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Second Opinion: Dentists Can Help Address the Access Problem Kenton M. Johnson, DDS, MS

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Dentists Can Help Address the Access Problem
– Kenton M. Johnson, DDS, MS
Second opinions are common in health care; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dental professionals to share their opinions on various topics, providing you with a "Second Opinion." Perhaps some of these observations will change your mind; while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession. — Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine
"Any realistic public health approach to the problem of treatment makes it clear that manpower as now utilized by the dental profession here (in the U.S.) is totally inadequate to the task before it." Would you believe these words were written by a dentist more than 50 years ago in the American Journal of Public Health?

A look at new government data shows that the "manpower" problem identified in 1958 remains a problem. In fact, the challenge is getting tougher. According to December data from the Department of Health and Human Services, nearly 51 million Americans now live in a dental health professional shortage area. Based on this new data, more than 460,000 people in my home state of Minnesota are living in one of these designated shortage areas.

These shortages aren't just the federal government's guesswork. We know these shortages exist because these areas are designated only after state or local officials submit data on the availability of dentists in their areas.

The ratio of dentists to population is at one of the lowest levels it has been in more than 50 years. The fact that several new dental schools are opening around the country is encouraging, but this development is not expected to make much of a dent in the access problem for low-income or rural Americans. The dentist shortage is especially serious for children. Although there are more than 47,000 pediatricians in America, there are only about 5,000 pediatric dentists in our country.

If we really believe that dental care is a crucial pillar of health care, we cannot allow this huge gap to persist.

Even where dentists aren't in short supply, there is usually an access problem. A recent report on oral health by the U.S. Government Accountability Office identified 25 states in which fewer than half of the dentists treated any Medicaid patients during the past year.

The consequences of this access problem are all around us. Each year, millions of low-income Americans go without even basic dental care. I have been troubled by this reality.

Unable to find a dentist or unable to afford one, many of these people wind up in hospital emergency rooms (ER), complaining of a severe toothache. A study of seven hospitals in the Minneapolis-St. Paul metropolitan area traced 10,325 ER visits to toothaches, abscesses or other untreated dental problems. Besides placing additional stress on an already overburdened health-care system, these ER visits carried a high price tag: $4.7 million.

In addition, of those who visited a hospital ER for dental-related problems, almost 20 percent visited more than once.

Even before the current economic downturn, both children and adults who were seen at local community clinics were unable to get the restorative care needed by private-practice dentists due to financial reasons. Seeing this unmet need made us realize that the basic needs of this uninsured population might be more effectively met by a mid-level dental provider. I see these mid-level providers as functioning in much the same way as a nurse practitioner does in the medical world.

There are lessons we can learn from the medical workforce, which includes specialists and a wide variety of practitioners. By contrast, the current dental workforce is limited to dentists, dental hygienists and dental assistants.

Are we ready to confront the dental workforce challenge that was identified more than half a century ago? I sure hope so. In Minnesota, our legislature demonstrated leadership in 2009 by agreeing to license two new types of dental provider – dental therapists and advanced dental therapists.

The Minnesota law was passed after lengthy study and vigorous debate. Although I respect the views of those who spoke out on each side of this issue, I welcome the opportunity provided by our state's law because I firmly believe it will help us serve more patients, especially children.

I am not suggesting that Minnesota's approach to this challenge is the same approach all other states should take. Each state should pursue dental workforce solutions that fit its particular experience and access needs.

Some of my fellow dentists have voiced concerns about the quality of care that mid-level providers would offer, but the evidence is growing – both from abroad and here in the U.S. – that these fears aren't justified.

Since 2004, dental therapists have been working in Alaska under a federal program. A study by RTI International found that dental therapists were providing safe and competent care. Midlevel providers have been deployed successfully for many decades in a number of countries, including Canada and Great Britain.

I think more private-practice dentists are beginning to recognize there is a role for mid-level providers to play as part of a diverse team of professionals.

Dentists should play the leadership role of managing this team. Having mid-level providers as part of the dental team means that dentists can be freed to devote their time to more sophisticated procedures that a dental therapist cannot perform.

We now have evidence that strongly suggests that this new kind of dental team is financially sustainable. A recent report by the Pew Center on the States found that most private-practice dentists could hire these new mid-level providers and reach a lot more patients without taking a financial hit. In fact, Pew's research concluded that in many cases a dental practice's profitability could be enhanced by employing dental therapists or another type of new provider.

For some dentists in private practice, the licensing and deployment of mid-level providers is a source of anxiety. But I don't think it has to be.

Let's not forget that there was a time when dental hygienists were also "new" to the dental world. Today, of course, registered dental hygienists are employed by most private practices where they perform a common set of preventive procedures. And most of these dental practices would find it hard to imagine their office operations without a hygienist on staff.

With hygienists on their staff, dentists can devote more of their time to more sophisticated procedures. Adding mid-level providers would increase the capacity of a dental practice to see more people, including low-income children and adults who often go a year or more without seeing a dentist.

I work with a group practice in the Twin Cities, and we are exploring additional ways – including the kind of dental team cited – to expand our capacity to serve more patients. We have found that we can serve Medicaid-enrolled patients better with a designated central office. We are currently looking at new staff models that include one dentist and up to three mid-level dental providers. This structure would utilize the current space and more effectively meet the needs of the patients.

The change of political leadership in our state will also play a part in both the way and the amount that dentists and dental therapists are reimbursed. By improving Medicaid reimbursement rates, states can make it more financially viable for dentists to serve low-income patients. But I believe this policy will not – by itself – address the unmet needs for dental care that we see in so many of our communities across America. Other strategies, such as new provider models, need to be fully explored.

In the years ahead, dental schools will need to prepare future dentists for this newly emerging dental team – one that includes dental therapists or other mid-level providers. Dentists will continue to be highly skilled caregivers, but they will also be managers of a team of practitioners.

Dentists can and should be active players in the drive to expand the dental workforce. By doing so, we can underscore our ongoing commitment as professionals to ensure that Americans of all ages and socioeconomic statuses get the quality oral health care they need.
Author's Bio
Kenton M. Johnson, DDS, MS, has been a general dentist in Roseville, Minnesota, with Metro Dentalcare since 1994. After completing dental school at the University of Tennessee College of Dentistry in 1990, he moved to the Twin Cities. In 1999, the Minnesota Dental Association (MDA) named him "Outstanding New Dentist." Dr. Johnson is currently active with the MDA's Elderly and Special Needs Adults Committee.
Dentaltown Magazine
September 2025
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