By Brett Milam, Editor - July 12, 2021
Ohioans for Dental Equity are making a push for more equity in the dental profession, as well as creating better access for rural residents, including here in Clermont County.
Modernizing the dental care workforce primarily entails implementing a dental therapist program in the state of Ohio, which would need to be done via legislation.
There are 12 other states that have already implemented such a program: Alaska, Arizona, Connecticut, Idaho, Michigan, Minnesota, Nevada, New Mexico, Oregon, Vermont and Washington.
On June 25, The Sun spoke via Zoom with Larry Hill and David Maywhoor about Ohioans for Dental Equity and the dental therapist program.
Hill works statewide with Ohioans for Dental Equity and the Ohio Public Health Association. Hill was formerly the dental director at the Cincinnati Health Department for 30 years and ran the only dental non-profit in the city, Cincy Smiles, the services of which also spilled over into Clermont County.
Maywhoor is the executive director of the OPHA and works with Hill on the dental equity project.
Also listening in on the call were Akia Clark, with AmeriCorps VISTA program helping on the project; and Daniel van Hoogstraten, also with Ohios for Dental Equity.
Oral health is a part of overall health, affecting our ability to speak, smile, eat, show emotions, self-esteem, school attendance and performance, attendance at work, and oral disease can lead to cavities, gum disease, oral cancer, diabetes, cardiovascular disease, pregnancy issues, and even death.
In 2011, Kyle Willis, a New Richmond resident, who was the nephew of famed musician Bootsy Collins, died of tooth decay at just 24-years-old when the infection spread to his brain.
The Bootsy Collins Foundation was created in his honor to raise awareness about oral health.
Willis’ story offers a cautionary tale for how important oral health is, if left untreated. In particular, Willis also didn’t have the insurance needed to get the procedure or antibiotics he needed for treatment.
“We know about Kyle because of his famous relative, but there are many other Kyles who we never hear about,” Hoogstraten said in an earlier email to The Sun.
One of the salient issues Ohioans for Dental Equity point out is both that the dentistry profession is experiencing shortages and that the profession as it exists isn’t diverse enough.
According to The Ohio State University College of Dentistry, there are 100 areas in the state considered a “dental professions shortage area.”
Clermont isn’t one such DPSA, although as Maywhoor pointed out, that doesn’t mean there isn’t an issue with access. In other words, a place could still be in need without receiving the DPSA designation. Local authorities in Clermont would actually have to officially request an analysis to determine if the shortage exists.
“But that doesn’t mean there aren’t shortage areas in the county,” Maywhoor said.
Hill added to the point that the numbers can be underreported.
Brown, Adams, Highland and Clinton Counties neighboring Clermont are in the red zone for DPSA, and Hamilton and Butler Counties are in the gray zone, meaning more specific areas within those counties count as DPSA.
Clermont County Public Health in its Community Health Assessment, updated in 2020, identified oral health as one of the eight most serious health issues facing the community. That assessment came from meeting with focus groups in the northern, central and southern parts of the county. Focus groups consisted of both community members and agencies providing services.
According to the assessment, Clermont does slightly better than the state average on the percentage of third grade students who had untreated cavities as of the most recent 2013-2015 data at 14.1 percent compared to the state average of 17.0 percent.
On a history of tooth decay from the same time period, 43.5 percent of third grade students reported as much, which is lower than the 51.0 percent figure for the state.
The one area where Clermont trends slightly higher than the state is in the percentage of third grade students that had one or more sealants reported at 49.7 percent. The state figure was 49.0 percent.
The College of Dentistry has its own program, Commitment to Access Resources and Education to address these DPSA areas, arguing that the number one unmet healthcare need in Ohio for children and adults in underserved areas is access to dental care.
While Clermont isn’t considered a DPSA, it does have three safety net dental clinics.
Safety net dental clinics serve people who don’t have a regular dentist, are enrolled in Medicaid or don’t have adequate dental health insurance, can’t afford to pay for care out-of-pocket and have unmet oral health needs, according to the Ohio Department of Health.
Clermont’s three safety net dental clinics are: 1.) Clermont Pediatric Dental Care at 3003 Hospital Drive in Batavia; it provides comprehensive services for children only; 2.) HealthSource West Clermont Dental at 1341 Clough Pike, Suite 150; it provides comprehensive services; and 3.) HealthSource Eastgate Dental at 4627 Aicholtz Road in Union Township; it also provides comprehensive services.
