlike medicine--over 80 percent of dentists are primary
care providers. Efforts to improve access must include initiatives
designed to address the barriers to bringing more of these dentists
into the Medicaid program if access is to improve. All practices,
including private dental practices, must have adequate funding to
remain viable. Reports issued by the U.S. General Accounting Office to
Congress in 2000 \23\ \24\ noted that Medicaid payment rates often were
well below dentists' prevailing fees and that ``as expected payment
rates that are closer to dentists' full charges appear to result in
some improvement in service use.'' Beginning in the late 1990s, several
States moved to increase Medicaid reimbursement levels to considerably
higher levels consistent with the market-based approach advocated
during the National Governors Association Policy Academies. Subsequent
evaluations suggest that Medicaid payments that approximate prevailing
private sector market fees do result in significant increased dentist
participation in Medicaid. States should be given the option of
receiving enhanced Federal matching funds if the State chooses to
redesign its plan in a manner that:
Pays dentists market rate fees;
Eliminates administrative barriers;
Ensures there are enough dentists signed up willing to
provide care; and
Educates caregivers, such as parents and guardians, on the
importance of seeking care.
3. Recommendations to improve CMS oversight of the dental Medicaid
The AAPD recommends that there should be a requirement that dentist
provider organizations such as the AAPD are represented on the CMS
Technical Advisory Group on dental issues. This is a common practice
for private dental insurers, and we believe that CMS needs input from
groups that represent the providers in the field who are actually
The AAPD is also concerned that stagnant Medicaid reimbursement
rates, sometimes a decade without increase, threaten safety net
programs that depend upon a mix of Medicaid patients to allow them to
treat the uninsured. Real costs for these government and non-profit
clinics in many cases have increased at a rate that makes their
While it is always a last resort, in support of children pediatric
dentists have been closely involved with litigation against State
Medicaid programs. Settlements in the States of Connecticut and Texas
resulted in vastly improved Medicaid dental programs, with significant
increases in provider participation and patient utilization. There is
currently a pending lawsuit in Florida--still in trial--that was filed
in 2005 by Florida Academy of Pediatrics and Florida Academy of
Expanding the reach of the current dental workforce: the Expanded
Function Dental Assistant (EFDA) Model allows for increased access
while maintaining the integrity of the dental home. The AAPD advocates
the use of EFDAs to increase the ability of the dental office to serve
populations who have difficulties in accessing dental care. This will
require a change in the dental practice act in many States. An EFDA is
a dental assistant or dental hygienist who receives additional
education to enable them to perform reversible, intraoral procedures,
and additional tasks (expanded duties or extended duties), services or
capacities, often including direct patient care services, which may be
legally delegated by a licensed dentist under the supervision of a
licensed dentist. Since the EFDA practices under the supervision of a
licensed dentist, within the dental home, children are ensured access
to comprehensive care, including restorative services to eliminate pain
and restore function. Additionally, research suggests that the use of
EFDAs can increase the capacity of the dental office. Beazoglou, et
al., in an economic analysis of EFDAs in Colorado, concluded that
private general dental practices can substantially increase gross
billings, patient visits, value-added, efficiency and practice net
income with the delegation of more duties to auxiliaries.\25\
Furthermore, the dental team can be expanded to include EFDAs who
go into the community to provide education and coordination of oral
health services. Utilizing EFDAs to improve oral health literacy could
decrease individuals' risk for oral diseases and mitigate a later need
for more extensive and expensive therapeutic services. Increased access
to screening, preventive services, parent and caregiver education
within the dental home provided by EFDAs, will improve the oral health
of high risk populations and result in a higher percentage of Medicaid-
enrolled children receiving preventive, diagnostic and treatment dental
services. Current research indicates that:
(a) Provision of oral health outreach and case management to
vulnerable populations will increase access to and utilization of
dental services at an earlier stage in the disease process and decrease
utilization of emergency rooms for treatment of oral problems.
(b) On-site oral hygiene instruction (for students and parents) and
case management will increase positive oral habits, leading to a
decrease in the need for expensive treatment services.
(c) Increased early access and positive oral habits will result in
lower costs overall.
The EFDA model utilizes a multi-level, multidimensional approach
and employs strategies that have been effective in improving health and
lowering costs. The following have shown significant promise to meet
the desired outcomes:
Getting children into care early--preferably by the age of
A study in the journal Pediatrics found that preschool-aged,
Medicaid-enrolled children who had an early preventive dental visit
were more likely to use subsequent preventive services and experience
lower dentally related costs. The average dentally related costs per
child according to age at the first preventive visit were as follows:
before age 1, $262; age 1 to 2, $339; age 2 to 3, $449; age 3 to 4,
$492; age 4 to 5, $546.\26\
Enabling providers to incorporate additional parent
education and empowerment activities into their practices, using proven
methods of health literacy.
An increase in early prevention and oral hygiene instruction
provided to children and parents/caregivers would substantially reduce
the overall cost to the system that results from delayed treatment and
lack of knowledge by vulnerable populations of good oral hygiene
practices. This hypothesis is supported by a study of school-based
dental programs in 13 States conducted by Bailit, et al. Review of
revenues and expenses in programs where services were provided by
hygienists with support staff found that screening and preventive
services in schools with portable equipment were financially feasible
in States when the ratio of Medicaid fees is 60.5 percent of mean
Incorporating case management into routine dental care,
based on both socioeconomic and biologic caries risk.
Kids Get Care in King County, WA, links every family with a case
manager who assists the family with medical and dental needs. These
results point to the cost-effectiveness of providing (and paying for)
case management services. The 16 practices participating in the first
year of the Children's Preventive Health Care Collaborative (CPHC) in
2005 achieved an aggregate 91 percent increase in the percentage of 1-
to 4-year-old Medicaid patients receiving fluoride varnishes during a
well-child visit. Fluoride varnish has been demonstrated to reduce
caries by 38 percent.\28\ According to the Washington State Department
of Health, dental care is the most frequent cause for treatment in the
operating rooms of Children's Hospital and Regional Medical Center.
Hospital treatment of this sort can cost $4,500 per child. By contrast,
the cost of three fluoride varnish applications per year per child is
The AAPD strongly believes the recommendations above would have the
most positive impact on improving access to children's oral health
care. Dr. Edelstein's testimony before the subcommittee also raised
important issues that must be considered in the implementation of
pediatric oral health coverage in State health insurance exchanges
under the ``essential health benefits'' provision of the Affordable
Care Act (ACA). Written testimony of the American Dental Association
strongly refutes the argument that creating thousands of dental
therapists is likely to have a positive impact on access. The AAPD will
continue its efforts to promote a dental home for all children,
starting with the first dental visit by age one.
More information is available about the AAPD's clinical guidelines,
and the AAPD Policy on Workforce Issues and Delivery of Oral Health
Care Services in a Dental Home, is available on our Web site.\29\
1. American Dental Association, Survey Center, Surveys of Dental
2. This article was part of an entire issue of the journal Academic
Medicine (November 2008, Volume 83, Issue 11) devoted to title VII
3. The 2- to 3-year pediatric dentistry residency program, taken
after graduation from dental school, immerses the dentist in scientific
study enhanced with clinical experience. This training is the dental
counterpart to general pediatrics. The trainee learns advanced
diagnostic and surgical procedures, along with: child psychology and
behavior guidance; oral pathology; pharmacology related to the child;
radiology; child development; management of oral-facial trauma; caring
for patients with special health care needs; and sedation and general
anesthesia. Three-year programs generally require additional master's-
level research and often prepare trainees for careers in academic
4. The term ``dental home'' refers to an ongoing relationship
between a dentist and patient, inclusive of all aspects of oral health
care delivery in a comprehensive, continuously accessible, coordinated
and family centered way. The AAPD and other professional organizations
involved in children's oral health recommend that a dental home be
established by no later than 12 months of age and include referrals to
dental specialists when appropriate.
10. Acs G, Pretzer S, Foley M, Ng MW. Perceived outcomes and
parental satisfaction following dental rehabilitation under general
anesthesia. Pediatr Dent 2001;23(5):419-23.
11. Low W, Tan S, Schwartz S. The effect of severe caries on the
quality of life in young children. Pediatr Dent 1999;21(6):325-26.
12. Milano M, Seybold SV. Dental care for special needs patients: A
survey of Texas pediatric dentists. J Dent Child 2002;69(2):212-15.
13. American Academy of Pediatric Dentistry. Definition of dental
disability. Pediatr Dent 2009;31(special issue):12.
14. U.S. Department of Health and Human Services. Oral Health in
America: A Report of the Surgeon General--Executive Summary. Rockville,
MD: U.S. Department of Health and Human Services, National Institute of
Dental and Craniofacial Research, National Institutes of Health, 2000.
