RESEARCH AND PRACTICE

Dental Therapy: Evolving in Minnesota’s Safety Net Karl Self, DDS, MBA, David Born, PhD, and Amanda Nagy, MPH

Dental therapy has evolved as a way to address specific oral health care needs. In New Zealand and Australia, dental therapy began as a way to address poor oral health in children. High levels of untreated disease coupled with a workforce shortage led the UK government to supplement dental care with dental therapists as new members of the health care team. In Canada and for people served by the Alaska Native Tribal Health Consortium, an important factor in the creation of dental therapy was the opportunity to extend care to native communities that were often geographically isolated.1 In the United States, many barriers impede access to oral health care for the nation’s most vulnerable populations, including lack of dental care coverage, an inadequate supply of dental providers (particularly in rural communities and inner cities), and the limitations of the dental Medicaid program.2---4 These concerns are mirrored in Minnesota.5 According to 2011 data from the Minnesota Department of Health, 56 of the 87 Minnesota counties are designated in whole or in part as dental health professional shortage areas.6 Populations living in health professional shortage areas have less access to routine primary care than do populations living in areas with an adequate health care workforce.7 Only one fourth of Minnesota dentists practice in rural areas. The current Minnesota dental workforce is also aging: 47% of dentists are older than 55 years, and 42% plan to retire within the next 10 years.8 Additionally, Department of Human Services data reveals that 862 000 Minnesotans were enrolled in a Minnesota Health Care Program (MHCP) in 2012 (MHCPs include Medical Assistance [Minnesota’s Medicaid program] and MinnesotaCare).9 Our October 2013 analysis of historical Minnesota Department of Human Services data shows that the number of Minnesotans eligible for dental care through Medical Assistance increased 59% from 2004 to 2012. It is hard to estimate the number of individuals who have problems accessing routine dental care in Minnesota. A 2012 Robert

Objectives. We identified Minnesota’s initial dental therapy employers and surveyed dental safety net providers’ perceptions of dental therapy. Methods. In July 2011, we surveyed 32 Minnesota dental safety net providers to assess their prospective views on dental therapy employment options. In October 2013, we used an employment scan to reveal characteristics of the early adopters of dental therapy. Results. Before the availability of licensed dental therapists, safety net dental clinic directors overwhelmingly (77%) supported dental therapy. As dental therapists have become licensed over the past 2 years, the early employers of dental therapists are safety net clinics. Conclusions. Although the concept of dental therapy remains controversial in Minnesota, it now has a firm foundation in the state’s safety net clinics. Dental therapists are being used in innovative and diverse ways, so, as dental therapy continues to evolve, further research to identify best practices for incorporating dental therapists into the oral health care team is needed. (Am J Public Health. 2014;104:e63–e68. doi:10.2105/AJPH.2014.301937)

Wood Johnson Foundation publication reported that whereas 80% of insured Minnesotans had a dental visit in 2010, only 58% of uninsured Minnesotans had a visit.10 The unmet oral health need is also conveyed by the high number of emergency department visits for preventable dental-related problems. Davis et al.11 found that in a single year patients made more than 10 000 emergency department visits to 5 major hospital systems in the Minneapolis---St. Paul metropolitan area. These patients incurred total charges of $5 million for dental issues such as toothaches and abscesses. People who are enrolled in an MHCP and other underserved populations often turn to safety net providers to receive their oral health care. Although previous literature conveys the impression that the “dental safety net” has no single definition, the American Dental Association describes the safety net as the sum of the individuals, organizations, public and private agencies and programs involved in delivering oral health care services to people who, for reasons of poverty, culture, language, health status, geography or education, are unable to secure those services on their own.12(p2)

Although safety net clinics provide a small portion of overall health care, they are an important resource for groups that face access

