Dental Therapists: A Solution to a Shortage of Dentists in Underserved Communities?

At the turn of the 21st century, several research groups released studies highlighting the problematic nature of oral health care in the United States. ¹ More than 15 years later, Surgeon General Vivek Murthy is still drawing attention to the “silent epidemic” ² of untreated oral disease in the United States and the difficulties in obtaining and affording adequate oral health care. ³ These issues have important implications for health disparities, particularly in low-income households. ²

The importance of oral health and the disparities in access to oral health care led some states to consider a new alternative to dental care: the dental therapist. ^4,5 The movement to establish dental therapists as members of the oral health care team is gaining momentum. ⁶ Nearly a dozen states and tribes pursued the idea of adding dental therapists to dental teams in the past year alone, to help reduce severe oral health disparities and meet unmet dental needs. ⁷ Dental therapists currently practice in Minnesota and on tribal land in Alaska and Washington State. ^5,7 They are authorized to practice in Maine and will soon be practicing in Oregon under a statewide pilot program. ⁶ In June 2016, Vermont authorized the practice of dental therapy. ⁸

In this commentary, we examine oral health challenges in the United States, the dental therapist option and related state regulations, and controversies about the use of dental therapists. We conclude that dental therapists may help overcome challenges in oral health and health disparities, and we recommend that states explore legislation to authorize dental therapists.

Oral Health Challenges and Dental Therapy

Oral health is integral to overall health. In children, untreated oral health issues may lead to a shorter attention span, sleeping and eating disorders, and lower behavioral and cognitive performance in school. In adults, oral health issues may make it difficult to hold or gain employment and may even affect relationships, because poor oral care can hamper confidence and create anxiety. Additionally, oral health has strong associations with other health issues, such as diabetes, stroke, and respiratory diseases. ²

Despite the adverse effects associated with poor oral health, only 62% of US adults aged 18-64 had at least 1 dental visit in 2014. ⁹ Lack of access to dental health services is frequently associated with low income, lack of insurance coverage for dental care, and low health literacy. ¹⁰ Those living below the federal poverty level have more dental decay than those who are economically better off. ¹¹ An estimated 114 million Americans lacked dental coverage nationwide in 2014. ¹² Approximately 19% of adults aged ≥65 have untreated caries ¹³ ; with a rapidly aging population, cases of untreated caries in older adults are expected to rise. The distribution of dentists also tends to favor high-income and urban areas, leaving many low-income or rural areas with a shortage of providers. ¹⁰ The United States has identified >4000 areas with dental health professional shortages and estimated that about 10% of Americans live in areas without access to dental health providers. ⁷ Compared with the general population, those with low incomes and in racial/ethnic minority groups in the United States are more likely to report oral health problems, and poor oral health in older adults is frequently associated with disability and reduced mobility. ¹⁰

Many oral diseases and associated health issues are avoidable through routine preventive and restorative care but often result in pain and infection, which may lead to expensive emergency department visits when unnoticed or untreated. ² To combat this crisis in oral health and eliminate the barriers to care for rural and low-income people, some states have considered using dental therapists to fill the gaps in dental services. ⁵

Dental therapy generally includes various routine preventive and restorative treatments, such as examination, diagnosis, treatment planning, exposing radiographs, oral health education, prophylaxis, fluoride therapy, fissure sealants, preparation of cavities, restoration, and primary tooth extraction. In some countries, dental therapists may also perform permanent tooth extraction. Most dental therapists work with some form of supervisory oversight, ranging from government dentists to private dentists, although some dental therapists may practice without dental supervision. ¹

Studies have found similar quality of care between dental therapists and dentists, according to a literature review. Research also shows increased access to dental care, declining rates of dental disease, and decreased costs associated with dental care after the introduction of dental therapists. ¹ Although a systematic review by the American Dental Association concluded that the quality of evidence in this area was poor, in selected groups that received dental treatment from midlevel providers, it found a decrease in untreated caries when compared with populations in which dentists provided all treatment. ¹⁴

Laws on Dental Therapists

Dental therapists, which first emerged in New Zealand in 1921, are found in 54 countries and are an important part of the oral health care delivery system worldwide. ¹ In the United States, dental therapists first appeared in tribal villages in Alaska in 2004 to serve the native population, through efforts by the Alaska Native Health Consortium. Therapists were authorized in compliance with federal law and work as part of the state’s community health aid program, conducting evaluations, providing fluoride treatments, excavating cavities, and performing fillings and simple extractions, while communicating with supervising dentists. Dental therapists must undergo 2 years of education and training after high school to practice. ⁴

In 2009, Minnesota approved the nation’s first statewide legislation to authorize dental therapists. Dental therapists are required to have a written collaborative agreement with a licensed dentist, and therapists must practice primarily in low-income areas or in areas that serve uninsured or underserved patients. Dental therapists may also work in areas identified as dental health professional shortage areas, which are designated by the Health Resources and Services Administration Bureau of Health Workforce as having shortages of dentists. Minnesota requires a bachelor’s degree in dental therapy or a master’s degree in advanced dental therapy as a prerequisite to practicing. ⁴

Maine enacted legislation in 2014 authorizing dentists to hire dental therapists. The law requires that a supervising dentist provide written authorization and protocols for the services performed by dental therapists and review patient records once every calendar year. ⁶

In Vermont, to be licensed as a dental therapist, an individual must be a licensed dental hygienist and have completed an accredited dental therapy graduate program. A dental therapist provides oral health care services under the general supervision of a dentist within the parameters of a written collaborative agreement. ⁸