15. Larson, K & Halfon, N. Family gradients in the Health and
Health Care Access of U.S. Children. Maternal and Child Health Journal
Volume 14, Number 3, 332-42, DOI: 10.1007/s10995-009-0477-yOpen Access.
16. Casamassimo, P, Thikkurissy, S, Edelstein, B. & Maiorini, E.
Beyond the DMFT: The human and economic cost of early childhood caries.
J Am Dent Assoc 2009;140;650-57.
17. American Academy of Pediatric Dentistry. Policy on the dental
home. Reference Manual 2007-8; 29(7): 22-23.
18. Nowak, AJ & Casamassimo, PS. The dental home: A primary care
oral health concept. Journal of the American Dental Assoc, 2002;
19. American Dental Association, Survey Center, Surveys of Dental
20. American Dental Association, Survey Center, Surveys of Dental
21. Testimony of Christy Jo Fogarty, RDH, MSOHP before the U.S.
Senate Subcommittee on Health, Education, Labor, and Pensions
Subcommittee on Primary Health and Aging Hearing on Dental Crisis in
America: the need to expand access February 29, 2012.
22. http://abcd-dental.org/ Accessed February 28, 2012.
23. General Accounting Office (GAO). Oral health: Dental disease is
a chronic problem among low-income populations; U.S. General Accounting
Office, Report to Congressional Requesters. HEHS-00-72, April 2000.
24. General Accounting Office. Oral health: factors contributing to
low use of dental services by low-income populations; U.S. General
Accounting Office, Report to Congressional Requesters. HEHS-00-149,
25. Beazoglou, T, Heffley, D, L. Brown, J & Bailit, H. The
importance of productivity in estimating need for dentists. J Am Dent
Assoc 2002: Volt 133, No 10, 1399-1404.
26. Savage MF, Lee JY, Kotch JB, Vann WF, Jr. Early preventive
dental visits: effects on subsequent utilization and costs. Pediatrics
27. Bailit, HL, Beazoglou, T, Formicola, A, Tedesco, L, Brown, L &
Weaver, R. U.S. State-supported dental schools: Financial projections
and implications. Journal of Dental Education 2008: vol. 72; no. 2;
28. Centers for Disease Control and Prevention Recommendations for
using fluoride to prevent and control dental caries in the United
States. MMWR 2001;50(No. RR-14):.
Prepared Statement of the American Dental Association (ADA)
The not-for-profit American Dental Association (ADA) is the
Nation's largest dental organization, representing more than 156,000
dentist members. The premier source of oral health information, the ADA
has advocated for the public's health and promoted the art and science
of dentistry since 1859.\1\
\1\ The ADA's state-of-the-art research facilities develop and test
dental products and materials that have advanced the practice of
dentistry and made the patient experience more positive. The ADA Seal
of Acceptance long has been a valuable and respected guide to consumer
dental care products. The monthly Journal of the American Dental
Association (JADA) is the ADA's flagship publication and the best-read
scientific journal in dentistry.
Most Americans have access to the best oral health care in the
world and, as a result, enjoy excellent oral health. But tens of
millions still do not, owing to such factors as poverty, geography,
lack of oral health education, language or cultural barriers, fear of
dental care and the belief that people who are not in pain do not need
dental care. Lack of oral health care is especially troubling in light
of the increasing body of knowledge of the interrelationships between
oral health and overall health.
Official recognition of the important role oral health plays in an
individual's overall health continues to grow, as for the first time in
the 30-year history of the Department of Health and Human Services'
``Healthy People'' series, Healthy People 2020 has recognized oral
health as a leading health indicator in the Nation's overall health.
A number of States are working to improve access to dental services
for many underserved. For example, according to information included in
the Pew Center on the States May 2011 report, Vermont has steadily
increased utilization among its pediatric Medicaid population from 48.9
percent in 2000 to 57.3 percent in 2009. This approaches private sector
utilization rates of between 60 and 65 percent. Data on the number of
third graders in the State with dental sealants indicates a rate of
66.1 percent.\2\ In addition, only 2.5 percent of Vermont's residents
live in a dental health professional shortage area. The report
indicates that it will only take one additional dentist to remove the
shortage designation in Vermont.\3\
\2\ The State of Children's Dental Health: Making Coverage Matter,
Pew Center on the States, May 2011, p. 21-22.
\3\ Ibid, p. 23.
The ADA believes that all Americans deserve good oral health and
oral care delivered by fully trained dentists. Early diagnosis,
preventive treatments and early intervention can prevent or halt the
progress of most oral diseases--conditions that when left untreated,
can have painful, disfiguring and lasting negative health consequences.
It is critical to understand that addressing only one or even a few
of the numerous barriers to care is the policy equivalent of bailing a
very leaky boat. Scattershot efforts can provide some measure of relief
among some populations for some time. But ultimately, we as a nation
must muster the political will to address all barriers to care. Not
doing so is a recipe for repeating past failures and missing
opportunities to effect lasting, positive change.
THE MANY BARRIERS TO OPTIMUM ORAL HEALTH IN AMERICA
Studies conducted by the ADA and the American Dental Education
Association indicate that the number of dental schools and graduates
will increase steadily through 2030 and that the number of
professionally active dentists will increase from its current level of
approximately 180,000 to as many as 200,000 over the same period.
(Although many factors can affect so large an undertaking as opening a
dental school, some observers estimate that there will be as many as 20
new schools by 2020). Further, the studies indicate that the age levels
of the dental workforce will even out, in part because the dental
population of baby boomers is retiring at later ages than its
predecessors. This means that the available supply of active dentists
will not suffer the major reduction that is commonly predicted.
Dentist workforce size is not a problem now, nor is it likely to be
in the predictable future. The real problem is where the dentists are
in relation to underserved populations. Put simply, the ADA believes
that access disparities can be greatly reduced by a combination of
getting dentists to the people and getting people to the dentists. Like
any other economic sector, health care is market-driven. This is
especially true with dentistry, whose private practice model has held
up so well because of its proven ability to prevent disease and, when
disease occurs, intervene early with cost-effective treatment. In the
economic sense, the populations in the most common underserved
settings--remote rural areas, Native American communities and inner
cities--cannot support a dental practice because no one is paying
adequately for their care. Even many children who ostensibly are
covered by federally or State-mandated programs live too far away from
dentists who participate in the programs and face transportation
barriers. For adults the problem is compounded by limited or non-
existent coverage under Medicaid and availability of participating
Several proven models exist to alleviate geographic barriers, and
others are being tested. The National Health Service Corps, the Indian
Health Service and the network of Federally Qualified Health Centers
use various combinations of incentives to place dentists in underserved
areas, including student loan repayment. Some States also offer tax
incentives for practitioners working in underserved areas. Some dental
programs join forces with various school or social service entities to
help address the need to provide transportation and other support
services to help patients keep appointments.
Education, Language and Culture
The more educated a population group, the greater the likelihood of
its members having a high degree of oral health literacy. They know how
to take care of their families' teeth and gums, and they seek (and can
afford) regular preventive dental care. They know whether their
community water system is fluoridated and how to compensate for
nonfluoridated water with supplements or topical applications. They
brush regularly with fluoridated toothpaste and use floss.
But too many others simply don't know about basic and affordable
measures for preventing disease. In some cases this relates to lack of
education. Many others have limited English proficiency or may come
from countries and cultures with much lower standards of oral health
than exist here. Some may not be comfortable interacting with people
perceived as authorities. Key to breaking down these barriers is
gaining trust, which can be accomplished through intermediaries from
the same cultures as the target populations or by providing oral health
education to schoolchildren who then can share what they learn with
older family members.
ADDRESSING THE BARRIERS TO ORAL HEALTH
Public Health Interventions
Efforts that emphasize oral health literacy and disease prevention,
such as community water fluoridation, sealant initiatives and school-
linked health education and care programs are critical for improving
the public's health, especially over the long term. Fluoridation, along
with other preventive initiatives such as dental sealant and fluoride
varnish programs, has led to great reductions in tooth decay.
The ADA has been a leader in health literacy, specifically in
dentistry, working alongside private and public colleagues in medicine,
pharmacy, nursing and public health to advance health literacy
improvement. The ADA's National Advisory Committee on Health Literacy
in Dentistry is a group of national and international health
communication and literacy experts who guide the Association's efforts
in this area. The committee has developed a 5-year strategic action
plan, focusing on education and training, advocacy, research, dental
practice and coalition-building. One of the Association's 3-year
strategic goals is to continue to be ``the trusted resource for oral
health information that will help people be good stewards of their own
health.'' The ADA's efforts are noted in the Health Literacy Action
Plan created by the Department of Health and Human Services.
