That’s what you’d conclude after reading the January 4th, 2016 Seattle Times article on Dental Therapists. It contains a number of questionable facts and conclusions, although the headline is at least correct: the Washington State Dental Association (WSDA) has lobbied extensively against allowing dental therapists here, claiming they would endanger public health. Realistically, the WSDA is just like any profession, being totally opposed to giving up any control over its services. For years the WSDA has also opposed independent practice by hygienists, which would hardly create a public health risk. Dentists just don’t want anybody else making rules about how dentistry is done. The hygienists, for their part, are kidding themselves if they think independent practice would significantly improve access to care, because hygiene is a loss leader for most practices. It gets patients in the door, and we diagnose treatment that can pay the bills, mainly crowns and implants. (Extractions and fillings are roughly break-even procedures, given the dominance of Washington Dental Service in forcing low fees.) It’s all about who is to be in charge–the hygienists chafe at having that be dentists, who in turn will fight tooth and nail to avoid giving up any control for any reason.

Perhaps in a therapist-mill, several working with one dentist, the therapist model can be economically viable. But it won’t work at less than 30 cents on the dollar, which is what this state’s Medicaid reimburses for dental treatment. It’s a sad fact that at current rates, you can either provide crappy care and make a little money, or provide decent treatment at a significant loss. (My office overhead is around 80%.) The Times states that “Experts agree that poor oral health can lead to far costlier diseases–including diabetes, heart disease and osteoporosis.” Recent research has not supported the link between poor dental health and diabetes; the jury is still out on the heart disease link, though it is clearly not a major risk factor; and there is little evidence that dental disease causes osteoporosis. The damages of poor oral health are mostly limited to the mouth–loss of chewing ability, change of facial profile and esthetics, pain, and speech, for starters. These are very real debilities, but to claim that overall medical expenses will go down when therapists can provide care is grandstanding. Therapists will initially be serving a publicly funded population, which means Medicaid will have to come up with the money. It may well be a good use of public health funds, but it’s not going to decrease health care expenditures.

Eventually, Therapists will move to the private sector as independent practices, and that does potentially create some savings, since the setup costs are lower than for dentistry. However, without crowns and implants to subsidize fillings and extractions, the savings won’t be tremendous. At some point, corporate dentistry will get on board, with large clinics featuring a dozen therapists and hygienists, and the natural cost-cutting treatment decisions to keep the clinic profitable. That dentists want to keep the present treatment model is only partly due to financial considerations:   having a dental home leads to more consistent care than bouncing from therapist to therapist in a big clinic.

So where do I stand on this issue? I’m pretty cynical, actually. I think Dental Therapists should be allowed on tribal lands now, and independent hygiene everywhere. I’m 60 years old, and I won’t be practicing in 20 years when we find out if it was a good idea or not. I think the therapist model will remain marginal in dentistry–we’re not like physicians, who need a PA or NP to see large numbers of people with the flu or medication needs. The patients dentists see typically need a surgical intervention (filling, crown, root canal, extraction). A hygienist can fill the PA need in a practice, but few offices do that because it’s too expensive. Therapists and independent hygiene will likely be mostly in public health and corporate clinic settings. I could be wrong, but in 20 years I’ll probably be dead, so you won’t get to say “Hah!  We were right!  Nyah Nyah Nyah!”