Extreme Dentist Shortage Leads To 'Dental Therapists' Filling Cavities

The vacant Walmart in Kansas City, Kan., opened its doors at 8 p.m. By 5:30 in the morning, there were 1,200 men, women, and children inside. Organizers had to close the parking lot. The 165 volunteer dentists could only fix up so many mouths.

The Kansas Dental Charitable Foundation held its 11th free clinic in February, known as the Kansas Mission of Mercy. In two days, volunteers treated over 2,000 patients, bringing the total that the clinic has helped over the past decade to more than 20,000.

"It feels really good," said Lisa Gonzales, a dentist who co-chaired the event, as she choked back tears. "But I'm still hung up on all the ones they turned away."

Kansas suffers from an extreme dentist shortage, mostly in its rural stretches. Twelve counties in the western part of the state, and three in the east, have no dentists at all.

The problem isn't limited to Kansas. Consider this:

And it's having a devastating effect on our oral health. According to figures from the Centers of Disease Control and Prevention, in 2003 and 2004 -- the latest years with data available -- 27 percent of children and 29 percent of adults had cavities going untreated, reported The New York Times. It's the highest level since the late 1980s.

"Dental students are graduating with tremendous student debt," explains Jim Towle, the executive director of the Alaska Dental Society. "You have to be able to work someplace where you're generating sufficient income. A dentist can't make a living in a village of 200 people."

The average debt of graduating dental students in 2011 was $181,000, according to a survey by the American Dental Education Association. One in five owed over $250,000.

The dental shortage is part of a larger and growing health divide between rural and urban America, as a result of income, insurance and access. In 1989, there were six more deaths per 100,000 people in rural areas than metro areas. In 2005, there were 82 more deaths.

A Controversial Solution: Dental Therapists

To solve the problem, a handful of states are toying with a radical idea. If you can't get dentists to move to these areas, the logic goes, get non-dentists to move there, and let them do the dentists' work.

Lawmakers in Kansas, New Mexico, and Vermont are currently debating proposals to create an entirely new kind of dental provider -- a "dental therapist" or "registered dental practitioner" -- who stands somewhere between dentist and dental hygienist. The new providers would be allowed to perform simple procedures, like filling cavities and extracting children's primary teeth.

In 2009, Minnesota became the first state to pass such a law. And in 2010, the W.K. Kellogg Foundation, created by the pioneer of morning sugar bombs, pledged to pour more than $16 million into its Dental Therapist Project, to encourage states to adopt the model.

Most public health workers are thrilled by these projects, which bring dental care to communities in desperate need. There's just one problem: Dentists hate them.

On the issue of "non-dentists performing dental surgery," the president of the American Dental Association said in a statement, "we stand firmly against it."

Organized Dentistry Fights Back

Alaska invented the in-between dentist back in 2004. Hard-to-reach villages have long lacked access to dental care. So the Alaska Native Tribal Health Consortium set up a program to send "dental therapists" to the hinterlands. To qualify, therapists need to take a two-year course in New Zealand and receive 400 hours of education in the U.S. It's significantly less training than the four years of dental school that fully-fledged dentists have to go through, on top of a bachelor's degree.

The American Dental Association and Alaska's state dental society filed a lawsuit to block the program, but dropped it back in 2007. According to Towle, the scheme hasn't had proper oversight, and there's been no assessment of whether it's working.

Last week, the W.K. Kellogg Foundation released a report that reviewed more than 1,100 evaluations of dental therapists in 54 countries, including the U.S., and found that there was no evidence that dental therapists provided substandard care.

It's also difficult to criticize the program, Towle said, because it services native populations. "We've had people who have been branded as racist because they've questioned certain parts of it," he says.

That includes Dave Eichler, a North Pole dentist, who in 2006 claimed that the dental health aid program relieved natives of personal responsibility over their widespread tooth decay. "Any culture that allows such disease will soon disappear and rightfully so," he said.

According to Mike Flynn, the Minnesota Dental Association's president-elect, who works as a dentist in an undeserved area, the problem isn't a shortage of dentists at all. Rather, the state government doesn't provide enough funding, so dentists can't afford to serve everyone who can't pay.

"It doesn't meet our overhead," he says. "I had to lay off a hygienist and two assistants."

More Independence For Dental Hygienists

Instead of introducing a whole new dental position, Maine and Colorado have tackled the access problem by licensing dental hygienists to practice without the supervision of a dentist. The Maine Dental Association didn't oppose the bill, because it was the "least-worst option," according to John Bastey, the association's director of governmental affairs.

But 81 percent of dentists oppose granting dental hygienists more independence, according to a 2007 poll by The Wealthy Dentist blog. If you break the results down by geography, however, the difference is stark. Fifty-eight percent of rural dentists supported the idea, compared to just 12 percent of urban dentists.

This may come down to differences in the perception of America's dental shortage. Another poll by The Wealthy Dentist, in 2009, found that three out of four dentists considered their areas "overserved," with too many dentists graduating each year and flooding an already saturated market.

"If I were younger I would open up in a rural area," said one dentist. "Competition in NYC is tough."