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barriers.13 Not surprisingly, safety net clinics have many challenges, including difficulties in recruiting and retaining dentists.4 Perhaps because of their staffing challenges, Minnesota’s safety net providers helped lead the way when the state began an initiative to create a midlevel dental provider to address the growing oral health concerns of the state. In 2009, Minnesota became the first state to establish licensure of dental therapists with an additional process for certification as an advanced dental therapist to extend oral health care to underserved populations. The legislation limits dental therapists to practice primarily in settings that serve low-income, uninsured, and underserved populations or in a dental health professional shortage area.14 In response to the state mandate, the Minnesota Board of Dentistry simultaneously approved 2 programs for educating licensed dental therapists. The University of Minnesota School of Dentistry dental therapy education program was designed to educate dental therapy students alongside dental and dental hygiene students in a team environment. This collegial approach to education will facilitate the delivery of a single standard of care to all Minnesota patients regardless of provider type.15 The program, initially designed to educate students to the

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licensed dental therapy standards, has since been modified to educate its students to also be eligible for advanced dental therapy certification. The other approved program was initiated as a collaboration of 2 institutions in the Minnesota State Colleges and Universities system formally designated the state college system. The Minnesota State Colleges and Universities system developed a dental therapy program for Minnesota licensed dental hygienists, offering them the opportunity to become dual licensed, both as a dental hygienist and as a dental therapist. This program was designed from its inception to educate dental hygienists to become licensed dental therapists and to become eligible for advanced dental therapy certification. As of October 2013, 28 individuals have been licensed as dental therapists in Minnesota.16 Nationally, there is interest about where these providers are practicing and what is known about the early adopters who employ the dental therapists. An earlier survey the University of Minnesota conducted in 2010 with Minnesota general dentists revealed a negative attitude toward dental therapy.17 However, in light of the legislative mandate that therapists primarily treat underserved populations, it is not surprising that safety net clinics, rather than traditional private practices, have become the predominate employer of dental therapists in these early years. Thus, the attitudes of safety net clinic dental directors and administrators are of particular relevance. To better understand early adopters’ attitudes toward and motivations for hiring a dental therapist, we undertook a survey in July 2011 to assess Minnesota’s dental safety net providers’ prospective views on dental therapy employment options.

METHODS Because a comprehensive list of safety net clinics in Minnesota does not exist, we created a list of safety net clinics (defined by the legislative criteria for acceptable practice settings for dental therapists) from several sources. The list included, but was not limited to Federally Qualified Health Centers (FQHCs), free clinics, nonprofit clinics, and individual and group for profit practice clinics that had a history of treating above average numbers of MHCP patients.

We developed a questionnaire to mirror a survey that had been sent to Minnesota general dentists in 2010, designing it to capture the personal characteristics of the respondent, clinic, or practice demographics as well as the respondent’s attitudes toward employment and use of dental therapists. The survey used a variety of item types, including multiple choice and Likert scale. We distributed the questionnaire via Surveymonkey to 90 individuals who had previously been identified as Minnesota safety net dental clinic leaders. The e-mail contained background and consent information inviting them to participate in the study and a link to a confidential 21-item electronic survey regarding issues related to the potential employment of dental therapists. We sent 2 reminder e-mails approximately 2 and 7 weeks following the initial mailing. A total of 32 surveys were completed for a response rate of 36%. We tabulated the data using Surveymonkey’s standard reporting procedures. We have reported the results as percentages on the basis of total survey respondents. Because this was a basic descriptive study and the respondent pool was relatively small, we did not perform any further statistical analysis. In October 2013, we sought to identify dental therapy employers in Minnesota. One surveyor contacted the 28 licensed dental therapists via telephone or e-mail. Via the nonstructured survey we collected a variety of information on the employing organization, including demographics such as clinic type, location, and patient population, which we used to reveal characteristics of the early adopters of dental therapy. All 28 dental therapists participated in the employment scan.

2011 Survey Responder Characteristics Although the number of respondents to the 2011 survey was small (32 of 90), there was good representation of the diversity of the oral health care safety net. Seventy-two percent of respondents were dentists, and 28% were nondentist directors. Of the dentist respondents, 86% had been in practice for more than 20 years. The respondents were nearly equally divided between FQHC clinics (31%), nonprofit clinics (31%), and private practice clinics (25%). Respondents were also almost equally distributed between men (53%) and women (47%). The key difference in gender related to the fact that 44% of male respondents were in a private practice type, whereas 92% of female respondents were in a FQHC or nonprofit clinic type. When asked about the clinic location, 53% of respondents described their service area as urban, whereas 44% characterized it as rural (Table 1). On average, Minnesota safety net clinics see a large MHCP population. Of all respondents, 56% stated that they served more than 40% MHCP patients. Eighty-five percent of responding FQHC and nonprofit clinics stated that more than 40% of the patients in their practice were enrolled in an MHCP. This compares to just 13% of private practices.

