Can Dental Therapists Ease the Dentist Shortage?

There’s a push in several states to permit dental therapists to practice, creating a tier of providers comparable to physician assistants. Where they’re authorized to perform basic procedures, supporters say, dental therapists could increase access to care in underserved communities, reduce wait times and free up dentists to do more complex procedures.

“We just don’t have enough practitioners that are willing to see patients who don’t have insurance or can’t pay out-of-pocket," says Robin Yang, division chief of oral and maxillofacial surgery and dentistry at Johns Hopkins Medicine. “If there’s a backlog of patients being seen for preventive care, practitioners don’t have time to treat the more complicated problems they are trained to do."Around 74 million people live in areas of the country where a dental shortage has been identified, according to federal government data.

Better options?

But not everyone believes dental therapists are the right solution to the problem. Critics, who include some dentists and certain state dental groups, say the process to authorize, educate and license therapists is time-consuming, and they would rather focus on other, potentially faster efforts to address dental shortages and care issues. These could include expanding the role of dental hygienists, starting the first visit to the dentist at age one to improve long-term oral health, changing Medicaid reimbursement rates or giving incentives to dentists to accept Medicaid.

Without changes to Medicaid, “it won’t move the needle in terms of access, regardless of whether you add another type of provider or not," says Greg Hill, executive director of the New York State Dental Association.

Dental therapists currently practice in five states—Washington, Minnesota, Oregon, Alaska and Maine—according to data from the Oral Health Workforce Research Center at the School of Public Health at the University at Albany, part of the State University of New York system. Some 14 states have legalized the practice, but there can be a long wait before it actually arrives because of a lack of infrastructure, such as local training options. Indeed, currently there are only five schools in the U.S. that offer training of dental therapists, who differ from dental hygienists in training and responsibilities, which can include simple extractions or placing temporary crowns.

Over the past few years, bills seeking to authorize dental therapists have failed in several states including Florida, Kansas and Maryland. This year, legislatures in New York, New Jersey and Massachusetts are considering such authorization.

In most states where dental therapists are allowed to practice, meanwhile, there are restrictions on whom they can treat, with the focus of care generally placed on tribal or underserved populations.

Dental therapists “can make access to routine care more accessible, so people won’t need more expensive procedures down the road," says Laura Hale Brannon, a project manager for the Dental Therapy Project, a part of the Dental Access Project at Community Catalyst, a nonprofit national health advocacy organization.

Starting with Alaska

The practice has come a long way since Alaska introduced it to tribal areas in 2004. Five years later, Minnesota became the first state to authorize the practice statewide, though therapists are required to primarily serve low–income, uninsured and underserved patients, or practice in a federally designated dental Health Professional Shortage Area.

“I think the current approach, which focuses on underserved populations in underserved areas, is a good starting point and this should be the continued focus of dental therapy," says Donald L. Chi, associate dean for research at the University of Washington School of Dentistry. “After we’ve made progress on meeting the needs of underserved populations, it may make sense to imagine how dental therapists could become part of the broader dental care delivery system."

The movement has been slow to gain momentum for multiple reasons, including interruption by the pandemic. The dearth of available education is also a factor. Of the five dental-therapy programs in the U.S., according to the American Dental Therapy Association, a trade organization, Alaska and Washington each has one while Minnesota has three. Three of these programs are accredited by the Commission on Dental Accreditation, which evaluates the quality of more than 1,400 U.S. dental and dental-related education programs.

Despite the critical need to connect underserved people seeking oral healthcare with qualified providers, there haven’t yet been a significant number of individuals being trained and working in those states, says George R. Shepley, president of the American Dental Association. Even Minnesota—which has been at a forefront of the dental therapy movement—had only had 146 licensed dental therapists as of mid-August, according to Rhonda Gravitis, president-elect of the Minnesota Dental Therapy Association.

There can be logistical issues in starting dental educational programs, even in states that allow dental therapy, says Elizabeth Ann Mertz, a professor in the school of dentistry at the University of California, San Francisco. Dental schools don’t always want to support these programs because they fear alumni backlash, she says.

Shotgun approach

Proponents of expanding dental therapy agree that other options for alleviating the provider shortage and access-to-care issues should be pursued. These could include Medicaid changes and earlier visits to the dentist, says Catherine Hayes, chair of the department of oral health policy and epidemiology at Harvard School of Dental Medicine.

Still, dental therapy, these advocates say, should remain as part of the tool kit.

“Nobody is suggesting that dental therapy is a panacea that’s going to solve all the problems," says Karl Self, an associate professor at the University of Minnesota and director of the division of dental therapy. “It doesn’t have to be one or the other. Let’s take that shotgun approach and try anything that’s going to work."

It took time for physician assistants to be recognized, “but I couldn’t imagine healthcare without them," says Sarah Chagnon, president of the American Dental Therapy Association. “I think communities, over time, will see dental therapists the same way."

Supporters also argue that the quality of care isn’t in question, since in all states where dental therapists are allowed, there are supervision requirements.

“This is part of the regular dental team and some of the things a dentist can do can now be done more cost-effectively by a dental therapist," says Jean Moore, an adviser to the Oral Health Workforce Research Center and director of the Center for Health Workforce Studies, an academic research center based at SUNY Albany’s School of Public Health.

In Alaska, having dental therapists has meant more preventive care and fewer teeth removed, says University of Washington’s Chi, who has published research on the topic. “I think we have very good evidence that they benefit individuals and communities."

Cheryl Winokur Munk is a writer in West Orange, N.J. She can be reached at reports@wsj.com.