The Centers for Disease Control and Prevention (CDC) has named
fluoridation one of ten most significant public health achievements of
the past century. The ADA actively supports fluoridation as part of its
mission to improve the public's health and dentists strongly believe
community water fluoridation should be a cornerstone of a broad-based
comprehensive integrated strategy for the prevention of tooth decay.
The most recent CDC data indicates that more than 72 percent of
community water sources in the United States are fluoridated. Healthy
People 2020 calls for nearly 80 percent of the population accessing
public water supplies to receive the benefits of fluoridation by the
end of this decade. Fluoridation is a public health measure that saves
money. A study conducted in 2006 concluded that the New York Medicaid
program spent nearly $24.00 less in treatment costs per child in
predominantly fluoridated counties versus counties with little
Safety Net Delivery Systems
Federally Qualified Health Centers
Federal law requires all Federally Qualified Health Centers
(FQHCs), as a condition of receiving Federal funding, to demonstrate
that they will provide dental services to the population served by the
facility either onsite or through a contractual arrangement. The demand
for dental services is also growing and efforts have been underway to
provide support for FQHCs to meet these needs.
The ADA is collaborating with the National Association of Community
Health Centers (NACHC) to increase education among our respective
members on the opportunities that exist for FQHCs to provide dental
services, including the ability of FQHCs to contract with private
dentists in the community to serve their patients. The ADA has also
offered an educational session during its annual session for members
entitled The ABCs of FQHCs. This educational session has been highly
successful and the 2012 session will be the fourth year it is offered.
The National Network for Oral Health Access (NNOHA), the
organization that represents community health center dentists, has
increased its efforts to provide health centers with technical
assistance through a cooperative agreement with HRSA's Bureau of
Primary Health Care. Through this agreement, NNOHA recently completed
webinars on the following topics aimed at improving both leadership and
clinical management of health center dental programs: FQHC dental
program productivity and financial impact; risk management for health
center dental providers; financial management of health center oral
health programs; and how to become an outstanding dental director.
NNOHA also has multiple dental practice management modules available
for FQHC dental programs.
Indirectly, the ADA is a major supporter of NNOHA:
Senior ADA staff serves on their board of directors as a
liaison between private practitioners and those dentists who practice
within health centers;
The ADA provides fiscal support for the National Primary
Oral Health Conference, which provides both leadership and clinical
training for health center dentists; and
NNOHA has been invited to participate in the Dental
Quality Alliance and other activities involving the ADA and other
stakeholders in the dental community.
The ADA promotes opportunities for dentists in FQHCs as
participants in the National Health Service Corps loan repayment
program through outreach with the American Student Dental Association.
This includes part-time opportunities for dentists within health
centers, which helps to promote an interdisciplinary approach to
patient care while allowing dentists to build a private practice and
secure loan repayment incentives.
FQHCs and other health centers may be limited in terms of their
ability to hire a full-time dental director and their ability to set up
adequate numbers of dental operatories. The ADA, NNOHA, NACHC, HRSA and
Safety-Net Solutions continue to strategize on how best to provide
technical assistance to community health centers. The ADA continues to
promote the opportunities that exist within community health centers to
Dental Schools and Dental Residency Programs
Dental schools can also be instrumental in improving the
availability of dental services for communities. Their clinics and
offsite training programs provide needed care to patients who otherwise
could not afford it. The possibility exists that some dental school
clinical practices could expand these services, using their medical
school counterparts' faculty practice model, increasing the numbers of
patients served, creating greater revenues for the schools, and
providing greater clinical training opportunities for students and
residents. Ninety-one percent of schools now require students to
complete a rotation in a clinic or other underserved community setting.
In 2008 through 2009, 57 dental schools reported over 260-average hours
of community-based clinical care provided by their students as part of
their dental education.
Dental schools are employing a number of creative approaches to
provide community outreach and care for the underserved. One such
example is the collaboration of the NYU College of Dentistry and the
Henry Schein Cares Foundation, which places dental students, faculty,
residents and hygienists in clinical settings operated by Caring Hands
of Maine (one of a number of domestic and international sites covered
by the program), in an effort to establish sustainable oral health
systems. Programs like this also offer the ancillary benefit of
bringing students into direct contact with underserved individuals
living in the community who have a demonstrable need for oral health
care and the real impact they can have in providing that care as
practicing dentists. Here again, any such training must be conducted
under the appropriate supervision of fully trained dentists, for the
benefit of both patients and students.
Hospital Dental Residency programs (Title VII of the Public Health
Service Act) provide a disproportionate level of care to the
underserved population. With funding for post-doctoral training in
general, pediatric and public health dentistry, the program has helped
create over 560 new general dentist positions in the past 25 years
(representing 80 percent of such growth) and 200 new pediatric dentist
positions in the past 15 years. In addition, research shows that
optimal funding for title VII dental programs will produce graduates
that are more likely to treat at-risk populations in their practices.
Models for Change in the States
Even under chronic funding constriction, imaginative people have
maximized available resources and leveraged natural allies to
dramatically improve the abilities of existing programs and systems to
deliver care where it is most needed. Just as no two patients are
alike, no two States are alike when it comes to ensuring that the
greatest possible number of their residents receives the dental care
they deserve. The barriers to oral health among the 50 States are just
as varied as the maladies that can send a patient to the dentist in the
first place. They range from a lack of dental insurance, to cultural
and language barriers, to underfunded State programs, to a lack of
understanding about the importance of oral health as part of one's
In the face of this complex challenge, there is no simple, one-
size-fits-all solution. Solutions that would help alleviate barriers to
care in New Mexico, with its large Native American population, differ
from those appropriate to California with its sizable urban and
ethnically diverse communities. That's why, as doctors of oral health,
dentists have been working closely for years with State and community
leaders to address challenges in ways that are most suitable to address
the particular barriers and nature of the underserved populations in
their respective States. And with that approach we have seen success in
In 2006, the Connecticut State Dental Society and a coalition of
oral health organizations successfully convinced the State legislature
to increase Medicaid's commitment to children's dental care and
guarantee a dedicated dental administrator, outside the larger medical
program administrator, commonly known as a carve-out. It didn't take
long for the results of this legislative win to become evident. Prior
to the new legislation, roughly 150 dentists participated in Medicaid;
today more than 1,300 dentists now see children enrolled in Medicaid.
Perhaps more telling is the dramatic increase in the number of children
actually receiving care. In the years following the new legislation,
22,000 more children in Connecticut received dental treatment and
32,000 more obtained preventive care as part of their Medicaid plans.
And as of March 2011, all child participants in Medicaid have access to
at least two oral health care providers within a 20 mile radius.
Maximum wait time for non-emergency appointments is now 20 days or
less; children needing emergency appointments wait no longer than 24
The upshot has been that children are no longer waiting in line for
care at charitable events like Connecticut Missions of Mercy, where
dentists and their teams provide free services to thousands of people
who face various barriers in accessing the dental delivery system. In
fact, the State's dental program manager has commented that Connecticut
no longer has a dental access problem, but rather one of utilization.
And addressing utilization problems calls for better oral health
education and the provision of services to help people access available
More than 2,000 miles away in the southwest, the dental profession
has been working with Native American communities to address their
unique oral health challenges. As part of this ongoing work, in April
2011, the Arizona Dental Association organized the Native American Oral
Health Summit, which brought together tribal leaders, members of the
dental profession, the Indian Health Service (IHS), and other community
and public health leaders. Summit participants collaboratively
developed several common goals, including increased funding for oral
health projects, improved application of IHS resources and the creation
of an education and workforce pipeline that encourages Native American
students to pursue dental careers. Following this successful effort,
State dental associations and Tribal partners are organizing similar
summits in other Native American communities across the country to
develop solutions that address local needs. In addition, dentists in
Arizona were instrumental in the creation of a pilot program that
provides free in-school dental screenings, so that tooth decay and
other oral disease in children can be identified and treated early. In
2011, the Arizona Dental Association Foundation was awarded a grant by
the Dentaquest Foundation, one of 20 across the country, to develop an
American Indian oral health coalition in the State. The goal of these
efforts is to address the challenges this population faces.
