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:
- According to The Health Resources and Services Administration, there are 48.7 million Americans who live in areas with dental-care shortages.
- The non-profit advocacy group Oral Health America says there should be one dentist for every 1,500 people. Right now, there is one dentist per 2,000 Americans.
- The distribution is hugely uneven. In Washington, for example, there's one dentist per 948 people in one urban county, but one dentist per 12,300 people in a rural one.
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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Claire Gordon has contributed to Slate's DoubleX, the Huffington Post, and the book Prisons: Current Controversies. While an undergraduate at Yale University and a research fellow at Yale graduate school, she spoke on panels at Yale and Cornell, and reported from Cairo, Tokyo, and Berlin.
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