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There is no shortage of dentists in Kansas. I am a young dentist who graduated top of my class a few years ago, and hasn't had a job for 3 months now. I have sent many applications, and letters to older dentists without any luck. I know of several other dentists in Kansas looking for a job as we speak, and I am considering applying for jobs as a hygienist so I can pay my student loans.

May 19 2013 at 3:56 AM Report abuse rate up rate down Reply

This is stupid and a poorly thought idea. I would train Dental Hygienist or Dental Assistant, both with a number of years of experience, but not someone fresh out of High School. Ive seen people fall into cardiac arrest in the chair, and your gonna have a 18 year old who doesnt even know the difference between a central incisor and premolar administering Anesthesia. Next theyll have 3rd graders doing open heart surgeries and writing prescriptions. What are we living in a third world country?!?

July 24 2012 at 5:07 AM Report abuse rate up rate down Reply
Theodora Kimmel

I will just say, on the matter of traveling from rural places in Kansas to get to dental health care, as provided by the example from Bodoking, not everyone knows the importance of dental care, nor does everyone have access to transportation (a huge issue in this country, and i must say I believe a lot of our problems stem from a lack of affordable, easily accessible from anywhere, forms of transportation, something the government would need to fund only a little but, but a process which would product so many jobs and so many interested investors). You can't assume that because your brother knew about the importance of his teeth that everyone does; just recently was it even pronounced that good dental care is good for your heart! Before then, removing plaque build up and filling cavities were for the sake of the teeth. Plus, dental care isn't perfect to begin with (just now are they admitting that mercury fillings aren't safe) so it seems dental care does need a major overhaul of some kind. Instead of pointing fingers at those "bad rural folks in Kansas" or the government awkwardly pouring money here and there at any "emergency" or true emergency situation, let's take a look at the facts. If a Nurse Practioner can practice just as a Doctor can without the guidance of a Doctor, why can't it be the same in Dentistry? Then MAJOR issues, like surgery, root canals, crowns, can be left to, Dentists, the way surgeries and the like are left to Doctors in other parts of the medical world. Sure, it saves insurance companies money, but so for the people too! And then, Dentists can remain in the more urban areas and pay off their huge med school bills by not only serving larger populations, but simply by performing the more expensive procedures as well. Expertise gets spread out and everyone gets access by allowing Dental Therapists and Dental Hygenists to do this basic work and provide basic care, and everyone gets taken care of, and can afford to do it, on their own.

July 09 2012 at 10:08 AM Report abuse rate up rate down Reply

Because of the amount of money that it takes to be trained as a dentist, dentists do not go to rural areas. If they set up practice there, they'd go bankrupt.

The insurance companies like the idea of having nondentists doing "dental thearpy." It saves them lots of money.

this is just another "transfer the wealth" scheme. When the government decided that the per capita supply of dentists was too low, and stepped up the process of educating them, it failed to notice that everyone who coulld actually afford a dentist already had one.

Basically, the politicians idea that everyone is entitled to have health care whether they can pay for it or not is simply a demand for return to slavery. Perhaps the federal government can get the slave traders in Sudan to sell them some Christian dentists. That would be much simpler than reworking the Constitution to enable enslavement of American phsycians and dentists to provide the care that our very nearly bankrupt government has absolutely no money to pay for.

But, as bondoking points out, our government can always find money to buy gunboats for third world countries like Kenya, and to provide health care for the people of those countries. But even that money is borrowed by the trillion.

July 05 2012 at 9:07 PM Report abuse rate up rate down Reply

Many years ago my brother-in law and sister were in Peru for a year and he developed a problem tooth. They traveled 4 hrs each way to the city to have his tooth fixed because his teeth are important to him. I do not think the people of Kansas are lacking access to care.......it is just a matter of how much the individual cares about himself. If you choose to live in a place that does not have an Emergency Medical System like we have in Orlando and you die of a heart attack because you chose to live 100 miles from nowhere, who is to blame but yourself? It is all about personal responsibility. I have been a dentist for 43 yrs and have not had a cavity since dental school. It is not because I have better teeth than ayone else.......it is because I take care of them..........like EVERYONE should.

Another point worth making is that I have noticed how poor people can always manage to find money for beer, cigarettes, cell phones, cars , etc. We all can find the money and the time for what is important to US. If your teeth are not a priority to you, then they are not to me either.

April 17 2012 at 1:48 PM Report abuse +2 rate up rate down Reply

I remember the case that was made for independent hygiene practice. They would go to nursing homes, rural areas, and other underserved venues. It didn't happen. I guarentee these mid-level providers will set up shop in areas where they can make a living, just like everyone else. Do you really want a psuedo dentist performing these vital functions?

