“I don’t think people realize how hard it is. Imagine you are working two jobs and you don’t have great command of the English language. Then, add on lack of transportation and [unstable] housing. Imagine how hard it is to get anything done, especially dental care. And then imagine you call and make an appointment, which can take 20 minutes, and you are paying for your cell phone by the minute. If you are moving all the time, it’s hard to confirm appointments. Dental care is hard to navigate. I think people try really hard but they have so many barriers. I’ve felt like giving up and I know the system and I don’t have the same barriers.”
Elizabeth Branca is an Advanced Dental Therapist with Children’s Dental Services (CDS), a nonprofit dental clinic that serves primarily young, low-income Minnesotans. A hygienist for 20 years (and an Advanced Dental Therapist since 2013), she is finishing up an appointment in today’s make-shift office at Sabathani Community Center in South Minneapolis. The visible gratitude and relief on the faces of the parents waiting in the lobby is evidence of the focus, care, and thoroughness she provides her patients. Her patient is a nine-year-old boy needing four teeth extracted. Elizabeth has just diagnosed him with three dental abscesses. It sounds like a serious case, and it is, but for Elizabeth, this appointment is typical.
“I see lots of bombed out teeth. I’ve seen children as young as two with decay in every tooth. In the time I worked at Children’s Dental Services, the decay levels haven’t gotten a lot better. In fact, they might be getting worse.”
Elizabeth was part of the second graduating class of Advanced Dental Therapists to come out of Minnesota. Her organization, CDS, was one of the first organizations to adopt the Advanced Dental Therapist Model. Her role as an Advanced Dental Therapist is a new, exciting, and innovative solution to the crisis Minnesota faces in dental access.
In the U.S., dental cavities, or caries, are the most common chronic disease of childhood, affecting 59% of children. Tooth decay is more than five times more common than asthma, which affects 11% of kids. Yet many children often go years without seeing a dentist due to lack of insurance or an available dentist.
In fact, Minnesota currently ranks last out of all 50 states when it comes to Medicaid funding rates for pediatric dental services, according to the Minnesota Dental Association.
Because of the low payment rates, many dental clinics—especially small and rural clinics—cannot afford to serve low-income patients. This contributes to Minnesota’s current access crisis where low-income patients with serious dental problems cannot get the treatment they need.
“People call and call until they can find a dentist to see them. I’ve driven to Litchfield for an hour and a half and [that patient] has driven an hour and a half to see me. Dentists won’t take medical assistance, but all dentists could, in my opinion,” shares Elizabeth, with both urgency and humility in her voice.
During the late 1990s, Minnesota suffered the greatest percentage of decline in the dentist-to-population ratio. This lack of care falls disproportionately on low-income Americans. Eighty percent of pediatric dental disease is concentrated in 25% of children, mostly from low-income and households of color. One example of the most tragic consequence of this lack of health care occurred in February 2007 when 12-year-old Deamonte Driver of Maryland died after bacteria from an untreated tooth abscess infected his brain. Children’s Dental Services’ Executive Director Sarah Wovcha says, “Deamonte’s death is a harbinger of an urgent problem and the ‘perfect storm.’ He had medical assistance, but was unable to find a dentist who would provide care for him.” In the United States, “We have successfully segregated dental health from medical health. And our mouth is really only three inches from our brain.”
To work towards a solution to this problem, in May 2009, with pressure and partnership from the Safety Net Coalition Oral Health Committee, the Minnesota legislature became the first in the nation to approve a type of role like Elizabeth’s. The Advanced Dental Therapist is the dental equivalent of a nurse practitioner, licensed to perform such procedures as filling cavities and extracting teeth.
“We’re able to meet basic needs because we are paid less, we’re mobile and many of us have hygiene backgrounds and so we can merge prevention and restoration together,” explains Elizabeth.
“That’s extremely important. We’re able to do more, go further in public health clinics and in greater Minnesota. We can do both cleanings and fillings. We can see patients from the beginning to the end.”
