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.
Agreed about access problems and unmet needs of vulnerable, underserved communities and populations. Agreed that dental therapists can perform preventive and basic restorative dental procedures. Strongly disagree that simply licensing dental therapists has a strong correlation with addressing the unmet needs of those people. Ensuing correlation is hugely based on the model implemented in the bill that authorizes their training and licensing.
Is this true? “Rural America has long struggled to access any type of health care… Coupled with higher rates of poverty, these rural communities face an uphill battle to achieve good… health.”
If so, then notice that the proliferation of medical mid-level providers for the last 50+ years is coexisting with perpetuation of the same issues that existed when medical midlevels were touted for what might, could, should address the unmet needs in those vulnerable, underserved communities and populations.
There is an ongoing disconnect between the hypothetical potential and reality. I say it is because the ones directing the distribution of the new providers are the providers themselves. Getting a license to practice and searching the job market for whatever job seems attractive to them (for whatever reasons) always ends up positioning the least help for those needing the most help, and most help is added for the benefit of those that have always had access to care.
The 3 known characteristics of midlevel providers are that they are safe, competent, and they save a lot of money in labor overhead for their employers. Whether or not midlevel providers make a dent in the unmet needs of communities and populations in need depends quite a bit on which jobs seem attractive to the midlevel providers, just as it is so for other primary care providers. Motivations are different for each individual, but a plan to simply expand the workforce is NOT equivalent to a plan to address the needs of target communities and populations.
Every midlevel employed in the for-profit private sector is one who is not employed in the public/non-profit sector where the mission is to address the needs of target populations and communities. How the licensing bill is written makes all the difference.
As far as dental therapists, the only model showing high participation and gradual improvement in dental health to a maintenance condition is one where candidates were recruited by, trained by, and deployed to where needed by a public health admin. The only place where that model is used in the US is in Alaska’s American Native Tribe Health Consortium, and other related American Native endeavors in WA, OR, et al.
To tout benefits of mid-level providers, in this case dental therapists, for the benefit of certain suffering, vulnerable, underserved populations and communities without serious consideration for how to make it actually happen, is naive about the potential or willfully ignoring the history of what has a very weak record of bringing substantial benefits to those most in need, compared with what has a decent track record for those targeted for care.
Stories like this lead the way in the race to the bottom by presenting a one sided view of a multifaceted problem. Here are a few pertinents:
If you want increased access to dental care in underserved areas, get it in writing.
Expanding the rights of Nurse Practitioners to practice medicine without a license has not resulted in more NPs relocating to rural areas. It has resulted in a greater divide between NPs and physicians with national NP organizations proclaiming that it’s all about collaboration then posting on their website “Physician supervision has nothing to do with patient safety and everything to do with physicians pocketbook.”. Charming. The majority of doctors I know have deep concerns unrelated to finances because:
Nursing is 🚫 interchangeable with medicine and hours spent as a doctor/ nurse counting as training for the others role is like saying hanging around Lebron James will make you an all-star baller.
Medical school is hard for a reason. Medicine is hard. The human body becomes more complex with every new discovery. Compare the 15,000+ hours of medical clinical training received by physicians vs the 500+ hours obtained by NPs and tell me who is equipped to practice medicine on graduation and who is not. And dentists, get ready to be called ” sexist” “elitist” “money grubbing” and “turf mongering” when you oppose this expansion out of concern for patient safety.
On the bright side, Dentists are smarter than Doctors. They did not sell their souls to insurance companies but they watched the deterioration of the physicians role that ensued. Hopefully they have seen the takeover of the house of medicine and will be smart enough to nip this “expansion” in the bud.
Please delete my other posting. TY
Stories like this lead the way in the race to the bottom. If you want increased access in underserved areas, better get it in writing.
Expanding the rights of NPs to practice medicine without a license has not resulted in more NPs to rural areas. It has resulted in a greater divide between NPs and physicians with national NP organizations proclaiming one day that it’s all about collaboration then posting on their website “Physician supervision has nothing to do with patient safety and everything to do with physicians pocketbook.”. Charming. The majority of doctors I know have deep concerns because:
Nursing is 🚫 interchangeable with medicine and hours spent as a doctor/ nurse counting as training for the others role is like saying hanging around Lebron James will make you an all-star baller.
Medical school is hard for a reason. Medicine is hard. The human body becomes more complex with every new discovery. Compare the 15,000+ hours of medical clinical training received by physicians vs the 500+ hours obtained by NPs and tell me who is equipped to practice medicine on graduation and who is not.
Dentists are smarter than doctors. They did not sell their souls to insurance companies but they watched the deterioration of physician that ensued. Hopefully they have seen the takeover of the house of medicine and will nip this “expantion” in the bus.