Michigan's Healthy Kids Dental (HKD) Medicaid demonstration program
is a partnership between a State Medicaid program and a commercial
dental plan, with the plan managing the dental benefit according to the
same standard procedures and payment mechanisms it uses in its private
plans. The proportion of Medicaid eligible children who saw a dentist
at least once increased from 32 percent to 44 percent in the pilot
program's first year. It also cut the number of counties with either no
dentist or no dentist able to accept new Medicaid patients in half--
from 19 to 10. This model demonstrates how contracting with a single
commercial entity that: (1) has a strong existing dental network; (2)
offers competitive market-based reimbursement and (3) streamlines
administration to mirror the private sector, can substantially improve
access to care for Medicaid beneficiaries. In each succeeding year from
program inception in 2000 through 2007, the proportion of the children
enrolled for 12 months in a calendar year with at least one dental
visit has continued to increase, with the access levels approaching 70
percent in children 7 through 10 years old, by 2007 for HKD counties.
But the dental community recognizes that more can be done and is
working to expand the HKD program to additional counties, which
includes the major urban areas of the State.
Tennessee's TennCare program, which was established in 1994, was
the first attempt by a State to move its entire Medicaid population
into a statewide managed-care system. The impact on dental services was
disastrous. The number of participating providers dwindled from its
1984 level of more than 1,700 down to 386 general and specialist
dentists available to treat the more than 600,000 TennCare eligible
children. In 2002, the legislature enacted a statutory carve-out of
dental services, which mandated a contract arrangement between the
State and a private dental carrier to administer benefits for children
(under age 21). The State retained control of reimbursement rates and
increased them to market-based levels.
The new rate structure, in combination with administrative reforms,
patient case management strategies and a requirement that the carrier
maintain an adequate provider network, has substantially improved
TennCare's provision of dental services. In just 2 years, the
utilization rate among eligible beneficiaries increased from 24 percent
to 47 percent. Though there have not been significant increases since
the carve out was done, as of January 2012, over 950 dentists were
participating in TennCare.
Alabama reformed its State-administered Medicaid dental program in
2000 to reimburse dentists at rates equivalent to those paid by
commercial insurers. (The program still reimburses dentists at year
2000 rates.) The changes included creation of the Smile Alabama!
initiative, which encompassed administrative reforms, a case management
program, and increased outreach to both patients and dentists. As a
result of the Smile Alabama! initiative, there has been a 216 percent
increase (from 151 to 477) in the number of dentists who see more than
100 Medicaid patients a year, while the number of counties with one or
no Medicaid dental provider had declined from 19 to 3 by September
2009. The effort resulted in an 84.3 percent increase in dental
utilization, from 25 percent (103,630) of eligible children in fiscal
year 2001 to 45 percent (190,968) of eligible children in fiscal year
This example, the smallest in scale, is in many ways the most
intriguing, embodying a diverse group of local entities crafting a
solution uniquely suited to local needs. In 2001, in Brattleboro, VT,
Head Start, the State health department, school officials and hospital
administrators collaboratively established a fee-for-service, for-
profit dental center to address the needs of the underserved in a rural
community. The organizers raised $450,000 in 3 months and built a
three-chair, state-of-the-art facility with sufficient infrastructure
to expand to five chairs. Now in its tenth year, the Estey Dental
Center serves both private paying and public assistance patients and
pays a percentage of non-Medicaid revenues to the non-profit
contracting entity (the community partners). In its first 2 years of
operation, the clinic cleared a huge backlog of children with acute and
chronic dental needs and began to increase adult utilization as well.
Maryland and Ohio
Dentists in Maryland have secured an expansion of dental Medicaid,
bringing care within reach for more of the State's citizens. After the
tragic death of Deamonte Driver, the Maryland Department of Health and
Mental Hygiene convened a Dental Action Committee (DAC). The DAC
created a dental action plan, including recommendations such as
increasing reimbursement levels, developing a culturally appropriate
oral health message for the target population and training dental and
medical providers to provide oral health risk assessments, among
others. According to data reported to CMS, dentists' participation
increased from 743 in July 2008 to 902 in February 2010 and utilization
rates increased for children enrolled in the program from 31 percent in
2007 to 36 percent in 2008.
Dentists in Ohio have advocated successfully for the State's local
health departments to purchase portable dental equipment, so that
dentists and other dental professionals can reach patients in nursing
homes, senior centers, schools, clinics and other community centers to
provide onsite dental care for underserved populations. Additionally,
dentists supported the creation of the Ohio Dentist Loan Repayment
Program. The program provides loan repayments to dentists that provide
care in designated underserved areas, as defined by the program, for a
minimum of 40 hours per week to Medicaid-eligible individuals and
others without regard to a patient's ability to pay. Funding for the
program comes from a portion of dentists' licensure fees.
These diverse initiatives share common elements. All of them
utilized existing workforce models. They wrought significant, positive
change through relatively minor funding increases combined with
dramatic changes in administration. Each made it possible for more
patients to receive care from the same population of dentists that
existed before the programs were launched.
Alternative Workforce Solutions
Dental Mid-level Models
Multiple groups have offered models intended to provide clinical
services--including surgery--to underserved populations. They are
largely targeted toward serving people in remote rural areas, with the
justification being that there are not and never will be sufficient
dentists able to practice near enough to those areas to serve their
residents. To a lesser extent, backers of these models also claim that
they will care for other underserved populations, including people in
inner cities and Native American tribal lands.
The designers of these models often cite various dental therapist
programs in other countries in which non-dentists perform such surgical
procedures as ``simple'' extractions, restorations and even pulpotomies
(root canals on baby teeth).
Both of these suppositions fail to withstand scrutiny.
The assertion that no dentists will serve these
populations risks becoming a self-fulfilling prophecy. Advocacy and
Federal finances directed toward experimental programs in which non-
dentists perform surgical procedures undoubtedly will sap resources
away from proven programs--such as the National Health Service Corps,
Indian Health Service, the Public Health Service, loan forgiveness, tax
incentives, and public/private partnerships, all of which are proven to
place dentists where they are most needed.
Claims that the efficacy of therapists has been ``proven''
in other countries are simply deceptive. The mid-level programs in
these countries differ so dramatically in scope of practice,
populations served and degree of dentist supervision, that referring to
them en masse is misleading at best. In fact, if you've seen one
foreign mid-level program, you've seen one foreign mid-level program.
Further, these claims largely lack longitudinal clinical
assessments of health outcomes. We know of no study comparing any
improvements in oral health among targeted populations to the potential
outcomes had the same resources been directed to providing these
patients with care from dentists. They are touted as brilliant
successes with very little empirical evidence to support those claims.
In fact, some evidence shows that countries like New Zealand, Great
Britain and Australia (who allow dental mid-levels to deliver surgical
procedures to children) have poorer oral health index scores than we
have here in the United States.
Dental mid-level models often are compared to physician assistants
or nurse practitioners, generally omitting the significant differences
among those models. Physician assistants and nurse practitioners
require up to 6 years of post-high school education, not the 2 years or
less suggested for many dental therapist models. Surgical procedures
are not part of the scope of practice of medical mid-levels, in stark
contrast to the proposed dental mid-level providers.
Significant differences also are present among various dental mid-
level models, most notably in their proposed scopes of practice and
degree of supervision. They share, however, a critical attribute that
the ADA opposes unequivocally: Allowing non-dentists to perform
surgical procedures, often with little or no direct supervision by
fully trained dentists.
Three mid-level models dominate the current discussion of these
Alaska DHAT Model
The Alaska Dental Health Aide Therapist (DHAT) model was designed
to mirror its New Zealand counterpart. At its inception, program
participants were even trained in New Zealand, in part because the
program's authors could not identify a U.S. dental school that would
participate in training non-dentists to perform surgical procedures.
The program has since worked out a training curriculum with the
University of Washington (although it is worth noting that the
relationship is with the University's medical school and not its dental
school). Now in its fifth year, the Alaska DHAT program is fielding a
modest number of therapists who are providing care.
In a case study released in October 2010, the W.K. Kellogg
Foundation declared the program a resounding success, even as the
study's principal author admitted that the evaluation did not assess
the overall impact of therapists' work. The study also failed to
address the economic basis for or sustainability of the DHAT model.
Kellogg's release of this study was a prelude to its larger
purpose--the rollout of plans to create DHAT programs in five
additional States: Kansas, New Mexico, Ohio, Vermont and Washington.
However, the Alaska program benefited from the Federal Government's
power of preemption, enabling the DHAT program to circumvent the
jurisdiction of the State's legislature, courts and board of dentistry.
Kellogg presumably must convince policymakers in the five targeted
States, each of them with unique rules and policies governing education
and health care, to allow DHAT programs to begin. The foundation has
committed $16 million to setting up the program. It is unclear how much
(if not all) of that sum will go toward the political activities needed
to legalize DHAT practice and how much will be devoted to actually
launching educational and training programs.
