In western Minnesota and other dentistry deserts, dental therapists fill a gap

FERGUS FALLS, Minn. – All six of Michelle Ehlert's children have Medicaid plans that should cover their dental care. But for years, she and her husband paid for dental care out-of-pocket — sometimes thousands of dollars a year.

They couldn't find a dentist near their home in Wilkin County who accepted Medicaid. When a mobile clinic that would treat Medicaid patients drove nearly 200 miles from Minneapolis to the rural county on Minnesota's western border, appointments that fit her family's schedule were "hit-or-miss," she said.

That all changed when Ehlert's family found a clinic in neighboring Otter Tail County run by Apple Tree Dental, where dental therapists, who prioritize treating Medicaid recipients, provide much of the clinic's care.

Now, "we actually go to the dentist like we're scheduled to," Ehlert said. "It really is indescribable how much of a difference it's made."

Dental therapists are licensed providers who offer basic care traditionally provided by dentists, including fillings and simple tooth extractions. Over a dozen states have turned to them to increase access to oral health care, and federal advisers say at least eight more are considering doing the same. Like Minnesota, some states have deployed therapists specifically to benefit underserved populations, such as rural residents, Medicaid recipients, and Native American tribes.

Still, dental therapists are not universally supported or available to most rural Americans.

Karl Self, director of dental therapy at the University of Minnesota School of Dentistry, said that recruiting these midlevel providers is a cost-effective way to expand care in rural Minnesota.

Dental therapists deliver a slice of specialized care that helps fill gaps, Self said.

"Dental therapists are sort of the restorative experts," he said. "They spend the vast majority of their time doing a very small segment of dentistry as a whole. But it's a very high percentage of the primary care needs of patients."

Under the supervision of a dentist, dental therapists can complete oral evaluations, fill cavities, and extract children's baby teeth. In Minnesota, dental therapists with advanced training can treat patients without having a dentist on-site.

That flexibility enables those therapists to provide care in communities without full-time dentists.

Self said dental practices can deploy therapists to satellite offices, offering basic care and reserving more complicated procedures for occasional visits from a dentist.

It was two years after Minnesota became the first state to license dental therapists. The new licensure came with strings attached, requiring the therapists to practice in areas that didn't have enough dentists to serve the population, or to primarily treat low-income, uninsured, and underserved patients.

Leiviska called clinics almost daily looking for a job but found that most operators and owners didn't know what dental therapy was.

"It took me almost a year to get in," she said. In the meantime, "I was working at Applebee's."

Once she did join a clinic, Leiviska said, more than 90% of her patients were uninsured or on Medicaid. She has used her advanced dental therapy training to practice solely in urban areas since, but providers like her have become an integral part of Minnesota's effort to fill dental care gaps in rural areas.

Across the border in Wisconsin, a bipartisan group of lawmakers introduced bills in 2017 and 2019 to create the license class. The Wisconsin Dental Association opposed the measures, arguing that the state should invest in its existing workforce rather than create another profession.

In Minnesota, 66 of 87 counties are listed as having such shortages.

Pinpointing dental care deserts takes only dentists into account; those numbers do not reflect whether counties in Minnesota have dental therapists.

According to Minnesota's latest workforce report, as of 2018, the state had 92 dental therapists, including 25 working in rural areas. That same year, there were 5,683 hygienists and 4,140 dentists — most of them practicing in the Twin Cities area.

Neal Irion is one of those dental therapists. He treats patients at the nonprofit Apple Tree Dental clinic in Fergus Falls, a town of about 14,000 in western Minnesota.

"I'm delivering — like, me personally — close to $1 million a year of dental care," he said. "That's a lot of fillings; that's a lot of exams."