Does dental profession need something like a nurse practitioner?
They look so collegial, the dental hygienist who often finds the cavities and the dentist who always fills them. But on Beacon Hill, these professionals, who typically work side-by-side, drill-by-pick, find themselves pitted against each other in a high-stakes battle over better access and higher quality oral care for the poor.
Advocates for hygienists say that poor and disabled people, often minority children, struggle to find good dental care because of a shortage of dentists willing to serve them. The group is pushing for a new class of advanced hygienists, sort of nurse practitioners for the mouth, who could offer the kind of help that they say these patients aren’t getting.
Traditional dentists, though, said such a role would endanger rather than help the poor by putting them in the hands of people who lack proper training and skills.
“We just don’t think it’s safe enough, when you consider that they’re doing irreversible procedures” like pulling teeth, said Dr. Raymond Martin, president of the Massachusetts Dental Society, which opposes the creation of so-called dental therapists.
But advocates for dental therapists say the dentists are simply worried that dental therapists would ultimately gain a toehold in the market.
“These are people who are not being seen by anybody, and it appears that the dentists would prefer to have no one see them than to have a very well-trained dental therapist see them,” said Senator Harriette Chandler, the lead sponsor of the dental therapists bill.
The legislation would allow newly qualified dental therapists to perform tooth extractions, fill cavities, and place temporary crowns in settings such as community centers, nursing homes, and schools.
This is the second time that Chandler, a Worcester Democrat, has filed such a bill. Last year, the plan passed in the Senate as an attachment to the state budget but failed to garner support in the House.
The idea is this: More options would make more dental care available.
And because dental therapists would earn less, more would be willing to accept the lower payments that come from MassHealth, the state’s Medicaid program, which covers low-income and disabled people.
Last year, the Massachusetts Dental Society spent $326,000 on lobbying to urge the defeat of Chandler’s bill and to monitor other measures on Beacon Hill, state records show. The society placed ads in newspapers across the state, signed by local dentists who called Chandler’s bill a “quick fix.”
This year there is a new twist. The dental society is backing a separate bill that would create a position similar to a dental therapist, but with more restrictions and requirements for higher qualifications.
The society employs well-known lobbyists Murphy Donoghue Partners and the public relations firm of Geri Denterlein to push for its version of the bill, as well as to address several other issues on Beacon Hill.
The society also has a political action committee with $145,000 in the bank and last year donated to a number of top lawmakers, state records show.
On the other side of the issue is Pew Charitable Trusts, a national organization that’s pushing to establish dental therapy programs in many states. It spent $561,000 last year lobbying on this issue alone in Massachusetts, public records show. Pew has hired the firm of strategist Will Keyser, who is also an adviser to Governor Charlie Baker.
The dental schools at Tufts and Boston University said they support the dental society’s bill on this matter. The Harvard University School of Dental Medicine said it supports both bills. The Massachusetts College of Pharmacy and Health Sciences, which runs a dental hygiene program, said it is watching both bills closely and has not chosen an official position.
The two sides disagree on why the state’s most vulnerable people are ending up in emergency rooms with preventable problems like decayed teeth, inflamed gums, and cracked teeth.
According to the dental society, many low-income people don’t seek dental care until an urgent issue arises. In rural parts of the country, poor people often can’t find a dentist nearby, the society says, but Massachusetts has two dentists within five miles of 95 percent of the people covered by MassHealth.
Advocates for dental therapists, however, say the problem is that few dentists accept MassHealth — just under 40 percent, according to the dental society’s president.
Dentists say the economics of treating MassHealth patients are impractical, because they are reimbursed at just half the rate they receive from private dental insurers.
Advocates say it would be more financially feasible for dental therapists to accept MassHealth, and they point to other states where they say it works.
In Minnesota, where a dental therapist program has been in place since 2011, one private practice that employed a dental therapist made an additional $24,000 in profit and served 500 Medicaid patients in the therapist’s first year, according to Pew.
A dental therapist program has been in place in Alaska since 2004, and Maine authorized one in 2014, according to Pew. Vermont signed one into law in June 2016.
The dental association, however, isn’t convinced. It isn’t sure that MassHealth’s reimbursements would be enough to pay for the new practitioners.
“We just want it to be effective, and we also want to know who is going to pay for this mid-level provider,” said Martin, the dental society president.
Meanwhile, MassHealth paid $11.6 million for emergency room dental care for adults between 2008 and 2011, according to Pew. Because many emergency rooms are not equipped to treat dental problems, many simply treat the symptoms, and patients still must see a dentist to address the underlying problem.
Advocates also say dental therapists could be trained to work specifically with people who have special needs and are often among the most underserved.
Maura Sullivan, a mother of three, knows that problem too well. Two of her children have autism, and she couldn’t find a dentist trained to calm their fear of sitting in a dentist’s chair and having someone touch inside their mouths.
Sullivan had to travel three towns away to find a dentist, but ultimately ended up in the operating room to have their dental work done, she said.
“We couldn’t find dentists, and we couldn’t find dentists who were actually able to work on my kids,” said Sullivan, who works for the Arc of Massachusetts, an organization that advocates for people with disabilities and supports the dental therapists bill.
“It was a lot of work to find that dentist, and I know so many people out there have yet to find that dentist,” Sullivan said.
CLARIFICATION: This story has been updated to include information about which Massachusetts dental schools have weighed in on the issue.