Advanced Dental Hygiene Practitioner
The American Dental Hygiene Association (ADHA) has for some years
advocated the creation of an Advanced Dental Hygiene Practitioner
(ADHP), a dental hygienist with a bachelor's degree who, after earning
a 2-year Master's degree, would be allowed to practice independent of a
dentist's supervision. In addition to the existing scope of hygiene
practice, ADHPs would diagnose oral disease, create treatment plans and
perform ``limited restorative procedures,'' including preparing and
placing restorations, extractions and pulpotomies. Like the DHAT, the
ADHP is expected to distinguish between complicated and uncomplicated
treatments and refer the former to a fully trained dentist. Here again,
the ADHA cites the use of various mid-levels in 40 countries as
evidence that a mid-level model will work in the United States, without
acknowledging the great variations in training and scope of practice
among those providers.
Dental Therapists in Minnesota
In 2009, the Minnesota legislature, facing formidable pressure to
enact an ADHP model, opted instead for a compromise worked out with the
State's dental school, in which the school will train two levels of
dental therapists. Dental therapists would graduate from an education
program with either a baccalaureate or a master's degree depending on
the student's past academic achievement. Dental therapists would
practice under the direct or indirect supervision of a dentist when
performing surgical procedures and could perform some non-surgical
procedures without the physical presence of a dentist but under a
dentist's general supervision. Those qualifying for advanced therapist
status must have completed 2,000 hours of practice as a dental
therapist, and have graduated from a master's-level advanced dental
therapy education program. Advanced dental therapists will then be
allowed to perform certain surgical procedures under a dentist's
general supervision with a written collaborative management agreement,
that is, without a dentist actually onsite with the therapist.
The models above share some basic flaws.
The mid-level providers are trained to provide many of the
same surgical services that a dentist now provides after only receiving
a fraction of the education of a dentist. These models have been
proposed to treat the existing underserved communities, who often have
the most complex dental needs.
They overload mid-level providers with more responsibility
than they should be expected to bear. Their proponents consistently
refer to certain surgical procedures, including extractions, as
``simple,'' saying that of course more complex cases will be referred
to dentists. However, fully trained and experienced dentists argue that
mid-levels' training cannot adequately prepare them to distinguish
between ``simple'' and ``complex'' cases. In fact, even fully trained
dentists do not conclusively pronounce a procedure as simple until it
has been successfully completed.
A second weakness rarely mentioned is the mid-level's
questionable ability to distinguish between teeth that cannot be saved
and should be extracted and those that could be saved by restorative
methods beyond the mid-level's training. If your only tool is a hammer,
every problem looks like a nail.
A greater and broader weakness among proponents of mid-
level practitioners is their near-obsessive focus on mid-levels as the
ultimate solution to access problems. Differences in opinion about the
appropriate scope and supervision of various dental team members aside,
arguing so vehemently for any single workforce model, while failing to
place equal or even greater emphasis on the numerous other barriers to
care is either naive or disingenuous. In some ways, these models are a
solution in search of only one part of a problem.
Shifting from the clinical to the policy point of view, we know of
no empirical studies of the economic feasibility of dental mid-levels.
Proponents of these models either imply or assert that care from these
providers will somehow be less expensive than that delivered by
dentists, because they will earn less than dentists. We know of no
evidence to support this. Compensation is a relatively small percentage
of the costs of establishing and maintaining a dental facility. The
difference between the salary of a dentist and that of a therapist or
advanced hygienist would likely be offset by their lower productivity
compared to a fully trained dentist and have a minimal effect on the
overall cost of delivering care.
A Different Approach to Augmenting the Dental Team
The ADA also is piloting a new dental position, the Community
Dental Health Coordinator (CDHC), but one that represents a completely
different philosophy. Modeled on the community health worker, which has
proven extraordinarily successful on the medical side, CDHCs will
function primarily as oral health educators and providers of limited,
mainly preventive clinical services. They help patients navigate the
system, including ensuring that the patient clears the red tape that
can complicate their receiving the care to which they are entitled,
finding dentists, booking appointments and helping to provide critical
logistical support such as securing child care, transportation and
permission to miss work in order to receive treatment.
The CDHC is based on some of the ADA's key principles for breaking
down barriers to care: education, disease prevention and maximizing the
existing system. Rather than focusing strictly on treating disease, the
CDHC provides education and preventive services. At its essence, oral
health education is prevention at the most effective level. Models that
focus exclusively, or almost exclusively, on performing procedures
ignore these critical success factors.
In many cases, underserved populations also face cultural barriers.
This is nowhere more evident than among Native American communities.
For example, in some tribes, the mothers prechew food before giving it
to their babies, which vertically transmits bacteria from the mother to
the baby. Additionally, increasing numbers of people living throughout
the country have limited English proficiency or come from cultures that
lack awareness of basic oral hygiene. CDHCs are recruited from these
same communities, ideally not just similar communities but the actual
communities to which they return and work. This critical factor can
minimize and even eliminate these barriers that, though not often
associated with access to oral health care, can affect it profoundly.
Prevention is essential. A public health model based on the
surgical intervention in disease that could have been prevented, after
that disease has occurred, is a poor model. The Nation will never
drill, fill and extract its way to victory over untreated oral disease.
But simple, low-cost measures like sealing kids' teeth, educating
families about taking charge of their own oral health, expanding the
number of health professionals capable of assessing a child's oral
health, and linking dental and medical homes will pay for themselves
many times over.
ADA Supports Public Health Intervention and Safety Net Delivery
Systems. Public health initiatives such as community water
fluoridation, sealant initiatives and school-linked health education
and care programs are critical for improving the public's health. The
ADA, NNOHA, NACHC, HRSA and Safety-Net Solutions continue to strategize
on how best to provide technical assistance to community health
centers. The ADA continues to promote the opportunities that exist
within community health centers to its membership.
Public-private collaboration at the State level works. Private
practice dentists, who comprise over 90 percent of practicing dentists
(just over 2 percent of dentists practice in FQHCs), will continue to
deliver the hands-on care to most of the population, regardless of
payment mechanism. A number of States have demonstrated that even under
chronic funding constriction they have been able to improve programs by
simplifying program administration, reducing red tape and assisting
patients with related, non-clinical needs. Make it easier for the
dentists to deliver care and the safety net will address the oral
health needs of more patients.
Everyone deserves a dentist. The existing team system of delivering
oral health care in America works well for patients in all economic
brackets. It does not need to be reinvented. Rather, it needs to be
extended to more people. States like Michigan, Connecticut and
Tennessee have shown that there are a sufficient number of dentists in
the country and that adjusting Medicaid payments can have significant
impact to bring them into the already existing system. Creating a
separate tier of care for underserved populations will sap resources
from solutions that already work, and will do comparatively little to
improve the oral health of those in greatest need.
Availability of care alone will not maximize utilization. In too
many cases, people are unable or unwilling to take advantage of free or
discounted care. Many dentists who treat Medicaid patients must contend
with a much greater incidence of missed appointments than they
experience with non-Medicaid patients. These missed appointments
represent erosion of available treatment time that the system cannot
afford to waste. This owes partly to the need for better attention to
social or cultural issues, oral health education, and greater support
for patients who need help with transportation, child care, permission
to miss work or other non-clinical services.
Treating the existing disease without educating the patient is a
wasted opportunity, making it likely that the disease will recur.
Anyone who enters a dental operatory for restorative care should leave
that operatory with an understanding of how to stay healthy and prevent
future disease. Excessive alcohol or sugar consumption can increase the
risk of oral disease. Tobacco use in any form increases the risks for
gum disease and oral cancer. Educating patients about these risks and
how to reduce them should be incorporated into every possible patient
Silence is the enemy. Let's take the ``silent'' out of ``silent
epidemic.'' Virtually every shortcoming in the safety net has at its
root a failure to understand or value oral health. When people, whether
lawmakers, the media or the general public, learn about oral health and
the consequences of oral disease, their attitudes and priorities
change. Awareness is on the rise, but we have far to go before
Americans know enough to make the personal and policy decisions that
ultimately will create a real safety net, one that prevents oral
disease and restores oral health in people who seek healthier and more
Dentists will continue to collaborate with policymakers and members
of the public health community around the country to craft access
solutions that are tailored to local needs and challenges. These
include increasing Medicaid funding; preventive measures such as school
dental screenings and sealant programs; expanding student loan
forgiveness programs to encourage more dentists to practice in
underserved areas; and reducing the red tape that sometimes makes it
difficult for dentists to provide care through Medicaid or to specific
communities, such as Native Americans.