Respondent Perceptions Safety net dental clinic directors overwhelmingly (77%) supported the concept of dental therapy. Of these clinic directors (as shown in Table 2): d

d

d

RESULTS d

The 2011 survey provided a snapshot of the attitudes and characteristics of potential employers before the availability of dental therapists to hire. The 2013 employment scan, on the other hand, sheds light on how the marketplace absorbed therapists once they became available. Looking at the 2011 survey, we were able to identify both characteristics and perceptions of the responders.

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75% considered Minnesota dental therapists to be appropriately trained, 66% believed that the public will accept dental therapists as providers 63% felt the dental therapists’ quality of work will be equivalent to that of a dentist, and thought their clinic dentists would be comfortable delegating procedures to dental therapists.

In addition to their support for the concept of dental therapy, the majority of safety net clinic directors (69%) anticipated hiring dental therapists in the future. Among the 37% of clinic directors who did not anticipate hiring a dental therapist, there were 2 primary

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TABLE 1—Demographics of Survey Sample and Respondents: Minnesota, 2011 Characteristic

Surveys Sent (n = 90), No. (%)

Survey Respondents (n = 32), No. (%)

Gender Male

43 (48)

17 (53)

Female

47 (52)

15 (47)

Clinic type FQHC

24 (27)

10 (31)

Nonprofit Private practice

28 (31) 38 (42)

10 (31) 8 (25)

...

4 (13)

Urban

50 (56)

17 (53)

Rural

40 (44)

14 (44)

...

1 (3)

No response Clinic location

No response Note. FQHC = Federally Qualified Health Center.

concerns (Table 2). The most frequently cited concern related to the availability of treatment rooms: 64% of those reluctant to hire a dental therapist stated that they have limited operatory space. This concern was shared by respondents in both urban (54%) and rural (44%) clinics and by respondents in FQHCs (33%), nonprofit practices (33%), and private practices (33%). Their second concern was cost-effectiveness. Fifty-seven percent of safety

TABLE 2—Perceptions and Concerns of Safety Net Dental Directors Regarding Dental Therapists: Minnesota, 2011 % Perceptions safety net dental directors have of DTs DTs are appropriately trained

75

Public will accept DTs

66

DT quality of work is equivalent to DDS

63

DDS comfortable delegating

59

procedures to DT Concerns of directors reluctant to hiring a DT Limited space

64

Cost-effectiveness

57

Quality of care Public acceptance

36 14

Note. DT = dental therapist.

net responders who were reluctant to hire questioned whether a dental therapist can be employed cost-effectively. Concern about this issue appears to be influenced by a clinic’s location, as 88% of those who voiced this concern were located in an urban area and only 12% of those concerned were in a rural area. Respondents were equally split as to whether incorporating dental therapists into the oral health care team would increase the number of dentists willing to provide care to those enrolled in a MHCP. In general, those associated with FQHC clinics anticipated dental therapists having a positive impact on dentists, whereas those in a nonprofit or private practice clinic were more skeptical. It is worth noting that although 100% of respondents reported that they had a good understanding of the role of the dental therapist in a dental practice, there was no consensus on the ideal ratio of dental therapists to dentist in clinical settings.

2013 Early Adopter Employment Scan As of October 2013, 22 organizations or practices employed dental therapists. All employers can be described as safety net providers on the basis of the volume of care they provide to underserved populations. The employing clinics are diverse in clinic type and clinic location. Early adopters include FQHCs, nonprofit community clinics, private practices, and various other types of organizations (Figure 1). Private practice clinics are currently

