Lawmakers in several states have considered proposals in 2017 to let dentists custom-build their ideal dental teams. Unfortunately, it is increasingly likely that most state legislatures will leave dentists’ hands tied when they adjourn, against the wisdom of dentists, dental hygienists, and free-market policy experts.
One kind of dental teammate inaccessible to dentists in most states is the dental therapist. Obstruction of dentists’ freedom to hire dental therapists ensues not from political bias but from special interests. Opponents include dentists who are concerned that patient care and the traditional dentistry model will be turned upside down if an enterprising dentist strays from the pack by hiring and supervising a dental therapist.
Dental therapists have practiced in more than 50 countries, including the United States, since the profession originated in New Zealand almost a century ago. The Alaska Native Tribal Health Consortium (ANTHC) launched its Dental Health Aide Therapist (DHAT) program in 2002 to increase the supply of providers for populations unreached by the traditional dentistry model. Minnesota introduced more robust training requirements than ANTHC’s DHAT program when authorizing dental therapy in 2009. Maine and Vermont have authorized the licensure of therapists, and therapists currently serve tribes in Oregon and the State of Washington.
The most common objection to dental therapists is they will provide low-quality care. This concern is theoretical, not fact-based. Two important quality-assurance measures ensure therapists give patients superior care: intensive training and supervision by licensed dentists.
Dental therapy students at the University of Minnesota (U of M) School of Dentistry undergo exactly the same training as dentists for the 70 to 80 procedures shared by each profession’s scope of practice. During a university site visit, Kevin Nakagaki, DDS, a dentist with the nonprofit healthcare organization HealthPartners, told visiting researchers, “Dental therapists are actually doing more of the same kinds of procedures by the time they leave school than dental students, because the dental students spread out. They have to do more kinds of procedures.”
In the fall of 2016, the U of M School of Dentistry converted its training program to a dual-licensed dental hygienist/therapy program. This buttresses the training of each midlevel provider, maximizing the value of each to dentists who choose to employ them.
Because dentists are trained to provide roughly 500 services and procedures, those who hire therapists gain flexibility to delegate. Therapists earn less per hour than dentists, enabling dentists who hire therapists to run their practices more efficiently. This has allowed some dentists to treat higher volumes of patients on Medicaid, which reimburses dentists less than private insurance—so much less that Medicaid patients frequently struggle to find providers who can afford to treat them.
Opponents sometimes object that letting dentists use therapists to treat Medicaid patients will result in a 2-tiered system of care—quality care for the rich and shoddy care for the poor. But preventing enterprising dentists from expanding their practices into underserved areas preserves a 2-tiered system of patients with access to care and patients lacking access.
The truly fatal flaw in objections over the quality of care provided by therapists is circular reasoning. Under current law and proposed legislation, dentists would retain absolute authority over whom they hire onto their dental teams. Not a single patient would go treated by a dental therapist without the express consent of a supervising dentist.
Moreover, supervising dentists would remain entirely responsible for the quality of care their supervisees provide. Just as dentists are accountable for hygienists and dental assistants in their employment, they would be accountable for dental therapists, starting with the decision whether to hire therapists at all.
Round and round we go. When arguing to lawmakers, dentists opposing dental therapy typically appeal to their own professional judgment as licensed dentists. But blocking dental therapists from licensure robs licensed dentists of the ability to exercise their professional judgment. Permitting therapists to practice at dentists’ discretion would be more consistent.
Recognizing supervising dentists as responsible for the care therapists provide defuses a related objection: that dental therapists are untested. This ignores therapists’ 95-year history and 15-year presence in the United States. It is often followed by the fallacy that permitting some dentists to hire therapists would prevent other dentists—or even the same dentists—from pursuing alternative means to expand services to underserved patients.
Opponents at least have this correct: dentists know best. So, instead of eating their own, dentists should support the right of dentists to make the best hiring decisions for their individual practices.