But State and Federal Governments must do their parts, at a minimum
maintaining their existing commitments to providing oral health care
for the millions of Americans who are most in need, especially
children. The dental profession and its allies will continue to lead
the fight to break down barriers to oral health for all Americans, and
we invite all organizations and individuals who share this goal to join
Prepared Statement of Pamela Quinones, RDH, BS, President, American
Dental Hygienists' Association (ADHA)
On behalf of the American Dental Hygienists' Association (ADHA),
thank you for the opportunity to submit testimony on the ``Dental
Crisis in America: The Need to Expand Access.'' ADHA commends the
subcommittee for holding a hearing to examine the challenges many
Americans face in accessing oral health care. Dental caries (tooth
decay) remains the single most common chronic disease of childhood,
five times more common than asthma.
According to the Health Resources and Services Administration,
nearly 48 million people live in 4,464 federally designated areas
without enough dentists.\1\ As a result, millions of children and
adults suffer unnecessarily, miss school or work and, in rare cases,
face life threatening infections from untreated dental decay. To
overcome these shortages, the U.S. Government estimates we need an
estimated 9,500 new dental practitioners.\2\ Augmenting the dental
workforce is an essential element of expanding access to dental care.
ADHA is pleased to participate in the dialog about ways in which
oral health access can be improved and the oral health workforce can be
optimized to improve the delivery of oral health care services. As the
links between individuals' oral health and total health continue to
emerge, it becomes increasingly important for stakeholders in oral
health to consider ways in which access to care can be increased.
ADHA is the largest national organization representing the
professional interests of more than 150,000 licensed dental hygienists
across the country. In order to become licensed as a dental hygienist,
an individual must graduate from an accredited dental hygiene education
program and successfully complete a national written and a State or
regional clinical examination. Dental hygienists are primary care
providers of oral health services and are licensed in each of the 50
States. Hygienists are committed to improving the Nation's oral health,
a fundamental part of overall health and general well-being.
As an organization, ADHA is committed to better oral healthcare for
all people and advocates in support of Federal oral health programs,
expanding access to care for underserved populations and maximizing
coverage for oral health services. ADHA and its State associations
actively pursue efforts to increase the public's ability to access oral
ORAL HEALTH IS INTEGRAL TO TOTAL HEALTH AND MOST DENTAL DISEASE
It is well-documented that America is in the midst of a health care
crisis as over 50 million Americans lack health insurance.\3\ However,
what is often overlooked is another vital statistic: the 130 million
people that do not have dental coverage in this country.\4\ The May
2000 report, Oral Health in America: A Report of the Surgeon General,
brought to light the ``silent epidemic'' of oral disease, which affects
our most vulnerable citizens--poor children, the elderly and many
members of racial and ethnic minority groups. The landmark report also
confirmed that total health cannot be achieved without optimal oral
Research continues to emerge demonstrating the link between oral
health and total health. The Centers for Disease Control noted the
relationship between periodontal disease and health problems like
diabetes, heart disease, and strokes.\6\ The tragic death of 12-year-
old Deamonte Driver who died in 2007 as a result of complications from
a brain infection that was brought about by an abscessed tooth was an
unfortunate demonstration of the impact of untreated oral disease. Just
last year, Kyle Willis, a 24-year-old father died from a tooth
infection because he couldn't afford the antibiotics he needed,
offering a sobering reminder of the importance of oral health and the
serious--even fatal--consequences that people without access to dental
care suffer. Lack of access to dental care forces too many Americans to
enter hospital emergency rooms seeking treatment for preventable dental
conditions, which emergency rooms are typically ill-equipped to handle.
The Nation lacks an effective dental safety net.
Most oral disease is completely avoidable with proper preventive
care; however, in spite of this proven prevention capacity, oral
disease rates among children and adults continue to climb.\7\ \8\
Preventing oral disease can positively impact total health and is also
cost-effective. Research indicates that low-income children who have
their first preventive dental visit by age one incur dental related
costs that are approximately 42 percent lower ($262 before age one,
$449 between ages two and three) over a 5-year period than children who
receive their first preventive between the ages of two and three.\9\
Regrettably, however, less than 20 percent of Medicaid-eligible
children received dental treatment services in 2010.\10\
Institutionalized seniors face even greater challenges in accessing
oral health services. Nearly 80 percent of the nursing home population
has untreated dental caries.\11\ Preventive care can diminish the need
for more costly restorative and emergency care, saving valuable health
care dollars in the long-run.
DENTAL HYGIENISTS ARE PRIMARY PROVIDERS AND IMPACT ACCESS TO CARE
Dental hygienists are prevention specialists who understand how the
connection between oral health and total health can prevent disease,
treat problems while they are still manageable, conserve critical
healthcare dollars, and save lives. Dental hygienists are primary care
oral health professionals who provide a range of oral health services
including prophylaxis (cleaning), sealants, fluoride treatments, oral
cancer screenings and oral health education.\12\
In order to become licensed as a dental hygienist, an individual
must graduate from one of the Nation's 332 accredited dental hygiene
education programs and successfully complete both a national written
examination and State or regional clinical examination. The average
entry-level dental hygiene education program is 86 credits, or about 3
academic years, in duration.\13\ Over 6,700 dental hygienists graduate
annually from entry level programs that offer a certificate, or an
Associate's or Bachelor's degree.\14\ There are currently more than 20
Master's-degree dental hygiene education programs in 16 States. In 48
States and the District of Columbia, dental hygienists are required to
undertake continuing education as part of the licensure renewal process
to maintain and demonstrate continued professional competence.\15\
As one of the fastest growing health care professions, as
identified by the U.S. Bureau of Labor Statistics (BLS), the dental
hygiene profession is well placed to significantly impact the delivery
of care in the United States.\16\ BLS data indicates the number of
dental hygienists is expected to grow 36 percent by 2018. In contrast,
BLS data indicates that the profession of dentistry is experiencing
only a 16 percent growth rate and anticipates the population of
dentists ``is not expected to keep pace with the increased demand for
dental services.''\17\ In States such as Vermont, North Carolina,
Oregon, and Georgia, the number of licensed dental hygienists in the
State far outweighs the population of licensed dentists.\18\
Furthermore, in Maine; the population of licensed dental hygienists
nearly doubles that of licensed dentists.\19\
The dental hygiene profession with its continuing growth offers a
cadre of competent and licensed providers who can deliver comprehensive
primary care services in an increasing array of settings. Currently, 35
States have policies that allow dental hygienists to work in community-
based settings (like public health clinics, schools, and nursing homes)
to provide preventive oral health services without the presence or
direct supervision of a dentist.\20\ Among the 35 direct access States
are the Senators' home States of Vermont, New Mexico, Pennsylvania,
Oregon, Rhode Island, Iowa, Kentucky and Alaska. Direct access to
dental hygiene services is especially critical for vulnerable
populations like children, the elderly, and the geographically isolated
who often struggle to overcome transportation, lack of insurance
coverage, and other barriers to oral health care. In 1998, California
and Washington became the first States to recognize and reimburse
hygienists as Medicaid providers. Today, 15 States (Arizona,
California, Colorado, Connecticut, Maine, Massachusetts, Minnesota,
Missouri, Montana, Nebraska, Nevada, New Mexico, Oregon, Washington and
Wisconsin) recognize and reimburse hygienists as Medicaid
providers.\21\ Medicaid dental regulations must be updated to better
reflect the way State dental practice acts have evolved and the way
dental care is now delivered.
Dental hygienists throughout the country have demonstrated their
ability to reach patients in alternative settings, thus drawing those
who are currently disenfranchised from the oral health care system into
the pipeline for care. In South Carolina, a school-based program brings
dental hygienists directly to low-income students in 341 schools in 38
targeted school districts. Importantly, the program has 12 restorative
partners, dentists who agree to see referred children in their private
offices, thus promoting the receipt of comprehensive services. Data
from the State has demonstrated that in the 5 years since the program
effectively began, sealant use for Medicaid children increased while
the incidence of untreated cavities and treatment urgency rates
decreased for that population.\22\ Indeed, the 2007-8 Needs Assessment
showed that there are presently no disparities between black and white
third grade children for sealant use in South Carolina.\23\
A program in Michigan, Smiles on Wheels, run by three dental
hygienists, brings care directly to patients living in nursing homes
who are not able to travel for dental care. For more than a decade,
California has recognized ``Registered Dental Hygienists in Alternative
Practice'' (RDHAPs) who provide unsupervised services in homes,
schools, residential facilities and in Dental Health Professional
Shortage Areas. A recent study of RDHAPs in California found that
``alternative care delivery models such as RDHAP are essential to
improving oral health and reducing health disparities.'' \24\
Direct access and direct reimbursement policy changes better
leverage the existing dental hygiene workforce and make care more
accessible for those who currently struggle to secure services in the
private dental office. Bringing patients into the oral healthcare
system for preventive and other oral healthcare services through
additional access points such as schools, community health centers, and
nursing homes can avert more costly restorative care, allow appropriate
referral to dentists, and help save valuable healthcare dollars in the
NEW ORAL HEALTHCARE PROVIDERS DEVELOPED TO IMPROVE ACCESS TO DENTAL
The significant challenges millions of Americans face in accessing
restorative dental care are well-documented. In response to the access
crisis, State policymakers, consumer advocates and oral health
coalitions are pioneering innovations to extend the reach of the oral
health care delivery system and improve oral health infrastructure.