April 17 2012 at 1:42 PM Report abuse rate up rate down Reply

Type your comment here As a practicing Dentist in a Metro area for over 40 years I see several problems with Mid-level providers. The point of having another level of provider is to treat patients who do not have access to care. Most metro areas have an excess of providers...many of which see medicaid patients and those people we consider the working poor. Many of us see these people at a very reduced fee schedule or for no fee at all. In metro areas the problem is not a lack of providers but a lack of funding to pay for the treatment of the poor and medicaid patients. The problem is totally different in rural areas. Mid level providers could be of service in those areas. The problem is how do you "restrict or make" mid-level providers go to the underserved areas. Those states who currently have mid-level providers in training have not published any outcomes to confirm that the graduates go to underserved areas and help reduce the number of patients without care. Who will pay for the treatment of patients by mid-level providers. I assume they will graduate with student debt like all providers and need offices and staff to work in and with. If the treat only the poor or medicaid patients, how will they repay their student loans and pay their overhead and staff. Medicaid pays about 40% of our normal fees for dental procedures. The cost or overhead of a general dental practice ranges from 55% to 62%. This means for every medicaid patient we see we loose at least 15%. How will mid-level providers in underserved areas repay their loans if they only see lowe income patients? Most of us incorporate poor patients in our practices because we consider it our professional obligation to treat this segment of the population, other patients in the practice allows us to provide this treatment. If adequate funding were available to treat poor patients, most practices would treat more of them and infact establish offices in underserved areas to provide care. As with most problems in society it is funding problem. Everyone wants smaller government and reduced spending. Along with spending cuts are people who do not receive care. I agree with spending cuts but we also have to increase revenue from the wealthiest people in the country which yes includes Dentists, Physicians and most professionals. Lets not graduate or establish another level of provider until we know it works based on outcomes and funding is available to provide care. DLS, DDS

April 17 2012 at 11:40 AM Report abuse rate up rate down Reply

I think that there is a combination of factors that is causing this problem, namely the inflated cost of doing business, especially in the medical/dental field, along with rampant unenployment and a lack of medical insurance.

April 17 2012 at 11:12 AM Report abuse rate up rate down Reply

In the meantime, the dentist has gone to school and has a school debt that is the size of a mortgage, then he bought a practice with debt that is the size of a mortgage, has malpractice insurance and umbrella insurance that is the size of a mortgage and finally he has an actual mortgage for his family home. Do you suppose you could make 4 mortgage payments on the average American salary of $45,000 per year? If not, then shouldn't your salary be 4 times that average?

April 17 2012 at 10:42 AM Report abuse +1 rate up rate down Reply
1 reply to ragk2's comment
The Adams Family

That same dentist who is so in debt because of his school loans, insurance and overhead fees can afford a brand new BMW and a wife who spends huge amounts of money on the finest clothing and jewelry for herself and the baby's she will pop out promptly after marrying him so as to insure her future paycheck if he should divorce her in the future. I am so tired of hearing about the fees and overhead the poor poor dentist has to pay in order to make a measly living that he is somehow able to afford driving the finest vehicles and live in the nicest of homes and the trophy wife who would never give him a second glance if he wasn't rich. Health care is a business in this country and people should not profit off of another person's health. (and I am not talking about breast implants, liposuction, and botox).

July 04 2012 at 4:59 PM Report abuse -1 rate up rate down Reply
2 replies to The Adams Family's comment

You sound so very bitter....I bet you're one of those who left school before graduation and now envy those of us who went on to college and made something of ourselves..

July 05 2012 at 8:52 PM Report abuse +1 rate up rate down

"Health care is a business in this country and people should not profit off of another person's health"

Sounds like you need to move to England. Go try their socialized health care, including dentistry. They have some of the worst restorative care in the industrialized world. Dentists go to school to learn a craft, a trade, that has benefits to their patients and deserve to be paid for their expertise. Schools are not free or cheap either. So dentists and medical doctors go to graduate schools to learn and they should not profit in their work? And a heart surgeon would learn his craft and do it for gratis? Try getting your important medical work done in a social medicine setting....good luck. Oh, and make sure you tell your physician to put the new heart in with the correct side up.

July 05 2012 at 9:24 PM Report abuse +3 rate up rate down

Let's put this into perspective. If you smoke a pack a day you pay about $120 per month just to kill yourself or $1,450 per year. The same is true if you drink a cup of coffee a day from your local coffee house. Combine the two and that's $2,900 per year. You don't complain about that because you want it and want to do it. Dentistry on the otherhand, you don't want and feel you shouldn't have to pay for it at all. That's the bottomline.

April 17 2012 at 10:36 AM Report abuse rate up rate down Reply
1 reply to ragk2's comment
Marti M. Backus M.A.

I don't smoke, drink alcohol, or go out for coffee. I am an independently practicing Therapist. My teeth are gradually going to h3ll-- and I'd probably be better off with DENTURES! Even if I HAD that $2900 in my hand, it would pay for ONE root canal & crown of several I need. Nobody TALKS about our dental care, where it costs $3000 to get one tooth completely repaired! Close to $300 for a filling. My ins is 80/20, but taps out at $1000 a year, AFTER I've paid a $200 deductible (they really only pay $800). How DO people pay for basic shelter/sustanence AND Health & Dental Care? I am so glad that most of my clients are on Medicaid. At least they can go to the Doctor!!!

April 17 2012 at 5:04 PM Report abuse rate up rate down Reply
3 replies to Marti M. Backus M.A.'s comment

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