Policy makers in other states are viewing Minnesota’s law as one answer to the lack of access to dental care for millions of Americans, particularly low-income and the uninsured.
“If a dentist typically does 500 procedures, an advanced dental therapist does about 50 procedures, the most common procedures in dental history,” explains Sarah. “This is a much more affordable option for a community clinic, a nonprofit, or a hospital to employ—freeing health dollars to employ additional providers.”
Elizabeth is proud that she’s making an impact where she previously couldn’t as a dental hygienist. “I’ve seen all the need that is out there. I used to only be able to do their hygiene and refer [patients]. That struck me and I felt I could do better, and I could help out more” says Elizabeth. As an Advanced Dental Therapist, “I love my job and I love working with kids. I’m glad I have this opportunity to do this. I’m glad I can help out even a little bit.”
An Affordable and Accessible Provider
An Advanced Dental Therapist makes dental care more affordable and accessible system-wide, freeing up dentists to focus on tougher cases and provide more specialized care. For CDS, adding Advanced Dental Therapists to their business model has been transformative.
“We’re definitely able to provide more access to dental care and be more financially sustainable as we do it.” —Sarah Wovcha
“Running a nonprofit dental clinic in Minnesota is a risky proposition because of the low medical assistance reimbursement rates.” says Sarah. One big win for nonprofits like CDS is that this incremental shift in the system enables nonprofit dental clinics to keep their doors open. Another big win is expanding dental care access to more Minnesotans who need it.
Because expanding access to care is CDS’s mission, that means Elizabeth shows up where the community needs her. “I do care in WIC offices, Head Start Centers, schools, community centers, county buildings where we set up in offices or conference rooms. It’s very hard for people to get around. If we go to Brooklyn Park, Brooklyn Center, or Richfield, it’s easier for folks to get care,” versus asking patients to travel to CDS’s main office in Northeast Minneapolis. “We also go out to Glencoe, Litchfield, Milaca. I have been set up in conference rooms, nurses’ offices, large closets, the stage, auditoriums, art rooms, and in the hallway,” shares Elizabeth with a smile. Wherever she is, she brings her serious sense of mission and dedication to providing quality care.
Elizabeth wants Pollenites to remember what a lack of dental care can mean for a child:
“You can’t be in school with a painful tooth. You aren’t paying attention, you might not be eating, speech can be affected.”
“We’re in crisis with dental care and we need to change the system so people aren’t going to emergency rooms for dental care. We need to make sure people have access to care. There are many ways to deal with that: more providers, increasing reimbursement rates, and making access better for everyone. And more advanced dental therapists are a great start.”
Still today, there are young people in Minnesota who hold dental coverage through Medicaid but don’t have access to local care. Area dentists aren’t able, or willing, to accept Medicaid patients due to absurdly low reimbursement rates. These children have parents who care about their kids’ teeth, only to spend hours of energy trying to find them a provider, even despite difficulty navigating a bureaucratic and complex system. Amid additional economic and structural barriers, those same parents are sometimes miraculously able to arrange transportation to drive long distances just to be seen by a provider. And yet, more often than is acceptable, those efforts fall outrageously short.
Our dental care system needs to change in immediate and absolute ways to ensure our whole population has a healthy mouth. As connected, passionate and engaged citizens, we need to push for more providers (especially in rural areas), increased reimbursement rates, and easier and better access for everyone. While they aren’t and can’t be the whole solution, Advanced Dental Therapists are a step in the right direction.
This story was created in partnership with the Minnesota Accountable Health Model – SIM Minnesota.
This story and project partners* featured in this story were funded by a $45 million State Innovation Model (SIM) cooperative agreement, awarded to the Minnesota Departments of Health and Human Services in 2013 by the Center for Medicare and Medicaid Innovation to help implement the Minnesota Accountable Health Model.
*Children’s Dental Services
Illustrations by Bomsymbol, sourced from the Noun Project.