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the largest group of early adopters, with 7 clinics employing dental therapists. There are 5 FQHCs and 4 other nonprofit communitybased clinics employing dental therapists. Additionally, 3 educational institutions, 2 hospital-based or hospital-owned clinics, and 1 large group clinic complete the list of early adopters who currently employ dental therapists. Employers are also diverse in their practice locations, spanning the state of Minnesota. Not counting the sites where care is provided through a mobile clinic (as an extension of a primary clinic), these 22 employers employ dental therapists at 24 clinic sites. Currently, 12 employer clinic sites are located within the 7-county metropolitan area and 12 employer clinic sites reside in greater Minnesota. In greater Minnesota, which is chiefly made up of rural and small towns, early adopters can be found in most regions of the state (Figure 2). By location, 7 of the 12 greater Minnesota clinic sites are located in towns of 8000 or fewer people, whereas 3 additional clinic sites have populations between 20 000 and 40 000 people. Also, 6 of the 7 private practice clinic types are located in greater Minnesota. Five employers also reported hiring more than 1 dental therapist to meet the needs of their patient population and to help improve access to oral health care within their communities.

DISCUSSION Although the issue of dental therapy has received considerable attention from the American Dental Association, the PEW Center on the States, the W. K. Kellogg Foundation, and other national organizations, we are only beginning to understand how dental therapy is evolving and how it will affect care in Minnesota. To our knowledge, this study is the first to identify initial dental therapy employers and the first to look at the perceptions of Minnesota’s dental safety net providers on dental therapy. In summer 2013, various members of the dental community expressed the concerns that dental therapists were not being hired and that the majority of those who had been hired were practicing in the 7-county Twin Cities metropolitan area, not in greater Minnesota,

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8 7

Employers, No.

6 5 4

4 3 2

2 1

0 Education

FQHC

Hospital

Large Group

Nonprofit Private Practice

Clinic Type Note. FQHC = Federally Qualified Health Center.

FIGURE 1—Dental therapy employers by clinic type: Minnesota, 2013.

where higher needs for provider support were felt to exist. These perceptions are largely unfounded. As these data show, the process is moving forward and dental therapists are being employed by operationally and geographically diverse clinics. We focused on documenting the employment of licensed dental therapists, as the process and outcomes of advanced dental therapy certification is still in its infancy in the state. It is important to note that the initial mix of dental therapy employer clinic types mirror the clinic types that responded to the 2011 prospective safety net survey that we performed before dental therapists began practicing in Minnesota. Although 77% of safety net clinic director respondents overwhelmingly supported dental therapy, only 10% of a sampling of Minnesota general dentists who were surveyed in 2010 supported dental therapy. Also, in 2011 nearly 7 of 10 safety net clinic directors anticipated hiring dental therapists in the future, compared with 2 of 10 general dentists who were surveyed in 2010.18 Therefore, it is unsurprising that safety net providers are, in fact, the early adopters of dental therapy. In Minnesota, licensed dental therapists have been hired in a variety of clinical settings, and they are being employed in different ways. These different practice settings will provide the state with a number of minilaboratories in which to study how best to employ a dental

therapist. The number of early adopting clinics that can be classified as located in a hospitalbased or hospital-owned facility or in an educational institution is surprising. Within these clinic types we find innovative uses of dental therapists. In 1 large urban county hospital, a clinic employs dental therapists to work with pregnant women on oral health care issues for both themselves and their expected child. This program originated as an innovative way to integrate oral health care with general health care. Another innovative example of using a dental therapist’s skill sets can be found in northwest Minnesota at a dental assisting education program. As a part of the dental assisting students’ clinical experience, they work with a dental therapist who performs basic restorative care. This is more costeffective than employing dentists for giving students experience in 4-handed dentistry and allows patients to receive restorative care onsite. By June 2014, 43 dental therapists will have graduated from an approved dental therapy program and potentially be licensed and eligible to be part of the Minnesota oral health workforce. The most significant concern of safety net clinic directors who are reluctant to add a dental therapist to their team is the lack of available treatment rooms. By their nature, virtually all these clinics have small financial margins and therefore must maximize the use of their treatment rooms on a daily basis.18

