Dental Therapy: It's Advantages and Downfalls

August 1, 2017
Peter Croatto

The role of dental therapy in dentistry is a contentious issue that has policy makers and dentists at odds with one another. While dental therapists can help in the effort to provide care to the underserved, many experts say that they can be used inappropriately by DSOs looking to save on dentists' salaries, among other problems. Continue below for DMD's comprehensive look at dental therapy and what it can — or cannot — offer in the United States.

Dental therapists are only a small piece of what the U.S. needs to improve access to dental care.

Dental therapists’ role, in theory, is clear: it allows more people in need of dental care to receive it.

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According to the Pew Charitable Trusts — which has pushed for dental therapists in U.S. states and tribal communities —more than 48 million people live in areas of the U.S. with a dental shortage.

Dr. Michael Flynn, a former president of the Minnesota Dental Association who works with the state legislature, dental therapists can do routine procedures: fillings, stainless steel crowns, and preparing teeth. They work with dentists, not alone, and in Minnesota, they work at non-profits, various community clinics and private practices.

Though the place of dental therapy may seem like a no-brainer, it is a contentious topic in the dental community. The conversation requires an examination of the entire industry. It’s a philosophical workout.

People having more access to dental care sounds great, but for those living in a dental desert, you want an experienced clinician trained in all aspects of dentistry, not just a few, says Dr. Jane Grover, director of the council on advocacy for access and prevention at the American Dental Association.

“You have to have somebody with that background and knowledge to be able to handle some of these very overwhelming disease situations where several things are going on at one time,” she said.

Getting dentists, let alone dental therapists, to those areas is a challenge.

“The whole dental team, it’s hard to get them out of the metro area,” Flynn says. “It’s not unique to Minnesota.”

Dr. David Rice, founder of igniteDDS, an educational community for dental students and young professionals, believes dental therapists cannot fully help the underserved because there is really no mechanism to make that happen.

“What will happen is what always happens: people will go to the same areas that they go to now, because those are the areas where they like to practice.”

B. Lane Hemsley, executive director of the Kansas Dental Board, sees a larger contextual issue that is frequently overlooked.

“Some of the reports that have been written in the past, has anyone ever gone to these communities or looked around and said, ‘Do any of these people really not know, or not have the capability, to get the access to the care they need?’” he said.

A dental desert may feature the medically indigent — or people who work at large ranches.

“The notion that these individuals don’t know how to get the care that they need — medically, dentally, pharmaceutically or otherwise — I think falls on deaf ears in many respects,” Hemsley says. “These are communities that have been in existence since the 1860s, 1870s and 1880s. These are not lost individuals that don’t have a way to seek out care.”

If a dental practice hasn’t opened in these towns, it’s because it’s not economically sustainable, he adds. Even when dental services are offered, there’s little guarantee they’ll be used.

“The issue we hear about from many of the primary care associations and some in the community health center world is that the no-show rate in the dental department is 35 to 50 percent,” Grover says. “That’s the average.”

A little more than half of those with commercial insurance use their third-party payer insurance to see the dentist.

“There has to be a better strategy to help people understand the value of oral health, help them manage the anxiety issues that they may have, and the transportation issues they may have to keep those dental appointments, to stay on track with those dental appointments, and to have their treatment plan completed,” Grover says.

That’s why case management and discussion of dental care is crucial. Years ago, Grover visited a radiation-oncology practice where an employee shepherded cancer patients and their families from prognosis to treatment and beyond.

“We don’t do that in the dental world,” she says. “We hand somebody a complicated treatment plan, we expect them to understand all the jargon, all the clinical appointment protocols, and we just want to say, ‘Bye, have a nice day.’ And there’s so much more dialogue that, if it happens, you have a compliant patient. You have improved home care and self-management goals. If you have family-centric care, then the kids are going to be on track for their preventive services and they’ll see lower disease rates.”

To reach the underserved, Grover says, outreach is required — to the local media, community organizations, and programs like WIC. Connecting with allied health professionals, including primary care physicians, is huge.

“Now, I’ve got a partner in managing [a patient’s] oral health,” Grover says. She mentioned a dental clinic director in North Carolina who put a case manager full-time in a pediatrician’s office to navigate patients over. The clinic gets 80 patients a month as a result.

Oftentimes, you hear about Mission of Mercy and charitable dental care events where dentists volunteer to provide free care,” says John Grant, director of dental programs at the Pew Charitable Trusts. “And that’s fantastic. But we’ve see time and again people lined up around the block, sometimes camping out for days. What that shows is that there’s a policy problem. Until we fix the foundation, that’s going to continue to exist. The dental care crisis in this country is largely preventable, and we know many of the solutions to fix the problem. The real question is, ‘What is it going to take to get us there?’”

