A strongly worded 5-page letter of rebuke was issued by American Academy of Pediatric Dentistry (AAPD) President, Amr M. Moursi, DDS, PhD to the Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) on August 11, 2022. (Click here to read the entire letter)
The AAPD found “dental therapists are an expensive, inefficient solution to the very real problem of oral health access. (US) Health Resources Services Administration’s (HRSA) focus should be on proven, evidenced-based, cost-effective solutions.” The AAPD’s findings are in direct response in opposition to the July 2022 report issued by HRSA, “Supporting Dental Therapy through Title VII Training Programs: A Meaningful Strategy for Implementing Equitable Oral Health Care.”
The AAPD was particularly disturbed that two of their highly credentialed nominees to the committee, Anupama Rao Tate, DMD, MPH, and Tegwyn H. Brickhouse, DDS, PhD, were disallowed from serving with ACTPCMD.
“HRSA’s delay in consideration and appointment of these two highly qualified and capable nominees is completely unacceptable. This inaction denied ACTPCMD the opportunity to consider differing viewpoints as to whether dental therapists are a solution to improving oral health access for children.”
ACTPCMD report generated five recommendations:
Recommendation 1 – The ACTPCMD recommends that Congress update the authorizing legislation for the Public Health Service Act Section 748(a)(1) to explicitly include dental therapy programs and trainees.
Recommendation 2 – The ACTPCMD recommends that Congress increase the funded appropriation for Title VII, Section 748 by $6 million annually to be utilized for dental therapy training programs.
Recommendation 3 – The ACTPCMD recommends that faculty of dental therapy training programs be eligible for the Dental Faculty Loan Repayment Program (DFLRP) authorized under Title VII, Section 748, of the Public Health Service Act and that the DFLRP receive a funding increase of $1 million to be set aside for faculty of Dental Therapy programs.
Recommendation 4 – The ACTPCMD recommends that the Secretary, HHS, include dental therapy as an eligible profession for scholarship and loan repayment through the National Health Service Corps (NHSC).
Recommendation 5 – The ACTPCMD recommends HRSA implement a longitudinal tracking mechanism for dental therapy trainees, faculty, and graduates, including data on trainee and faculty diversity, retention in the profession, educational debt load, graduate practice location, and populations served.
The AAPD firmly disagreed with these recommendations and offered detailed, cogent, and referenced arguments in opposition.
- The AAPD believes that oral health services to our nation’s highest-risk children should not be provided by non-dentists with less education and experience, especially when there is no evidence-based research to support the safety, efficiency, effectiveness, or sustainability of such an approach.
- Every child in our nation deserves the same high quality of oral health services delivered in the safest way possible. The most vulnerable children should not be treated by the least trained, and certainly not under the guise of promoting “equity.”
- There is no clinical or ethical justification for children with more severe oral health needs to receive lesser care.
- Dental therapists receive significantly less education and training than dentists. (General dentists attend four years of dental school after college; pediatric dentists spend an additional two or more years beyond dental school.)
- The knowledge to perform specific dental procedures does not mean that the providers have the ability to determine whether or when various procedures should be performed, or to safely manage the full range of a child’s oral healthcare.
- Although the few limited studies on the technical quality of procedures performed by dental therapists have found that the resulting work is comparable to that produced by dentists, there is no evidence to suggest that they deliver expertise comparable to a dentist in such fields as diagnosis, pathology, trauma care, pharmacology, and care of special needs patients.
- While nurse practitioners are not allowed to perform major irreversible surgeries, dental therapists with less training would be allowed to perform irreversible surgeries on child patients.
- Despite 14 states having some form of dental therapy on the books, Minnesota is the only state with any practicing dental therapists, with the exception of one in Maine (which has no training program). There is no data — none — that suggests that oral health outcomes, access to care, or cost of care improve in any place where dental therapists have practiced. That includes Minnesota, as well as prior tribal pilot programs in Oregon and Washington. Independent assessment of the data on the Minnesota dental therapy program found it has not yet been proven to be as effective as promised. Patient access to care was not meaningfully increased, nor did care become more affordable. Minnesotans continue to experience the same barriers to obtaining good oral health.
- Evidence from Canada and Minnesota shows dental therapists often do not locate in underserved areas. For example, about 3 out of 5 dental therapists licensed in Minnesota were working in the Twin Cities metro area as of April 2016. Only 8 dental therapists were located in the 70 percent of Minnesota’s counties fully or partially designated as Health Professional Shortage Areas.
- Dental Therapy programs are incredibly expensive to start, with little to show for it. Vermont has spent over $2.4 million since 2016 to start a program, including a $1.6 million federal grant, a $400,000 HRSA grant in 2018, and an additional $400,000 from the state. Not a single dental therapist is training or practicing in Vermont.
- Studies from other countries that purport to justify the dental therapist experiment overstate their conclusions and lack adequate data to substantiate them. For example, there has not been a reduction in caries in these countries.
- Although advocates argue that dental therapy model will reduce costs, dental services cost the same amount to the patient and the state no matter who performs them. For example, Minnesota Medicaid offers identical reimbursement rates for dentists and dental therapists. Essentially, dental therapy creates a new layer of bureaucracy without delivering any new service or savings to patients.
- There is no shortage of dentists in the United States and no shortage of care available for children. The number of pediatric and general dentists is growing faster than the child population and the demand for dental services, a trend expected to persist through 2040. It is not dentists that are lacking, but adequate reimbursements in Medicaid. Despite these challenges, over the past 20 years there has been a near doubling of the pediatric dentist workforce and a significant expansion in children dentally uninsured and receiving treatment under Medicaid and CHIP. It certainly can be improved, but dental therapists are not the answer.
- The best way to provide needed dental care to underserved children is through a Dental Home – the existing model of a dental team working together with the direct supervision (or physical presence) of a dentist.
- Children will be best served by protecting the financial support of dental Medicaid, which will encourage access to care through current providers already prepared to serve, and by expanding loan repayment assistance programs that have the proven result of placing dentists in designated Health Professional Shortage Areas.
Like in any high-stakes poker game, there are numbers of players with a seat at the table related to dental therapists.
In this particular match, few are willing to reveal all their cards. Motivations and agendas may be cryptic.
Not all play by the same rules. Some players are truly surrogates who represent clandestine interests, be those parties political or economic.
Specific terms are utilized like trump cards; “access-to-care,” “equity,” and “systemic racism.” These phrases have different meanings to each at the table, and little meaning or relevance to some, except as a tool to pry advantage.
Any attempt to deny a valid stakeholder a seat at the table of discussion, on improving dental Medicaid with or without dental therapists, will represent an affront to some. Others see it as reasonable treatment of a perceived adversary.
Still others now view the process with disgust, not worthy of reasoned professionals.
ABOUT THE AUTHOR
Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation. Davis also currently chairs the Santa Fe District Dental Society Peer Review Committee. He can be reached at MWDavisDDS@Comcast.net.