Research & Commentary: Dental Therapists Could Help Solve Arizona’s Dental Shortage

Published November 10, 2017

Similar to the situation in many other states, Arizona faces a serious shortage of dental providers. According to a report by the Goldwater Institute and the Texas Public Policy Foundation, of Arizona’s seven million residents, “2.4 million are living in areas designated as dental health professional shortage areas, which means there one or fewer dentists per 5,000 people.” The dental care shortage has accelerated in recent years; according to the American Dental Association Health Policy Institute, the dentist-to-population ratio in Arizona increased by 7.1 percent from 2005 to 2015.                                                 

Arizona’s Dental Practice Act makes it illegal for anyone other than dentists to perform many kinds of dental care. Strict licensing standards have become a significant barrier to entry in many fields, including the dental industry. Supporters of strict state licensing standards argue they assure quality, but critics say the arduous and often expensive licensing process harms the dental market by hindering entry for new providers, thereby impeding the market competition needed to lower costs and improve access for patients. 

States across the country have begun to look toward non-dentist employees such as dental therapists and hygienists to cover their dental health shortages. Dental therapists can perform up to 95 services and procedures, compared to about 40 performed by hygienists and 30 performed by dental assistants. Similar to a physician’s assistant or nurse practitioner, dental therapists would be required to pursue additional education to perform additional basic dental procedures that are not currently performed by dental hygienists. Expanding the level of care being offered through DTs would free up time for dentists to focus on complicated cases and provide basic care to more patients.

In Arizona, a coalition of dental therapy advocates called Dental Care for Arizona has submitted a sunrise application to begin the process of implementing legislation to authorize the use of dental therapists. This application will go before the Health Committee of Reference in November or December 2017. The committee will hear testimony on the proposal and recommend whether legislation to create scope of practice and licensure for dental therapy should be considered by the full Arizona Legislature.

In a 2017 Policy Brief, The Heartland Institute’s Michael Hamilton and Bette Grande and the Texas Public Policy Foundation’s (TPPF) John Davidson, a senior fellow at TPPF, wrote, “A dentist who  chose to hire dental therapists would retain complete freedom to direct the care given by each midlevel provider in his or her office, including care by dental therapists, just as dentists currently direct the work of dental hygienists. The dentist’s authority, responsibility, and autonomy would remain paramount. For this reason, as one Michigan state lawmaker told The Heartland Institute in September 2016, ‘I put the concern over quality right back in the dentists’ laps.’ Dentists would keep the full measure of quality assurance and responsibility they now have.”

Minnesota became the first state to authorize the expanded licensing of dental therapists in 2009. After just one year of licensing dental therapists, patient visits increased by 27 percent. Last year, legislation expanding the scope of practice for dental therapists was filed in 12 states.

Dental pain has even begun to place a burden on the nation’s emergency rooms. According to Pew Charitable Trusts, over two million people in 2012 reported to local emergency rooms for dental pain, costing taxpayers $1.6 billion, with Medicaid’s share totaling $520 million. Dental health is both important and overlooked, 101 people died in hospital emergency departments from 2008 to 2011 due to preventable dental disease. According to AZ Central, from 2011 through 2014, “more than 41,000 Arizonans resorted to hospital emergency rooms for oral health care.”

How these laws are fashioned is important. Any new law authorizing dental therapists must ensure the laws call only for general supervision, not direct supervision, which means the dental therapist would not need to be in the direct company of a dentist to provide dental services. This is important because limiting therapists to direct supervision would dull the effectiveness of the proposal and do little to provide increased services.

Allowing dental therapists to practice in more states would help to close gaps in dental care access and ensure patients receive preventive and restorative treatments when and where they need them.

The following articles examine dental health care and the licensing of dental therapists in greater detail.

The Reform that Can Increase Dental Access and Affordability in Arizona
Naomi Lopez Bauman, director of healthcare policy at the Goldwater Institute, and John Davidson, senior fellow at the Texas Public Policy Foundation, examine the dental access shortage in Arizona and how dental therapists could help fill this gap. “Limiting the supply of providers not only increases the cost of care services; it forces consumers and government payers to pay prices higher than they might otherwise. To increase dental access and affordability for Arizonans, lawmakers should allow for dental therapists,” wrote Lopez Bauman and Davidson.

The Case for Licensing Dental Therapists in North Dakota
In this Policy Brief, Michael Hamilton, Bette Grande, and John Davidson ask North Dakota lawmakers: “Does licensing dental therapists in North Dakota pose a risk to public health great enough to justify depriving (1) dentists of their right to employ and supervise dental therapists and (2) patients of their right to access providers of their choice?” They argue the answer is clearly “no.” Far from jeopardizing the public health, licensing dental therapists would likely expand patient access to high-quality oral care services and reduce oral care costs in North Dakota.

Dental Utilization for Communities Served by Dental Therapists in Alaska’s Yukon Kuskokwim Delta: Findings from an Observational Quantitative Study
This study from the University of Washington examines whether dental utilization rates in Alaska Native communities were associated with the number of dental therapist treatment days and quantifies differences in dental utilization rates between communities without dental therapist treatment days and those communities with the highest number of dental therapist treatment days.

Early Impacts of Dental Therapists in Minnesota
The Minnesota Department of Health and Minnesota Board of Dentistry examine in this report how authorizing dental therapy in Minnesota resulted in increased access for previously uncared-for patients.

A Review of the Global Literature on Dental Therapists
This report from the W.K. Kellogg Foundation provides a 460-page review of the benefits of dental therapy as demonstrated in more than 50 countries.

Dental Care Health Professional Shortage Areas (HPSAs),%22sort%22:%22asc%22%7D  
The Kaiser Family Foundation analyzes the dental-health professional shortage areas in each state in order to show which states have the largest discrepancies in dental-care access.

Pew Charitable Trust: Dental Campaign
Pew Charitable Trust has been providing research and analysis to encourage state lawmakers to allow dental therapists in their states to ensure patients have greater access to preventive and restorative treatment services. “Pew’s dental campaign works to close gaps in dental-care access by increasing the number of available providers and expanding the reach of preventive services through the use of dental sealant programs in high-need schools. Research shows that such programs are a valuable, cost-effective way to treat the children most at risk of tooth decay.”

5 Dental Therapy FAQs  
While states continue to grapple with what dental therapists are, how much education dental therapists receive, and where therapy is practiced, Pew Charitable Trusts has put together a helpful FAQ page to answer the most important and difficult questions related to dental therapy.

Older Americans Need Better Access to Dental Care
Almost 40 percent of seniors did not visit a dentist in 2014. As the number of older Americans increases in the coming decades, the demand for care for this age group will intensify. In this fact sheet, Pew Charitable Trusts examines the health risks seniors currently face, from poor access to mental health services to dental-care barriers. “The use of dental services declines as people age due to a variety of factors. Perhaps the single greatest barrier is the inability to afford care. Seniors with dental insurance are 2.5 times more likely than those without coverage to visit a dentist, and about half of seniors lacked insurance in 2015.”


Nothing in this Research & Commentary is intended to influence the passage of legislation, and it does not necessarily represent the views of The Heartland Institute. For further information on this subject, visit The Heartland Institute’s website, and PolicyBot, Heartland’s free online research database. 

If you have any questions about this issue or The Heartland Institute’s website, contact John Nothdurft, The Heartland Institute’s government relations director, at [email protected] or 312/377-4000.