Grant believes dental therapists are an important component of the solution. Others have a hard time seeing that perspective. When asked the big-picture role of dental therapists, Grover says, “I don’t know if I’ve got an answer for that one.”

Oral surgeon Dr. David Lustbader, president of the Massachusetts Dental Society, also remains dubious.

“I’m not sure if they bring anything to the table,” he says. “It wouldn’t make sense to bring a recently graduated dental student, which I’d much rather see them do. If they were in an area of need, our bill also provides them to practice at a federally qualified health center. For a health center having trouble attracting dentists because of salary and location, they may be able to fill a need. In terms of a private practice, other than maybe some of the larger group practices, they could focus as nurse practitioners do, but again, that would be under direct supervision.”

Lustbader says dental therapists could be useful if they learn triage and treatment plans for emergencies.

“We forget that dentistry is a specialty of surgery — these are irreversible procedures,” he explains. “Personally, would I want my family member going to somebody who only had 18 months of training to do a crown prep or a restoration? Absolutely not.”

Massachusetts and Kansas are considering legislation for dental therapists. Massachusetts’ bill is supported by the Pew Charitable Trusts and sponsored by state senator Harriette Chandler.

“We’ve been dealt lemons and we’re trying to make lemonade,” Lustbader said. “We have some political allies who were very upfront with us and said, ‘You’ve got to come up with something,’” he says. “[Chandler] is an extremely powerful politician. It’s a passion of hers and she wants it done. You have to expend a lot of political capital to keep killing a bill that someone wants passed.”

To reach those truly in need, Rice proposes offering young dentists loan forgiveness in exchange for time practicing in underserved areas.

“The Millennial generation is really community-driven — they really do want better, more than every other generation,” Rice says. “I would say dentistry as a whole is pretty giving, but if you take an inherently community-driven generation of people, and you give them an opportunity to give back but also not lose their shirts because they have so much debt from school, then everybody can win. You can have this perpetual cycle of talented young people coming in and out of the quote underserved area. To me, boy, that’s easy.”

The government, Rice added, “lights money on fire like it’s going out of style.” Why not put some in more of an investment strategy, so there is investment in the future of dentistry and the health care of communities?

Grant acknowledges that it will take time for dental therapists to gain acceptance. He uses nurse practitioners and physician’s assistants — once scoffed at, now commonplace in doctor’s offices — as examples. Dental therapists, he says, give dentists another tool, providing an opportunity to run a more efficient, profitable business.

In July, two case studies examining the addition of dental therapists in two Minnesota private practices found Grand Marais Family Dentistry’s net benefit was 13 percent of its average monthly revenue. For Midwest Dental, it was 2.4 times the average monthly revenue. This coming academic year in Minnesota, the fields of study for dental hygienists and dental therapists at the University of Minnesota or Metropolitan College will be combined into a dual degree.

“Dental therapists increased the clinics’ productivity because they focus on routine restorative procedures, allowing dentists to work on more complex and higher-fee procedures,” the Pew Charitable Trusts wrote. “Patients reported high satisfaction with the quality of care, technical skills, and chairside manners of the dental therapists .”

For Flynn, discussing the differences between dentists and dental therapists distracts from the main goal: treating those who lack access to care. Whether a dentist runs a practice or is working at a free clinic, he adds, a clinical environment is created where the doctor does the diagnosing, and the dentists can delegate more responsibility—either to a hygienist, a dental therapist or an assistant, depending on how they’re trained and what that individual state allows their benefit set to be.

“No matter what health care system you’re looking at, it’s an integration of a trained level of teamwork to get the job done at the end of the day,” Flynn said.

Rice believes dental practices, especially dental service organizations (DSOs), will use the economic advantages of dental therapists to a patient’s disadvantage, a tactic he cannot embrace. Instead of 10 dentists, a practice can have one dentist and nine dental therapists.

“It is going to diminish the level of care that we’re able to deliver, because we have people with less of an educational experience now doing more expanded function,” Rice says. “So, in essence, it’s medicine all over again as opposed to having a better model like we’ve had in dentistry. It contributes, in my humble opinion — and the opinion of many — to that downfall.”

Swap a state for the nation and Hemsley expresses the current state of affairs.

“While everybody is on different sides of this issue; I think everybody wants what’s right for Kansas,” he says. “They want what’s right for the Kansas dental community. Their visions are just different. Their direction is the same. It’s just how to get there.”

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