The Dentists Lobby Continues to Oppose Low-Cost Dental Care Option in Washington

This is what an oral health crisis looks like. Washington State Department of Health

On Thursday the Seattle Center Foundation will host its annual free health care clinic. As in 2018, over 3,500 people —mostly renters without health insurance—will show up to access medical care and dental services throughout the weekend. The line for admission at the Fischer Pavilion will begin at 5:00 a.m., but if it's anything like it was a couple years ago—and there's no reason to believe it won't be—people will start lining up much earlier than that.

A bill to establish the practice of dental therapy in Washington state aims to reduce the size of that line, and to address the broader oral health crisis facing the state. But a powerful dentist's lobby opposes the legislation, mostly because they'd rather have more money from the state to spawn more dentists. Which would be good! But that's no reason to put the kibosh on a proposal that would greatly improve much-needed access to dental care at no cost to taxpayers.

According to Washington's Department of Health, 37 of the state's 39 counties are short on dental health care professionals. For people living on low-incomes, this shortage leads to a lot of sad, largely preventable outcomes.

Washington's most recent Oral Health and Well-Being Survey shows that "44% of low-income adults were embarrassed or avoided smiling due to the condition of their oral health, 59% had difficulty biting or chewing, and 24% reduced participation in social activities due to the condition of their mouth and teeth." Over a quarter of respondents said the appearance of their teeth "affected their ability to interview for a job."

How Dental Therapists Can Help

Dental therapists are like nurses for your teeth. They are mid-level practitioners who go to school to learn how to clean teeth, fill cavities, extract loose molars, and perform basic dental duties. They are supervised by dentists, and they basically exist to handle a lot of routine work so that dentists can focus on more complicated cases. Since dentists tend to recruit therapists from places that face the severest shortages of care, e.g. most of rural Washington, including Indian Country, clinics can also build trust with communities who view itinerant practitioners as clumsy newbs looking to pay off their student loans.

The profession is somewhat new in the U.S., though New Zealand has been using them to great effect for about a hundred years.

The first dental therapists on this continent started practicing among Alaskan Native communities in the mid-oughts, but now 11 states have made space for the practice. Three years ago, Washington approved dental therapists to operate in tribal settings, and the state now has 8 therapists working at five clinics.

Three of those therapists work with Dr. Rachael Hogan, the dental director at the Swinomish Dental Clinic. Dr. Hogan cannot speak highly enough about the tangible and intangible ways these new dental care providers—two of whom are Swinomish tribal members—have improved the quality and kind of services she can offer at the clinic.

"We've increased prevention and outreach by 100%, and we've increased our crown and bridge work by 70%," she said in a phone interview. "It's fulfilling for the patients because we can get these major aesthetic treatments done, and it's really rewarding for the dentist because we get to work at the top of our scope."

In addition to streamlining work inside the clinic, Dr. Hogan sends her dental therapists out to daycare and head start programs weekly, which increases the clinic's visibility in the community. "Now all of those 0-5 year-olds are familiar with dental clinic faces," she said. "We can also connect more deeply with childcare providers. [The dental therapists] are out there singing songs in Lushootseed about brushing teeth and showing people how to do it properly—it's been amazing."

She says she's also been able to expand the clinic's elder outreach, connecting with medical teams to provide immunization and oral hygiene instruction in people's homes. "Sometimes it's as simple as cleaning their dentures for them, or handing out toothbrushes, which helps elders who maybe find it difficult to leave their house enough," she said.

This increased amount of time with the community isn't just nice and sweet. It leads to better health outcomes.

After completing his training in Alaska, Daniel Kennedy, an Alaska Native, started working for Dr. Hogan as a dental therapist in 2016. His first patient was a 4-year-old. "That little kiddo looked at Dan and immediately opened his mouth. It was as if he were looking at an uncle," Dr. Hogan said. "It was amazing how quickly he bonded with patients, which usually takes years. I've seen how it is when you bring in locum providers—itinerates. It takes a lot of time for people to build trust, and a lot of time that trust is never built."

