By Melanie Bavaria with Miriam Wasser

THIS PAST JUNE 2, Governor Peter Shumlin of Vermont smiled as he signed into law a bill set to create a new type of oral health-care professional in Vermont: the dental therapist. The signing took place at Vermont Technical College’s Williston Campus, the school that will be responsible for educating these new mid-level providers as an extension of its existing dental-hygiene program. The cheery group of dignitaries standing behind Shumlin as he made Vermont the third U.S. state to authorize dental therapists, however, was a stark contrast to the conflict that marked the bill from the outset.

For many years, a growing number of states have been embroiled in a fierce debate about mid-level providers, with both pro and con arguing that their position is the best one for both patient safety and dental professionals alike.

Legally able to perform more tasks than hygienists but fewer than credentialed dentists, dental therapists are roughly analogous to a nurse practitioner or physician assistant. They do both preventive and restorative procedures and are required to work as part of a team led by a dentist. Like hygienists, they function under the supervision (usually general supervision) of a dentist through a collaborative work agreement.

The reason therapists are needed, proponents say, has to do with access to care across the country — or, more precisely, lack thereof. According to the Pew Research Center, “more than 38 million people in the United States live in areas with dentist shortages. Access to care is also limited for the 72 million children and adults who rely on Medicaid and [the] Children’s Health Insurance Program: Only about one-third of U.S. dentists accept public insurance.” Untreated dental problems are a leading cause of kids’ missed school days; dental pain, meanwhile, is responsible for some 2 million emergency-room visits a year.

ACCORDING TO the Vermont statute, which echoes laws already passed in Minnesota and Maine, low-income and Medicaid patients must make up at least 50 percent of a dental therapist’s patient base, or the therapist must operate in a federally designated Health Professional Shortage Area (HPSA), thereby bringing basic care to rural areas that might be dozens of miles from the closest dentist, or urban areas whose nearby practitioners don’t take state insurance.

The entire idea got its start in 2004 in Alaska, whose array of Native American tribes, scattered over the Last Frontier’s staggering vastness, turned for dental treatment to this new kind of mid-level provider. Dental organizations reacted the way any guild would: by expressing concern about the safety, professionalism and reliability of these come-latelies.

Controversy has raged ever since — yet mid-level dental therapists are hardly a new idea. They have existed around the globe for nearly a century; 54 countries already integrate them into their dental industries. Until recently, though, America was not one of them — not until those Alaskan tribes began experimenting, which they were able to do within the context of the Community Health Aid program. Authorized by the federal government for the last four decades, CHA permits native tribes to provide health care for their communities outside the boundaries of states’ licensing regulations. Using CHA and the 1975 Indian Self-Determination Act, the Alaskan Native Tribal Health Consortium in 2004 established a network of therapists to reach remote tribal areas where their members, particularly children, were plagued by poor oral health and the follow-on problems that can accompany it.

Before 2004, when the first therapists (who were trained in New Zealand) began practicing in Alaska, almost 80 percent of American Indian and Native Alaskan children between ages 2 and 5 suffered from tooth decay, the highest rate of any population cohort in the country and five times the national average. By 2009, 13 therapists were serving more than 42 previously undeserved villages. Pew Research notes that in 2016, some 30 mid level providers were working across Alaska, with at least
five more a year set to join for the foreseeable future. They’ve brought routine dental care to more than 40,000 adults and children who lacked it.

“I get an e-mail at least every month from some office interested in hiring a dental therapist.”

GREAT NEWS, RIGHT? Well, sure — and legislators, community clinics, hygiene advocates and dental schools in Minnesota, among others, took notice. The Gopher State had long been concerned about its dental track record: A startling 70 percent of its counties are fully or partially designated HPSAs for dental care. Access was a particular problem for low-income Minnesotans: Although 75 percent of the state’s dentists were enrolled as Medicaid providers, a quarter of those saw only between three and 20 Medicaid patients a year, while an additional 10 percent saw just one or two. Thirty-two percent didn’t treat Medicaid patients at all or weren’t accepting new patients. Additionally, as of 2012, nearly half of Minnesota dentists were 55 or older.

In 2009, Minnesota’s legislature became the first to authorize dental therapists and “advanced” dental therapists. (The latter indicates the completion of an additional 2,000 hours of field experience and is permitted a slightly broader scope of practice activities.) Two years later, the University of Minnesota and Metropolitan State University, which has a number of locations across the state, graduated their first classes of dental therapists.

According to a Minnesota Department of Health report titled Early Impacts of Dental Therapists in Minnesota — released in 2014, within five years of the law’s passage, as mandated by the legislature — the relatively small number of therapists at work had already made an impact: More patients were being seen, travel times and wait times were both reduced, and clinics that had hired therapists were reporting personnel cost savings and increased productivity. Today, Minnesota has 61 dental therapists and advanced dental therapists practicing throughout the state. UMD and Metro State remain the only two schools in the country with formal dental-therapy programs, though Vermont Technical College now has one in development.

