A recent article in the Jamaica Plain News regarding oral health care for underserved populations (“Councilor O’Malley Supports State Bills to Improve Oral Health Care for Those in Need,” August 3, 2017) raises an important question: Why don’t underserved populations in urban communities like Jamaica Plain and rural areas like Western Massachusetts receive preventive and restorative dental treatment that would improve their overall health?
A substantial volume of research tells us that dental care for low-income and elderly populations is disproportionately influenced by poverty, geography, lower levels of oral health education, language or cultural barriers, and even fear of dental care.
That’s why the Massachusetts Dental Society (MDS) has a bill pending before the legislature that not only seeks to make dental care more accessible and affordable, it also offers the comprehensive approach that Massachusetts needs if it wants to successfully provide basic dental care to its neediest citizens.
The MDS bill introduces a new mid-level oral health care provider to increase access to care. It also includes several measures to promote routine preventive care, increase awareness about the scientifically-proven benefits of community water fluoridation, and help people connect with caregivers in their local communities. The legislation would require a new staff position at the Department of Public Health to oversee coordination of routine preventive care, including guidance for people who have difficulty scheduling and keeping dental appointments. It will also require oral health screenings of every child prior to kindergarten.
Unfortunately, the legislation supported by Councilor O’Malley and the Boston City Council only seeks to create a new mid-level dental provider license that will not, by itself, solve the problem of oral health care for underserved populations. In fact, the recent creation of a Public Health Dental Hygienist (PHDH) license in 2009 made no difference in addressing a well-known public health crisis. The goal behind the PHDH initiative was increased access for routine preventive care, especially for children in communities like Jamaica Plain. At the time, a survey touted by supporters of the new certification claimed 30 percent of licensed hygienists in the state—more than 2,000 providers—were likely to become PHDHs by 2016.
As of 2014, just 33 PHDHs were licensed to provide services in Massachusetts.
Moreover, despite claims by The Pew Charitable Trusts and other advocates that mid-level dental providers significantly reduce the “access gap” for underserved populations, there is no peer-reviewed evidence that mid-level providers substantially increase access to care. The one operational mid-level program in Minnesota has raised serious questions about its effectiveness. Minnesota, which introduced mid-level dental therapists in 2009, is instructive. Today, approximately 60 people are licensed to practice. Officials expected to produce savings as a result of the mid-level program, but Minnesota’s program has yet to deliver: the state continues to report a high rate of Medicaid patients who seek dental care in the emergency room. Researchers at the Mayo Clinic in Rochester, Minnesota and at St. Louis University independently reviewed a recent Minnesota study that claimed significant benefits associated with mid-level dental providers. Both analyses found fundamental flaws in the study, including overestimated employment rates for mid-level providers due to double or triple-counting of therapists.
Unfortunately, the introduction of mid-level dental providers cannot reduce the cost of dental care for underserved populations. Medicaid reimbursement rates are exactly the same for dentists and dental therapists.
It’s also important to note that the legislation supported by Councilor O’Malley and the Boston City Council does not provide thorough safeguards for public safety because it would allow mid-level therapists—including those with as little as three years of post-high school education— to perform irreversible procedures such as drilling and extraction of teeth. A recent statewide survey of registered Massachusetts voters conducted by the MassInc Polling Group revealed that 73 percent of respondents did not feel comfortable allowing mid-level dental practitioners to perform irreversible procedures without direct supervision from a dentist.
The survey results confirmed what dentists in Massachusetts have heard directly from patients—future mid-level dental professionals must be directly supervised when performing irreversible procedures. There is a substantial volume of Massachusetts residents with complex oral health care needs, particularly underserved populations, so direct supervision by a licensed dentist is extremely important.
To effectively treat this patient population, it is essential that mid-level dental practitioners have the highest possible level of education, training and supervision. The MDS bill would ensure appropriate treatment by requiring mid-level dental professionals to attain the exact same credentialing standards for licensure requirements set forth for physician assistants and nurse practitioners. The MDS legislation also seeks to ensure that newly licensed mid-level practitioners treat underserved populations by requiring that they only work in areas of the state that are officially designated as dental practice shortage areas or in federally qualified health centers.
The MDS firmly believes that Massachusetts has a real opportunity to address a longstanding oral health care problem. But this can only happen by broadening the focus from an unproven mid-level provider “solution” to a wide-ranging law that addresses the root causes of dental care gaps in the Commonwealth.
Dr. David Lustbader is the president of the Massachusetts Dental Society.