Where dental therapy is longer in the tooth

Expanding access: A decade of dental therapists in Minnesota

By KEVYN BURGER | September 30, 2019

Gary Plotz is the equivalent of a dental one-man band.

The only dentist practicing in rural Murray County, Minnesota (population 8700), Plotz works long days in his office in Slayton, 80 miles from Sioux Falls, South Dakota, and 180 miles from the Twin Cities. Plotz can give his patients implants, crowns, bridges and root canal procedures, perform minor oral surgical procedures and straighten and whiten their smiles.

But these days Plotz, 40, doesn’t spend much of his time on what dentists call "restorative care," drilling and filling cavities. For those appointments, and for exams and care for his pediatric patients, he relies on his dental therapist, Lydia Diekmann.

“In our area, we have a big need for basic services so it’s a perfect scenario for a dental therapist. Having Lydia on staff allows me to offer advanced care to a greater number of patients, with a shorter waiting time,” he says.

When its Legislature authorized dental therapists a decade ago, Minnesota became the first state in the nation to license dental therapists. It’s a profession that is new to the United States but is common elsewhere in the world. The profession began in New Zealand in 1921, and now dental therapists provide care in more than 50 countries.

Like nurse practitioners in the medical field who offer patients more care than a nurse but less than a physician, dental therapists are mid-level professionals who can provide more oral care than dental hygienists but less than dentists. Dental therapists, who work under the supervision of dentists, are trained to provide routine health care services and build cost efficiencies into the health care system.

“Dental therapists allow the dentist to practice at the top of the license and meet complex treatment needs. They can do about 60 common procedures; dentists are trained to do hundreds,” explains Bridgett Anderson, executive director of the Minnesota Board of Dentistry, which regulates the state’s dental profession.

In September, the Minnesota Health Department Office of Rural Health and Primary Care released a report on Minnesota’s Dental Therapist Workforce.

Based on 2018 research, the report counted 92 dental therapists working in Minnesota, a number that has grown to 100 today.

“With only 100 in a dental workforce of 17,000 (which includes dentists, dental assistants and dental hygienists), their impact is anecdotal, but it is all positive,” Anderson says, noting that the board has to date not taken any disciplinary or corrective action against a dental therapist.

“The only downside is, there aren’t enough of them,” she adds. “There are degree programs at Metro State University and the University of Minnesota, and there’s a proposal to add another program at Minnesota State University-Mankato. As more graduates are practicing, the profession will exponentially grow.”

The Minnesota legislation that established the dental therapy profession requires that they work in settings that primarily serve low-income, uninsured and underserved patients or in areas designated as dental health professional shortage areas.

“Access is a problem and a challenge in both greater Minnesota and metropolitan areas. While we have people who are qualified for care through coverage in public programs, if there isn’t a dentist, it doesn't mean much,” says Joe Lally, executive director of the Delta Dental of Minnesota Foundation, which annually invests $5 million in nonprofits, community clinics and programs that provide safety net care and prevention and education.

The foundation has created dental therapy scholarships to recruit students of color to the emerging profession. It also has provided grants and funded pilot projects in two rural communities to pay the first year’s salary of a dental therapist as incentives for them to add the position. When the year was up, the foundation’s research concluded that the addition of the dental therapists generated positive financial returns at both clinics.

“When the grant ended, both clinics retained the therapist position, they saw the value of it,” Lally says. “It saves money in the larger dental economy because the dental therapist isn't paid at the same rate as a dentist. There are people who are getting care because there is a dental therapist on the team.”

Katy Leiviska was accepted in the inaugural class of dental therapists at the University of Minnesota, beginning her coursework in 2009 and graduating in 2011. She had applied to dental school but changed her plans when she heard about the new program.

“I liked the people-centered care and the smaller scope of practice. The schooling was less expensive and shorter,” says Leiviska, now 33. “But it took me 11 months to find my first job. It was new and controversial. Dental practices thought they couldn't spend the time and resources to figure out how to integrate a dental therapist.”

Leiviska was not alone in meeting resistance.

“Dentists were wary. They weren’t ready to change. I saw surveys when the legislation passed that 80 percent did not want dental therapists,” says Karl Self, a dentist and dental educator who directs the dental therapy program at the University of Minnesota.

Self has tracked attitudes about dental therapists from Minnesota dentists and is preparing to publish his findings in a scholarly journal. Spoiler alert: He’s found that attitudes — and the employment picture for dental therapists — have changed dramatically.

“Now 60 to 70 percent (of dentists) support the change, and in the last two to three years, we’ve reached a tipping point. Now we don’t have enough dental therapists for the dentists who want to hire them. Dentists are always asking us why we can’t produce more,” says Self.

He credits inter-professional connections forged in the academic setting for breaking down barriers among the newest generation of dentists.

“We educate dental therapists alongside our dental students; they collaborate, take some of the same exams and must demonstrate the same quality of care,” Self says. “Our graduates who are now buying practices and making hiring decisions know their value. They see dental therapists as a way to provide more services to their community, with better economics.”

The job that Leiviska ultimately found was with HealthPartners, which had lobbied at the state capitol for the dental therapist legislation. She works at the nonprofit’s two dental clinics in St. Paul, providing services for low-income patients who are eligible for state-based care.

“I’m a good tool in the toolbox,” she says. “I see kids, the immigrant population, patients just out of the prison system. I’ve worked with a lot of patients who can’t get jobs because their teeth look bad and the smile is the first thing anyone notices. I can give them their confidence back.”

In just a decade, the environment for dental therapy students has become more welcoming. In the final year of her program, Claire Roesler, 24, is seeing doors open even before she earns her diploma, leaving her upbeat about her opportunities.

“I’m not concerned at all about finding a job. There are so many options and openings. In the class above us, all of them had jobs when they graduated.”

Roesler, from Wisconsin Rapids, grew up the daughter of a small-town hospital administrator. That experience inspired her to pursue dental therapy.

“I’m passionate about bringing care to underserved and rural communities, and I want to make a difference, so this is a good fit for me. I like that it’s an up-and-coming career. It’s exciting to be at the front of that.”

Plotz met his dental therapist when she was was his patient. Diekmann was still in high school when she expressed interest in dentistry and shadowed him on the job. When she was in college, Plotz suggested that she pursue dental therapy.

“I told her, when you finish I will have a job for you. I think it encouraged her, knowing there would be a position waiting,” he says.

Diekmann, 29, began working in Plotz’s office after graduating from the University of Minnesota program in 2013. Plotz has supported her taking additional training to become an advanced dental therapist, which allows her to work more independently.

“I always wanted to return home to work. I know this community, how tight the bonds are,” Diekmann says. “I’d say I know at least half of our patients from school or family or being raised here. We can have a good first conversation, I ask about their grandma or their brother that I graduated with, and that puts the patients at ease.”

“Out here, we have a lot of mid-level providers in health care, so when we explained Lydia was like a nurse practitioner or physician’s assistant, patients were receptive,” Plotz says. “Lydia has been great for our patients and our area. It’s been a positive experience all the way around.”

Kevyn Burger is a Minneapolis-based freelance writer.