Getting to the Root of the Problem: Innovations in Dental Care

At our 2019 Annual Meeting, Eilidh Peterson, vice president of Brattleboro Memorial Hospital
Medical Group and Population Health, and several other participants shared collaborative and innovative approaches to meeting the oral health needs of their communities.
Peterson reported that her organization had Identified on its last two community needs assessments that the surrounding community was in need of access to dental care. Among the top five unmet needs on each was dental care for adults who were uninsured, underinsured or on Medicaid.
“While Vermont is far from alone [in underfunding Medicaid for dental services], a patient in Vermont who is on Medicaid receives a coverage cap of $510 a year,” she noted. “That covers about two fillings a year. It doesn’t cover the recommended two cleanings per year. And it definitely doesn’t cover what most adults who have gone their whole lives without dental care need, which is a full mouth restoration. It doesn’t come close to covering that or extractions or dentures,” she said.
Because of these restrictions, she explained, private practice dentists struggle to accept patients who are on Medicaid.
She said BMH also saw the need for dental care access in the emergency room.
“We had patients present to our emergency room who were in need of oral health care. And as we all know, the ER is not the place for a patient with oral health care needs,” she stated. “What happens with these patients is that their symptoms might be treated. They might get pain meds, which is another problem. They might get antibiotics, if they have an infection, which is great. But they’re not having their teeth fixed. They’re not having their true oral health needs met. And so, these patients present again and again with these same problems. And in our community, it’s because they had nowhere else to go,” she added.
“So it’s an inappropriate use of the ER; it’s also an inappropriate use of health care resources,” she related. “This is not where we want to be spending our funds in the ER.”
She said her team checked on access through “secret shopper” calls to dental offices. They found that no dentists were accepting adult patients who are on Medicaid; and none had sliding scales for charges.
“Patients could only go to the ER for care,” she said. “We knew we had a need.”
Then BMH partnered with the United Way, which was also doing work around oral health—they developed an oral health task force, bringing in dentists, the Vermont Technical College (VTC) and other interested parties.
The task force examined many possible solutions, thinking at first if they could support local dentists, they could find solutions there. But because of Medicaid restrictions, the local dentists couldn’t help.
“When it became apparent that our local dentists weren’t going to be the solution,” she remarked, "BMH and the United Way said, 'We’re going to open a dental center.’”
The team devised a business plan with help from Brattleboro Development Corporation. An unexpected win came when a local private practice looking to expand into a bigger building donated dental equipment to the fledgling dental center—a value of about $100,000. The center’s founders were able to open well ahead of schedule.
“An important thing about the center is its location,” Peterson noted. “it’s on the main drag; it’s on a bus line; and it’s on the hospital campus. The third thing is important because we know the mouth is part of the body. It plays an enormous role in overall health,” she said.
She explained that the United Way hires most of the staff for the center. The hospital employs the dentists.
“The dentist is part of medical staff,” she related, “which is good for cross referrals.” BMH donates the space for the center. The organization employs a sliding scale for fees and seeks to Integrate medical and dental care, while using new resources such as dental therapists.
“It never will be self-sustaining,” Peterson stressed. “We will always be looking for grants.” She noted that the Thompson Trust has pledged $150,000 per year for the next three years.
Carmen Derby, executive director of the United Way of Wyndham County, gave her view of the project.
“The United Way also completes community assessments,” she explained, which led the organization to a goal of having all people receive preventative and ongoing dental care.
“We had this goal in 2009—I’m proud that so early on, our committee knew that that this was important,” she stated. In 2011, the United Way funded an adult dental day, where local dentists provided services. Later, the organization provided transportation for patients.
“In 2018—the last time we did a dental day, we had more than 1000 patients,” she said.
In 2016, the United Way joined the community conversation about how to provide access to dental care on more than just one day per year. She noted that her organization is in a unique position, having close relationships with the hospital, nonprofits, dentists, businesses and the Vermont Department of Health. Construction companies donated to the project. Banks helped with business plan. These relationships came in handy when the United Way helped launch the dental center.
“We did all the hiring, filed with state, found IT and other suppliers. We had nothing other than a building and donated equipment when we started. We set up offices, conducted training on software, etc.,” she reported.
As of the end of August, the center had seen 172 patients and provided 934 services.
“The majority of that is extractions,” she admitted. “But we’ll be turning that curve.” As the center provides more preventive care, those extractions will become less frequently necessary.
She explained that because the population served by the center struggles with resources, patients often don’t keep their appointments. This is frustrating, since the center maintains waiting lists for some procedures.
“The goal is to fill that chair whenever there’s a dentist there,” she said. “When patients don’t show up, we don’t judge. We listen. We work to eliminate barriers. We make reminder calls, send text messages, remind them to call us. We know the bus routes and work around them. We treat patients as family members,” she explained.
