Difficulty getting dental care is the norm in much of the United States, especially in rural areas. One problem is that there aren’t enough providers. Mid-level dental providers, or dental therapists, can help fill that gap, but they face resistance from dentists.
Rural America has long struggled to access any type of health care, including dental care. In certain parts of Appalachia, there are only four dentists for every 100,000 people, far lower than the national average of 61 dentists per 100,000 people. Coupled with higher rates of poverty, these rural communities face an uphill battle to achieve good oral health.
Delaying dental care means more than a missed cleaning; it leads to more serious oral and overall health issues — and more intensive care — later on. Adults living in Appalachia have higher rates of oral disease and missing teeth than in other parts of the country.
The lack of dentists, and subsequent poor access to dental care, will only get worse as the current dental workforce heads toward retirement. Rural areas are struggling to recruit and retain dentists. Dental therapists could be part of the solution.
Dental therapists are analogous to physician assistants. They are licensed to do more than a dental hygienist but not as much as a dentist. Working under the supervision of a dentist, dental therapists provide routine preventive and restorative care such as cleanings, fillings, and simple extractions. Their training is rigorous and comprehensive, but shorter than that for dentists, making them a cost-effective solution.
Although there is growing interest in dental therapists, they still aren’t widely used because they face challenges from the dental community around general acceptance, scope of practice, and supervision requirements. It’s reminiscent of the fights over mid-level medical providers.
The American Dental Association opposes the use of dental therapists. In response to a request for comment, Michael Graham, senior vice president for government and public affairs, emailed me that there are better ways to address access issues, such as expanding Medicaid coverage to encourage existing providers to accept more patients. While certainly worthwhile, the two solutions aren’t mutually exclusive.
One hurdle dental therapists face is the concern about scope creep — that they will become licensed to provide care that only dentists can do now. The American Medical Association is concerned about scope creep for mid-level medical providers and it’s not surprising that the dental community feels the same.
Dental therapists are not meant to do everything dentists do, but some scope creep is actually ideal: access to dental care will only increase if more providers can offer the same care.
Scope of practice laws are set at the state level and vary considerably. Appalachian states tend to have restrictive laws for non-dentist providers, while Alaska has been a national leader in expanding access to care with dental therapists since the early 2000s, particularly for Native populations.
Some dentists worry about the quality and safety of care that dental therapists provide. But evidence suggests that the care they offer is excellent — if they are given the opportunity to train and practice.
One way to increase the use of dental therapists is to push for acceptance within the dental community. If dentists could be brought on board, access to care could be expanded more quickly. Changing the current mentality would require outreach and education campaigns that explain the role of dental therapists — both their limitations and capabilities — to emphasize the positive potential in utilizing this new kind of provider.
Another way to expand the use of dental therapists would be to increase the number and efficiency of training programs. Graham from the American Dental Association rightfully pointed out that “approved programs often take a long time to be implemented, if they get off the ground at all.” If dental therapists can’t train, society can’t reap the benefits they offer.
Promoting and enacting broader scope-of-practice laws would offer dental therapists more job security and flexibility. As it stands, the state-to-state variation in these laws limits both awareness of the field and job prospects for dental therapists. If they were able to practice — and at the top of their license — in more than a handful of states, there would likely be more dental therapists, better utilized dental therapists, and greater access to dental care.
Access to dental care is essential for both oral and overall health. Without an adequate number of providers, countless Americans will continue to forgo dental care, leading to more significant oral health — and overall health — issues later. Dental therapists offer a cost-effective, quality solution.
It’s high time the dental community sees the benefit to mid-level providers and acts on it.
Elsa Pearson is a senior policy analyst at Boston University School of Public Health.