SYLVIE DOUGLIS, BYLINE: NPR.
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ADRIAN MA, HOST:
This is THE INDICATOR FROM PLANET MONEY. I’m Adrian Ma.
WAILIN WONG, HOST:
And I’m Wailin Wong. You know, for a lot of people, myself included, going to the dentist comes with a bit of anxiety. But this was actually not the case for Kari Ann Kuntzelman, not even as a kid.
KARI ANN KUNTZELMAN: I kind of felt like it weirdly was, like, a safe space. I had to have extractions and a surgery, and I didn’t have any, like, traumatic experiences. It was kind of the opposite. And so that’s really when I figured out that I wanted to do something in the dental field.
MA: This is amazing. I feel like Kari Ann’s unusual bravery qualifies her to, like, fight crime.
WONG: (Laughter) It’s like a superpower.
MA: Yeah, absolutely. And this is why when Kari Ann got older, she thought about becoming a dental hygienist. But then she learned about this job called a dental therapist.
WONG: Now, you might think this is someone who, like, holds your hand while you get a tooth extracted. But a dental therapist is someone who is trained to do basic exams and cleanings, as well as some procedures that are usually reserved for dentists, like filling cavities and pulling teeth.
MA: Now, in countries like New Zealand or the United Kingdom, dental therapists have actually been practicing for years, some even for decades, but they’re a much newer addition to the dental workforce in the U.S. There are only about 200 dental therapists and only five states where they’re currently working.
WONG: This could be changing, albeit slowly, as some states see them as a cost effective way to deliver care, especially in underserved areas. Wisconsin’s governor signed a law this year allowing dental therapists to be licensed there. Similar legislation is up for consideration in Illinois and New York.
MA: But professional dentistry organizations have their own ideas about how to make dental care more accessible. So after the break, we’ll drill down on the debate over this emerging profession in the U.S.
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WONG: Let’s think about the different people you encounter at your dentist’s office. There’s someone who might help you get seated and take your X-rays. That’s typically a dental assistant. Then there’s someone who removes plaque from your teeth and applies fluoride. That’s the dental hygienist. And then if you need a cavity filled or, God forbid, a root canal, that’s a job for the dentist.
MA: Now, if that office has a dental therapist, that person might clean your teeth and fill a cavity or do simple extractions. You’d only see a dentist if you needed a more complicated procedure like taking out your wisdom teeth. Beth Mertz is a professor at the University of California, San Francisco, and she researches the health workforce with a focus on dentistry. She says dental therapists are similar to nurse practitioners in a doctor’s office.
BETH MERTZ: They can do a lot of primary care or, you know, do all the basic health care that you need, but they did not go to medical school. They’re not a physician, and there are certain specialty things that they can’t do.
WONG: In the U.S., a typical dental therapy program takes three academic years versus two or four years for a typical hygienist program. A dental therapy program is much shorter and less expensive than dental school, which usually requires four years on top of a bachelor’s degree.
MA: The first state to introduce dental therapists was Alaska in 2005. Health officials identified a need for basic dental care in tribal communities, especially ones located in rural areas. Today, Alaska has its own three-year dental therapy program through Ilisagvik College, the state’s lone tribal college, and most of the graduates are of American Indian or Alaskan Native background.
WONG: Kari Ann Kuntzelman is one of those graduates. She’s a member of the Chickasaw Nation of Oklahoma. And today, she’s licensed to practice dental therapy in Oregon. She’s also the president of the American Dental Therapy Association. And Kari Ann says having dental therapists in an underserved community can dramatically shorten the wait time for people to get care. It could be one week versus six months.
KUNTZELMAN: If you don’t have, like, a dentist or a dental therapist that lives in your community, which most of these communities don’t have that, they could go very long time without getting preventative services, let alone, like, emergency type services.
MA: Federal data show that 58 million Americans live in areas with a shortage of dental health providers. The government defines a shortage as having one or fewer providers for every 5,000 people.
WONG: Poor insurance coverage is another barrier to accessing care. More than 20% of adults and 9% of children have no dental insurance. That’s according to the American Dental Association.
