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Research & Commentary: Dental Therapists Could Help Address Ohio’s Dental Care Shortage

April 13, 2018

In this Research & Commentary, Matthew Glans examines a proposal in Ohio that would improve access to dental care for all Ohioans and lower unnecessary barriers by allowing dental therapists (DTs) to provide needed care to Ohio patients.

Ohio is considering a proposal to improve access to dental care for all Ohioans and lower unnecessary barriers by allowing dental therapists (DTs) to provide needed care to Ohio patients.

According to the Ohio Department of Health (ODH), in 2009 there were 56 dental health professional shortage areas in the state. Today, there are 88. ODH also found the dental care shortage falls hardest on Ohio’s children. According to ODH, 17 percent of Ohio’s third graders have untreated tooth decay. Children in low income households and those without private insurance have almost twice the number of untreated cavities and toothaches.

Dental pain has even been found to place a burden on emergency rooms. According to Pew Charitable Trusts, more than 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 important and overlooked; 101 people died in hospital emergency departments from 2008 to 2011 due to preventable dental disease.

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. 

To address dental health shortages, states across the country have started to examine ways to better utilize non-dentist oral health care professionals, such as dental therapists and hygienists. Dental therapists can perform up to 95 services and procedures, compared to about 40 performed by hygienists and 30 performed by dental assistants.

The Ohio proposal would create a new mid-level care license for dental therapists, allowing DTs to practice under the supervision of a dentist. Expanding DTs’ role 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, cleanings, fillings, and X-rays.

While general supervision, where a DT can practice without a dentist being physically present, is the ideal arrangement, this bill does provide a reasonable path toward greater autonomy for DTs. The proposal would allow a supervising dentist to draft a written practice agreement detailing exactly what a dental therapist can do without a dentist being physically present. To qualify for the agreement under the proposed legislation, a DT would have to successfully complete 400 hours of clinical practice under the direct supervision of a dentist.

If written agreements are required for dental therapists to practice independently, then the only effective arrangement would be one in which an agreement is written as broadly as possible and does not require overly excessive fees. Similar agreements governing how nurse practitioners may function have acted as a barrier to entry because they are overly expensive.

According to the Pew Charitable Trusts, midlevel providers are authorized to provide routine preventive and restorative care in more than 50 nations. “Compared to dentists, dental therapists perform fewer procedures, require less training, and command lower salaries. Research has confirmed that they provide high-quality, cost-effective routine care and improve access to treatment in parts of the country where dentists are scarce.”

Some opponents of expanding the scope of practice in dentistry argue it will result in worsening quality of care. In testimony before the North Dakota House Human Services Committee, Michael Hamilton, then a research fellow for The Heartland Institute, argued these concerns are unfounded. “If therapists obtain licensure in North Dakota, dentists would remain responsible for the quality of treatment patients receive in their offices from any and all employees, whether dental hygienists, dental assistants, associate licensed dentists, or dental therapists. Therefore, to block dental therapy based on concern for quality of treatment is to doubt the quality, competence, and judgment of licensed dentists.”

Permitting dental therapists to practice without a dentist physically present would help to close gaps in dental care access and help ensure patients get the preventive and restorative treatment they need.

The following articles examine dental health care and dental therapist licensing in greater detail.
 

Ohio Senate Considers Dental Therapy Bill
https://www.heartland.org/news-opinion/news/ohio-senate-considers-dental-therapy-bill
Zachary Williams writes in Health Care News about a bill that would permit dental therapists in Ohio.

Dental Utilization for Communities Served by Dental Therapists in Alaska’s Yukon Kuskokwim Delta: Findings from an Observational Quantitative Study
https://www.heartland.org/publications-resources/publications/dental-utilization-for-communities-served-by-dental-therapists-in-alaskas-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.

The Case for Licensing Dental Therapists in North Dakota
https://www.heartland.org/_template-assets/documents/publications/Policy%20Brief%20Dental%20Therapy%20North%20Dakota.pdf
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.

States Consider Authorizing Dental Therapy to Expand Access
https://www.heartland.org/news-opinion/news/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
https://www.heartland.org/publications-resources/publications/a-review-of-the-global-literature-on-dental-therapists
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
https://www.heartland.org/publications-resources/publications/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.

How Reforming Licensing Laws Can Help Fix America’s Dentist Shortage
http://reason.com/blog/2016/08/22/how-reforming-licensing-laws-can-help-fi
Eric Boehm, a reporter at Reason.com, examines the dentist shortage and argues in favor of reforming state dental licensing laws for dental therapists as a potential solution. “Children’s Dental Services … treats about 30,000 patients each year, mostly from the Twin Cities’ Hispanic, Hmong and Somali immigrant communities. The dental therapy model was first adopted by nonprofits and community clinics to lower costs, says Karl Self, the director of the University of Minnesota’s therapy program. But now, Dr. Self adds, private practices are hiring dental therapists, too. ‘We’re seeing that dental therapists can add value to the overall oral health team,’ he says.”

Dental Care Health Professional Shortage Areas (HPSAs)
http://kff.org/other/state-indicator/dental-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D  
The Kaiser Family Foundation analyzes the dental care 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
http://www.pewtrusts.org/en/projects/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
http://www.pewtrusts.org/en/research-and-analysis/q-and-a/2016/04/5-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.

 

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 Health Care News, The Heartland Institute’s website, and PolicyBot, Heartland’s free online research database. 

The Heartland Institute can send an expert to your state to testify or brief your caucus; host an event in your state, or send you further information on a topic. Please don’t hesitate to contact us if we can be of assistance! If you have any questions or comments, contact Lindsey Stroud, Heartland’s government relations manager, at lstroud@heartland.org or 757/354-8170.

Author
Matthew Glans joined the staff of The Heartland Institute in November 2007 as legislative specialist for insurance and finance. In 2012, Glans was named senior policy analyst.
mglans@heartland.org @HeartlandGR