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Research & Commentary: Dental Therapy Would Help with Michigan’s Dentist Shortage

September 27, 2017

In this Research & Commentary, Matthew Glans examines a new proposal in Michigan to improve access to dental care by expanding the role of dental therapists.

Michigan is now considering a proposal that would improve access to dental care for all residents of the state by allowing dental therapists and hygienists to provide needed care. Similar to the situation in many other states, Michigan faces a serious shortage of dental providers. According to a 2016 report by the Mackinac Center for Public Policy and the Texas Public Policy Foundation, of Michigan’s 83 counties, 76 of them have at least one area with a shortage of dental providers.

This shortage is even more problematic for lower-income patients. Nationally, only 27 percent of adults on Medicaid had a dental visit in 2015. In 2016, only half of all children covered under Medicaid or Healthy Kids Dental received dental services. According to the Michigan Council for Maternal and Child Health, of Michigan’s 6,641 licensed dentists, only 10 percent saw one or more adults with Medicaid coverage in 2015.

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.

A proposal now under consideration by the Michigan Legislature would improve access to dental care by creating a “new licensure category for dental therapists that would allow them to do certain procedures in specified settings outside of a dentist’s office, subject to being under the general supervision of a dentist as specified in a required written practice agreement.”

The proposal would not require dentists to employ a dental therapist, and it would stipulate that a dental therapist cannot work without a supervising dentist. The supervising dentist would be given authority to draft a written practice agreement detailing exactly what a dental therapist can and cannot do. It also calls 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.

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 a report from the Anderson Economic Group, in 2011, Michigan patients made more than 7,000 trips to the emergency room for preventable dental conditions, creating a cost to hospitals of $15 million to triage patients.

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.
 

Dental Therapists: A Proposal to Expand Access to Dental Care in Michigan
https://www.mackinac.org/S2016-06
Michael Van Beek of the Mackinac Center for Public Policy and John Davidson of the Texas Public Policy Foundation examine the potential of using dental therapists to help address the state’s dental care shortage. The authors argue Michigan should consider this approach because it will: “1) help deal with the current identified dental care shortage areas, 2) put downward pressure on the price of dental services, making it more affordable for more people, and 3) respond to Michigan’s future demand for dental services.”

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.

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.

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.

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-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.

Older Americans Need Better Access to Dental Care
http://www.pewtrusts.org/en/research-and-analysis/fa
ct-sheets/2016/07/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 john@heartland.org or 312/377-4000.

Author
Matthew Glans joined the staff of The Heartland Institute in November 2007 as legislative specialist for insurance and finance.