The NCSL Blog


By Bryan Kelley

Maine will join Alaska and Minnesota as the first states to have mid-level dental providers, similar to physician assistants and nurse practitioners in the medical field.

woman in dental chairGovernor Paul LePage signed LD 1230 on April 28, which establishes a new licensed profession— dental hygiene therapists—who will be able to perform services such as preventive care, routine fillings, simple tooth extractions, administration of local anesthesia, and crown placements under the supervision of a dentist.

This legislation aims to expand access to dental care, especially in rural areas of Maine where there is now a low ratio of dentists available to meet the population’s needs. According to a report from Pew’s Children’s Dental Campaign, the introduction of a mid-level provider to Main Street Dental Care in Montevideo, Minn., increased the number of Medicaid patients able to receive care and allowed the dentist to focus on more complex procedures requiring greater expertise.

Lack of access to dental care can lead to negative health consequences, as well as significant financial costs both for individuals and for state budgets. For instance, nearly $110 million was spent to treat 330,000 tooth-decay related trips to the emergency room across the country in 2006. The most common payer for children in these cases was Medicaid. As state budgets pick up a large part of these expenses, many state legislators are interested in efforts to increase access to preventive dental care in order to improve children’s health and reduce these costs.

Economics aside, untreated dental problems can lead to tragic consequences. In 2007, for example, 12-year old Deamonte Driver died in Baltimore when bacteria from an abscessed tooth traveled to his brain after being unable to find a dentist that accepted Medicaid. If the issue had been addressed early on, extracting Deamonte’s tooth would have cost only $80; instead, he underwent two brain surgeries costing around $225,000 and died less than a month later. At the time of his death only about 16 percent of Maryland’s dentists accepted Medicaid-enrolled patients.

All Medicaid-enrolled children have coverage for pediatric dental services, but that does not guarantee that children receive services. In 2011, for instance, 52 percent of children enrolled in Medicaid did not receive any dental care, including preventive visits. Barriers to access—such as the large number of rural and urban areas with an insufficient number of dentists; an inadequate number of dentists willing to treat Medicaid-enrolled patients; a lack of transportation or flexible work schedules for parents and guardians; and a lack of knowledge among parents and others about the importance of oral health—contribute to the lack of dental care for so many Medicaid-enrolled children.

Without regular, preventive dental care, simple problems can develop into larger, more expensive and painful complications. Children with painful oral health problems who lack access to dental care may turn to emergency rooms for much more expensive treatments—but, since ERs typically do not have dentists on staff, the underlying problems frequently go unaddressed, and patients are instead given prescriptions to relieve pain or antibiotics for infection. In light of the high costs, and potential health complications caused by lack of access for Medicaid-enrolled children, some lawmakers are working to increase access via innovative state programs.

In addition to creating mid-level dental providers, states have established a range of policies to reduce barriers to dental services and improve access to care for underserved populations. For example:

  • In 2009, Colorado found that Medicaid paid more than $8 million to treat 2,198 children under the age of 5 for dental disease in operating rooms. In response, the state established Medicaid reimbursement to primary care providers to provide school-aged children with oral health risk assessment and fluoride varnish services. Colorado also increased Medicaid reimbursement fees to dentists as of July 1, 2013, to provide incentives to accept more children with Medicaid coverage.
  • The District of Columbia and 33 states have publicly or privately funded dental loan repayment programs to attract graduating dental students to underserved areas.
  • Thirty-six states allow dental hygienists to perform some services without the specific authorization of a dentist, such as applying fluoride and sealants, enabling them to practice in settings such as schools and nursing homes. Sixteen states also allow Medicaid reimbursement directly to dental hygienists for certain services.
  • 2011 New Mexico House Bill 187 allows Community Dental Health Coordinators—under the general supervision of a dentist—to provide basic preventive services, such as applying fluoride varnish, and help patients make dental appointments, in community settings.
  • In parts of California, Virtual Dental Homes electronically link dentists with dental hygienists and assistants who perform preventive services and screenings in schools, nursing homes and other community settings. Dentists view records remotely, develop treatment plans and refer patients to dental offices for further care.

To learn more about dental access barriers and innovative state initiatives to increase access to Medicaid dental benefits for both children and adults, read NCSL’s new Improving Access to Medicaid Dental Benefits LegisBrief. You also can read Click here to read NCSL’s LegisBrief on Oral Health Workforce.

Bryan Kelley is a research analyst with NCSL’s health program.

Email Bryan.


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About the NCSL Blog

This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.