Complications from poor oral health can range from tooth decay and gum disease to pneumonia, cardiovascular disease, and birth complications.[1] Studies show that gum disease may also have a psychosocial impact on individuals due to loss of confidence and ability to socialize which contributes to developing anxiety and depression.[2] Despite the central role oral hygiene plays in overall quality of life, in 2017 almost 65 million people in the United States, or more than one in five people, lived in dental deserts.[3]

 

What is a Dental Desert?

A dental desert is a health professional shortage area where individuals do not have access to dental care.[4] To be recognized as a dental desert, the ratio of people to dentists must  be 5,000 to one or worse.[5] Even though there is not a nationwide shortage of dentists, many dentists often establish practices in prosperous urban and suburban areas rather than rural areas and low-income neighborhoods.[6] The lack of access to dental care requires millions to miss school and work to travel to the nearest dentist,[7] even if they can afford to pay for dental care.

 

What About Medicaid?

Medicaid does little in terms of helping those living in dental deserts. Although Medicaid covers dental services for child enrollees, it is up to each individual state to determine what dental benefits, if any, are provided to adults.[8] There is no minimum requirement for dental care coverage for adults under Medicaid.[9] As of January 2021, there are three states that provide no dental care coverage for adults, nine states only cover dental emergencies such as treatment for infections, thirty-two states provide restorative services such as fillings, crowns, and root canals, thirty-two states provide preventative services like cleanings and fluoride application, and thirty-one states cover cleaning below the gumline.[10] Unfortunately,  only 75,000 or 38 percent of the 200,000 licensed dentists in the United States accept Medicaid.[11] Because of this limited coverage, many United States residents living in formally recognized dental deserts may have to travel even further to find a Medicaid-covered dentist. There are likely many more low-income individuals in unofficial dental desserts because dentists near them will not accept Medicaid.

 

Dental Therapists

One solution to eliminating dental deserts is to rely more heavily upon dental therapists for more routine oral care. This is because dental therapists are able perform preventative and restorative care at a lower cost than a dentist.

Part of this reduced cost comes from lower educational costs. To become a dentist in the United States, an individual must earn a bachelor’s degree, take a dental admissions test, attend a four-year dental school, and then pass dental licensure exams.[12] Dental therapists also go through rigorous and thorough training, but for only two to three years following high school, which lowers their cost of education.[13] With this education,[14] dental therapists can perform preventative and restorative care like cleanings, fillings, and extractions as a member of a dentist-led team.[15] While dental therapists are required to be part of a dentist-led team, most do not have to work in the same physical office as their supervisor and can travel to communities in dental deserts—increasing access to care .[16] Dental therapists earn lower salaries when compared with dentists, lowering costs to patients.[17]

Data from several states shows that the dental therapists can help provide efficient preventative and restorative dental care. Currently, dental therapy is authorized in some capacity by thirteen states with four of those states authorizing dental therapists to practice on tribal land.[18]

A Minnesota state evaluation found that clinics saved $35,000 to $50,000 of annual savings for each dental therapist hired when compared to the cost of employing a dentist.[19] Furthermore, in Alaska it was found that dental therapists brought in $127,000 on average in net collected revenues after subtracting the costs of employment.[20] Dental therapists not only provide more cost-effective dental care, but also more culturally competent care because they are more culturally diverse and serve the communities they are from.[21]

Alaska Native tribes were the first group in the United States to consider using dental therapists to increase access to dental care.[22] Prior to 2003, Alaska Natives across 200 villages had to transport their members by boat or air for basic dental procedures and accrued high expenses for Medicaid.[23] In response to a tooth decay epidemic, the Alaska Native Tribal Health Consortium began training dental therapists in 2003.[24] Tribal leaders invested in training local community members to do basic procedures rather than paying more to bring dentists to their communities.[25] A study published in 2018 found that the presence of dental therapists in Alaska Native communities resulted in the provision of more preventative care (defined as exams, cleaning,  fluoride, or cleaning and fluoride) and less tooth removal.[26] Following the study, the researchers recommended implementing more state-level policies which rely on dental therapists as part of an extensive plan to “meet the dental care needs of underserved communities and help achieve health equity and social justice.”[27]

During the 2021 legislative session, nine states were considering dental therapy legislation.[28] State legislators in Florida have been proposing dental therapy bills since 2018 without success.[29] Advocates for passing a dental therapist bill in Florida emphasize the success of the practice in other states, including Minnesota.[30] The Minnesota Legislature authorized the licensing of dental therapists in 2009.[31] Although dental therapists in Minnesota only account for one percent of the dental workforce,[32] a 2016 study by the University of Minnesota found that ninety percent of uninsured patients or patients on public assistance who received medical care at a dentist’s office were seen by dental therapists.[33]  Another study by the Minnesota Department of Health showed a third of all dental therapist patients saw a reduction in wait times for appointments—they also saw a reduction in the travel time it took them to get to their appointment.[34]

States can reduce the prevalence of dental deserts both by expanding Medicaid to include coverage for restorative and periodontal treatments and by licensing more dental therapists.  Dental therapy is not a replacement for states providing more Medicaid coverage for dental care; both are solutions to dental deserts that can co-exist to improve health outcomes for low-income individuals, especially those in rural areas.

 

[1] Mayo Clinic Staff, Oral health: A window to your overall health, Mayo Clinic (Oct. 28, 2021), https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475.

[2] Dawit T. Zemedikun et al., Burden of chronic diseases associated with periodontal diseases: a retrospective cohort study using UK primary care data, 11 BMJ Open 1, 1 (2011), https://bmjopen.bmj.com/content/bmjopen/11/12/e048296.full.pdf.

