Tanya Van Rose-Bell used to drive 60 to 90 minutes to reach a dentist, after she moved to the Lakes Region 14 years ago.
With dentists scarce in rural and small-town Maine, she said she would drive to Westbrook or Brunswick for care. And although she didn’t miss an appointment, she knows many people who rarely visit the dentist because of the travel time. They can’t easily take time off from work, or they don’t have a car, she said.
“A lot of people here do not have good teeth,” said Van Rose-Bell, of Bridgton.
How to improve access to dental care in rural Maine is at the root of a dispute between dentists and dental hygienists that’s being played out before the Legislature. The hygienists want to create a new, mid-level dental provider – a dental therapist. The dental therapists would be licensed to perform more dental procedures than a hygienist – such as filling cavities – but not as many as a dentist. Dentists argue that a new type of provider will not help improve dental care in Maine, saying it’s a side issue that does nothing to address the fundamental financial reasons some people are not receiving the care they need.
The House and Senate have both voted in favor of the dental therapists bill, but while the House voted overwhelmingly in favor, the Senate vote was 19-16, and a Senate vote in favor of final passage, which could happen this week, is not certain. Gov. Paul LePage has not indicated whether he would sign or veto the bill, should it reach his desk. The only states that have dental therapists are Minnesota and Alaska, but many other countries, including New Zealand and Canada, have the position.
The issue does not appear to be partisan, as both Democrats and Republicans are split on the issue. For instance, Democratic House Speaker Mark Eves of North Berwick is a sponsor of the bill, but Senate President Justin Alfond, D-Portland, voted against it.
A number of Republicans, including Rep. Carol McElwee of Caribou, support the effort to create licensed dental therapists to help fill in the gaps where there are shortages.
“We are desperate for dentists here in Aroostook County,” said McElwee.
Van Rose-Bell, 45, said although she has subsequently found a Bridgton dentist, she had previously started seeing an independent dental hygienist in Bridgton, Cathy Kasprak, for cleanings so she wouldn’t have to travel as much. She still sees a dentist, but not as frequently now that she’s getting her six-month cleanings from Kasprak.
“It takes the pressure off to have (Kasprak) here,” Van Rose-Bell said. “It’s so convenient.”
LONG TIME BETWEEN VISITS
At her three-year-old independent dental hygiene practice in Bridgton, Kasprak said she hears a lot of sentences that begin with, “I haven’t been to a dentist in …”
“They’ll say it’s been five years, 10 years,” said Kasprak, who estimates that more than half of her 1,000 patients fall into that category. “I can’t do everything, but at least they’re walking in the door.”
While Kasprak is not a dentist, a 2009 state law allows her to open a practice to perform cleanings and other basic dental services. Kasprak and others are trying to add the dental therapist position in Maine, a proposal that is drawing fierce opposition from dentists. Kasprak said she would go through the two-year dental therapist program and 1,000 hours of training to become a therapist and be able to perform more procedures at her Bridgton office. No dental therapist could operate without the written approval of and supervision by a Maine dentist, although the therapist could work in a separate building.
While the therapist position is controversial, no one disputes that Maine’s dentists are graying and the number of dentists in rural Maine ranks far below national averages of dentists per capita. In some counties – such as Washington, Lincoln and Somerset – the median age of dentists is 60 or older. Surveys of Maine dentists show that about 40 percent plan to retire or cut back their hours in the next five years.
And dentists in rural areas are sometimes hard to find. For instance, in Cumberland County there are 76 dentists for every 100,000 people, but in Somerset County there are only 17 dentists for every 100,000. Most rural areas have half as many – or fewer – practicing dentists per capita as Cumberland County, according to America’s Health Rankings, which compiles statistics on a number of health-related issues, including county-by-county data.
Dr. Jonathan Shenkin, an Augusta dentist and representative of the Maine Dental Association, said therapists are a smokescreen over the real issue: money.
“It’s a crisis of financing, not a crisis of providers,” Shenkin said. “If people can’t afford a dentist, they’re not going to be able to afford a dental therapist. This is not like competing pizza restaurants in New York City.”
Shenkin said many people are confusing need with demand on the issue: People may need to see the dentist, but if they don’t want to or can’t afford to, it’s not going to matter whether dental therapists or dentists set up shop in an area. Without customers, their practices are not going to survive.
But Kasprak said access is an issue. Of the dentists who operate in more rural areas, many don’t accept MaineCare patients or they’re already at capacity and are not accepting any new patients, she said.
‘WHERE ARE THE PATIENTS?’
Kasprak said the dentists are afraid they will lose money to the dental therapists, even though by expanding the population of people who receive oral care, dentists will benefit.
“We will be giving more referrals to dentists. I see it as a ‘win’ for all of us,” Kasprak said.