LEGISLATION LIKE that passed in Minnesota and Vermont, for all its seeming successes, has been rare. One reason: fervent opposition to credentialed therapists on the part of the American Dental Association and state dental associations. The ADA “remains firmly opposed to allowing non-dentists to perform surgical procedures. . . . The supply of dentists is adequate to serve America’s needs,” the organization has said in an official statement.

Missouri’s state board considered legalizing dental therapists but has decided against it for the time being. Several other states — New Hampshire, North Dakota, California, Connecticut and Washington — have debated similar legislation, but none has passed.

Even Maine, the second state after Minnesota to authorize dental therapists, has encountered high hurdles along the track to implementation. The only two accredited programs in Maine declined to establish dental-therapy programs as part of their existing hygiene programs, leaving Maine with the ability to have dental therapists but no way to produce a workforce.

From the beginning, the very concept of dental therapy has been plagued by vague comprehension of what exactly it might mean: Would dentists, for example, lose patients to unqualified quacks who couldn’t get in as legitimate practitioners? Proponents of dental therapy, by contrast, argue that dentists’ jobs aren’t threatened, given that therapists are legally bound to be part of a team supervised by a dentist.

Proponents also take issue with the idea that dental therapists are less qualified. Some dentists fear that with just two or three years of training (depending on the state), they’re not adequately prepared to perform the procedures they’re permitted to.

“I disagree with the premise that they’re less trained,” says Karl Self, director of the University of Minnesota’s dental-therapy program. “They have the same competency, they take a board examination at the same time the dental students do, and the examiners are blind as to who is doing the work. We’ve built in a lot of safeguards to ensure we have high-quality individuals coming out [of school] and practicing.”

In the time since therapists have been practicing in Minnesota and Alaska, not a single patient has filed a malpractice claim regarding their work. A Review of the Global Literature on Dental Therapists, a report published by the W.K. Kellogg Foundation in 2012, surveyed more than 1,000 studies and determined that none indicated reason for concern.

In 2015, the Commission on Dental Accreditation voted to establish an accrediting process for dentaltherapy programs, as it has for all hygiene programs and dental schools, lending legitimacy to the profession. CODA accreditation will, the theory goes, streamline education programs, giving lawmakers nationwide an easier path to successful legislation.

“The fact that there are standards, a common way of looking at the profession, is going to give policymakers in other states much more confidence that this is a profession worth inviting into their state,” Self says.

AMERICANS WHO STRUGGLE to access dental care typically shoulder at least one of three principal burdens: They can’t afford it; there are no dentists in their area, or none who take their insurance; or they face linguistic barriers. The goal of dental therapy, Self says, is to mitigate the impact of all three whenever possible.

At the moment, insurance companies pay the same amount for a procedure whether it’s performed by a dentist or a therapist, but therapists enable primary providers to expand their practice at a lower cost. Thus while treating Medicaid patients isn’t cost-effective even for dentists who want to treat them, with dental therapists they’ll get the same reimbursement rate, but at half the cost, given that therapists make, on average, just 50 percent of what a dentist earns. Likewise, therapists can see patients who have come in for routine treatment, freeing the dentist to spend time on more complicated procedures. In rural areas, the presence of therapists makes patients more likely to seek preventive dental care regularly and not strictly when the situation is dire.

Jodi Hager, an advanced dental therapist and president of the Minnesota Dental Therapy Association, started her career in 2004 as a hygienist, working at a nonprofit clinic focusing on underserved populations in rural southwestern Minnesota. She’d spend time at Head Start schools, educating kids about oral health, but she was impotent to help kids with cavities or other problems until the clinic — four hours away from the furthest schools she visited — could send a dentist.

“ ‘I’m doing this already,’ ” Hager remembers thinking, “ ‘so wouldn’t it be great if I could do restorative care while I’m there?’ ” When Minnesota passed its mid-level providers law in 2009, she enrolled in Metro State’s dental-therapy program. Today she works for the same nonprofit, seeing up to 14 patients a day, mostly children. Many patients still regularly drive two or three hours to get to the clinic, which Hager notes has a waiting list “that’s thousands of people long,” but the number the clinic is able to treat has increased dramatically.

Katy Leivska, another dental therapist in Minnesota, works in St. Paul; most of her patients are urban dwellers and on state insurance, and in general they “haven’t been able to find an office that takes their insurance, or they’re pushed out,” she says. “Dental therapists allow appointment wait lists [for these populations] to be shortened.” In the long run, she adds, this will lower the state’s outlays given that, say, treating a cavity early is much less expensive than a more
complicated procedure later on.

When the St. Paul clinic brought her on just one day a week to help out the lead dentist, the results were dramatic. In under two months, Leivska helped the clinic reduce its wait time for an appointment from 14 weeks to three. She now works there full-time; clinic bookkeepers have calculated that by hiring her, they cut their budget by nearly a third in 2015.