Among these innovations is the creation of a mid-level oral health
provider to provide much-needed restorative dental care to underserved
populations. Currently, more than 50 countries, including Canada, New
Zealand, Australia, and the United Kingdom, allow mid-level
practitioners to practice in oral health.\25\ In Alaska, Dental Health
Aid Therapists (DHATs) have provided restorative oral health care
services without a dentist onsite since 2004.\26\ In an evaluation
issued by the W.K. Kellogg Foundation, researchers found that non-
dentist providers safely and efficiently deliver quality oral health
care to patients and improve access to services.\27\
In recognition of increasing patient need and workforce realities,
ADHA, the American Dental Association and others have called for new
types of oral health care providers. ADHA welcomes a robust review of
all new provider models. In 2004, ADHA became the first national oral
health organization to propose a new oral health provider, the Advanced
Dental Hygiene Practitioner (ADHP) and the ADHP competencies were
created.\28\ The ADHP is designed to be a primary care dental
professional able to deliver care in a capacity between that of a
dentist and a dental hygienist. The ADHP model was developed after
review of advanced nursing models in the United States and ``mid-
level'' oral health models internationally. The ADHP would provide
preventive, therapeutic, diagnostic, prescriptive, and minimally
invasive restorative services directly to the underserved. The ADHP
would be a member of a comprehensive healthcare team, and would refer
patients in need of more advanced oral healthcare services to dentists.
An ADHP would be State-licensed and a graduate of an accredited
In 2009, Minnesota became the first State to pass legislation
creating two new types of oral health practitioners, a dental therapist
and an advanced dental therapist, making new providers a reality in the
lower 48 States.\29\ Metropolitan State University in St. Paul,
Minnesota offers a Master's level program that educates students, using
the ADHP competencies, to practice as Advanced Dental Therapists (ADTs)
in Minnesota. This program builds on the dental hygiene education model
by requiring students to have dental hygiene licensure and a
Baccalaureate degree prior to entry. The ADT is modeled after the nurse
practitioner model and is designed to facilitate collaboration between
the ADT and dentist, but does not require onsite supervision. The first
class of ADT students graduated from Metropolitan State in June 2011
and will need 2,000 hours of supervised practice before they can obtain
their ADT certification. They will then practice with dual ADT and
dental hygiene licensure. By virtue of their dual licensure, ADTs are
able to provide the full preventive skill set of a dental hygienist in
addition to the ADT restorative skill set.
The dental therapist program offered at the University of Minnesota
is modeled after the physician's assistant model which requires onsite
supervision from a dentist for most services provided. This program
does not require entering students to first be a licensed dental
In addition to Alaska and Minnesota, the W.K. Kellogg Foundation
announced it was spearheading a $16 million campaign to establish mid-
level practitioner models in Kansas, New Mexico, Ohio, Vermont, and
Washington State.\30\ The trend is toward combining the dental
therapist model with a dental hygiene-based model that builds on the
education and expertise of the existing dental hygiene workforce. This
is a particularly sensible approach when future U.S. oral health
workforce projections are taken into account.
ADHA is a proponent of exploring new workforce models in dentistry
and exploring better ways of utilizing existing dental and medical
providers. ADHA believes patients will benefit most from mid-level
providers who are rooted in dental hygiene, as these providers can
deliver both preventive and minimally invasive restorative care. As
such, ADHA supports dental hygiene-based workforce models that are
licensed, receive appropriate education for their respective scope of
practice from an accredited institution and can provide care directly
to the public.\31\
alternative dental health care providers demonstration projects
Congress recognized the need to improve the oral health care
delivery system when it authorized the Alternative Dental Health Care
Provider Demonstration Grants, Section 340G-1 of the Public Health
Service Act. The Alternative Dental Health Care Providers Demonstration
Grants program is a Federal grant program that recognizes the need for
innovations to be made in oral health care delivery to bring quality
care to the underserved by pilot testing new models. This is an
opportunity for dental education programs, health centers, public-
private partnerships and other eligible entities to apply for funding
that will allow for innovation, within the confines of State laws, to
further develop the dental workforce and extend the reach of the oral
health care system. This grant program, administered by the Health
Resources and Services Administration (HRSA), would fund workforce
innovations, including building on the existing dental hygiene
workforce, utilizing medical providers, and pilot testing new
providers, like dental therapists and advanced practice dental
hygienists, who practice in accordance with State practice acts.
Dental workforce expansion is one of many areas that need to be
addressed as we move forward with efforts to increase access to oral
health care services to those who are currently not able to obtain the
care needed to maintain a healthy mouth and body. The authorizing
statute makes clear that pilots must ``increase access to dental care
services in rural and underserved communities'' and comply with State
licensing requirements. Such new providers are already authorized in
Minnesota and are under consideration in Vermont, Kansas, Maine, New
Hampshire, Washington State and several other States.
The fiscal year 2012 Labor, Health and Human Services funding bill
included language designed to block funding for this important
demonstration program. We seek your leadership in removing this
unjustified prohibition on funding for the Alternative Dental Health
Care Providers Demonstration Grants. The Federal Government must signal
that investment in exploring new ways of delivering dental care is a
meritorious expenditure, and underscores the Nation's commitment to
expanding access to critical oral healthcare.
Please keep the following points in mind as you consider funding
this dental workforce grant program for the underserved:
The existing dental delivery model has increased in
efficiency and is highly effective for those who have access to a
dental office and are covered through insurance. However, the system
fails the more than 80 million Americans who lack dental insurance,
those who are geographically isolated, and those who are unable to
travel to a private dental office for treatment.
Reports that these workforce pilots will allow non-
dentists to do dental surgery/irreversible procedures are unfounded.
All grants must, by statute, be conducted in accordance with State law.
The grant program cannot authorize or allow non-
dentists to perform irreversible/surgical dental procedures UNLESS
State law allows for the provision of such services.
All pilots must be specifically designed to increase
access in rural and other underserved areas. This is a dental workforce
grant program for the underserved.
Nearly 48 million Americans live in dental health
professional shortage areas according to the Health Resources and
Services Administration (HRSA), and HRSA included funding for this
program in its fiscal year 2012 budget justification.
An estimated 9,500 new dental practitioners are needed to
end the Nation's dental care shortages. New types of models must be
explored and, by statute, HRSA must contract with IOM to evaluate the
demonstrations, which will yield valuable information to inform
decisions about the dental workforce of the future.
All evidence available demonstrates the safety and quality
of care delivered by non-dentist providers, including for Dental Health
Aide Therapists in Alaska. Dental therapists have successfully been in
practice overseas for nearly a century. Funding to support pilot
testing of new dental workforce models will yield additional data on
the economic viability of new oral health providers.
The Alternative Dental Health Care Providers Demonstration
Program is a grant program to pilot dental workforce innovations that,
by statute, must ``increase access to dental health care services in
rural and other underserved communities'' and must be compliant with
``all applicable State licensing requirements.'' New types of dental
providers are essential to solving the Nation's oral health access
crisis and this grant program will help determine what types of
providers are viable.
The promise of the Alternative Dental Health Care Providers
Demonstration program will go unfulfilled unless it is adequately
funded. Without the appropriate supply, diversity and distribution of
the oral health workforce, the current oral health access crisis will
only be exacerbated.
ADHA, along with more than 60 other oral health care organizations,
advocated for funding of these grants and for oral health workforce
programs, as well as oral health prevention-related activities such as
oral health literacy campaigns, dental caries and disease management
grants, school-based sealant programs, and for the oral health
infrastructure and national oral health surveillance efforts. ADHA is
proud to support these efforts, which will improve the Nation's oral
health, a fundamental part of overall health and general well-being.
The American Dental Hygienists' Association appreciates this
subcommittee's interest in addressing the dental crisis in this country
through expanding access to dental care in America. The oral healthcare
delivery system needs significant restructuring to overcome barriers to
care for the underserved. ADHA remains a committed partner in
advocating for meaningful oral health programming that makes efficient
use of the existing oral health workforce, explores new ways to provide
dental care, improves access to care, and delivers high quality, cost-
effective care. ADHA firmly believes that better utilization of the
existing oral healthcare workforce will help improve access to care for
vulnerable and underserved populations. Thank you for the opportunity
to share ADHA's commitment to increasing access to comprehensive oral
1. Health Resources and Services Administration [HRSA]. Shortage
Designation: Health Professional Shortage Areas & Medically Underserved
Areas/Populations; 2012. http://bhpr.hrsa.gov/shortage/.
