MOORHEAD, Minn. - Nine-year-old Samantha Velline looked ready for the beach, wearing sunglasses and sitting in a reclining lawn chair in the Clay County Family Service Center in Moorhead.
However, she and brother R.J. were among eight patients to be seen on Wednesday, Jan. 17, in a makeshift dental clinic set up in a conference room between tables and stacks of chairs.
Dental therapist Teresa Bushnell went to work, plying Samantha's cheek with anesthetic before filling a cavity, while the child's aunt, Sarah Winbourn, looked on.
"She takes it like a champ, way better than I do," Winbourn said about her niece.
Samantha received the basic dental care from what's considered a "mid-level" dental provider.
There are more than 70 licensed dental therapists like Bushnell working in Minnesota, with the aim of making dental care more accessible to lower-income people.
"We don't have a lot of the bells and whistles that different dental offices have," Bushnell said.
What they do have is the ability to perform basic procedures, including filling cavities and extracting badly diseased or loose teeth.
The North Dakotans for Dental Access coalition endorsed the dental therapy concept in the 2015 and 2017 legislative sessions, but lawmakers turned down the idea.
The bills were fought by the North Dakota Dental Association, which represents nearly 90 percent of dentists in the state. Executive director and retired Fargo dentist Brent Holman offered the main reason they oppose the model.
"It fails to consistently improve access to care or rates of decay or cost of care for patients," he said.
Sarah Wovcha, who leads the non-profit Children's Dental Services in Minnesota, for whom Bushnell works, said there are no negatives.
"I have no skin in the game other than getting better dental access to low income people," Wovcha said.
Holman has concerns about the lesser amount of training required for dental therapists, who would be allowed to perform "irreversible surgical procedures."
He wonders why the state would consider duplicating services that dentists already provide at a much higher level of training.
He also said there's not enough evidence to show that dental therapists would, in fact, reduce barriers to care, particularly to those who are low income.
Instead, the focus should be on improving the dental Medicaid system, maximizing the current dental hygiene and assistant workforce, expanding "safety net" clinics and working with tribal communities, which have three to four times the amount of dental disease than the rest of the population, Holman said.
Rather than looking to Minnesota, he said the state must find answers within its own borders.
"All of those problems need to have North Dakota solutions," Holman said.
An assessment done in 2012 by the School of Public Health, University at Albany, N.Y., highlighted the low number of dentists in North Dakota willing to accept Medicaid patients, resulting in limited dental care availability, even in areas where there are plenty of dentists.
Minnesota first to approve
Dental therapy is practiced in dozens of countries, including Canada and New Zealand.
Minnesota was the first state to approve the use of dental therapists, doing so in 2009.
Since then, Maine and Vermont have followed suit, and a few other states are exploring it.
Native tribes in Alaska, Washington and Oregon use dental therapists to deal with dental care shortages.
Like in North Dakota, the idea was controversial when introduced in Minnesota.
The Minnesota Dental Association and dental schools "thought it was risky and second class," Wovcha said.
Allowing dental therapy does not hurt private practice dentists, she said.
Instead, it can help them make ends meet, with dental therapists focusing on simpler procedures and dentists on technical cases, allowing more patients overall to be seen.
Dental therapists train in only 50 of the most common procedures, compared with more than 500 for a dentist.
Wovcha likens them to nurse practitioners or physician assistants, who've become valued parts of a medical team, without infringing on doctors.
Children's Dental Services has seven dental therapists to complement the 17 dentists on staff, and she said there's no evidence they provide lower quality care.
'Nice to make a difference'
Winbourn heard about the dental therapy opportunity through her niece and nephew's school.
She appreciates having an alternative to seeing a dentist or waiting hours for walk-in dental care for the kids.
"I live paycheck to paycheck taking care of them," Winbourn said, "and missing a day of work is missing $100."
She said she's confident the children are getting quality care from Bushnell.
Once a math teacher, Bushnell changed course, intending to go to dental school. She finished her prerequisites and took her dental admission test but was put on a waiting list.
Then, she learned about the dental therapy option from an oral surgeon.
Once enrolled, she said she took many of the same courses as others studying to be dentists.
"We have the same board exams, the same requirements to meet and fulfill in order to get our credentialing done," Bushnell said.
A resident of Hibbing, Minn., Bushnell sees patients in the Iron Range region of northeast Minnesota and Duluth, and travels to Moorhead about every six weeks.
She said she's glad to serve areas where the need is greatest.
"It's nice to make a difference," Bushnell said.