In February of 2007, 12-year-old Deamonte Driver of Maryland died from lack of dental care, the infection from one single rotting tooth having spread to his brain. His death could have been avoided easily by a simple tooth extraction.
Deamonte’s death is illustrative of the stark class and racial disparities that exist in access to dental care nationwide. Now, several bills making their way through the Massachusetts Legislature would create a new mid-level dental job, similar to a nurse practitioner, which advocates say will improve dental care for the state’s underserved populations. But what that position will look like is still a source of debate.
The job, referred to as a “dental therapist” or “public health dental practitioner,” would function as a position somewhere between a dental hygienist and a dentist, able to perform preventive care and some basic procedures.
Similar legislation has passed in states such as Maine, Vermont and Minnesota, and is meant to address that inequality.* A 2015 survey of Massachusetts residents found that one in five had an unmet dental care need that was directly linked to cost, and that low-income families were the least likely to have received any dental care.
Part of the reason for that disparity is that many dentists don’t accept payments from Medicaid, which typically offers lower reimbursements than private insurers. Only 35 percent of the state’s dentists treated a MassHealth patient in 2014, and only 26 percent billed the Medicaid program at least $10,000, according to The Kaiser Family Foundation.
Advocates for greater access to dental care say that a mid-level practitioner would address that imbalance by providing a qualified professional at lower cost to provide basic care to patients who typically don’t see a dentist. And in other states, analogous laws appear to be working.
In a report to the Minnesota Legislature in 2014, that state’s Department of Health and Board of Dentistry found that after dental therapists began practicing there in 2011, dental care was increasingly provided to underserved patients, emergency room use may have been reduced and both wait and travel times decreased for rural patients seeking dental care.
However, discussion over just how that practitioner would be allowed to operate in Massachusetts has spawned two competing bills.
Rep. Peter Kocot, D-Northampton, is co-sponsoring one piece of legislation that would create the new class of provider. The bill would also create a dental hygiene coordinator position in the state’s Department of Public Health, increase public education about the health benefits of fluoridated water and mandate oral health screenings for every child prior to entering kindergarten.
That bill was brought forward by the Massachusetts Dental Society, which lobbies on behalf of dentists. The society has previously opposed legislation that would create the new class of provider, and dental associations have traditionally squashed similar efforts nationwide for fear of competition from hygienists.
This year, however, the state society broke with the American Dental Association by supporting Kocot’s bill. Society President Ray Martin said other dental societies have likely opposed the creation of the new position because of financial concerns.
“They’re scared and they’re worried about potential competition,” Martin said.
But he insisted that isn’t the case with the bill the state society proposed to Kocot. “I’m not so worried about any economic impact if they go to underserved areas.”
Under Kocot’s proposed legislation, mid-level practitioners would exclusively be treating those underserved populations. The legislation includes a provision that dental therapists could only serve patients on MassHealth or at federally qualified community health centers.
Martin said those limitations are meant to keep dental therapists from migrating to large corporate clinics. The proposal also specifies that the practitioners would need at least two years of postgraduate education, would have to be supervised by an on-site certified dentist and couldn’t perform tooth extractions.
Proponents of another bill under consideration, however, say those restrictions are unnecessarily burdensome and would limit the position’s effectiveness at reducing inequity.
Sen. Harriette Chandler, D-Worcester, and Rep. William “Smitty” Pignatelli, D-Lenox, are two of the other bill’s sponsors, and their proposal — identical to a budget rider that passed the Senate last year before being pulled from the final budget bill — allows dental therapists to be supervised without a dentist having to be physically on site. The measure would also allow dental therapists to perform some nonsurgical tooth extractions, and leaves specifics about a dental therapist’s education up to the national Commission on Dental Accreditation.
Those provisions have led to pushback from the dental society, who said a dentist should be present for irreversible procedures, and that if the new position is going to be compared to a nurse practitioner, there should be a provision to require at least the same level of education.
“Erring on the side of competency and erring on the side of experience only helps that person that’s seeking out care,” Kocot said.
But Chandler and Pignatelli’s bill has the endorsement of a number of medical and advocacy organizations, including the Massachusetts Dental Hygienists’ Association, the Massachusetts Hospital Association, the Massachusetts Public Health Association and the state’s branch of the AARP.
Jeremy Crandall is an officer with the dental campaign at The Pew Charitable Trusts, which has been a driving force behind that bill. By allowing dental therapists to operate independently in places like schools or senior centers, they could eliminate a significant hurdle to dental-care access: transportation.
“The most important piece is that when they see a problem right there on site, they’re able to treat it right there on site,” Crandall said. “When you can treat disease right there on site, you can make such a difference in the lives of the patients you are seeing.”
“These mid-level therapists, they can go where they work under the authority of a dentist, but they can also go where the patient is,” Chandler said.
That “general” supervision by a dentist, as opposed to the “direct” physical supervision required in the bill the state dental society supports, would be essential to increasing the number of patients receiving dental care at places like the Community Health Center of Franklin County, the center’s CEO Ed Sayer said.
“We do a lot of dental work, there’s tremendous demand and the main limitation is that we don’t have enough qualified staff,” he said.
The organization has been searching for a dentist for a year, Sayer said, but the health center’s rural location has made finding one difficult.
Under Chandler and Pignatelli’s bill, however, a dental therapist could work independently at health centers by collaborating with a supervising dentist at another location.
Sayer also said that by insisting that dental therapists’ patients use MassHealth or be seen at federally qualified community health centers, the dental society’s bill leaves out the uninsured and those paying dental costs out of pocket.
Despite the differences between the two bills, all parties seem optimistic that a compromise version of the law will make it through the Legislature this year. Chandler and Pignatelli both praised the state’s dentists for putting forward a mid-level practitioner bill this year.
“It’s a recognition that there’s an access problem that we need to address,” Pignatelli said of the dentists’ proposal. “Let’s have the conversation.”
“Our biggest sticking point might be for the dentists to be willing to sit down with us,” Chandler said. Last year, she said, the dental society walked away from negotiations over her bill.
“This is the first step of the process to come up with a compromise bill,” Kocot said.
Public hearings would be held on the bills in the coming month, he said, after which the two sides would begin hammering out specifics. “I’m cautiously optimistic.”
*In Alaska, a dental therapist program was created only for those living on federal tribal land.
Dusty Christensen can be reached at dchristensen@gazettenet.com.