Arizona lawmakers ponder dental therapy to address shortage

Posted: Dec 15, 2016 3:55 PM
Arizona lawmakers ponder dental therapy to address shortage

Hospital emergency rooms are normally a repository for broken bones, accident traumas and sudden or severe medical complications. In Arizona, ERs were also the go-to treatment option for more than 45,000 people with dental problems from 2010 to 2015.

The state’s Medicaid program picked up the tab for 41 percent of these cases — nearly 19,000 visits. At an average of $749 per visit, that’s quite a chunk of public dollars going to treat something that could be prevented at a dentist’s office for about a third of the cost.

Kristin Mizzi Angelone, a dental policy expert with the Pew Charitable Trusts, notes that the entire process is not only expensive, but typically futile.

“When people visit the emergency department for dental problems, they are generally treated only for their acute needs and then referred to a dentist,” Angelone tells “Clearly, patients who seek preventable dental care in the ED do not have regular access to a dentist.”

With 2.3 million Arizonans living in federal Dental Professional Shortage Areas, having enough dentists to go around is a measurable problem – nowhere more acutely than on the state’s Indian reservations, where 76 percent of American Indian children have a history of tooth decay.

But state lawmakers could decide as soon as Friday on a pathway to relief.

Under the state’s “Sunshine Review” process, a proposal to allow licensing and practice of dental therapists is slated for review by 10-member Committees of Reference (CORs). These subsets of the House and Senate Health Committees are expected to hear testimony on dental therapy and make a recommendation to the full legislature.

If adopted, Arizona would join Minnesota, Maine and Vermont (as well as tribal lands in Oregon, Washington and Alaska), as jurisdictions that authorize dental therapists. Several other states are also considering dental therapist licensing in the coming year, including Michigan, North Dakota, Ohio, Texas,  Kansas and California.

DENTAL MISMATCH: Arizona lawmakers are chewing on new licensing regulations for dental therapy to address statewide shortages.

Much as nurse practitioners and physician assistants are to doctors, dental therapists work under the supervision of dentists and are licensed to perform many of the same procedures — such as fillings and tooth extractions — but at lower cost.

Heartland Institute research fellow Michael Hamilton is the author of an upcoming policy brief on dental therapy. He says dental therapists are improving retention rates and enabling dental practices to serve more low-income patients. Regular dental care in Alaska, for example, has reached an estimated 40,000 Alaska Native people in 80 previously unserved areas.

“Dentists at for-profit and nonprofit practices report providing greater volumes of Medicaid patients with faster, more satisfying care, due to employing dental therapists,” Hamilton said. “Dental therapists perform many services only dentists provide in most states, for 50 to 60 percent of the average hourly wage as dentists.”

Other benefits to on-boarding a dental therapist include the ability to extend office hours, take treatment to patients — such as nursing homes and schools — while allowing dentists to focus on more complicated procedures.

Despite the reported benefits, dental therapy still has strong opposition from the powerful American Dental Association and its state affiliates, which consistently deny the existence of any dental shortage.

A recent op-ed by Dr. Gary Jones, a Mesa, Ariz., dentist and past president of the Arizona Dental Association, says Arizona has 15 percent more dentists now than it did 10 years ago, making the access problem a matter of distribution rather than numbers.

“And we already have more dentists per capita than the projected national average by 2035. Adding another layer of health providers, with all the new costs that entails, would not solve access issues,” Jones wrote.

Angelone questions Jones’ claims of “new costs,” adding that dental therapists come with lower risk, and thus lower malpractice insurance rates.

“On average, medical malpractice insurance in Minnesota for an office who brings in a dental therapist is only an additional $100 per year,” she said. “That’s such a low amount it is basically a paperwork fee.”

The other primary dentist group criticism is quality of care.

“These dental therapists, with only three years of post-high-school education, could perform irreversible surgical procedures such as cutting and removing teeth,” said Jones. (Education and training typically take three years for dental therapists, compared to four years for dentists.)

Angelone counters that dental therapy has been practiced in more than 50 countries around the world since the 1920s, and more than 1,100 studies on quality have found no compromise to care. Nor have there been any legal complaints or liability claims made against a dental therapist since they began practicing in Alaska in 2004, and Minnesota in 2011. In addition, a study by the Minnesota Departments of Health and Dentistry found high patient satisfaction.

“I don’t know what happens in that last year of dental school, but it must be something quite extraordinary,” she said.

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The Goldwater Institute, an Arizona-based free-market think tank is part of a broad coalition of support for dental therapy. Goldwater’s Director of Healthcare Policy, Naomi Lopez Bauman, says Arizona has already expanded the scope of several other practice areas — and continues to do so — with many benefits, despite opposition at the time of the changes.

“Dentistry has been left behind in a decades-old model that is in desperate need of an update,” she said.

Jones, a self-described “lifelong Republican who believes in free-market solutions, wrote that dental therapy does not qualify as such a solution because it needs “extensive government subsidies.”

Bauman dismisses that claim, telling that Arizona’s is the most free-market proposal to date, with the fewest restrictions on dental therapy practice locations of any state that has considered the model.

“Arizona, because of its rural and remote areas, would greatly benefit from this free-enterprise solution to its dental access crisis,” she added. “We recognize that health care is a politically charged issue in the current political environment. But it doesn’t have to be.”

Among Jones’ solutions are greater use of teledentistry and a new class of workers called “community dental health coordinators,” who would help connect people with dentists and hygienists and, among other things, make sure they show up for appointments. Another of Jones’ proposals doesn’t exactly fit his stated opposition to “extensive government subsidies,” notes Hamilton. Jones wants a Medicaid expansion to pay for adult dental care.

Hamilton also points out that dental therapy in no way limits lawmakers or dentists from pursuing any of those solutions simultaneously.

“Dentists worried the dental therapy model won’t work for them would remain free not to hire therapists,” he said. “Enterprising dentists could do so. Liberty isn’t as bad as some make it sound.”