Taking a bite out of the dental care access problem

Dental therapists in Minnesota help more low-income kids and adults get the oral care they need

By KEVYN BURGER | October 15, 2019

Minneapolis, Minn. — Nine-year-old Adham Salama arrives at the dental clinic in Minneapolis with his mother and a mouthful of trouble.

“He has cavities on his baby teeth and his adult molars,” advanced dental therapist Elizabeth Branca explains to his mother through an Arabic translator, after completing the boy’s first-ever dental exam; the family arrived in Minnesota from Egypt eight months ago.

“He might need a root canal on one of his teeth, we’ll have to see. And this tooth is broken. We’re going to have to help it come out,” says Branca.

While Adham’s mother makes follow-up appointments, Branca sprints down the hall to another treatment room where she’d already injected novocaine into Sofia Sanchez’s mouth. The 4-year-old was reclining in a dental chair, gripping her mother’s hand and breathing in nitrous oxide while her mouth went numb.

“Getting sleepy now, sweetie?” Branca asks, taking a seat on a stool and scooting in next to her. “I’m going to hold your mouth open with a little pillow,” she says, inserting a mouth prop to position the child’s jaw.

While she fills two of Sofia’s baby teeth, Branca chats with her mother, asking about the family’s plan to eliminate chocolate milk. At Sofia’s previous exam, Branca identified the sugary drink as one of the culprits contributing to the child’s tooth decay.

“She doesn’t even ask for it anymore,” says Noemi Sanchez proudly. “When you told her, she listened better than when I tell her.”

Sanchez has come to appreciate Branca’s skill.

“She takes her time and explains what she’s doing. I was nervous at first because I was afraid of pain for my baby,” she says. “She is so gentle, and I know this is for Sofi’s own good.”

Closing the gap

Days are busy and full for Branca, who works for Children’s Dental Services, which employs eight dental therapists. The nonprofit treats low-income and uninsured youth and pregnant women in office visits at its two full-service clinics and through its mobile dental clinics that travel to schools and Head Start programs around Minnesota.

“We can see them where they are. These kids have complicated lives. They live in homeless shelters, they’re immigrants, their parents don’t have transportation. There are a lot of barriers to care,” she says.

Access to dental care for low-income people is a national problem. Minnesota policy-makers took steps to address the problem with legislation passed in 2009 that licenses dental therapists. A bipartisan group of Wisconsin lawmakers is advancing legislation that would enable dental therapists to practice in the Badger State.

Dental therapists are mid-level professionals, often compared to nurse practitioners or physician’s assistants in the medical field. They have less education than a dentist but more than a dental hygienist. They work under the supervision of a dentist.

Dental therapists practice in more than 50 countries, but Minnesota became the first state in the nation to license them to work with needy families and in underserved rural communities; two-thirds of Minnesota counties have a shortage of dentists.

In Wisconsin, more than 1.2 million residents live in dental care shortage areas.

“Dentists are retiring faster than new ones are coming into the profession. Dental therapists are a key part of the solution in addressing a gap in care that has been building for years,” says Sarah Wovcha, executive director of Children’s Dental Services. “They represent the most cost-effective and outcome-effective innovation that we’ve seen.”

Dental therapists extend care by providing basic dental procedures that previously only a dentist could do. For example, Branca is trained to fill cavities and conduct exams, opening time in a dentist’s schedule for more complex treatments. Dental therapists are paid at a lower rate than a dentist, making time in their chair more affordable.

“Only 40 percent of kids on medical assistance are seeing a dentist, but in the recent past, primary dental services have moved further out of the grasp of working poor and even middle-class families,” Wovcha says.

While the Minnesota Board of Dentistry reports there are only 100 dental therapists now practicing in Minnesota, the Minnesota Department of Health concluded that dental therapists provided care in 94,392 patient visits in 2016.

A recent workforce report on dental therapists found that about half of them work in private practice, many in rural communities where dental health resources are stretched thin. Another 35% have jobs in community-based, nonprofit, faith-based clinics or community health centers/federally qualified health centers, with the remainder employed in schools, hospitals or academic settings.

“We need more of these trained providers because we all pay the price for the crisis in oral health. If dental pain sends someone to an emergency room, it costs five times more than in a preventative setting,” Wovcha says.

Keeping teeth healthy

Katy Leiviska knew that her career as a dental therapist would allow her to work with a wide range of patients, but she recalls one workday that crystallized the experience.

“I escorted the 103-year-old patient that I had just seen out into the waiting room and greeted my next patient, who was 3,” says Leiviska.

A member of the first class of dental therapists to graduate from the program at the University of Minnesota School of Dentistry, Leiviska bounces back and forth between two HealthPartners clinics in St. Paul that serve mostly patients who qualify for state-based aid.

“When a patient needs a higher level of care, I consult with the dentists. That’s the way it’s designed to work,” says Leiviska, an advanced dental therapist. “If a tooth needs a root canal, I refer them. If a patient needs an antibiotic, I can’t prescribe it, but the dentist can.”

On a recent day, Leiviska’s first appointment was with an 85-year-old woman who needed two fillings. The next occupant of her chair was a 4-year-old boy who arrived with his mother and a translator who explained the treatment in their native Nepali language. That was followed by an appointment with 8-year-old Gideon Parker. He came for dental sealants, a protective procedure to deter decay.

“None of this hurts, I promise you 100 percent,” Leiviska tells Gideon as he reclines beneath a bright light. “Open really big! I’ve some tooth shampoo to use here.”

Gideon’s mother, Jennifer, is comfortable with a dental therapist treating her son.

“At his last appointment, they told us we should do this as soon as possible, but it’s hard to schedule; we waited a month for this,” Parker says. “I’m grateful she could see us. I want to keep his teeth healthy.”

While dental therapists often represent a new classification of oral care professionals to patients, dentists are becoming accustomed to their presence. One of the dentists who Leiviska works with at HealthPartners was in some of the same classes with her at the University of Minnesota; another colleague has previous experience working with the mid-level professionals.

“I grew up and went to dental school in Canada, where we’ve had dental therapists for many years,” says Darrell Boychuk, an oral surgery specialist who practiced in a remote part of Saskatchewan, where dental therapists are crucial in delivering oral health care to Inuit and First Nations people.

Many dental therapists enter the profession to make a difference. The most recent Health Department survey of dental therapists quizzed them about job satisfaction. An astonishing 95% answered that they were satisfied or very satisfied with their profession.

“This work is so rewarding. I know there are children who aren’t missing school or going to the emergency room because of what we can do for them,” says Branca. “But I see a lot of bombed-out mouths, kids who need extensive care and are living with pain. I sometimes can’t sleep when I’m thinking about them.”

Kevyn Burger is a Minneapolis-based freelance writer.