Allowing ‘dental therapists’ in Michigan will expand access to oral care

In 2000, former Surgeon General David Satcher released “Oral Health in America: A Report of the Surgeon General.” The report — the office’s first-ever on the oral health of Americans — revealed oral disease as an expansive problem that caused “needless pain and suffering, complications that devastate overall health and well-being, and financial and social costs that diminish the quality of life and burden American society. What amounts to a ‘silent epidemic’ of oral diseases is affecting our most vulnerable citizens — poor children, the elderly, and many members of racial and ethnic minority groups.”

Sixteen years later, health officials are still citing the “silent epidemic” of poor oral health in our country, and the story is no different in Michigan.

Oral health is more than pearly white teeth — research has shown that oral health is linked to the health of the entire body. For those who can’t find a dentist to treat them, tooth loss, gum disease and pain negatively impact daily life and can erode their overall health. Consider:

  • More than one-third of all Michigan seniors have lost six or more natural teeth due to tooth decay or gum disease. Low-income seniors are more than three times as likely to have lost six or more teeth from tooth decay and/or gum disease.
  • Almost 3 out of 4 new mothers in 2008 did not receive dental care during their most recent pregnancy. Research shows gum disease is associated with preterm birth.
  • 66 percent of third-graders in the Upper Peninsula had a history of dental decay in their primary and/or permanent teeth, compared with 56 percent statewide.

This situation exists despite efforts in Michigan to create and expand meaningful supports, particularly expansion of the Healthy Kids Dental program, which will cover all children on Medicaid in all counties beginning next year. According to the 2016 University of Michigan’s Child Health Evaluation and Research Unit, approximately 40 percent of children covered under Healthy Kids Dental did not receive dental services in 2014.

Years of studies, reports and task forces show us there is no one solution to this problem. But one strategy that hasn’t been tried in Michigan yet is adding mid-level dental providers to our state’s workforce to expand access to care.

Senate Bill 1013, introduced earlier this month by Sen. Mike Shirkey, would authorize a type of midlevel dental professional called a dental therapist. These providers would be able, with appropriate training and licensing, to deliver routine but critically necessary care such as filling cavities.

Similar to a physician assistant on a medical team, dental therapists would not work independently, but under the supervision of a dentist. Only dentists who want to hire dental therapists to expand their practices would do so.

Right now many people in Michigan have difficulty finding a dentist who will see them. They may face those challenges because there are not enough dentists where they live, or because no dentist nearby accepts Medicaid, or because they have barriers to traditional dental settings like a physical disability.

One of the key provisions of SB 1013 is to ensure dental therapists help create access for underserved populations. The bill requires them to practice in safety net settings like a public clinic or that at least 50 percent of their patients are on Medicaid, uninsured or face other significant barriers to getting dental care.

Some dentists who do see Medicaid and uninsured patients want and need dental therapists. They are overwhelmed by demand and want to utilize the skills a dental therapist could contribute.

In a released statement on SB 1013, the Michigan Dental Association said dental therapists are not needed in Michigan, and the “most impactful solution is to more effectively utilize” the state’s existing dentists, hygienists and dental assistants.

Licensing dental therapists to work in Michigan won’t be the magic bullet that solves the problem of poor oral health for so many individuals, but it is a cost-effective strategy that could make an impact. For providers who don’t see underserved populations, and don’t want to hire a dental therapist, you have to wonder why would they care if someone else is willing?

Faced with access-to-care issues in their states, Minnesota, Maine, Vermont and tribal governments in Alaska, Washington, and Oregon allow dentists to hire these midlevel providers. At least 15 other states are considering bills similar to Michigan’s. Rather than viewing a new provider as a threat and settling for the status quo, Michigan should join these states by embracing the opportunity to expand care to those who need it.