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They are thus challenged to incorporate an additional new provider type into clinic operations. Program expansion worked for clinics that had additional treatment room space or that had new programs ready to roll out. Other early adopters worked around the lack of space by bringing in a full-time dental therapist when a dentist vacancy opened up a treatment room, part-time to fill a previously open chair a couple of days a week, and even temporarily to fill a leave of absence such as a maternity leave. The latter 2 options have given clinics the opportunity to first work with a dental therapist on a limited basis, which helped them begin to understand their limited scope of practice and to assess the second most significant concern noted—costeffectiveness. Many people characterize the dental therapist as analogous to a nurse practitioner or physician assistant because the dental therapists work collaboratively with a dentist and the nurse practitioner and physician assistant work collaboratively with a physician. A look at the impact physician assistants have had on medical practices reveals an increase in the number of patients treated and an increased economic benefit to the practice.19 Because of these effects, as we consider the continued evolution of dental therapy, there may be lessons we can learn from our medical colleagues. A 2010 study20 looked at how physician characteristics influence their attitudes toward nurse practitioners. The study looked at Mississippi, which was an early employer of nurse practitioners because of its long history of having a medically underserved population. The study found that physicians who work most closely with nurse practitioners have significantly more positive attitudes about nurse practitioners on most measures than do physicians who lack nurse practitioners in their primary practices. This phenomenon appears to be taking place with initial dental therapy employers. As a case in point, 5 employers have hired multiple dental therapists. We anticipate that dental therapy will spread quicker in the coming years as University of Minnesota School of Dentistry dental graduates—who have been educated alongside dental therapy students and have worked closely with them, providing patient care in

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Note. HPSA = Health Professional Shortage Area.

FIGURE 2—Dental therapy clinic sites: Minnesota, 2013. clinical settings—become more influential in hiring decisions in the practices where they are employed. The 2013 employment scan provides some insight into the evolution of dental therapy in Minnesota. Yet it is a snapshot in time, as additional employers continue to bring dental therapists into their practices. The primary limitation of the 2011 survey is the comparatively small sample size. In addition, there may be a response bias in that supporters of

dental therapy were more eager to participate in the survey. Despite the small number of respondents, the characteristics of the responding clinics are diverse and consistent with the makeup of Minnesota safety net clinics who have hired a dental therapist thus far. The practice of dental therapy is taking root in safety net clinics throughout Minnesota. This study provides the first, to our knowledge, insight into the marketplace for these

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therapists. Dental therapists were created to address access to care issues, and we found that they are being hired to work in settings that allow them to have that impact. Although it is impossible to identify all providers who are a part of the safety net, the 2011 survey shows what appeared to be strong support among Minnesota safety net clinics for moving forward with dental therapists. Not unexpectedly, the concept of midlevel dental providers remains controversial in

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Minnesota, and dental therapy as a profession is still in its infancy. Understanding what motivates early adopters to hire dental therapists and understanding how they are used in different clinical settings will be an important research priority over the next several years. As innovative ways of employing dental therapists are explored and best practices are discovered, that information will need to be discussed and documented. Once this information becomes known, it should be shared broadly to ensure it reaches both current dental therapy employers and those who have been waiting on the sidelines to see how this new provider plays out in practice. j

About the Authors Karl Self, David Born, and Amanda Nagy are with the Department of Primary Dental Care, School of Dentistry, University of Minnesota, Minneapolis. Correspondence should be sent to Karl Self, DDS, MBA, Director, Division of Dental Therapy, University of Minnesota School of Dentistry, 515 Delaware Street SE, Minneapolis, MN 55455 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted February 16, 2014.

Contributors Karl Self generated the concept for and oversaw the study and led the writing. David Born led the design and implementation of the 2011 survey. Amanda Nagy led the design and implementation of the 2013 employment scan. All authors were involved in the study’s design and data analysis and contributed to writing the article.

Human Participant Protection The University of Minnesota institutional review board determined that this study was exempt from review under federal guidelines category No. 2.

