Five Colorado counties don’t have a single dental provider, meaning people often drive long distances for routine care.
One in five Coloradans report having fair or poor oral health, 53 of Colorado’s 64 counties have dental health professional shortages, and adults in rural areas have almost twice the prevalence of tooth loss when compared with their urban counterparts.
Only 28% of Colorado dentists served any Medicaid enrolled patients in 2018, and in low-income schools, 44% of all kindergarteners had at least one cavity, according to data collected by Healthier Colorado, a nonprofit that works to influence public policy to improve health care for people across the state.
A law passed last year was intended to help close those oral health gaps by authorizing dental therapists to work in the state. But it may be years before enough of these mid-level clinicians are working in Colorado to make a difference.
On May 1, Colorado will begin issuing licenses to people who have completed dental therapy degrees or have practiced in the military or are licensed in the 13 other states where their work is legal. The degree is not offered by any Colorado colleges, nor does the state currently offer a licensing exam.
For now, people interested in the profession must train elsewhere. Only Alaska, Minnesota and Washington have education programs.
Healthier Colorado, which lobbied last year for the passage of Senate Bill 219, hopes to work with partner organizations — such as the American Academy of Pediatrics, Delta Dental and the Colorado Community Health Network — to create a statewide dental therapy education program.
Clinicians could expand capacity, but where will they train?
Dental therapists, similar to physician assistants, can offer more care than a dental hygienist but less care than a dentist. Therapists can fill cavities, clean teeth, place temporary crowns and perform extractions, for example.
Once a local education program is created, perhaps at the community-college level, Coloradans will begin to see many more dental therapists, who are supervised by dentists, working in dental practices, schools, mobile clinics, nursing homes and other community settings, said Kyle Piccola vice president of communications and advocacy for Healthier Colorado.
Research in Massachusetts, one of the states considering authorizing the practice, suggests adding a dental therapist to a clinic could expand capacity by 1,920 appointments per year.
“It’s proven to be really safe, and that it’s proven to have really phenomenal health outcomes for people is important,” Piccola said. “Eventually, this is going to be a really big deal.”
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At least one critic has said it’s unclear if there’s enough state funding to help educate and train dental therapists, especially while Colorado already underinvests in higher education including for dentists and dental hygienists.
Colleen Lampron, president of AFL Enterprises, a public health contracting company in Denver, is a former executive director of the National Network for Oral Health Access. She supports bringing dental therapists to Colorado but called Senate Bill 219 flawed.
“We already don’t have enough resources to train our dentists and dental hygienists and now you want to add a completely new profession, with a new curriculum and new graduation requirements,” she said. “Where are the people going to come from to teach these courses and how will we pay for it?”
The University of Colorado School of Dental Medicine, for example, suspended admissions to its dental hygiene program indefinitely because of cost concerns, she said. The last class of CU dental hygiene students graduated in May 2009.
There are four accredited dental hygiene programs offered in Colorado, at the community colleges of Northwestern Colorado, Pueblo and Denver, and at Concorde Career College.
Piccola said Senate Bill 219 merely created the scope of practice and authority to license dental practices and that Healthier Colorado leaders plan to work with state budget writers and community colleges to find funding for a new dental therapy education program.
Dental therapy education programs in other states have been set up through local partnerships and private and public funding, Piccola said. “This is an effort to build a pipeline of dental therapists to address oral health.”
The Colorado Consumer Health Initiative conducted a 2022 survey to assess Coloradans’ oral health needs and experiences.
Despite a desire for good dental health, half of the 422 respondents reported having oral pain or feeling self-conscious about their mouth’s appearance. Forty-seven percent of respondents who needed immediate care said they had to wait for more than one month to secure an appointment and 73% said they did not access care because it was too expensive.
“The mouth is part of the body, and we’ve learned, if you have gum disease, that can make it harder to control diabetes, and it has an effect, perhaps, on heart disease,” said Dr. Terry Batliner, a Colorado dentist who has worked alongside dental therapists in other states including in some in the most remote parts of the country.
“When people are trying to find a job, keep a job and work in the broader American society, it’s important to look good,” he said. Missing teeth, he said, “are really a disadvantage for folks.”
Dental therapists needed especially in mountain, rural communities
Dental health problems also are a leading cause of school absenteeism for Colorado kids.
Batliner, a member of the Cherokee Nation of Oklahoma, was associate director of Center for Native Oral Health Research at the Colorado School of Public Health and worked with the W.K. Kellogg Foundation to help expand access to dental care in U.S. communities.
He said dental therapists are especially needed in mountain communities and rural areas of Colorado, where there are few dentists. Dental therapists also can help reduce the cost of oral care.
“They get paid between what a dentist and a dental hygienist gets paid,” he said. “So they’ll be providing, oftentimes, the same stuff that a dentist would provide, but they won’t get paid as much, and so, that can reduce the cost that is passed onto the people.”
Employing local providers who understand the unique stresses and issues that affect their own communities helps them talk effectively with their patients about how to prevent disease because they can better relate to them, he said.
“And that has happened in Alaska,” said Batliner, one of several people who testified at the Capitol in support of Senate Bill 219 last year. “Most of the people who are dental therapists in Alaska are Native Alaskans.”
As of October 2021, Alaska had licensed 36 dental therapists. Minnesota, where there are three training programs, had 133, according to the American Dental Therapy Association.
Dr. Carol Niforatos also testified in support of the bill. She oversees the dental program at the Colorado Coalition for the Homeless, which provides care to about 6,000 people per year. Most of the organization’s clients are people who are homeless and none are turned away when they walk in for an appointment.
“I support any thoughtful improvement in access to care for any underserved populations,” Niforatos said. “Vulnerable populations tend to need the types of services that dental health therapists are licensed to provide, which are basic level to urgent needs, and removal of teeth that are causing patients pain or abscesses.”
Adding dental therapists to Colorado offices has been in discussion for about a decade, said Niforatos, who hopes to add such a provider to her office.
Overall, there’s been a decline in the number of dental hygienists working in the U.S., with a drop-off occurring during the pandemic, she said.
“They’re a lot scarcer,” she said, “so, dental health therapists may be able to meet those needs because of the lack of hygienists.”
Information about how to become a licensed dental therapist in Colorado, along with a checklist, is available on the Colorado Dental Board’s website.