The patchwork of accreditation and recognition of providers can be problematic for multistate health care systems. ^15,16 Unlike the practice of medicine in the United States, the scope and practice of dental care providers, including dentists, dental hygienists, and dental assistants, vary widely by state because of dental practice regulations. ^{16 –18} For example, in Pennsylvania, expanded function dental assistants provide restorative and surgical dental care under the supervision of a dentist, whereas other states allow only dentists to provide such treatments. ¹⁸ The variation places a burden on health care systems to learn the differences in laws among states and limits the reliance on team-based care. To encourage greater standardization in the United States, the Commission on Dental Accreditation—which accredits dental education and training programs in the United States through a voluntary process—has begun to solicit comments to move toward more uniform standards for accreditation of dental therapists, although proposals are still subject to debate. ¹⁹

Controversy About the Use of Dental Therapists

Although some researchers believe that dental therapists would be more cost-effective than dentists and provide more people with dental care, others say that the savings and access come at a sacrifice. ²⁰ Some opponents argue that if the work performed by dentists and dental therapists is reimbursed at the same rate by Medicaid, as is the case in legislation proposed in Washington State, then no cost savings would be realized. ⁷ However, dental therapists are paid roughly one-half of what dentists are paid and are often employed in low-income or school settings. ²¹ Even if Medicaid pays the same for procedures performed, schools and governments can more readily afford the lower cost of employing dental therapists because they are not as costly as dentists. Therefore, more people could receive dental care from a greater number of providers. Surveys of school dental programs in New Zealand and Australia have shown the use of dental therapists to be cost-effective, generally costing less for total care than in the private sector where only dentists practice. ¹

Dentists also have lobbied against dental therapist laws because of fear of competition. ⁷ Although dental therapists may be more willing than dentists to work in underserved areas, it is not clear what their long-term distribution might be. Here, history may be a guide. The adoption of physician assistants (initiated and supported by federal funding, with the goal of increasing the number of primary care providers, particularly in underserved areas) did not achieve its intended purposes, because physician assistants became more likely over time to enter into subspecialty areas of medicine than into primary care. ²² Nevertheless, because dental therapists are limited in scope of practice, require dental supervision (at least in the United States), and are often limited to dental shortage areas, they may serve a more complementary rather than competing role. Rather than competing with dentists, dental therapists could offer a cost-effective way to provide dental care to many people who could not otherwise afford or access care and fill a void in dental coverage that dentists are unable to meet. ²¹ Moreover, dentists who hire or supervise dental therapists would expand their practices by accessing communities and patients for whom they would not normally provide care, which makes the competition argument moot.

For some professionals in the dental community, quality and safety are the foremost concern when dental therapists are used. Some dentists believe that dental therapists are unable to handle more complex issues that may arise during routine dental procedures. The argument against using dental therapists is that dentists are better educated and have more extensive training than dental therapists for effective oral care, whereas dental therapists are relatively untrained, inexperienced, and unable to handle complications. ¹ So far, no US state has passed legislation allowing for independent certification of and practice by dental therapists, meaning that there will always be some level of supervision by a dentist. Other concerns include the creation of a discriminatory dental care system in which patients with access and means can obtain routine care from dentists, whereas those without means or access must obtain care from the less experienced, riskier dental therapist. This argument against using dental therapists again ignores the evidence that dental therapists are likely to fill a limited role of providing care to those without access to dentists. ²⁰

In Minnesota and Alaska, one-third of the dental services provided are preventive, and most clients are publicly insured children, low-income adults, American Indians/Alaska Natives, and others who lack access to other dental care. ⁶ For such patients, dental therapy does not replace regular dentistry; rather, it supplements regular dentistry to improve their overall oral health. Additionally, numerous studies of international programs have shown that dental therapy is high-quality and safe dental care. No evidence has been found to suggest that the experience with dental therapy has had any negative repercussions on oral health outcomes. ¹

Conclusion

Some dentists have expressed concern about the use of dental therapists, but studies from around the world on the use of dental therapists show positive and cost-effective results. If used by more states, dental therapists could help fill important gaps in dental care in the United States. Not only have dental therapists been shown to be safe and cost-effective, but they have also been shown to substantially improve the overall dental health of the nations that have embraced them. Therefore, states should follow suit by passing legislation that allows for the use of dental therapists, particularly in underserved communities. Additionally, coordinated efforts should be made to standardize and broaden the scope of practice of state dental practice acts, and policy reforms should be made to enable self-management of oral disease by patients as well as wellness, prevention, and disease management in the professional dental care delivery setting. As the debate about dental therapy continues, the United States could explore other alternatives to increase access to oral health care and improve oral health (Table).

Table.

Suggested measures to increase access to oral health care and improve oral health in the United States

Area	Description
Workforce	Expanding dental residency programs, which are funded by federal dollars and on average provide $500 000 in uncompensated care to underserved areas, and increasing the number of community coordinators and dental hygienists, which will potentially help alleviate some of the burden placed on dentists 23
Reimbursement	Reforming Medicare and Medicaid dental insurance reimbursement, which generally does not offer adult benefits and currently favors surgical and restorative treatment (which by itself does not address the underlying disease of dental caries) at the expense of preventive dental treatment, to promote healthy oral care practices and preventive dental care–seeking behaviors by high-risk populations
Primary care	Improving oral health education, assessment, care, and referrals in the primary care setting to expand oral health care and maximize the efficiency of existing medical visits, given the public’s lack of understanding of the dental disease process, which can be controlled with alteration in diet, oral hygiene practices, and greater exposure to fluorides
Data	Increasing data collection of oral health information across the United States to allow for better assessment of oral health polices, which in turn would help the government at the state, local, and federal levels to plan, pass laws, and issue regulations that are best suited to regional oral health issues
Technology	Expanding the use of teledentistry and mobile dentistry to provide access to vulnerable populations 24