[dropcap]I[/dropcap]n late June, Governor Ned Lamont signed legislation that made Connecticut the latest state to allow dentists to hire dental therapists. The trend is part of an effort to expand oral health care to underserved communities.
Like dental hygienists, dental therapists provide preventive care. They also perform a narrow range of routine restorative procedures, including filling cavities and extracting loose teeth, that are normally done only by dentists.
Nevada and New Mexico adopted dental therapy laws earlier this year, following Arizona and Michigan in 2018, Vermont in 2016, Maine in 2014 and Minnesota in 2009.
Nevertheless, dental therapists are working statewide only in Minnesota. (They practice on tribal lands in Alaska and Washington and in Oregon under a pilot program, and this year became authorized to practice on tribal lands in Idaho.) That’s because it can take years to create and fund dental therapy training programs and overcome strong resistance from state and national dental societies, which contend that only dentists are qualified to drill and extract teeth.
“Almost anywhere where dental therapy is getting passed, it has been a tough battle,” said Dr. Cheyanne Warren, a dentist who supports the dental therapy model and is creating a training program in Vermont.
ACCESS TO DENTAL CARE
Dental therapy laws are a response to the crisis in access to dental care in communities nationwide.
Nearly 54 million Americans live in 5,833 federally designated “dental health professional shortage areas,” where the population-to-dentist ratio is more than 5,000 to 1. While shortage areas are present in every state, the greatest number are in the South and Midwest. Fifty-nine percent are rural.
In addition to localized dentist shortages, “we’ve got a Medicaid population that has relatively few providers accepting their insurance,” said Jane Koppelman, senior manager of the dental campaign at The Pew Charitable Trusts, a research and public policy organization that champions the use of dental therapists. Medicaid is the joint federal and state health insurance program for low-income individuals and people with disabilities.
At least 55 million Americans are entitled through Medicaid to some dental coverage beyond emergency care, said Koppelman. Yet only 39 percent of dentists in the United States accept patients with Medicaid and other public insurance, according to an analysis by the American Dental Association (ADA), the national professional society for dentists.
The reason, dentists often say, is low reimbursement rates and limited dental coverage for adults in many states. State Medicaid programs must provide dental coverage for children; it is optional for adults. The ADA would like to see Medicaid rates raised, adult coverage expanded and outreach broadened.
“There is a critical need to connect underserved people seeking care with dentists ready to treat them,” the ADA, which declined an interview request, said in a statement to Rural Health Quarterly. “This can be accomplished through community health worker outreach and improved funding for dental services in Medicaid.” The ADA’s proposed fix does not include dental therapists.
Medicaid reimbursement rates to dentists are too low, agreed Drew Christianson, an advanced dental therapist and president of the Minnesota Dental Therapy Association, a professional membership organization. But dental therapists, although not a “silver bullet,” are a cost-effective way for dentists to extend their practices to underserved communities and must be part of any comprehensive plan to expand access to oral health care, Christianson said.
The stakes are high. Dental health is integral to overall health and well-being, numerous studies show. Untreated cavities and gum disease —which are largely preventable with proper dental care—are associated with increased incidence of strokes, heart disease, diabetes, asthma and other medical conditions. Poor oral health can also reduce a person’s ability to smile, speak, enjoy food and even to find and keep a job.
WHO ARE DENTAL THERAPISTS
Dental therapists practice in 54 countries around the world. In 2003, Alaska’s Tribal Health Consortium sent tribal members to New Zealand for dental therapy training in order to provide care to underserved Alaska Natives. Training now occurs at a program affiliated with Ilisaġvik College, a tribal community college in Utqiaġvik, Alaska.
Minnesota has the only other dental therapy training programs in the United States. Metropolitan State University offers dental hygienists a Master of Science degree in advanced dental therapy. The University of Minnesota Dental School offers a dual degree: a Bachelor of Dental Hygiene/Master of Dental Therapy. With additional training, the dental school graduates too can become advanced dental therapists.
Together, the two programs graduate between 12 to 14 dental therapists annually, who then obtain a license by passing “the same clinical competency exams as dentists for the services they are authorized to provide,” according to the Minnesota Board of Dentistry, the state regulator of dental professionals.
The state currently has about 100 of these mid-level professionals, “a drop in the bucket,” said Christianson. Still, they are making a “huge difference” in the lives of the roughly 150,000 people they see annually, he said.
Minnesota’s dental therapists must work under the direct supervision of a dentist. Advanced dental therapists may work under general supervision, without the supervising dentist on site, although the dentist specifies which legally allowed services the advanced therapist can provide when the dentist is not present.