MA: Yeah. And in a hearing this month, Vermont Senator Bernie Sanders described the lack of affordable dental care in the U.S. as absurd. He pointed out that gum disease has been linked to cardiovascular and digestive issues and that dental health problems can cause children to actually miss school.
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BERNIE SANDERS: People don’t receive high quality dental care. They are in danger of living their lives with severe pain. We need to understand that a major cause of absenteeism, interestingly enough, from school is a result of toothache and dental pain.
WONG: The gap in access for tens of millions of Americans is not about the number of people working in dentistry. In fact, the dental workforce is looking pretty healthy right now. Data from the American Dental Association show that the number of graduates with dental degrees rose 8% between 2019 and 2023. And the Bureau of Labor Statistics expects that the number of dental hygienists will rise by 7% over the next few years.
MA: Beth Mertz at the University of California, San Francisco says the problem is not the number of dentists. It’s about how the system for dental care in the U.S. just doesn’t give dentists economic incentives to work in lower-income communities.
MERTZ: I don’t think we have a shortage of dentists per se, but their incentives in where they practice are so tied to people’s ability to pay out of pocket for care that what you get is, you know, wealthier areas that have an oversupply of dentists, and then you have areas like rural areas or more low-income areas that have no dentists or have very little access to those dentists.
WONG: Beth says that dental therapists help fill gaps in these rural or low-income areas. Most dental therapists in the U.S. are required by law to practice on tribal lands or in areas where people have trouble accessing dental care.
MA: Dental therapists are also required to work under the supervision of a dentist. But depending on the state, that dentist does not have to be physically present. This could free up dental therapists to provide, for example, more mobile services to rural or tribal communities.
WONG: Beth says dental therapists can also help boost the productivity of a brick and mortar dental practice. When they take on simple fillings and extractions, dentists can focus on more complex procedures that pay more.
MERTZ: If you’re a dental practice and you’re using the individuals that work for you to the top of their scope as opposed to at the bottom of their scope, that’s going to be generally where reimbursement levels are higher.
MA: But the American Dental Association says dental therapists are actually not the solution to more equitable oral care. Jane Grover is a senior director at the ADA, working with the association’s Council on Advocacy for Access and Prevention. And she says just look at all the dentists and hygienists that are already working or are going to enter the labor force.
JANE GROVER: If you’ve got this dental workforce that’s growing, diverting funds to a new program, a new dental team member is puzzling.
WONG: Now, the ADA does acknowledge the problem of unequal access to dental care, but it’s focused on other solutions like advocating for states to expand Medicaid coverage for adults and encouraging more dentists to accept Medicaid. Low reimbursement rates and red tape are often cited as reasons that dentists don’t take this kind of insurance.
MA: Another solution Jane cites is loan repayment programs. These are national and state programs where dental graduates can get help with their student loans. And in exchange, they commit to practicing for a certain period of time in an underserved community or with low-income patients.
GROVER: So the opportunity to be of service in an underserved area and achieve loan repayment is pretty great. It’s a pretty great incentive.
WONG: On the federal level, in 2022, an advisory committee issued a report on dental therapy and recommended that Congress make $6 million in annual funding available for dental therapy training programs.
MA: And one of the benefits the committee cited is that dental therapy provides a career path for people in dentistry from underrepresented backgrounds. They can then return to their communities and provide more culturally sensitive care to patients.
WONG: Kari Ann Kuntzelman has experienced this firsthand as a dental therapist who has a Native background.
KUNTZELMAN: I’m serving my family. I’m serving my friends. My neighbors are coming to the clinic to see me. It kind of goes back to, you know, when you have a provider that looks like you, that talks like you and has the same background, you’re more likely to feel comfortable and to build that trusting relationship.
MA: And maybe feel just a little bit less nervous at the dentist’s.
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WONG: This episode was produced by Julia Ritchey with engineering by Kwesi Lee. It was fact-checked by Sierra Juarez. Kate Concannon is our editor, and THE INDICATOR is a production of NPR.
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