In another measurement, Ohio is considered one of the top states with the highest number of people living in dental health professional shortage areas in the country at 1.8 million, according to a July 1 report by the Health Resources and Services Administration, an agency of the United States Department of Health and Human Services.
According to HRSA, 306 practitioners are needed to remove designations of HPSA
What is dental equity?
Maywhoor explained that there are two directions for dental equity: 1.) That the profession is not very diverse and so getting people from diverse communities to see themselves represented as providers; and 2.) The lack of access in parts of Clermont County and in the greater Southwest Ohio region, which he believes should be addressed with a public health approach.
“That is, we investigate, we analyze, we assess, we offer evidence-based solutions and programs and provide access to all kinds of care as a result,” he said.
Hill added that his understanding of equity in oral health care is that everyone, regardless of their condition, would have an equal opportunity to access care.
“And that’s not what we have in Ohio; it’s not what we have across the country,” he said.
The COVID-19 pandemic has also called particular attention to the inequity in health care, including oral health.
“Dental always seems to be the tagalong piece after medicine and I think what people forget is that you can’t take a four square inch area of the body, ‘Oh, but that’s different,’” Hill said.
And it’s not particularly a new phenomenon either. William Gies, a Columbia University biochemistry professor, often credited as the founder of modern dental education, published The Gies Report in 1926, which was influential to that end. However, it also pointed out the chasm between dental health and physical health, noting, “The traditional indifference of physicians to the preservation of the teeth, and to the prevention or cure of dental diseases, has long been an anomaly of the practice of medicine.”
“If normal teeth were merely inert masses of stone, like pieces of marble which they outwardly resemble, or if they were devoid of vital coordinations with the tissues that hold them in place, their neglect by medicine might not be difficult to understand. But they are living parts of an animate human body, perform various important functions, and from infancy to senility, by becoming deficient or undergoing deterioration, my occasion distress, disability, or death,” Geis said in his biting conclusion.
Nearly a century later, Hill was optimistic, though, saying he feels they’ve approached the “turn-around spot” where physicians are starting to understand the importance of oral health.
There are also projects going on around the country, including the Patient-Centered Primary Care Collaborative, to foster better integration of, and collaboration with, oral care.
In fact, PCC recently finished a year-long initiative in 2021 to work on such integration, or as they called it, “putting the mouth back into the body.”
“Primary care, as the main point of entry and access to support for patients in the health care system, represents a remarkable opportunity to better meet patients’ oral health needs across the socio-economic spectrum,” PCC said.
The PCC report highlighted, among other items, that the uninsured rate for dental insurance is four times higher than for medical insurance, which often leads to adults going to the emergency department for care, as Willis did, making up a vast majority of such visits for dental problems that are largely preventable.
Among the PCC’s recommendations, they are aligned with the Ohioans for Dental Equity’s goal of not just incorporating oral health learning into all health professions training programs, but broadening the scope-of-practice laws to allow all clinicians, including dental therapists, to deliver oral health services “consistent with their full scope of practice.”
To the latter, that oral health exists as a “tagalong piece” affects policy decisions and outcomes as well, particularly regarding dental therapists.
Maywhoor and Hill explained that a dental therapist is a mid-level practitioner akin to a nurse practitioner. Even though the model for care has been around for decades in other parts of the world, such as New Zealand, it’s a rather nascent program in the United States, beginning in the early 2000s in Alaska.
The idea is that a dental therapist is someone who can perform some of the procedures that are needed the most under the supervision of the dentist. The dental therapist receives three years of “intensive training” to be able to perform such procedures.
By comparison, a dentist has a minimum of eight years of college, but only four of those are dental education and training, so the dental therapist is 75 percent of the way there to perform about 10 to 15 percent of the services, Hill said.
Maywhoor said the dental therapist program is an evidence-based way of providing needed dental access to low-income communities.
In 2017, the Federal Trade Commission wrote a comment letter to then Ohio State Senator Peggy Lehner about dental therapy. Lehner, a Republican, introduced a bill alongside Democratic State Senator Cecil Thomas representing parts of Cincinnati, to license dental therapists. The FTC noted that, “workforce modifications expanding the use of mid-level providers, such as dental therapists, can increase the supply of basic services and improve the overall quality and convenience of care. Such measures are viewed as an important strategy to address access and cost challenges.”
The following year, the U.S. Departments of Health and Human Services, Treasury and Labor collaborated with the FTC and the White House to recommend to the states that they improve choice and competition in health care markets “while still ensuring safe care” through the emerging implementation of dental therapists.
The American Dental Hygienists’ Association also supports expanding access to care through dental therapy.
