Author's Note: This post is part of a series examining America's oral health care crisis. Be sure to read the previous article, "Why a Trip to the Dentist Costs So Much Now -- And What We Can Do About It."
Lack of access to dental care has reached such crisis proportions in the United States that lawmakers in many states are finally taking action.
Maine last week became the most recent state to expand the dental workforce when Republican Gov. Paul LePage signed a bipartisan bill to permit "dental therapists" -- modeled after physician assistants and nurse practitioners -- to treat patients.
In addition to the escalating cost of dental care, a big reason why many Americans don't get the checkups and preventive care they need is the growing shortage of dentists in the United States. The Department of Health and Human Services last year reported that approximately 45 million Americans live in regions of the country that have a scarcity of dentists relative to the population. The problem is especially acute in rural areas and communities of color where few dentists practice.
If you live in a nice neighborhood and pass by many dentist offices every day on your way to work, chances are you're unaware that a problem even exists. But talk with someone who has no access to a car or public transportation and can't get to the nearest dentist miles away. Or someone in a poor neighborhood of your city who walks past any number of dentist offices on a daily basis but can't find one who treats Medicaid patients. It's like being in the ocean but knowing you can't drink the water.
While there is a distribution issue caused by the preference of dentists to practice in more well-to-do parts of cities and suburbs, we also have far fewer dentists per capita than we used to have. We need 6,000 new dentists to eliminate the shortage, according to the government.
There's little chance we'll get them, however, at least anytime soon. A big part of the problem is the fact that fewer students are graduating from dental schools now than 30 years ago when the U.S. had 90 million fewer people. In 1980, according to the American Dental Association, the U.S. produced 6,300 dentists. By 1990, after the closure of several dental schools, only 4,000 students graduated.
In a nation with changing demographics, what is also clear is the lack of diversity in the dental profession. Only 5.5 percent of dental school graduates in 2010 were African American, according to the American Dental Education Association. Just 6.1 percent were Hispanic and only 0.68 percent were Native American.
Although a few new schools have opened in recent years and more students are graduating than in 1990, increasing numbers of older dentists are now retiring -- so many, in fact, there might not be enough new graduates to replace older dentists who are closing or selling their practices. The American Association of Dental Schools predicted recently that the number of practicing dentists in the United States will actually start to decline this year as the rate of retirement accelerates.
This affects every state, some more than others. Kansas, for example, has a dental shortage in 91 of its 105 counties. And in Maine, there is only one dentist for every 2,300 people, compared to the national average of one to 1,600, and as few as one for every 5,900 in some counties.
The Portland Press Herald reported last month that in Cumberland County, where Portland, the state's biggest city, is located, there are 76 dentists for every 100,000 people, while in rural Somerset County there are only 17 dentists for every 100,000.
To draw the attention of the public and lawmakers to the crisis in the state and the critical need for more dental providers, editorial writers at the Bangor Daily News began the newspaper's lead editorial on April 3, 2011, with these unsettling words: "People are pulling their own teeth, not in some distant Third World country but right here in Maine."
Citing a 2010 study, the newspaper went on to note that the top reason young adults go to the emergency room was dental problems, which it called "a waste of limited medical resources and money."
When that editorial appeared in Bangor, Maine's lawmakers had just launched a study to determine both the extent of the crisis and how to begin to address it. One of the outcomes was the bill Gov. LePage signed into law last week that will expand the dental workforce to include midlevel dental therapists.
Midlevels are not new to dentistry. They've have been treating patients in at least 50 other countries for many years, starting in New Zealand in the 1920s. In fact, the first dental therapists to practice in the U.S. -- and who have been caring for patients in Alaska for 10 years -- were trained at the University of Otago in New Zealand.
While their scope of practice is limited to routine services, including preventive care and education, dental exams, fluoride treatments, cleanings, fillings and simple extractions, dental therapists -- who work under the supervision of dentists -- actually receive more clinical training hours than dentists do on the services they provide.
Supporters of the new law in Maine say local colleges could start offering a two-year, 2,000-hour training curriculum in dental therapy as early as next year. Before they start practicing, they are considering how to change a provision added by opponents just before passage that would severely restrict access by requiring dental therapists in Maine to practice under the direct supervision of a dentist rather than under general supervision, which is common elsewhere, including in Alaska and, since 2009, in Minnesota.
The legislation in Maine was supported by both Democrats and Republicans, as it has been in other states, and advocates for expanding the workforce to include dental therapists span the ideological spectrum. In Kansas, for example, the coalition of organizations supporting the effort to license dental therapists ranges from the Black Health Care Coalition of Kansas City to the Kansas chapter of the conservative Americans for Prosperity. A growing number of dentists are also supportive.
Despite this broad support, however the U.S. continues to lag behind much of the rest of the world in providing better access to dental professionals for one reason -- opposition by organized dentistry. More about that in the next Hidden Epidemic column.