Dr. Hogan is confident the success she's seeing in the Swinomish can scale all over the state. Dr. Miranda Davis, a dentist who oversees dental therapists in Oregon, agrees. At the clinics she supervises, she's seen wait times for appointments drop and patient satisfaction shoot through the roof. "I believe dental therapists would be beneficial to all communities," she said.

Dentists vs Dentists

To spread this benefit across Washington, lawmakers must pass HB 1317, which currently awaits a vote on the House floor.

However, though Rep. Eileen Cody has introduced the bill every year for nearly the last decade, some Democrats haven't taken up the cause, mostly due to opposition from the Washington State Dental Association (WSDA).

During testimony on the bill last year, Trent House, a lobbyist for the WSDA, rehearsed the arguments they've been using for a while now. Let's list them off.

Because dental therapists serve rural communities, House said, they see a lot of Medicaid patients. Since Medicaid patients "often present with the most medically complex conditions," dentists don't think dental therapists have the training necessary to care for those patients.

And despite what Dr. Hogan and Dr. Davis say, the WSDA doesn't think dental therapists will actually increase access to care in rural communities. During testimony, House pointed to Minnesota, where he says "only a fraction of dental therapists are working in rural communities." He also, weirdly, pointed to Canada, which closed down its last dental therapy school years ago.

Instead of going down the dental therapy path, Dr. Nadareh Naseri, a dental resident at Seattle Special Care Dentistry, proposed increasing the number of "dental residency programs and outreach programs affiliated with dental schools."

Both Hogan and Davis welcome more funding for dentists, but they say it doesn't have to come at the expense of authorizing dental therapy as a profession, which costs the state nothing.

Dr. Hogan also strikes a note of caution on the issue of solving the access issue with outreach programs that don't draw from workers who live in rural communities. "Right now there's a lot of money being spent to recruit dentists to work in rural areas," she said. "But the population's needs are really great, and the new dentist's skill set isn't there yet because of lack of experience. By the time they become good, they move onto private practice, which is a bummer. With dental therapists, for the most part, they're not interested in going on to dental school. They want to stay close to their community."

Several factors led to the collapse of dental therapy in Canada, according to a 2017 study in the International Journal for Equity in Health, but the biggest one was simply that the government stopped funding the few, small education programs it set up to train therapists. That's unlikely to be much of a risk here in Washington given the fact that the government isn't paying for anything here.

And while it's true that only 41% of Minnesota's 86 dental therapists work in rural areas, that number is way up from 2013, when 27% of the state's dental therapists were working in the country. The Minnesota Department of Health attributes the initial urban focus to the fact that "the Minneapolis/St. Paul metropolitan area were the early adopters of these new professionals." The agency encourages the state to "expand awareness and understanding of how dental therapists can be incorporated into rural practices," especially since they can do it so cheaply.

As for the argument that dental therapists can't handle "medically complex conditions" presented by Medicaid patients, the WSDA can rest easy in the knowledge that dental therapists don't handle those problems. They do outreach work, clean teeth, fill cavities, and all the other small stuff so that dentists—who, it's worth repeating, supervise dental therapists—can handle the "medically complex conditions" presented by Medicaid patients.

And though they just handle the small stuff, they handle it well. In 2018 the University of Washington published the first known study of the longterm effects of dental therapy. They found that more access to dental therapists meant better preventative care practices and fewer extractions.

During testimony, the co-author of the study, Dr. Donald Chi, said communities with the highest number of therapists saw 5% fewer children need their four front teeth extracted. Though 5% seems small, Chi said, in Washington this would correspond to about 15,000 fewer children requiring that procedure. "Ask any dentist, myself included, and they'll agree that these extractions are the hardest thing to do emotionally. When you think about the impact on young children and families—the ability to bite into an apple, and to smile with a full set of teeth—it's huge," he added. "Dental therapists can make a difference."