Oral healthcare faces significant challenges in Massachusetts. For example, 40% of the children in pre-kindergarten through fourth grade in Cambridge have a history of tooth decay, according to the city’s Public Health Department. In 2014, the state’s Department of Health reports, low-income seniors were 7 times more likely to have lost all of their teeth than seniors with household incomes exceeding $75,000.
State Senator Harriette Chandler and Representatives Smitty Pignatelli and Kate Hogan believe their legislation authorizing the use of dental therapists will address these and other oral healthcare problems in the state. Dental therapists are dental hygienists who, after completing additional training, are certified to perform more advanced procedures while working under the supervision of a dentist—in effect, operating more affordably for underserved patients.
“More than 530,000 people in Massachusetts live in areas with a shortage of dentists. Also, 44% of children, which is over 284,000 kids, on MassHealth didn’t see a dentist in 2015,” said Bryan Barash, Chandler’s legislative director and general counsel. “So really the picture that we’re seeing here is that while we do have a number of dentists here in Massachusetts, there are significant gaps in access, and some of the folks who need care the most aren’t getting it.”
The Training
The bill would require dental therapists to complete a certified educational program before licensure by the board. Dental therapists also would need to practice under the direct supervision of a dentist for at least 500 hours or complete one year of residency before practicing under general supervision. Plus, they would have to enter into a written agreement with a licensed dentist spelling out the scope of their supervision and work.
Once these requirements are met, dental therapists would be allowed to interpret radiographs, place space maintainers, perform pulpotomies on primary teeth, conduct oral evaluations of and assess dental disease, formulate individualized treatment plans that would be authorized by the supervising dentist, and perform nonsurgical extractions of permanent teeth. They also would be permitted to dispense and administer analgesics, anti-inflammatories, and antibiotics.
“Dental therapists are going to be trained exactly the same way that dentists are in this limited set of procedures. The studies we’ve looked at, and the research that we’ve done, indicate that dental therapists, for the procedures they are authorized to do, are as qualified as or, depending on the study that was done, even slightly better at performing this limited set of procedures,” said Barash.
Additionally, the training will include how to serve patients with special needs such as those with autism spectrum disorder and other developmental disabilities, mental illness, cognitive impairment, complex physical limitations, and the vulnerable elderly. These populations often have limited mobility, making travel for dental appointments particularly difficult. Dental therapists, then, would be able to travel to them to provide care.
“It’s really about bringing care to those people if you want to effectively make sure they get access, and this is especially true for senior and high-needs populations,” said Barash. “We’ve had seniors tell us, ‘Look, there’s a dentist’s office across the street. I can’t get there. I’m in a nursing home, and they can’t find staff who have the time to take me over. And I’m in a wheelchair, and it’s not accessible.’”
The Need
Ideally, patients would have access to a dentist that they could see regularly for routine care before oral problems get worse. When economic or geographic factors prevent them from having a dentist and they find themselves in acute need of treatment, though, they visit their local hospital’s emergency department (ED). These hospital visits have been taking a toll on the state’s healthcare system, too.
The Massachusetts Health Policy Commission (MHPC) reports that ED visits for oral issues are 4 to 7 times more expensive than dental office visits. Also, MassHealth pays for 48.8% of all of the preventable oral health ED visits. And while dental office visits average between $90 and $200, ED visits for oral health conditions can range from $400 to $1,500 without even properly treating the issue, meaning the patient will have to see a dentist eventually anyway.
“A significant amount of money and resources are spent on hospital visits for emergency care for dental issues, and these are basically the kinds of issues that dental therapists would be able to treat,” said Barash. “Instead, it gets to the point where someone’s got an abscess, and they end up in the emergency room. And even once they’re there, they don’t exactly get oral health treatment. The infection is treated, but the actual core problem, the cavity or whatever it might be, isn’t actually treated. So it’s not that uncommon that they end up back there again.”
The MHPC also says that one tenth of the state’s population live in federally designated dental health professional shortage areas. And while MassHealth covers some dental care, not all dentists accept it. In 2014, 35% of dentists treated a MassHealth patient, and only 26% billed at least $10,000 to the program. So many areas don’t have dentists, and of those that do, not all of the dentists there accept the insurance patients may have.
These factors are compounded by the difficulties in recruiting new dentists to practice in these areas. The American Dental Education Association reports that the average debt per dental school graduate was $261,149 in 2016. Naturally, many new dentists opt to work in more financially lucrative regions, not rural or urban areas where the populations have low incomes and depend on programs like MassHealth for dental care—and reimbursement from public insurance isn’t as high as reimbursement from private insurance.
“One of the biggest problems we see, and I think it’s a national problem, is the more rural the area, the more likely it is you’ll have a situation where you might have only one dentist in a half-hour ring of an area, and he is 75 years old now. He may not want to be working 50 hours a week to take care of that whole population,” said Barash.
On the other hand, Barash explained, dentists in states that allow dental therapists now can hire them to stabilize their practices financially. When reimbursement is an issue, dentists can have the therapist perform treatment, making it more cost-effective and freeing up the dentists’ time to take on more complicated and therefore more profitable cases. Or, by having the therapist perform this work, dentists can reduce their own work hours.
“I know one example in Minnesota where you had a guy who was starting to retire,” Barash said. “He brings in a dental therapist. The numbers work a little better for him as he does that, and what ended up happening was he was able to bring in a younger dentist to come in and take over his practice because financially it made more sense.”
The Debate
The bill proposed by Chandler, Pignatelli, and Hogan is currently in committee. On July 17, Governor Charlie Baker inserted language establishing licensed dental therapists into the fiscal year 2018 budget. But the state legislature vetoed the governor’s amendment, which largely followed the guidelines established in the bill proposed by Chandler, Pignatelli, and Hogan. The ADA and the Massachusetts Dental Society also oppose the licensure of dental therapists.
According to the ADA’s Health Policy Institute (HPI), the number of dentists will continue to grow through 2035 and outpace population growth. Also, 27% of dentists indicate that they have the capacity to add more patients. Rather than add a new category of providers, the ADA said, underserved patients can be connected with dentists ready to treat them via community health worker outreach and improved funding for dental services under Medicaid, which in turn would increase the number of dentists participating in the program.
The HPI further concluded that 22 states could add extensive dental benefits to their existing Medicaid programs by adding 1% to their Medicaid budgets. Most state Medicaid budgets allocate 2% to dental services, the HPI said. It also noted that states such as Maryland, Texas, Connecticut, and Michigan have reformed their Medicaid programs using evidence-based solutions and seen progress in improving care. Still, the legislators believe their plan also would be effective and cost-effective in reaching underserved patients.
“We have a number of programs in the state that are designed to increase access, and some of them do a great job. But at the end of the day, if half of the kids on MassHealth aren’t seeing a dentist, we’ve got to keep trying to push the ball here. What the numbers suggest, looking at other states, is that authorizing dental therapists does move the ball and increase access,” said Barash. “We are absolutely committed to increasing dental care in any way we can. This is just something we see as a very promising avenue to do that.”
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