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Maine moves toward using dental therapists to extend care Date: 03/24/14

Image by U.S. Pacific Fleet via Flickr.
Image by U.S. Pacific Fleet via Flickr.

 By Mary Otto

Technically trained dental auxiliaries known as dental therapists have been providing care in many countries around the world for decades. Here in the United States, they have been working in tribal areas of Alaska since 2005. The state of Minnesota has approved another version of the model, with the support of dental hygienists and oral health advocates who say the new providers will help get a range of needed services including routine care, fillings and simple extractions to poor and rural communities.

All the while, dentists’ groups have fiercely opposed the idea.

Among their objections: They say no one but dentists should be allowed to drill or pull teeth.

Now the debate is playing out in Maine, and as the state legislature mulls the dental therapist question, Joe Lawlor and his colleagues at the Portland Press Herald have been keeping readers informed. For one recent Sunday edition, Lawlor crafted a long feature, “Access to Dental Care in Rural Maine Center of Dental Therapists Debate,” that explored the controversy. Supporters of the bill, including independent dental hygienist Cathy Kasprak, pointed to the uneven distribution of dentists throughout the state as contributing to problems with access to care. A majority of the state’s dentists operate their practices in population centers, with far fewer locating in small towns and rural areas such as Bridgton, a town of 5,000 in the state’s southwestern Lakes Region where Kasprak offers cleanings and other basic services.

“Dentists in rural areas are sometimes hard to find,” Lawlor reported. “For instance, in Cumberland County there are 76 dentists for every 100,000 people, but in Somerset County there are only 17 dentists for every 100,000. Most rural areas have half as many – or fewer – practicing dentists per capita as Cumberland County, according to America’s Health Rankings, which compiles statistics on a number of health-related issues, including county-by-county data.”

“Kasprak said she hears a lot of sentences that begin with, 'I haven’t been to a dentist in ...'” he added.

“They’ll say it’s been five years, 10 years,” said Kasprak, who estimates that more than half of her 1,000 patients fall into that category. “I can’t do everything, but at least they’re walking in the door.”

But meanwhile Jonathan Shenkin, an Augusta dentist and representative of the Maine Dental Association, told Lawlor that the real problem with dental access in Maine is money.

“It’s a crisis of financing, not a crisis of providers,” Shenkin said. “If people can’t afford a dentist, they’re not going to be able to afford a dental therapist. This is not like competing pizza restaurants in New York City.”

Low reimbursement rates by MaineCare, the state’s version of the federal Medicaid program for low-income residents are a major reason why more dentists are not working in underserved communities, Shenkin said.

Fewer than 30 percent of the state’s dentists are accepting new MaineCare patients and only about half of Maine’s 680 dentists serve any MaineCare patients at all Lawlor noted, citing a 2013 report by the Maine Department of Health and Human Services.”

“Maine’s reimbursement rates rank 34th among all states and are among the lowest in New England. Maine reimburses for many preventive or typical services – such as cleanings and fillings – at about one-third of the average in New England,” Lawlor wrote.

A bill to increase MaineCare dental reimbursements by $2.3 million is pending before the Legislature, but debate has been crowded out by the push to create dental therapists, Shenkin told him.

Meanwhile, Maine Governor Paul LePage, who has steadfastly refused overall Medicaid expansion and has campaigned against welfare fraud seems unlikely to expand Medicaid in other ways, such as for adult dental care, Lawlor wrote.

Kasprak told Lawlor she hoped to go back to school and become a dental therapist to bring more types of care to patients in her independent practice. But since Lawlor filed that report, an amended version of the bill, requiring dental therapists to work under the direct supervision of dentists, might make that plan harder for her.

Lawlor responded to some questions to help bring AHCJ members up to date on the story and how he has approached it.

Q: The latest version of Maine’s dental therapist bill requires direct supervision of a dentist over the therapist. What does that mean? Does the therapist have to be working in the same office as the dentist?

A: This is something that we will get into in a future story. From my understanding, that amendment watered down the bill and so it will make it more acceptable to the dentists. Direct supervision would mean that the therapist would have to work more closely, be actually in the same office as the dentist.

Q: What was the reaction from the hygienists and other advocates who supported the original language?

A: From what I understand, the hygienists are saying, “OK, lets get something passed and we can amend it later.”

Q: If the bill is passed, would Maine’s new dental therapists go to Minnesota for training or would Maine set up its own program?

A: From what I understand, if this passed there would be a program at a local college or university. They would need an extra year of schooling and 1,000 hours of training. The idea is that if this were approved it would create a demand that the local colleges and universities would fill by offering the training.

Q: In your ongoing coverage of this issue, what has struck you most about the debate?

A: It’s one of those issues where it is hard to really know. After all your reporting you look at one side and you say, “Oh! That sounds reasonable.” And then you look at the other side and you say “Yeah! That sounds reasonable.”

You don’t know what to think when it is all said and done. It doesn’t seem really clear cut one way or the other. Even in Minnesota where (a dental therapist bill) was approved there is a lot of back and forth over whether it has done anything. And if not, why hasn’t it done anything? Is it because the law that was approved was so watered down that people haven’t had the opportunities to get these new practices operating? Is there really not a demand for it? I guess until it is a little more established someplace it would be hard to determine.

Q: So it might take more time to know?

A. Right. And even in Minnesota it was only about three or four years ago. It’s hard to really know what the effects will be until several years from now.

Q: Advocates say that as many as 20 states are at some stage in a discussion about trying dental therapists. Any advice for other reporters who might see this issue coming up in their states?

A: I think my only advice would be try to cut through the rhetoric and see if there is any way to determine whether the proposal would really increase access for people who are having a hard time getting dental care.

One thing that I learned there are some states where Medicaid dental care is not covered for adults. For children it’s a mandate, but for adults in many states – including Maine – it’s not covered under Medicaid.

Each state has the ability, within reason, to alter their Medicaid program. One of the things they could do is have dental care covered under Medicaid for adults. Its seems like that has a much bigger impact on whether people are getting their checkups and getting cavities filled rather than waiting until the teeth need to be pulled and ending up in the ER. That seems a lot more impact on demand for services.

If you make (dental care) a covered expense under Medicaid then maybe that would increase demand for a new classification (of providers.)

But they are not really debating that or talking about whether adults should be covered by Medicaid.

Q: Interesting. Have you thought this much about dental care before?

A: No, I haven’t. You are always learning something new.