3. U.S. Census, Income, Poverty, and Health Insurance Coverage in
the United States: 2009.
4. National Association of Dental Plans, Dental Benefits Improve
Access to Dental Care; 2009. http://www.nadp.org/Libraries/
5. U.S. Surgeon General, Oral Health in America: A Report of the
Surgeon General. 2000.
6. U.S. Centers for Disease Control and Prevention. Links between
Oral and General Health. Atlanta, GA: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, 2004.
7. U.S. Centers for Disease Control and Prevention. Links between
Oral and General Health. Atlanta, GA: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, 2004.
8. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G,
et al. National Center for Health Statistics. Trends in oral health
status: United States, 1988-94 and 1999-2004. Hyattsville, MD. U.S.
Department of Health and Human Services, Centers for Disease Control
and Prevention. 2007.
9. Savage Matthew, Lee Jessica, Kotch Jonathan, and Vann Jr.
William. ``Early Preventive Dental Visits: Effects on Subsequent
Utilization and Costs.'' Pediatrics 2004.
10. Centers for Medicare and Medicaid Services, Annual EPSDT
Participation Report. CMS-416; 2010. www.medicaid.gov.
11. Kambhu PP, Warren JJ, Hand JS, et al. Dental treatment outcomes
among dentate nursing facility residents: an initial study. Spec Care
12. American Dental Hygienists' Association, Important Facts About
Dental Hygienists, Chicago, IL, 2009. http://www.adha.org/careerinfo/
13. American Dental Hygienists' Association, Dental Hygiene Program
Directors Survey, 2006, American Dental Hygienists' Association,
Chicago, IL, 2008.
15. American Dental Hygienists' Association, States Requiring
Continuing Education for Licensure Renewal, Chicago, IL, 2008 http://
16. Bureau of Labor Statistics, U.S. Department of Labor,
Occupational Outlook Handbook, 2010-11 Edition, Dental Hygienists,
Washington, DC, 2010. http://www.bls.gov/oco/ocos097.htm.
17. Bureau of Labor Statistics, U.S. Department of Labor,
Occupational Outlook Handbook, 2010-11 Edition, Dentists, Washington,
DC, 2010. http://www.bls.gov/oco/ocos072.htm.
18. American Association of Dental Boards, Composite 23d Edition,
20. American Dental Hygienists' Association, Direct Access States
Chart, Chicago, IL, 2010. http://www.adha.org/governmental_affairs/
21. American Dental Hygienists' Association, States Which Directly
Reimburse Dental Hygienists for Services Under the Medicaid Program,
Chicago, IL, 2009. http://www.adha.org/governmental_affairs/downloads/
22. South Carolina Rural Health Resource Center, 2007-8 South
Carolina Oral Health Needs Assessment Data, 2008.
24. Mertz, E., ``Registered Dental Hygienists in Alternative
Practice: Increasing Access to Dental Care in California,'' University
of California, San Francisco, Center for the Health Professions, May
2008, p. 44.
25. Nash, D.A. ``Dental Therapists: A Global Perspective,'' Int
Dent J. 58(2): (April 2008) 61-70.
26. Nash, D.A. and R.J. Nagel, ``A brief history and current status
of a dental therapy initiative in the United States.'' J Dent Educ
27. W.K. Kellogg Foundation, ``Evaluation of the Dental Health Aide
Therapist Workforce Model in Alaska'' North Carolina, 2010.
28. American Dental Hygienists' Association, Advanced Dental
Hygiene Practitioner Competencies, Chicago, IL, 2008. http://adha.org/
29. See, Minnesota Senate File 2083, 2009.
30. Kathy Reincke, W, ``W.K. Kellogg Foundation Supports Community-
Led Efforts in Five States to Increase Oral Health Care Access by
Adding Dental Therapists to the Dental Team,'' November 2010. W.K.
Kellogg Foundation. News Release.
31. American Dental Hygienists' Association, Policy Manual,
Chicago, IL, 2012. http://adha.org/downloads/ADHA_Policies.pdf.
Prepared Statement of Lilia Larin, D.D.S., MS, President,
Hispanic Dental Association (HDA)
Chairman Sanders, Ranking Member Dr. Paul, and distinguished
members of the Subcommittee on Primary Health and Aging, the members of
the Hispanic Dental Association (HDA), whose mission is to provide for
the elimination of oral health disparities in the Hispanic community,
welcomes today's hearing on a topic that is important not only to our
Nation's oral health--but to the overall health of all Americans.
The Institute of Medicine's April 2011 report ``Advancing Oral
Health in America'' affirms accessing oral health care is difficult for
``While access has improved over time, many people--typically
those who are most vulnerable--still lack the oral health
services they need. Accessing oral health care is particularly
difficult for certain populations, including people whose
income falls below the Federal poverty level, African-
Americans, Latinos, and children covered by Medicaid.'' \1\
\1\ ``Advancing Oral Health in America,'' Institute of Medicine of
the National Academies Report Brief, April 2011.
The Hispanic community continues to grow, composing 16 percent of
the Nation's population according to the U.S. Census and accounting for
more than half (51 percent) of the United States' population growth of
9 percent since 2000, according to the Pew Hispanic Center.
In November 2011, a nationally representative survey among 1,000
Hispanics and 1,000 general population adults, led by the HDA and
sponsored by Procter & Gamble (P&G) brands Crest and Oral-B, found
that Hispanics--the fastest growing segment of the U.S. population--
have significant barriers to overcome to achieve better oral health.\2\
Overall, Hispanics believe that more information about good oral health
habits, better access to affordable oral health care, and more Hispanic
and Spanish-speaking dentists and dental hygienists in their
communities would help them ``a lot'' in achieving and maintaining good
\2\ ``Hispanics Open Up About Oral Health Care'' survey conducted
by GfK Roper Public Affairs & Corporate Communications, November 2011,
The survey's results are quite revealing and alarming with respect
to the lack of access to oral health care by the Hispanic population.
First and foremost, nearly one in five Hispanics, 18 percent, have
not visited the dentist at all in the past 2 years, and only 30 percent
of Hispanics are visiting the dentist regularly over the past 2 years
(regularly as defined by two or more times a year). This is compared to
45 percent of the general population who stated that they visited the
What is the main reason why so many Hispanics have missed a dental
visit? The lack of dental insurance.
Approximately 16 million Hispanic adults do not have
access to dental insurance.
The lack of dental insurance among close to half of Hispanic
adults, 45 percent, is one of the key reasons many Hispanics are not
visiting the dentist regularly. In fact, 51 percent of Hispanics cite
lack of insurance as a reason why they have ever missed a dental visit.
Hispanics are also far less likely to have access to dental insurance
for their children, 56 percent.
In sum, 7 in 10 Hispanics say it would help ``a lot'' if
they had better access to adequate insurance or other dental coverage
and better access to affordable oral health care.
Moreover, even if individuals have dental insurance, other barriers
may prevent or dissuade them from receiving much-needed services.
Therefore, in addition to access to affordable care and insurance, oral
health literacy (knowledge gaps) and cultural competence present
significant barriers to many Hispanics. For example:
Forty-six percent of Hispanics do not know, or incorrectly
believe to be false that poor oral health may be linked to other health
complications, including stroke, heart disease and diabetes.
Hispanics rely equally on their parents, 61 percent, and
their dentist/hygienist, 60 percent, as sources for oral care
Fifty-nine percent of Hispanics feel that more Hispanic
dentists/hygienists in their community would be similarly helpful.
We must work to correct the many misperceptions Hispanics have
about oral health through education and awareness and work to address
dental workforce shortfalls to increase the number of underrepresented
minorities in health professions schools as well as promote cultural
and linguistic competence in the health professions. In fact, the
Council on Graduate Medical Education (COGME), a committee authorized
by Congress in 1986, has issued reports calling for the need to
increase underrepresented minorities in health professions.\3\
The existence of all these barriers makes preventative measures
such as community water fluoridation become all the more important,
especially to underserved or vulnerable populations. Preventative
measures provide an easier, less costly solution to treatment.
In conclusion, the Hispanic Dental Association is committed to
working with all oral health stakeholders and policymakers to improve
the State of oral health among the growing U.S. Hispanic population and
for all Americans.
[Whereupon, at 11:26 a.m., the hearing was adjourned.]