References 1. Nash D, Friedman J, Mathu-Muju K, et al. A review of the global literature on dental therapists. 2012. Available at: http://www.wkkf.org/knowledgecenter/resources/ 2012/04/Nash-Dental-Therapist-Literature-Review. aspx. Accessed September 13, 2013. 2. Sanders B. Dental crisis in America: the need to expand access. 2012. Available at: http://www.sanders. senate.gov/imo/media/doc/DENTALCRISIS.REPORT. pdf. Accessed October 2, 2013. 3. Bailit H, D’Adamo J. State case studies: improving access to dental care for the underserved. J Public Health Dent. 2012;72(3):221---234. 4. Edelstein B. The dental safety net, its workforce, and policy recommendations for its enhancement. J Public Health Dent. 2010;70(suppl 1):S32---S39. 5. Pew Center on the States. The Minnesota story. 2010. Available at: http://www.pewtrusts.org/ uploadedFiles/wwwpewtrustsorg/Reports/State_policy/

060_10_DENT%20The%20Minnesota%20Story% 20Brief_web.pdf. Accessed September 2, 2013. 6. US Department of Health and Human Services. MUA/P by state and county. Available at: http:// muafind.hrsa.gov/index.aspx. Accessed October 8, 2012. 7. Liu JJ. Health professional shortage and health status and health care access. J Health Care Poor Underserved. 2007;18(3):590---598. 8. Minnesota Department of Health. Fact sheet: Minnesota’s dentist workforce 2009---2010. 2011. Available at: http://www.health.state.mn.us/divs/orhpc/pubs/ workforce/dent10.pdf. Accessed September 16, 2013. 9. Minnesota Department of Human Services. Minnesota health care programs. 2012. Available at: https://edocs.dhs.state.mn.us/lfserver/public/DHS-4932ENG. Accessed October 25, 2013. 10. Kenney GM, Zuckerman S, Goin D. Virtually every state experienced deteriorating access to care for adults over the past decade. 2012. Available at: http://www. rwjf.org/en/research-publications/find-rwjf-research/ 2012/02/urban-institutes-aca-implementationmonitoring-and-tracking-seri/virtually-every-stateexperienced-deteriorating-access-to-care-f.html. Accessed October 3, 2013. 11. Davis EE, Deinard AS, Maiga EW. Doctor, my tooth hurts: the costs of incomplete dental care in the emergency room. J Public Health Dent. 2010;70(3):205---210. 12. American Dental Association. Breaking down barriers to oral health for all Americans: repairing the tattered safety net. 2011. Available at: http://www.ada. org/sections/advocacy/pdfs/breaking-down-barriers. pdf. Accessed November 2, 2013. 13. Byck GR, Cooksey JA, Russinof H. Safety-net dental clinics: a viable model for access to dental care. J Am Dent Assoc. 2005;136(7):1013---1021. 14. Minnesota Board of Dentistry. Minnesota Statute 150A.105 Subd2 and Subb8. 2010. Available at: http:// www.dentalboard.state.mn.us/Portals/3/Licensing/ Dental%20Therapist/DTLEG.pdf. Accessed October 24, 2012. 15. University of Minnesota School of Dentistry. Dental therapy programs. 2012. Available at: http://www. dentistry.umn.edu/programs-admissions/dentaltherapy/index.htm. Accessed August 13, 2013. 16. Minnesota Board of Dentistry. Active licensee totals. 2013. Available at: http://www.dentalboard.state.mn. us/Portals/3/ActiveAll%2010-1-13.pdf. Accessed November 22, 2013. 17. Patel H, Born DO, and Grothe R. Minnesota dental professionals’ attitudes and expectations regarding the new dental therapists. Poster presented at the 63rd Annual Session of the American Academy of Pediatric Dentistry; May 28, 2010; Chicago, IL. 18. Boulard G, Tobler L. How secure is the safety net? The future of the nation’s community health care centers and public hospitals is grave. State Legis. 2005;31(3): 16---19. 19. Rodriguez TE, Galka AL, Lacy ES, et al. Can midlevel dental providers be a benefit to the American public? J Health Care Poor Underserved. 2013;24(2): 892---906. 20. Street D, Crossman JS. Does familiarity breed respect? Physician attitudes toward nurse practitioners in a medically underserved state. J Am Acad Nurse Pract. 2010;22(8):431---439.

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American Journal of Public Health | June 2014, Vol 104, No. 6

Dental therapy: evolving in Minnesota's safety net.

We identified Minnesota's initial dental therapy employers and surveyed dental safety net providers' perceptions of dental therapy...
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