Research & Commentary: Dental Therapists Could Help Solve Massachusetts’ Dental Shortage

Published September 15, 2017

Massachusetts is now considering a proposal that would improve access to dental care for all Bay Staters by allowing dental therapists and hygienists to provide needed care. Similar to many states, Massachusetts faces a serious shortage of dental providers. According to the Pioneer Institute, over 500,000 residents in Massachusetts live in dental shortage areas, as defined by the U.S. Department of Health and Human Services, and in 2014, only 35 percent of dentists treated Massachusetts Medicaid patients. This means 44 percent of children enrolled in MassHealth did not see a dentist in 2015. These shortages extend beyond the young. According to the Massachusetts Department of Health, low-income seniors in 2014 were seven times more likely to have lost all their teeth than seniors with household incomes exceeding $75,000.  

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. 

A proposal being considered by the Massachusetts General Court would improve access to dental care by permitting dental therapists (DT), a new type of dental care provider.

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. The proposal would allow a DT to perform procedures such as basic tooth extractions, fillings, and X-rays.

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.

Minnesota became the first state to authorize the expanded licensing of dental therapists in 2009. Based on the available evidence, the results of Minnesota’s reforms have been positive. 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.

The Massachusetts proposal was created in cooperation with the Commission on Dental Accreditation (CDA), a subdivision of the American Dental Association. DTs would be required to meet strong training standards – including three years of additional schooling, rigorous testing, and a year-long residency program – before operating outside the direct supervision of a dentist.

Another proposal, backed by the Massachusetts Dental Society, calls for permitting DTs to perform expanded services, but only under the direct supervision of a dentist. This limits the effectiveness of the therapists and does little to solve the dental care shortage.

The Pioneer Institute argues allowing general supervision is essential and that the CDA-backed plan would help underserved populations: “This bill is uniquely designed to target those living in dentist shortage areas by allowing DTs additional freedoms to operate under non-profits and in a licensed mobile dentistry program. By reaching out to underserved populations, the culture around oral healthcare can begin to change. At least six states have authorized dental therapists to practice in some form, with more than a dozen others currently considering this issue,” said Pioneer in a press statement.

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.

Allowing dental therapists 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 it.

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

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.

States Consider Authorizing Dental Therapy to Expand Access
Mary Tillotson writes in Health Care News about the movement by several states to consider allowing dental therapists additional power to treat patients. “Millions of rural Americans lack access to proper dental care, a shortage 12 states are considering filling by authorizing dental therapy, an oral-care-industry profession roughly equivalent to a physician assistant or nurse practitioner,” wrote Tillotson.

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.

Healthcare Openness and Access Project: Mapping the Frontier for the Next Generation of American Health Care
The Healthcare Openness and Access Project (HOAP) is a collection of state-by-state comparative data on the flexibility and discretion US patients and providers have in managing health care. HOAP combines these data to produce 38 indicators of openness and accessibility. The project provides state-by-state rankings over a number of variables, including occupational licensing.

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.