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Stephen C Brown
Fri, 07/01/2016 - 11:20am
Hard to overstate lack of affordable dental care as a long-term health crisis. This is a major risk factor for many chronic debilitating health conditions, traditionally not "counted" because of the false wall between "Medicine" and "Dentistry". Any provision of basic dental health maintenance services, such as fluoridation of drinking fluids, routine exams, filling cavities, and periodontal cleaning should be promoted, widely available, and low-cost.
Sat, 07/02/2016 - 4:34pm
Although this idea, conceptually, might work, in reality we will be spending millions of dollars creating a system that is already being changed (the expansion of Healthy Kids dental to all counties in Michigan--and the addition of the Healthy Michigan Plan for adults). These programs incentivize dentists to see more patients because they actually can be profitable. The old Medicaid system is not profitable and incentivizes a mass production mentality to make a profit. This is not good for dentists or patients. Dentistry already has a mid-level type provider; they are called hygienists and they do a great service, and can do more as we understand the role between oral health and overall health. The research backing these concepts is emerging more and more so dentists are more willing to teach patients about this as well without risk of practicing outside of their scopes. Willing and compliant patients are also needed to make this system work. In Minnesota where the midlevel provider pilot program exists, it's hard to get therapists to remain in rural settings--just like it is to get physicians, dentists, and other professionals to move or live in these areas. There is not a problem with the number of dental professionals; there is a problem with getting them to live in rural settings. It's a distribution problem--not a number of providers problem. Why create another layer? A better approach may be to give more grants and funding to professionals to practice in these areas in exchange for a decreased student debt load--or a financial break on a start up practice. The debt and stress load on doctors is a topic I wish others would spend time and money on before we lose more bright, interested, and creative people in the healthcare profession. Physicians are already starting to exit the profession in droves. Do we want this in dentistry, too? Let's not always follow a certain model --like the PA model in physicians's offices--without careful thought. Furthermore, why not teach our kids in middle school and high school about overall medical and dental health? The research and information changes rapidly even for professionals trying to keep up. The health education and information that many kids are getting at home is abysmal and totally outdated. Health starts at home with good habits, correct information, and a culture of preventative care. Maybe the therapists could start in the homes of families and in our public schools-- not in a clinic or a practice. That would be more impactful in my opinion.
John Saari
Sun, 07/03/2016 - 7:48am
I think we all ready have a layer, the hygienist, could do cavities etc, with more pay and you would have a surge of them spread throughout the Countryside.
Thu, 07/07/2016 - 8:07am
Expanding the Hygenist role makes sense.
Marge Buehner
Fri, 07/29/2016 - 12:44pm
How many individuals in Long-term Care Facilities receive dental care? Very few and why? Dentists do not, as a whole, go abd deliver care. This is where dental therapist would be a great asset. I see the horrifying state of mouths when I take hygiene students to deliver hygiene services . I only know of 1 dentist who sees these patients. Let make dental therapists a reality for these individuals.
Sun, 12/10/2017 - 4:31pm

Marge Buehner, making dental therapists a reality is a far cry from getting care to those individuals. In other words, dental therapists don't graduate with portable equipment and eagerness to go where no dentists have gone before. They look for jobs...and go where the jobs are. There needs to be an administrator of some sort that facilitates bringing care givers to the areas of need, as well as facilitating how the care is paid. My main point is that addressing Access to Care problems takes time, effort, and money addressing "How" and "Where" in order for the "Who" to get to the unmet needs. The current push for dental therapists without incorporating them into a system designed to address Access issues will have a result like all previous "expansion of the workforce" efforts. (Efforts over the last 50+ years to address this in medicine and dental care have brought us to where we are today. The stumbling block was about "How" and "Where" adding more "Who's" won't be a very effective or efficient solution.

Sun, 12/10/2017 - 4:17pm

" According to the 2016 University of Michigan’s Child Health Evaluation and Research Unit, approximately 40 percent of children covered under Healthy Kids Dental did not receive dental services in 2014."

But 60% of the children did. What was the difference? What are the components of the problem for the 40% that was not a problem for 60%?
There is a huge chance that whatever got in the way of children seeing a dentist will also get in the way of seeing a dental therapist.

Licensing dental therapists is not synonymous with solving the problems associated with the unmet needs. If children and their dental health were considered a public priority, then public health dental clinics in the schools would remove all barriers. That is the main scenario in the history of dental therapists in other countries. That specific approach was effective in controlling dental problems in school-age children.

No country has solved dental Access to Care issues without a public dental health policy and the funding to carry it out. Dental therapists are just the employees. In a setting whose mission is to address Access to Care barriers, both dentists and dental therapists will make a difference by addressing unmet needs. The dental therapist, however, has a very limited range of skills. They are more like an advanced dental assistant or dental hygienist rather than being like a mini-dentist. However, dental therapists in private practices are employees and the commitment to addressing Access to Care issues is not automatic as it is in public health and non-profit clinics.

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