NYS bill seeks to expand access to dentistry by licensing dental therapists

The dental therapist may see you soon.

State legislation pending in Albany would license dental therapy in New York, a profession that supporters say would lower costs, expand access to dentistry, shorten waits and improve oral health.

Working in a profession akin to a physician assistant or nurse practitioner, dental therapists are legal in more than 50 countries and 14 U.S. states but so far not in New York. Dental therapists, whose place on the dentistry hierarchy is above hygienists but below dentists, are trained to do routine exams and procedures, including filling cavities and limited tooth extractions. 

Dentists would still have the monopoly on advanced treatments such as root canals and need to be on site to handle difficult cases. 

Two-tiered dental care

Such legislation is generally opposed by leaders of dentist associations, including Dr. Eugene Porcelli, executive director of the Nassau County Dental Society. Porcelli and other opponents say patient health would be jeopardized, creating a two-tiered system of care in which only the privileged see a full-fledged dentist and others an inferior practitioner.

Only a dentist, the associations say, has the full spectrum of education and training necessary to diagnose, treat and prevent dental and other health ailments.

The sponsor of the legislation in the State Assembly, Carrie Woerner (D-Saratoga Springs), said that a stratified system already exists — under the current system, one in which the poor, including children, are sometimes locked out of dentistry altogether.

"The two tiers are, you can have care if you have dental insurance, or you’re willing to pay cash, and otherwise you can’t have care," Woerner said in an interview.

Woerner’s legislation would license dental therapists but require them to work in a dental office under a dentist’s supervision. A version of the bill would limit dental therapy practices to settings that serve low-income, uninsured and underserved patients or at certain other medical facilities.

Porcelli said everyone deserves to see an actual dentist, including those in underserved communities. Instead of creating a new professional training program that costs money to develop, he said, the government should raise the reimbursement rates for Medicaid, the insurance program for the needy.

"Why not take that money and put it into Medicaid fees that are more reasonable with what the costs involved are?" said Porcelli, who practiced in Garden City for decades before retiring, in 2021. He added: "The reimbursements on most procedures is close to the cost to provide the procedure, if not slightly below, and that’s part of the problem." 

And then there is scheduling. At one point when he was practicing, he took Medicaid. He stopped accepting it.

"The problem was, the low reimbursement fees, I was losing money, but the other issue was I found that unfortunately, a lot of patients didn't appreciate the fact that they were getting this treatment so they wouldn't show up for appointments," he said.

According to a 2022 study in the journal Medical Care Research and Review, only a third of dentists accept Medicaid. (Woerner says she supports an increase in Medicaid reimbursement rates for dentistry.)

The American Dental Association opposes model legislation authorizing dental therapists, released this summer by the Arlington, Virginia-based American Legislative Exchange Council, an influential conservative group.

More than 80% of voters favor licensing dental therapists, according to a survey from the Pew Charitable Trusts.

Doing without dental care

An estimated 68.5 million adults go without dental insurance, according to the 2023 State of Oral Health Equity in America survey by the CareQuest Institute for Oral Health. In parts of New York, two-thirds of the population live in high needs areas for oral health, according to a study published in July by the Center for Health Workforce Studies at the University at Albany's School of Public Health.

The first dental therapists were proposed nearly 125 years ago, and New Zealand started the first dental therapy program, for what were then called dental nurses, according to an article last year in Journal of the Academy of Distinguished Educators on the profession's history.

"Predictably, when a new oral health care provider role is proposed by legislators or public advocates — which potentially overlaps with existing practice roles — there will be resistance," wrote dentist Andrew Spielman, a professor at the NYU College of Dentistry.

Now, said Jean Moore, who has done research showing that dental therapy expands access, that pushback is "mostly coming from organized dentistry."

"Think about this: When nurse practitioners came on the scene and were proposed as providers who could help address primary care shortages, who voiced the loudest opposition?" said Moore, director of the center.

Moore cited Minnesota as an example of a state in which dental therapists handle basic work, freeing up dentists to perform more complex procedures.

"We haven’t seen issues where care was compromised, and in fact we find that it enhances access to care," she said.

The prospects of the legislation are uncertain. Gordon Tepper, a spokesman for Gov. Kathy Hochul, did not answer a query. Last month, Hochul signed legislation expanding which health professionals are allowed to provide fluoride treatment, which prevents tooth decay and strengthens tooth enamel.

One of the places where dental care is cheaper than at a private office is dental school clinics, such as at New York University's and Stony Brook University's, where students help.

In a typical year at Stony Brook, 12,000 to 15,000 patients from across the region visit the clinic there, according to Dr. Patrick Lloyd, the dean of the university's School of Dental Medicine.

On an average day, students studying dentistry, residents learning specialty dental fields and faculty serve 325 patients for procedures from cleanings to filings and bridges.

These patients span all age groups and arrive with various dental and medical ailments, Lloyd said. While the center accepts various insurance carriers, including Medicaid, the dean added that "the majority that come to the school are private paying patients."

Patients with "less complicated" needs, including cleanings and some root canals and crowns, can be seen by dental students under the guidance of a licensed dentist and pay about 50% of that of a traditional dentist, Lloyd said. Patients pay around 75% of the cost if seen by residents studying specialties, and about the same as a private dentist if treated by faculty.

'See those kids early'

Bridget Walsh, a senior policy analyst at the Albany-based Schuyler Center for Analysis and Advocacy, said that clinics at dental schools can’t alone shoulder the unmet need for dental care.

There aren’t enough dental students. There aren’t enough appointment slots. There aren’t enough dental schools, and some patients live far away.

Walsh said allowing dental therapy would be particularly beneficial for children, especially in underserved neighborhoods. The need is acute in parts of the state where there are shortages of dentists, of those who accept Medicaid, or both.

"The idea would be you could see those kids early in their need for care before them having to wait weeks or something to get a cavity filled, or months in some cases for some kids," she said, adding: "We want to shorten the waitlist for kids ... If you've got a small cavity, you want to treat it before it becomes painful or becomes abscessed, becomes infected."

On average, it’s about half the cost to hire a dental therapist than a dentist, according to Laura Brannon, a project manager who works with the National Partnership for Dental Therapy.

Brannon said standards for the profession are set by the same entity as for dentists, and in some states prospective dental therapists take the same licensing exam as dentists, just a smaller portion of it.

"The constraining factor is how many dental therapy programs there are, but there are a lot of schools working on opening new ones right now," she said.

There are about 200,000 professionally active dentists nationwide, according to the American Dental Association, compared with just about 200 dental therapists, according to Brannon, "but that is growing."