However, the American Dental Association, which represents 162,000 dentists, opposes the dental therapy model.
“Rather than add a new category of providers, the ADA believes there is a critical need to connect underserved people seeking care with dentists ready to treat them. This can be accomplished through community health worker outreach and improved funding for dental services under Medicaid which in turn would increase the number of dentists participating in the program,” the ADA said in a 2017 response to news coverage of dental therapists being proposed.
The Ohio Dental Association, which represents 5,000 member dentists, nearly 70 percent of the state’s licensed dentists, also opposed the idea of legalizing dental therapists in Ohio in a 2017 statement.
“Allowing undertrained individuals to perform irreversible surgical procedures puts Ohio’s most vulnerable patients at risk,” ODA President Dr. Kevin Laing, a general dentist from Van Wert, said.
In addition, contrary to what Ohioans for Dental Equity believe, the ODA believes that there is not a shortage of dentists in Ohio. Still, on the access front, ODA believes the solution isn’t to create a new level of dental provider, but “overcoming barriers to providing preventative care to patients in need.”
David Owsiany, ODA executive director, said in that same 2017 statement that creating a dental therapist category in Ohio is a “radical proposal.”
“We need to focus our efforts and funding on programs that are proven to improve access to care, like the Ohio Dentist Loan Repayment Program, which has incentivized dozens of dentists to provide quality care to underserved patients in professional shortage areas,” he said.
In a follow-up, current statement to The Sun, Owsiany said, “While more needs to be done, the results have been impressive. Ohio is meeting the national goals and exceeding the national averages in terms of access to dental care for both adults and children.”
Owsiany provided an infographic based on Ohio Department of Health 2017-2018 data, showing as much. For example, 84 percent of children had visited a dentist within the past year, which is higher than the national target of 49 percent. Ohio also exceeds the target of 28 percent at 48 percent for the percentage of children with one or more dental sealants.
The percentage of children with untreated cavities is 20 percent; the national target is 26 percent.
Finally, the percentage of children with a history of tooth decay is 48 percent; the national target is 49 percent.
On the adult front, 68 percent of adults reported visiting a dentist in the last 12 months, higher than the national average of 64.9 percent.
One program ODA supports is the Ohio Dentist Loan Repayment Program, which incentivizes dentists to go into communities of need and receives assistance in repaying their loans.
As of 2017, Clermont was one such county with a dentist funded through the loan repayment program currently under contract.
In addition to desiring to expand that program, ODA also wants to update Ohio’s laws to permit dentists to utilize tele-dentistry to extend the reach of dental teams into underserved communities.
Owsiany said equity has continued to be a challenge in all aspects of health care and ODA’s focus has been to “ensure that all Ohioans have access to the full range of dental services that only a dentist is trained to provide.”
“We do not believe the underserved are well served by creating a two-tiered system. It makes no sense directing Ohio’s most vulnerable patients to lesser trained providers,” he said.
One way Owsiany said they have addressed the equity problem is to increase the number of the aforementioned dental safety nets in underserved communities. The number of such safety net dental clinics grew from 88 in 1999 to 122 in 2008 to 173 by 2019. In addition, in the last 20 years, the percentage of those providing comprehensive services has increased from 82 percent to 88 percent.
“These safety nets supplement the dental providers already in these communities,” Owsiany said.
Representation matters to Ohioans for Dental Equity
Hill pushed back against the idea of a dental therapist being dangerous or unaccountable, noting that the dentist would be in charge and supervising the dental therapist and controlling what they can provide.
“The other thing is, in most of the programs, the therapist in one way or another, can communicate with the dentist on a daily basis,” he said. “But the dentist is aware, or should be aware, of what the therapist is going to do that day.”
In addition, the dentist can decide whether the dental therapist will work remotely in their community or under direct supervision.
Maywhoor also wasn’t impressed with the Ohio Dentist Loan Repayment Program. He said the problem with the program is that dentists will go to low-income communities to get assistance in paying off their loans, but then don’t stay in those communities.
According to the ODH, the program is a two-year contract, with an incentive to receive up to $35,000 annually for a third and fourth year of service if the dentist remains at the practice sites and maintain eligibility.
Maywhoor said what he wants to see are people coming from the community of need, going to a good, accredited education program and then going back into those communities of need.
“That’s for me, the most effective model,” he said.
But also, it’s that representation piece.
“And for a young person, a young child, African American girl, sitting in a dentist chair, looking up and seeing an African American dental therapist, it says to her, ‘This is something I can do,’ but we’ve gotta open that door first,” Maywhoor said.