This commentary was originally featured in Real Clear Health on August 24, 2017.
After World War II, America faced a severe shortage of primary care. Doctors struggled to meet the rising demand brought on by the baby boom, while the cost of care became increasingly unaffordable. In 1965, the first nurse practitioner training program launched at the University of Colorado. The result: a mid-level practitioner and increased access to care for the average American family.
Today, history repeats itself in the form of a national dental crisis. There are 5,493 dental health professional shortage areas (HPSAs) nationwide, in which there are more than 5000 patients per dentist. While lawmakers and dental professionals explore ways to expand access to care, some states are looking to the past for solutions.
Minnesota, Maine, and Vermont are licensing mid-level dental practitioners, called dental therapists, to address their care shortages. Dental therapists are the nurse practitioners of dentistry. Their training qualifies them to perform up to 80 procedures, including routine, preventative, and restorative dental care. To compare, dental hygienists and assistants typically perform 30-40 procedures, while dentists can perform up to 600. Dental therapists treat some of the most common dental issues, such as cavity fillings and simple extractions.
A recent study from the University of Washington shows that dental therapists significantly improved oral health outcomes in Alaska Native communities. For some populations, “the proportion of children who received preventive care increased five-fold.”
Unfortunately, incumbent dentists care more about protecting themselves from competition than promoting oral health. Dental therapists face the same opposition from organized medicine that nurse practitioners faced in the ‘60s.
The first generation of nurse practitioners was strongly opposed by medical and nursing organizations. The American Medical Association and the National League of Nurses sought to discredit nurse practitioners, claiming they were simply “playing doctor,” and that patients were not safe in their hands.
Today, there are approximately 234,000 nurse practitioners licensed in the U.S. A large body of literature demonstrates the high quality of care they provide. They have become essential to the medical team — working with doctors, not against them.
Like nurse practitioners in the 1960s, dental therapists face strong opposition from national and state dental associations. In 2011, the American Association of Public Health Dentistry developed a curriculum for training dental therapists. Shortly after, the American Dental Association (ADA)–the nation’s largest association for practicing dentists–expressed an “unequivocal opposition to non-dentists performing surgical/irreversible procedures.” The ADA’s main concern with dental therapists was not the quality of care they provide, but the fact that they were “non-dentists.”
The 84th Texas Legislature considered a bill establishing licensure requirements for “dental hygiene therapists,” another name for dental therapists. The Texas Dental Association testified against the bill, backed by the full force of the ADA. The bill failed, despite having bipartisan support from organizations such as the Texas Hospital Association, AARP, and the Center for Public Policy Priorities. About a dozen states have considered dental therapy legislation, and the same sad story has played out in most.
A survey conducted by the Texas Dental Hygienists’ Association shows that 87 percent of hygienists support “a new workforce model (with more services, collaborative agreements with dentists, nontraditional settings and additional education and licensure).” All of these benefits are integral parts of the dental therapy model.
Much like nurses in the 1960s, dental hygienists want opportunities to broaden their scope of practice and treat underserved patients. They want to be dental therapists.
To draw another parallel, the development of nurse practitioners was an important economic victory for women. In the mid-20th Century, nearly all doctors were men, and nearly all nurses were women. Nurse practitioner programs offered women more education, more responsibility, and higher pay. Today, 98 percent of dental hygienists are women and about 70 percent of dentists are men. Dental therapy is a higher-paying job opportunity for many female hygienists. It is also likely to attract new, diverse groups of people to the field of dentistry.
The Department of Health and Human Services projects a national surplus of dental hygienists by 2025. However, hygienists cannot meet patients’ unmet demand for dental care alone. So long as dentists have a monopoly on most dental procedures, hygienists can do nothing to help those who need restorative or preventative care. To make matters worse, the 2025 projections include a national shortage of 15,600 dentists.
Adding dental therapists to the team would free up dentists’ time and allow them to operate at the height of their training, to perform those procedures only a fully trained dentist can do. It would also grant hygienists more career opportunities, allowing them to escape an oversaturated job market. Most importantly, allowing dental therapists to practice will improve access to oral care.
Innovation is an effective way to combat shortage. Delivery systems can be innovated just like goods and services. The creation of nurse practitioners was a clever, effective market solution to a shortage of primary medical care. State lawmakers would be wise to apply the same solution to the lack of dental care.