By Mary Otto
Michigan recently become the latest state to approve the use of midlevel dental providers – dental therapists – as part of an effort to expand oral health care to communities that have long lacked it.
Outgoing Republican Governor Rick Snyder signed legislation authorizing the new provider model in late December.
In a statement, Snyder said that dental therapists would serve as “a unique tool to target the currently underserved populations in our state.”
With the new measure in place, Michigan joins Minnesota, Maine, Vermont and Arizona in approving the use of dental therapists statewide. The model also is in use on tribal lands in Alaska, Washington and Oregon.
The auxiliaries, often compared to nurse practitioners, have been in use in countries around the world for years, but are relatively new to the United States. They receive training in a range of dental services including drilling and filling teeth and work as members of dentist-headed teams.
The new Michigan law “allows graduates of an accredited dental therapy education program who have completed 500 hours of clinical practice, supervised by a dentist, to provide preventive and specific restorative dental services to patients,” Dimensions of Dental Hygiene reported. The providers will work under supervision of a dentist through a written practice agreement, the trade publication noted.
Michigan’s new providers will be expected to serve in safety net settings including federally-qualified health centers, rural health centers, school-based clinics and in communities with shortages of providers, explained Snyder in a story by James Gemmell of Grand Rapids-based Fox 17.
Seventy-eight of the state’s 83 counties currently have at least one dental provider shortage area, according to the Michigan Dental Access Coalition, a group of health and social advocacy organizations that supported the passage of the dental therapist law.
The lack of care has disproportionately impacted vulnerable residents, including seniors, pregnant women, children in low-income homes and those living in rural areas, advocates say.
Such concerns are common nationwide. At least a dozen additional states are considering adopting dental therapists as a cost-efficient way of expanding care according to the Pew Charitable Trusts which supports the technically-trained workers and tracks legislative efforts to increase their use.
The model has faced strong opposition from state and national dental organizations. Over the years, dentists’ groups have fought dental therapist initiatives, contending that only dentists are qualified to perform what they regard as “ irreversible procedures” such as drilling and extracting teeth.
In the months leading up to the passage of Michigan’s new law, Debra Peters, president of the Michigan Dental Association argued against the measure in a guest commentary published in Bridge, a nonprofit news site serving the state. She said that dental therapists would lack the expertise to serve vulnerable and medically complex patients who had long lacked care.
“Adding more provider types to the workforce…may seem like an easy solution. But complex problems are rarely solved by easy solutions,” Peters wrote. “These are not patients who need simple extractions and cleanings. Band-Aid treatments would only result in more visits for the patient, more cost, and potentially serious complications,” Peters wrote.
In response to provider shortages, the ADA has developed a model called a community dental health coordinator. The workers, who receive training in disease prevention, care coordination and patient navigation, are tasked with getting people into care.
Background and resources
The dental therapist model got its start in the 1920s in New Zealand and is now well-established in many developed countries including the U.K., Australia and the Netherlands.
Here in the US, dental therapists began offering care on tribal lands in Alaska in 2005 as part of a longstanding federally authorized program that trains residents of Alaska Native tribal villages to provide basic care to their neighbors.
In 2009, Minnesota became the first state government to pass legislation authorizing the model. Dental therapists are now working in underserved areas of the state as Stephanie Dickrell reported for the St. Cloud Times.
Maine and Vermont also have laws in place that allow dental therapists though they are not yet working in those states. Dental therapist programs have also been launched by tribal communities in Washington and Oregon. Journalist Will Drabold took at look at the tribal effort in Washington for the Seattle Times.
Other states are considering giving the model a try.
“States such as Florida, New Mexico, North Dakota, Washington and Wisconsin are now considering legislation,” wrote Jane Koppelman, senior manager for the Pew Charitable Trusts’ dental campaign in a January 2019 column entitled Efforts to Expand Access to Oral Health Care to Continue in 2019.
Technical schools in Vermont and Washington are expected to move forward with plans for training programs for the providers, Koppelman wrote.
The shortage of care in thousands of US communities is helping to drive the dental therapist movement.
The U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA)has developed shortage criteria that are used to designate Health Provider Shortage Areas (HPSAs) for primary medical care, dental and mental health providers nationwide. HPSAs may be urban or rural areas, population groups, or medical or other public facilities.
As of January 15, 2019, there were 5,834 federally designated dental health provider shortage areas across America, according to HRSA. The HRSA Data Warehouse will allow you to see if your community is among them.
The push for dental therapists took a significant step forward in 2015, when the Commission on Dental Accreditation (CODA), which accredits dental and dental-related education programs, voted to adopt training standards for dental therapy-related programs nationwide.
The move, which came in the wake of urging by the Federal Trade Commission, opened the way for accredited dental institutions to train the auxiliaries.
Nonprofits including the Pew Charitable Trusts, Community Catalyst and the W.K. Kellogg Foundation hailed the step. All three organizations have continued to back grassroots efforts to put dental therapists to work in states and maintain libraries of research and analysis that support the model.
The American Dental Association, which criticized CODA’s decision to move forward with accreditation for dental therapists, has remained opposed. The ADA maintains that only dentists have the skills to perform what it calls irreversible procedures such as drilling and extracting teeth. The organization, which, in 2019 counted more than 161,000 dentist members nationwide, calls for increased spending on public dental programs and loan forgiveness for new dentists working in underserved areas.
The ADA Health Policy Institute offers policy papers that reflect organized dentistry’s perspective on oral health issues. The think tank also analyzes public and private data to compile state report cards on dental care access and availability.
