A special need for dental care

Dental therapists could help address oral care shortage

By ANNE TRAUTNER | June 23, 2021

When Barbara Price began working at the Hartfel House in Menomonee Falls 32 years ago, residents there were receiving dental care.

A local dentist treated the residents of the assisted living facility, which houses up to eight men with developmental disabilities. Over the years, that dental clinic continued seeing the patients at least once every six months.

But several months ago, the dentist moved. Adults with special needs are typically on Medicaid, but no one else in the office was willing to take Medicaid patients.

So, Price, director of the Hartfel House, began looking for a new dentist. She searched websites. She made phone calls.

“Every person I talked to told me they didn’t take Title 19 (Medicaid) patients,” Price says. “I couldn’t find a single dentist. It has been a real frustration. I have an individual with Down syndrome, and people with Down syndrome tend to have heart issues. Getting him dental care has really been worrisome. Dental health has a lot to do with heart health. I don’t want him to have bad stuff in his mouth and then it goes to his heart. It would be not good.”

Price eventually found Community Smiles Dental, a nonprofit dental provider for low-income families that has clinics in Waukesha and Menomonee Falls. It was the only option for Hartfel residents.

This is not an isolated incident. Wisconsin has a widespread dental access problem, especially among disadvantaged populations. In an effort to address this shortage, a bipartisan group of Wisconsin lawmakers has introduced legislation to create the dental therapy profession in Wisconsin, a proven solution that doesn’t require taxpayer money. Gov. Tony Evers proposed the same solution in his first budget.

The bill passed the Senate unanimously in April. It enjoys broad support in the Assembly as well, but has yet to be brought to a vote.

Dental therapists would help address the shortage throughout Wisconsin and also help supplement the care provided by shorthanded dentists at places like Community Smiles Dental.

“This would allow our dentists to focus on the more complex treatments and have the dental therapists work on some of the simple restorations, some of the things that we are paying a lot of money for the dentists to take care of. It would help reduce some of the personnel costs,” said Renee Ramirez, chief executive officer of Community Smiles Dental

Inadequate Care

Inadequate access to dental care for disadvantaged residents is nothing new. In 2005, a group of community outreach nurses who worked in Waukesha Public Schools noticed that while children from families who receive health benefits through Medicaid had access to doctors and optometrists, they could not find a dentist.

“The children were walking around in pain with multiple cavities in their mouth, which ultimately became abscesses,” Ramirez says.

The nurses wanted to solve the problem.

“It broke their hearts,” she says. “They saw that it just wasn’t right; the equality piece was really missing.”

So, the nurses brought the issue to hospital leaders, and a dental coalition was created. In May 2008, a nonprofit organization called the Waukesha County Community Dental Clinic opened its doors to Medicaid patients.

“We opened with a focus on children because we knew that if we would identify issues early enough, we could help them create healthy habits,” Ramirez says. “We were also a resource for adults who had an urgent or immediate need.”

By 2012, the clinic was treating 3,000 children a year. Dental health was improving as cavities were treated before becoming full-blown abscesses, according to Ramirez. Approximately 84% of the patients were returning for six-month appointments; about 75% of those had no new cavities.

Services expanded, and in 2018, a new clinic opened in Menomonee Falls as the program served children and adults in Waukesha, Washington, Ozaukee and Milwaukee counties.

In January 2021, the Waukesha County Community Dental Clinic was renamed Community Smiles Dental.

Currently, Medicaid reimburses Community Smiles 25 percent of the usual and customary rates for care, according to Ramirez. Fundraising helps the Community Smiles clinics cover the difference.

“Private practices can’t operate that way,” says Ramirez. “Very few dentists accept Medicaid; if they do, they limit the number of individuals. Some dentists say they can take five Medicaid patients a week or maybe five a month. Well, that just doesn’t cut it when you have 115,000 kids in Milwaukee County who are on state Medicaid insurance.”

According to the Wisconsin Department of Health Services, there are currently over 30,000 people on Medicaid/BadgerCare in Waukesha County. Washington County has over 12,000 Medicaid/BadgerCare recipients and Ozaukee County has more than 6,000.

Dentists alone cannot address the shortage.

A proven solution

Dental therapists have been working in neighboring Minnesota since 2009. They are licensed to do fluoride treatments, repair cavities and extract diseased teeth under the supervision of a dentist. Dental therapists provide mid-level care in much the same way that physician assistants and nurse practitioners do in doctor’s offices.

In addition to Minnesota, dental therapists practice in Oregon, Washington and tribal lands in Alaska. Legislation was signed into law recently authorizing dental therapists in Michigan, Vermont, Maine and Arizona.

“The physicians focus on the more complex medical issues, and the physician’s assistant can come in and evaluate a patient,” Ramirez says. “They can write prescriptions and supplement what the doctor is doing, which allows that medical clinic to do more with cost savings. Likewise, I see the dental therapists doing the same thing.”

Price says patients with special needs in particular would benefit.

“What typically happens is they aren’t very good at doing their own tooth brushing, but my folks are high functioning enough that they don’t allow us to do their tooth brushing for them,” she says. “I was very lucky with the previous dentist that I was able to get our residents in every six months for cleaning, to keep a check on things before things went really bad. Typically, because people with special needs tend to be on a lot of medications that weaken their teeth to begin with, it is very difficult.”

Treating patients who are impaired or in a wheelchair also can be challenging, Price says.

“Because Title 19 only covers certain things, our folks with special needs end up having to have a lot of extractions,” she says. “They can’t always get crowns or caps or anything like that. If the tooth goes bad, it is pulled it out. That’s why I have two residents in my facility who are not in the Community Smiles program — they no longer have teeth.”

“I think that it would be wonderful to have dental therapists offer their services,” Price says.

Anne Trautner is a freelance writer living in Washington County, Wisconsin. Permission to reprint is granted as long as the author and Badger Institute are properly cited.

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