I’m seeing my dentist tomorrow for a cleaning. I go two or three times a year. Last year I even wrote about going to Costa Rica for a dental visit to have an implant finished. While I was there, I had some aging veneers that were deteriorating replaced with crowns. I see my dentist far more than I see my primary care physician. Whereas I can have lab tests performed even if I don’t see my physician, the same is not true of dental visits. Dental visits are hands-on. There are no substitutes for dental examinations or dental hygienist cleanings. Yet, many people neglect dental care due to the cost, often made less convenient by a lack of dentists in their immediate area. Kaiser Health News and the Tampa Bay Times ran a story about so-called dental deserts:
Annual dental checks are essential to overall health. But of the 67 counties in Florida, experts say, only one has enough dentists to treat all patients. Nine counties in Florida have fewer than three practicing dentists apiece. Lafayette County, in north Florida, doesn’t have a single one.
About 6 million Floridians live in dental deserts, according to data from the U.S. Department of Health and Human Services. That’s the largest state population living without basic dental care in the U.S.
The consequences can be catastrophic, as people try to navigate a health system with few providers willing to serve them and costs that make services unattainable.
Dental deserts are not just isolated to Florida. Dental deserts are common across the United States. Approximately 70 million Americans live in dental deserts. Rural areas and intercity areas far removed from where affluent residents live are the hardest hit. The cause of dental deserts, at least according to public health advocates, are twofold: High student loans for dental education and low Medicaid reimbursements for dentists willing to treat Medicaid patients.
Nearly 8 in 10 Florida dentists reported they did not accept Medicaid patients, according to the most recent workforce survey from the state Department of Health. More than 70% of respondents cited low Medicaid reimbursement rates as the main reason why.
The average dental student graduates with about $300,000 in student debt, according to the American Dental Education Association. Even if dental school was free most newly minted dentists would still gravitate to better paying jobs in suburban areas. Private dental practices would still cater to cash-pay or privately insured patients rather than Medicaid enrollees. High student debt may be the catalyst that forces new graduates to seek more lucrative positions, but most would migrate to better-paying areas anyway. The earnings to pay off student debt are fungible. Once the debt is paid, the earnings can then be used to pay off a big house, nice cars, vacations, etc. Furthermore, dental deserts aren’t necessarily about a shortage of dentists, many just don’t want to work in areas with lower incomes. According to the Tampa Bay Times:
Enrollment has been ticking up nationally, with more than 26,000 students in school last year. That’s about a tenth the number of working dentists in the U.S., according to the American Dental Association.
But the majority of those graduates aren’t practicing in underserved communities and don’t accept uninsured patients or those enrolled in federal health insurance plans.
Here is the deal. Just like physicians, most dentists don’t want to work in areas with fewer amenities far from metropolitan cities. Many also don’t want to live and work in intercity areas with a greater proportion of enrollees in bureaucratic state Medicaid programs. One solution to the problem of underserved areas is dental therapists. According to the Georgetown Journal of Poverty Law & Policy:
One solution to eliminating dental deserts is to rely more heavily upon dental therapists for more routine oral care. This is because dental therapists are able perform preventative and restorative care at a lower cost than a dentist.
Part of this reduced cost comes from lower educational costs. To become a dentist in the United States, an individual must earn a bachelor’s degree, take a dental admissions test, attend a four-year dental school, and then pass dental licensure exams. Dental therapists also go through rigorous and thorough training, but for only two to three years following high school, which lowers their cost of education. With this education, dental therapists can perform preventative and restorative care like cleanings, fillings, and extractions as a member of a dentist-led team. While dental therapists are required to be part of a dentist-led team, most do not have to work in the same physical office as their supervisor and can travel to communities in dental deserts—increasing access to care.
Dental therapists are licensed in 13 states and several tribal nations. However, the impact of dental therapists will be determined by how aggressive states work to integrate them into the dental profession. Less than a handful of states (Alaska, Minnesota and Washington) have college programs to train dental therapists. Dental therapists who work in practices that accept Medicaid are associated with more dental visits and better dental care for low-income participants. However, neither should the services of dental therapists be limited to just poor people in underserved areas.