[3] Wendell Potter, 63 Million in U.S. Now Living in “Dental Deserts,” Twice as Many as in 2000, As Dentists Shun Rural Areas and Low-Income Communities, Medium (Oct. 31, 2018), https://medium.com/@wenpotter/63-million-in-u-s-4176d3698a8b.

[4] Sarah Childress, Do You Live in a “Dental Desert”? Check Our Map, PBS (June 26, 2012), https://www.pbs.org/wgbh/frontline/article/do-you-live-in-a-dental-desert-check-our-map/.

[5] Dental Care Health Professional Shortage Areas (HPSAs), Kaiser Fam. Found. (current through Sept. 30, 2021), https://www.kff.org/other/state-indicator/dental-care-health-professional-shortage-areas-hpsas/.

[6] Potter, supra note 3.

[7] Wendell Potter, ‘Dental deserts’ a problem in rural America, Kearney Hub (Mar. 24, 2018) https://kearneyhub.com/lifestyles/dental-deserts-a-problem-in-rural-america/article_c0d631a8-2f16-11e8-a828-0be2df026d8e.html (last updated July 24, 2019).

[8] Dental Care, Medicaid.gov, https://www.medicaid.gov/medicaid/benefits/dental-care/index.html (last visited Jan. 19, 2023).

[9] Id.

[10] Medicaid Coverage of Adult Dental Services, MACPAC (Jan. 2021), https://www.macpac.gov/wp-content/uploads/2021/01/Medicaid-Coverage-of-Adult-Dental-Services.pdf.

[11] Maria Bucci, A Lack of Awareness Impacts the Care of Medicaid Dental Patients, Dentistry Today (Jan. 27, 2020), https://www.dentistrytoday.com/a-lack-of-awareness-impacts-the-care-of-medicaid-dental-patients/.

[12] Dentist Requirements: What it Takes to Become a Dentist, Colgate, https://www.colgate.com/en-us/oral-health/dental-visits/dentist-requirements-what-it-takes-to-become-a-dentist (last visited Jan. 13, 2022).

[13] Wendell Potter, States developing solutions to ‘dental deserts’ problem, Medium (Mar. 23, 2018), https://medium.com/@wenpotter/states-developing-solutions-to-dental-deserts-problem-5dc2506db504; Dental therapists offer a low-cost alternative to dentists, UPI (Mar. 24, 2022), https://www.upi.com/Health_News/2022/03/24/dental-therapist/2251648144502/

[14] Id.

[15]  Colgate, supra note 13.

[16] Potter, supra note 15.

[17] Jane Koppelman and Rebecca Singer-Cohen, A Workforce Strategy for Reducing Oral Health Disparities: Dental Therapists, 107 Am. J Pub. Health 513, 516 (2017).

[18] Ann Lynch, Update on Dental Therapy in the United States, Dimensions of Dental Hygiene (Nov. 25, 2020), https://dimensionsofdentalhygiene.com/update-dental-therapy-united-states/.

[19] Koppelman, supra note 17, at 515.

[20] Id.

[21] UPI, supra note 13.

[22] Matt Parke, Service with a smile: Alaska’s solution for America’s dental care crisis, WorkingNation (May 15, 2020), https://workingnation.com/dental-health-aide-therapist-alaskas-solution-health-crisis/.

[23] Id.

[24] Id. The Alaska Native Tribal Health Consortium trained these dental therapists by sending them to the University of Otago in New Zealand to complete their dental therapist education in two years.

[25] Tera Bianchi, Let Dental Therapists Serve All Communities Statewide, Seattle Times (May 7, 2021), https://www.seattletimes.com/opinion/let-dental-therapists-serve-all-communities-statewide/.

[26] Donald L. Chi et al., Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta, 78(2) J Public Health Dentistry 175, 175 (Mar. 2018), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6019600/.

[27] Id.

[28] Lynch, supra note 18.

[29] S.B. 1498, 2018 Leg. (Fla. 2018); S.B. 684, 2019 Leg. (Fla. 2019); S.B. 152, 2020 Leg. (Fla. 2020); S.B. 604, 2021 Leg. (Fla. 2021).

[30] Kelly Hayes, “I Want People To Know There’s A Solution”: A Fight To Provide Rural Dental Care, NPR (Oct. 1, 2019), https://www.wuft.org/news/2019/10/01/i-want-people-to-know-theres-a-solution-a-fight-to-provide-dental-care/.

[31] Expanding Access to Care Through Dental Therapy, Am. Dental Hygienists Ass’n, https://www.adha.org/resources-docs/Expanding_Access_to_Dental_Therapy.pdf (last visited Jan. 13, 2022).

[32] Stephanie Dickrell, 6 years in, dental therapist experiment is working, experts say, SC Times (Apr. 9, 2017), https://www.sctimes.com/story/life/wellness/2017/04/09/6-years-dental-therapist-experiment-working-experts-say/97958494/

[33] Christine M. Blue & Mary Beth Kaylor, Dental Therapy Practice Patterns in Minnesota: A Baseline Study, 44(5), Cmty. Dental Oral Epidemiology, 458, 458 (Apr. 25, 2016), https://pubmed.ncbi.nlm.nih.gov/27112771/.

[34] Minnesota Department of Health & Minnesota Board of Dentistry, Early Impacts on Dental Therapists in Minnesota, Minn. Gov’t (Feb. 2014), https://mn.gov/boards/assets/2014DentalTherapistReport_tcm21-45970_tcm21-313376.pdf.