Both Hager and Leivska say that while it was tough for many in their classes to secure jobs, the tide has turned. “Initially, because it was new and nobody really knew how to incorporate it, hiring was a little slow,” Leivska says. “Now I get an e-mail at least every month from some office interested in hiring a dental therapist.”

Hager agrees. “The stigma put on dental therapy in the beginning is fast disappearing in Minnesota,” she says. “It’s tricky right now, because the programs are graduating only a small number every year. I anticipate us having more jobs than people.”

OPPOSITION TO dental therapists’ very professional existence, however, is by no means gone. The ADA and other dental groups argue that the ongoing debate over dental therapy — its efficacy, its safety — is diverting attention from existing solutions. Jane Grover, who worked at a health clinic in Michigan for 12 years before joining the ADA as the director of its Council on Access, Prevention and Inter professional Relations, says many underused services are already in place and that solving access-to-care problems is largely a matter of educating the public about what’s available, not creating a new class of dental professionals.

“The struggle many of us face in health centers is that patients aren’t aware of those opportunities,” Grover says. “I saw patients and families every day who would say, ‘I didn’t know that there was a dental clinic here, that I could get my teeth cleaned here, that my Medicaid covered dental.’ When you look at the ‘I didn’t know’ factor of underutilized care, it’s pretty significant.”

Additionally, Grover says, many access-to-care difficulties stem from state regulations and payment problems rather than too few dentists or refusal to take Medicaid. More dental schools are opening, she points out, and are producing more dentists with each class. States could increase Medicaid reimbursement rates and create programs that enable dentists to treat Medicaid patients more easily and cost-effectively — such as the Access Health program in Muskegon, Michigan, where Grover used to work. The problem, she maintains, is that not enough states are acting.

In 2015, the ADA published a research paper with the deathless — albeit self-explanatory — title Gap in Dental Care Utilization Between Medicaid and Privately Insured Children Narrows, Remains Large for Adults. In 2013, it found, use of dental care in two states — Texas and Hawaii — was higher among children on Medicaid than those on private insurance. Grover argues that this, along with the finding that in 28 states, dental-care use between 2005 and 2013 among adults with private insurance actually declined, shows that the true issue of import isn’t access to care or insurance, but the perceived importance of dental care in the first place.

That, she says, is why the Community Dental Health Coordinator model pioneered by the ADA in 2006 is one key way to improve access to care for the under-served. CDH Coordinators connect patients with culturally relevant information and dental education, and help guide them along every step.

Still others think dental therapists might work in some states but not in others. Dr. Ariane Terlet is chief dental officer at La Clinica de la Raza in Oakland, and was one of the California Dental Board delegates whom the Pew Foundation invited to get an inside look at Minnesota’s dental-therapy program a few years ago. First, she says, California hygienists have more tasks they’re permitted to perform than in other states — a difference she says obviates the need for mid-level providers in the Golden State. Second, she insists the purported solution targets the wrong problem: Minnesota has a shortage of dentists, so dental
therapists helped make up that pay gap.” California, by contrast, suffers from no such shortage, she says — an assertion confirmed by a 2009 study by the UCLA Center for Health Policy Research.

Dr. Frank Catalanotto, chair of the Department of Community Dentistry and Behavioral Science at the University of Florida, disagrees that California — or any state, for that matter — couldn’t benefit from an infusion of dental therapists. If state officials think they have plenty of dentists and therefore don’t need therapists, “Somehow they’re going to have to explain the incredibly large number of patients who are not receiving care,” he says. “They’re going to have to explain the incredibly large number of emergency-room visits for preventable dental problems. They may have plenty of dentists, but they’re not reaching those populations that need care.”

Dr. Catalanotto, too, has observed in person the programs in both Alaska and Minnesota. “There is,” he says, “no doubt in my mind that this is one of the answers to access problems.” For him and other dentaltherapy advocates, passage of the Vermont law last spring was encouraging. Meanwhile, Native American tribes in the West continue to lead the way. Since January 2016, the Swinomish Indian Tribal Community in Washington and two others in Oregon have hired dental therapists; one of the Oregon initiatives is part of a state pilot program. Mid-level provider proposals of various kinds are being bandied about in the statehouses of Kansas, Massachusetts, Michigan, New Mexico and Ohio.

Proponents of dental therapy guardedly acknowledge that the dominoes seem at last to be falling in their direction. “You’ve got Maine and Vermont. You have significant numbers of other states where it’s on the docket,” says the University of Minnesota’s Karl Self. “To me, it’s a foregone conclusion at this point.” Stay tuned, though: With many dentists and powerful advocacy groups implacable in their opposition, the debate seems likely to continue for some time.

MELANIE BAVARIA is a regular contributor to Incisal Edge.
This is MIRIAM WASSER’s first contribution to the magazine.