Dental therapists in Minnesota must practice in settings that serve low-income and underserved communities, including federally qualified health centers and mobile dental units. They may work for private practice dentists as long as 50 percent of the therapist’s patients are on public programs, have a chronic condition or disability, or are low-income and uninsured.
Dental therapy laws in other states have varying requirements.
EVIDENCE FOR DENTAL THERAPISTS
The ADA said there is scant evidence to support dental therapy.
“Available data have yet to demonstrate that creating new midlevel workforce models significantly reduced rates of tooth decay or lower patient costs,” the organization said in its statement.
The number of studies of dental therapists in the United States is small, yet they seem to indicate positive results.
A 2018 article in the Journal of Public Health Dentistry found improved health outcomes in Alaska. The authors studied 10 years’ worth of Medicaid data and electronic health records for thousands of individuals. The use of dental therapists was associated with an increase in preventive care and a decrease in tooth extractions.
A 2016 article in the journal Community Dentistry and Oral Epidemiology documented improved access in Minnesota. After studying four dental practices, the authors concluded that “Dental therapists are treating a high number of uninsured and underinsured patients, suggesting that they are expanding access to dental care in rural and metropolitan areas of Minnesota.”
In addition, in case studies, two Minnesota dental practices increased revenue and saved money by employing dental therapists. Minnesota Medicaid reimburses a dental practice or clinic at the same rate whether a dentist or a lower-paid dental therapist performs the procedure. “You don’t have the most expensive person on the dental team doing rudimentary tasks that a lower-paid, qualified person can do,” said Koppelman. “It’s basic cost efficiency.”
However, Minnesota’s reimbursement policy means savings are not accruing to the state, at least not in the short term. The health department anticipates longer-term savings as the growing number of dental therapists improves access to routine oral health care and reduces the Medicaid population’s need for higher cost dental treatment and use of emergency rooms, it said.
VERMONT AND MAINE
Years after enacting dental therapy laws, Maine and Vermont still do not have dental therapists.
Vermont is furthest along. Warren has created the curriculum and found most of the funding for a dental therapy training program at Vermont Technical College, a public college with a dental hygiene program. Warren expects to submit an accreditation application to the national Commission on Dental Accreditation (CODA) this fall and then to the New England Commission of Higher Education.
“I think it is safe to say that we will have a class that starts in the fall of 2021,” said Warren. The program will accept 12 students, to include dental hygienists who will study for four terms, and high school graduates, who will study for nine terms.
But it has taken years to get the training program to this point. “We thought this process would be easier than it has been,” said Warren. Dental training programs are notoriously expensive, and the college and state had no extra funds, she said. “We had to search for money.”
Federal and philanthropic grants provided the funds to set up the program. Tuition and fees are expected to total $50,000 for the shorter program for hygienists and more than $100,000 for high school graduates, comparable to the other dental therapy training programs, said Warren. However, in Alaska, the tribes cover 100 percent of the costs, she said.
Warren hopes her program will become a regional provider of trained dental therapists, and it may have to if Maine continues down its current path. Despite enacting a dental therapy law five years ago, the state is no closer now than it was then to creating its own training program.
The Maine Dental Association, the professional organization for dentists, does not appear to support the idea. Executive director Angela Cole Westhoff declined an interview request to discuss dental therapists and emailed a statement that avoided mentioning them. Instead, Westhoff expressed support for expanding the state Medicaid program’s limited dental coverage for adults and extolled the volunteer programs that deliver “millions of free dental services to underserved Mainers.”
Neither the dental hygiene program at the University of New England in Portland nor the one at University of Maine at Augusta has taken steps to add a dental therapy program. Domma Giatas, the latter’s executive director of planning and communications, told Rural Health Quarterly that the state’s dental therapy law, as currently written, is the problem. Unlike the laws in other states, Maine’s law does not allow dental therapists with sufficient experience to work without a dentist present. They must always be directly supervised.
“Until and unless Maine law allows for a dental therapist to practice under general supervision… there is limited interest for standing up a program given the associated costs,” said Giatas. “The need for direct dental supervision is a barrier to employment opportunities for those who might receive training, especially in rural areas.”
“This is an excuse not to start a program,” said Bonnie Vaughan, a dental hygienist and a lobbyist to the state legislature for the Maine Dental Hygienist Association, which would like the opportunity for its members to train as therapists. Direct supervision of dental therapists is not a barrier to employment, Vaughan said.
Meanwhile, there are campaigns to pass dental therapy laws in other states, including Florida, Massachusetts, Mississippi, Ohio and Wisconsin. “We’re seeing a tipping point where more states will see that they’re not out in the wilderness if they pass dental therapy [bills],” said Koppelman.