But that’s not how Dr. Travis Castleberry, a 27-year-old dentist in Blue Hill, sees it.
“You’re just dividing up the people who are already seeing a dentist,” Castleberry said.
Castleberry said he moved to Ellsworth in 2013 after graduating from Temple University in Philadelphia, but his business struggled and he had to take on side work to survive financially.
“I thought, ‘Where are the patients?’” Castleberry said. “People think there’s so few dentists here that you can just hang a sign up and get patients in your door, but that’s not the case.”
He opened another practice in Blue Hill several months ago, and since then his caseload has improved.
Dr. William Caddoo, 70, of Ellsworth said he’s trying to sell his practice to a young dentist, but hasn’t yet found anyone to take it over.
“People just don’t want to come this far north,” Caddoo said.
But Caddoo said dental therapists are not the answer, because therapists would need much more training to adequately treat patients.
Castleberry said his student loan debt load is about $200,000, but he went to a state school, and he knows many new dentists who owe $300,000 or more and would not be willing to locate in rural Maine, in part because it would be difficult to pay off such a loan. He said most new dentists will not want to move to rural regions of the country, even with the help of a federal loan repayment program that encourages dentists to locate in rural areas.
“I grew up in rural Pennsylvania, and I was looking for a rural experience. But I would say people in general do not want to move to a rural area. People like to be where other people are,” said Castleberry, who did not qualify for the loan assistance program. “I don’t know what the answers are.”
Will the new dental school at the University of New England help improve the dental shortage in rural areas? Castleberry and another dentist serving in a sparsely populated region, Dr. J. Douglas Huntley in Greenville, said they are skeptical.
Huntley, whose practice is located in a part of the state where it sometimes takes patients more than an hour to drive to his office, said the debt load for UNE students is going to be too challenging to locate in rural Maine, even with a loan forgiveness program, and many will want to be in Portland or even out of state.
“Of course they’re going to go to Portland, where there’s already enough dentists,” Huntley said. “It’s not addressing the problem; it’s perpetuating the problem.”
MONEY SEEN AS BIGGER ISSUE
Huntley said he believes the dental therapist position is not needed, and that the state instead should use the tools it already has to focus on prevention, the type of work performed by what is known as a public health status hygienist. Huntley said the public health hygienist is tasked with going into schools and other community centers to bring dental care to larger numbers of people.
“That position (public health status hygienist) is tolerated and not supported by the state,” Huntley said.
According to the American Dental Association, even if only one dentist from each UNE graduating class set up shop in Maine, it would help improve the ratio of dentists from below the national average to close to the national average. But the ADA report concludes that 53 percent of new dentists will choose to set up their practices in more urban areas, comparable to the current distribution of practicing dentists.
Shenkin said other issues are holding back improved dental care in Maine – including poor funding for preventive services, such as sealants for children, and weaknesses in the MaineCare program, which offers very low reimbursement rates for children’s dental services and none at all for adults.
Shenkin said the low reimbursement rates by MaineCare, the state’s version of the federal Medicaid program for low-income residents, are a major reason more people aren’t getting good care. Maine’s reimbursement rates rank 34th among all states and are among the lowest in New England. Maine reimburses for many preventive or typical services – such as cleanings and fillings – at about one-third of the average in New England.
When Connecticut boosted its Medicaid reimbursements for dental care in the mid-2000s, usage increased, and Connecticut now has the second-highest percentage nationally of people who have seen a dentist in the previous year, according to a 2013 report by America’s Health Rankings.
Fewer than 30 percent of Maine dentists accept new MaineCare patients because of the low reimbursements, and only about half of Maine’s 680 dentists serve any MaineCare patients at all, according to a 2013 report by the Maine Department of Health and Human Services.
A bill to increase MaineCare dental reimbursements by $2.3 million is pending before the Legislature, but debate has been crowded out by the push to create dental therapists, Shenkin said. And it’s questionable whether LePage, who has steadfastly refused overall Medicaid expansion and has campaigned against welfare fraud, would be likely to expand Medicaid in other ways, such as for adult dental care.
If reimbursements were to increase substantially, Shenkin said, “that’s a major piece of the puzzle that would help tremendously.”
According to the 2013 DHHS report, about half of the dentists who did not accept MaineCare patients would consider doing so if reimbursements were increased.
Meanwhile, only children with MaineCare receive a dental benefit, while adults are left out. About half of the states provide a Medicaid dental benefit for adults. Shenkin said even if MaineCare paid for one cleaning per year for adults, that would help improve Mainers’ oral health and increase demand for services.
Other programs to provide dental sealants for children in schools and to help pay for dental care at health centers have been slashed. In 2011, nearly seven in 10 elementary-school children had sealants applied to their teeth, but the program has since been cut by about 40 percent, according to the DHHS.
Joe Lawlor can be contacted at 791-6376 or at: