Dental Therapists: Friend or Foe?

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Dental therapists are an increasingly popular topic among dental students. Still, many dental students, and even some dentists are not aware of what a dental therapist is. So it follows that many dental professionals are largely unaware of the issues surrounding dental therapists.

What are dental therapists?

Simply put, a dental therapist is the dental equivalent to a physician assistant or nurse practitioner. Dental therapists may receive either a bachelor’s or a master’s degree in dental therapy and can then operate under the supervision of a general dentist.

With 2,000 hours of relevant dental experience, dental therapists (DTs) may become credentialed as advanced dental therapists (ADTs). ADTs may work independently from a dentist if they have a collaborative agreement with a dentist in their area. Currently, UMN offers a 32 month dental therapy program, and a 4.5 year dual-degree Master’s in both dental therapy and dental hygiene.

It’s worth mentioning that both programs demand significantly less time than the seven or eight years it takes to become a dentist. That said, dental therapists are allowed to perform significantly fewer procedures than dentists are.

What can they do?

There is a lot of confusion about dental therapists’ scope of practice. Dental therapists are credentialed to perform the following basic dental procedures without a dentist present: administration of anesthetic and nitrous oxide, taking radiographs, mechanical polishing of teeth, charting, patient counseling, and others. They are currently allowed to practice in several states including: Alaska, Washington, Oregon, Maine and Minnesota.

Dental therapists may also perform the following procedures if a dentist is on-site: cavity preparation, temporary crown placement, extractions and pulpotomies of primary teeth, re-cementing of permanent crowns, and repair of prosthetic devices. For a more exhaustive list of dental therapist procedures, click here.

Do we need them?

Often the question comes up, why do we need dental therapists? This question has led to many heated debates online and in state legislatures across the nation. One such case happened here in Arizona. A bill to create a dental therapist program in the state was recently killed during a sunrise session of the state legislature.

Proponents of the Arizona bill argued that dental therapists increase access to care for rural and impoverished demographics. Detractors argue that cuts to AHCCCS (Arizona’s medicaid program) during the ’08 recession is what led to diminished access to care for these patient populations. They also argue that dental therapists threaten the livelihood of dentists here in Arizona.

I can’t say that we do need therapists, or that we don’t need them. But I hope that this article will help inform readers to reach their own conclusions. It’s worth mentioning that the state of Minnesota seems to think that it needs dental therapists. Furthermore, the Minnesota board of health completed a study in 2014 which suggests that therapists are doing exactly what the state had hoped they would do.

Who is behind all of this?

Dental therapists for their part are backed by powerful trusts such as the Pew Foundation and the W.K. Kellogg Foundation. On the other side, dentists have the ADA, one of the most powerful lobbies in the United States. The ADA, Pew, and Kellogg have been fighting pitched battles across the country in states like Michigan, Ohio, Texas, Maryland, New Hampshire, Kansas, New Mexico, and Hawaii.

Should dentists worry?

Because dental therapists are cheaper to train, and their education is less extensive, they offer some competitive advantages that most dentists are simply unable to match. However, it is probably a stretch to think that dental therapists will be significantly encroaching on dentists’ territory anytime soon.

Of the 32 licensed dental therapists working in Minnesota in 2014, only three worked in private practice. The majority work in community health clinics and at the universities. Furthermore, 84% of the patients seen by therapists were enrolled in public health insurance programs. Will it always be like this? Probably not. But who can say what the long-term effects will be?

A paper written by Burton L. Edelstein, and published in the American Journal of Public Health, points out that those who can already afford dental care are largely happy with the care they receive. Dental therapists are likely not going to lure away Americans who can already afford to go to the dentist any time soon. In his paper, Edelstein quotes Caswell Evans, who wrote in the US surgeon general’s report Oral Health in America that, “US dental care works well for those who can access it and afford it. The others are left out in the cold and they suffer the consequences.”

So dental therapists are a good thing then, right?

The access to care issue is one that proponents of dental therapists like to bring up. Many Americans lack access to even basic dental care. It seems the moral thing to do is to offer more affordable care with dental therapists. They are cheaper to train than dentists after all.

However, the morality of tiered healthcare is also an issue. Should poor people receive care from providers with less training simply because they can’t afford someone who has more training? Dental therapy’s detractors will sometimes argue that therapists are playing right into the tiered-healthcare model: high standards for the wealthy, lower standards for everyone else.

Also of issue is the fact that many Americans underutilize existing dental care services. Even when they can afford it, many Americans simply opt out of going to the dentist.

Furthermore, roughly 100 million Americans simply can’t afford to see the dentist. Obviously, this is a huge problem. You can’t blame state legislatures or health advocacy groups from trying to solve it. But you also can’t be surprised when professional organizations oppose solutions that threaten its members.

What about us future dentists?

Many dental students have expressed their concerns about dental therapists and worry that they will make dentists irrelevant. To that I say, not so fast. Dental therapists have been around in other countries for decades (since 1921 in New Zealand), and they have been in the United States (Alaska) since 2003. UMN started training dental therapists in 2009, and eight years later I am writing this article to inform many dental students who haven’t even heard of them.

Will dental therapists be the transformational change that brings down the cost of dental care, increases access, and cuts into every dentist’s bottom line? No, no, and probably not.

Nurse practitioners and physician assistants have done some wonderful things for medicine. But they have not solved the access to care problem, healthcare costs continue to skyrocket, and so far physician salaries have been threatened more by other factors. If the medical field is any indication for what’s to come, then I suspect that we can expect more of the same in dentistry.

That’s not to say however that dental therapists don’t have a place in this profession. In New Zealand for example, dental therapists have provided access to millions of school children. In Alaska, they have provided care to remote and indigenous populations who were otherwise without it.

My two cents

In my opinion, we should work with therapists, hygienists, and assistants, towards a real and substantive solution that brings down costs, increases access, and elevates us all. This is not a zero sum game! We should welcome mid-level providers into the profession. But we should have the same high expectations for therapists that we demand of any dentist when it comes to the procedures they will perform.

A general dentist can place braces on a patient without supervision from an orthodontist. But if they wind up with a malpractice suit, then that dentist is held to the same standard that an orthodontist would be. Therapists should also be held to the same standards as a dentist.

Dentists and dental specialists take the same national board examination (NBDE parts I and II) to ensure that they have basic competence in a wide range of dental procedures. If dental therapists are going to perform an array of these procedures, even under supervision, they should also be required to pass an equivalent national board examination to demonstrate proficiency in them.

Dental therapists should take a national board exam like the rest of us

The current CRDTS exam attempts to mirror the regional CRDTS taken by dentists. But why shouldn’t therapists take a national board exam that mirrors the NBDE?

Currently, dental therapists do not take NBDE I or II. They do share some classes with dental students, but only a few. In fact, looking over the course curriculum for dental students and dental therapy students at UMN, it seems there are few similarities except that both are related to dentistry. Comparing the two we see that dental students take a significantly larger course load. Also, very few of the classes overlap between the two programs.

Dental student curriculum

Dental therapist curriculum

The Minnessota Department of Health website says: “dental therapists learn along-side of dental and dental hygiene students and complete the same clinical competencies as dental students where the scope of practice of a dental therapist is the same.”

One could argue however that a knowledge of systems is required to know how chemical x may interact with condition y.

The camel’s nose

2,000 hours of work experience and an additional credentialing process allows dental therapists to become advanced dental therapists. Many dentists argue that this is simply the camel’s nose under the tent. They argue that advanced therapists will eventually go the way of nurse practitioners and demand complete independence from dentists.

I do find such a prospect somewhat troubling. In my opinion, simply working for 2,000 hours does not automatically give someone competence in something. Proficiency comes from deliberate practice and learning.

An OR nurse may spend thousands of hours working with and observing a neurosurgeon. But that does not mean that he/she understands what the neurosurgeon is doing or why they are doing it.

Riding along jump seat in the cockpit as a flight attendant doesn’t make you a competent pilot. Simply watching a pilot push buttons in a cockpit is not the same thing as training to be the pilot in the cockpit. If all it took was watching someone do something for an extended period of time, then I should be able to swim like Michael Phelps.

Advanced dental therapists have 2,000 hours of clinical care to their name in addition to their training as a dental therapist. But those 2,000 hours do not equate to the knowledge and experience of a dentist. So why can they operate autonomously with only a collaborative agreement? Is this only the first step to complete independence?

What if a therapist doesn’t know they made a mistake? They never ask for help from the dentist they collaborate with, because they don’t know they need to. If you don’t know what you don’t know, this seems to me a dangerously likely scenario. It is ultimately the patient who suffers.

Whose side are you on?

There are dentists on both sides of this issue. Some claim that the dental therapists they hired were incompetent. They claim that their dental therapists could not treat patients without close supervision. Other dentists have said that they wish their dental therapists had even broader scope of practice. They claim that therapists are a useful extension of their dental team. I suppose it depends on the dentist and how they employ their therapists that determines which side of the debate they fall on.

I don’t think that dental therapists are an immediate threat to the profession of dentistry. Frankly, there are bigger problems affecting the viability of dentistry as a profession today than dental therapists.

As I see it, dental therapists are a band-aid solution to rising costs and underutilization of dental care in the United States. Citizens are unhappy and legislators are scrambling for solutions.

We don’t have a shortage of dentists in the United States. What we have in this country is a poor distribution of dentists. But merely hoping that dental therapists will practice in undesirable locations seems misguided. Why should they be any more likely than dentists to practice in a rural setting? This seems to me a fundamental misunderstanding of what motivates people to choose where they will live and work.

Getting dentists to work in underserved communities is as easy as increasing incentives through student loan forgiveness programs. Such programs already exist, but they are woefully underfunded. With rising tuition costs these programs often fall far short of the mark.

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