She discussed some of the processes the center put in place after listening to patients.
“Kids with two households get two toothbrushes because we want them to have no barriers to brushing their teeth,” she noted.
She also explained that, instead of buying cheap plastic toys as incentives for young patients, the United Way tapped its relationship with Scholastic Books. Every child now goes home with a book at the end of the visit.
She related how one young patient touched the hearts of staff by asking “Is it going to be all mine?”
“She had her own book for the first time,” Derby said. “We’re very proud to be part of that.”
Next, James Trimarchi, Director of Planning for Southwestern Vermont Health Care (SVHC), talked about his organization’s experience launching Bennington Dental Center.
“Because of tooth decay and gum disease in Bennington, more people who live in our region have had a tooth extraction than have a full set of teeth,” he began. “The rate of emergency department visits for dental issues is double what it is across the state and rising,” he added.
“We’re also facing the aging of the dental workforce. As tight as access is now, very soon it will be tighter,” he remarked.
He related that they opened the dental center in 2018 after receiving a Certificate of Need from the state. The facility has five dental chairs, x-ray capability and three dentists. They recruited one dentist straight from dental school.
“We’re not only delivering dental care at the center,” he noted. "We’re having conversations  about long-term dental health—for example talking to parents about juice and sippy cups,” he said.
So far, the center has seen 6,400 visits from over 100 zip codes.
“People are traveling very far for dental care,” Trimarchi said, “even from other states. We’re already full into next year.”
About 45 percent of the patients have Medicaid.
 “This is a fragile population, trying to piece things together, so we do have no-shows,” he said, adding that the center double and triple-books when they can.
“It does and will forever require a Southwestern Vermont Health Care subsidy,” he noted, explaining that the center is working on promoting efficiency and on growing the clinic.
“Oral health is at crisis levels in the Bennington area,” he concluded. “Access is restricted and will get worse. We’ve started our journey to solving the problem--this is the first of many steps we’ll be taking to solve it.”
Dr. Cheyanne Warren, dental therapy program director at Vermont Technical College (VTC, joined the session to talk about how dental therapy, a relatively new approved specialty in Vermont, can help mitigate the dental care access problem in our state.
Vermont was the fourth state to approve the specialty. Now 12 states have done so.
“We don’t have a dental school here in Vermont,” Warren said. “There was a shortage of dentists and they were hard to recruit. We had a good hygiene program, though. When the idea of adding a dental therapy program arose, VTC came right to the table and said they wanted one,” she expressed.
She explained that the Commission on Dental Accreditation set the standards for dental therapy. Dental therapists receive all the training dental hygienists get plus additional coursework. In total, the master’s in dental therapy is a three-year program that includes an externship in the last semester.
She quoted a return on investment study.
“A dental hygienist's return to school for the master’s in dental therapy is cost-effective, with the [new] salary they’d be making, until the age of 58,” she said.
When the first VTC dental therapy class, beginning in fall of 2021, graduates, the new dental therapists will be able to do everything dental hygienists do, plus all of the following and more:
·      Offer preventive services
·      Prescribe antibiotics
·      Do brush biopsies
·      Extract primary teeth
·      Extract Class III mobile permanent teeth
·      Prepare cavities and restore primary and permanent dentition
·      Execute pulpotomies and SSCs on primary teeth
·      Place direct and indirect pulp caps on permanent teeth
·      Administer nitrous oxide
“They can provide a huge amount of preventive and restorative care and exams,” Warren stated. “This will reduce wait times and overhead times. Dentists are now more productive. The whole team is more productive.”
Dental therapists can practice in hospitals, Federally Qualified Health Centers (FQHCs), private practice, nonprofits and educational programs.
“We hope to increase access in different settings through the externship program,” she noted, stating that the program will send externs to various settings all over state, hoping they’ll go back to those communities after graduation.
“If all the new dental therapists are snatched up in private practice, are we really doing all we can do? We want them to go to areas where they’re needed the most,” she said.
New graduates must receive 1000 hours of dental supervision. After that, they maintain collaborative agreements with dentists, but can practice on their own.
Peterson wrapped up the session by answering the question, “Why should hospitals care about dental care?”
“These are our patients,” she stated. “When we see them in the ER, it’s not the right use of resources. Yet, untreated dental care can lead to health issues like heart problems, diabetes and even death.”
She told attendees that the Medicaid cap increased this year, but it would not alleviate all the issues.
“We need to think about new model of care. Look at existing resources; form partnerships. Build business plans. Use dental therapists. We need dentists to be passionate about this new model of care. It’s now part of our contracts with dentists—to be willing to collaborate with dental therapists,” she said.
She ended by urging participants, “Get started—don’t let perfection be the enemy of good.”

Watch the full video of this session