Ep. 249: Ever Heard of a Dental Therapist?
There's a dental provider already working in 14 states that most dentists have never heard of, and it could reshape the profession. In this week's episode, Jeff breaks down what a dental therapist is, what they can legally do, where they practice, and the two very different futures they point to: a force multiplier for independent practices, or a tool corporate uses to make high-volume dentistry pencil out. Plus, where it leaves the three tiers of dentistry, and the squeezed middle.
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Questions From This Episode
What exactly is a dental therapist, and what are they allowed to do?
A dental therapist is a mid-level provider trained to handle basic preventive and restorative care such as cleanings, sealants, fillings, and simple non-surgical extractions. They cannot perform implants, molar endodontics, complex surgery, or full treatment planning. Training takes roughly two to four years depending on prior background, far shorter and less expensive than dental school, and exactly what they can do varies by state.
Where are dental therapists currently allowed to practice?
They are authorized in 14 states as of this recording, with roughly a dozen more states considering legislation. In most states they are restricted to federally designated underserved areas, generally rural regions with a high patient-to-dentist ratio, though a couple of states, including Arizona and Michigan, wrote their laws without that restriction.
Could dental therapists eventually practice anywhere, not just underserved areas?
It is a real possibility. Nurse practitioners followed a similar path: created in the 1960s and initially restricted to underserved, supervised settings, they now have full independent practice authority in 27 states plus DC, with no physician supervision required. That shift took decades and was largely driven by provider shortages, the same pressure now building in dentistry as the profession's older, practice-owning generation retires faster than new dentists are entering.
How could a private practice use a dental therapist to its advantage?
As a force multiplier. A dental therapist earning roughly 80,000 to 100,000 dollars a year, with far less student debt than an associate, can handle basic restorative and hygiene-adjacent work, freeing the dentist to focus on complex procedures or see more patients. In practice, that could mean the dental therapist preps fillings and temporaries on a case while the dentist moves on to the next patient.
Should independent dentists worry about DSOs using dental therapists to undercut them?
It is worth watching. A DSO or a public-private partnership could staff a rural underserved area with a roving dentist and several dental therapists, keeping costs low enough to make in-network reimbursement rates work in a way an independent, fully staffed practice cannot. That is a real possibility in tier two of the profession, but it does not change the case for tier one independent practices; the fundamentals that make an out-of-network, patient-centered practice profitable are unaffected either way.
Episode Transcript
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What is a dental therapist, and have you ever heard of one? If you are like 80 percent of the dentists I've asked, the answer is probably no. It's a real thing. It's not a hygienist, and it's not an assistant. It's a type of provider that performs limited dental procedures and currently practices in 14 states, with others potentially on deck to legalize it.
So while you may never have heard of this position, it could potentially reshape the profession in the coming decades. For this week's episode, we're going to look at what a dental therapist is, what they're legally allowed to do, keeping in mind that it varies state to state, where and how they currently practice, and what the future might look like, including how a private dentist could use one of these providers as a force multiplier, as well as how corporate dentistry could potentially, for lack of a better word, abuse it.
My name is Jeff Blumberg, and I'm your host. Let's start by explaining what this position actually is and what they can do. What a dental therapist is varies state to state. For example, Minnesota has two levels of dental therapist: dental therapists and advanced dental therapists. The scope of what they do is preventive care, hygiene-type procedures, plus basic restorative work: cleanings, sealants, fluoride, fillings, and simple non-surgical extractions. Bread and butter, high-volume stuff.
Not implants, not molar endodontics, not complex surgery, not comprehensive diagnosis, full-arch treatment, or treatment planning. It's a very defined lane. And again, how they operate and what they can do varies from state to state, there are no absolutes. Every state writes its own dental practice act, so what a dental therapist can do in Minnesota isn't identical to what they can do in Arizona. Extractions are a big variable, for example. Some states allow non-surgical extraction of permanent teeth, others only baby teeth. It really depends on where you are.
As I mentioned, Minnesota has the dental therapist, or DT, and the advanced dental therapist, or ADT, with the ADT generally having a wider scope. From my recollection, a DT can extract deciduous teeth, while an ADT can do simple extractions on adult teeth as well, though don't hold me to the specifics since it varies. Maine, for example, calls the position a dental hygiene therapist. So there's real variation here.
Now, how do they practice? If you're familiar with the concept of supervision, there's direct supervision, indirect supervision, and general supervision. Direct supervision means the dentist is in the office, diagnoses and authorizes the treatment, stays, and checks the work before the patient leaves. Indirect supervision means the dentist is on premises and authorized the treatment but isn't standing over the provider's shoulder. General supervision means the dentist authorized the treatment but does not have to be in the building when it's performed.
That top rung, general supervision, is where I see the hinge point for how this could transform in the coming years, because the dentist doesn't have to be on site for the dental therapist to operate, if that's the law in that state. In multiple states, including Minnesota, Idaho, Washington, and Oregon for some procedures, and Connecticut under a signed collaborative agreement, the dentist can authorize the work in advance, with riskier procedures kicked back up to the dentist, and the dental therapist can then work under general supervision.
So here's where it gets interesting. You have a very limited dental provider, for lack of a better term, who can perform basic restorative dentistry, depending on where they practice. But the training for the position is what stands out. It's roughly a three-year program. If I'm not mistaken, CODA requires a program of about 27 months in length, with certain prerequisites. If someone has no background in hygiene or no bachelor's degree, it could take three to four years. If they're already a hygienist with a bachelor's degree, it might only take two.
The big difference is you have someone who, in that short window, can do basic dental-type work without walking out with tons of debt. A dentist walking out of dental school is typically carrying anywhere from 300,000 dollars in debt on the low end, sometimes considerably more, while a dental therapist isn't walking out with anywhere near that.
So in summary: we've got a trained mid-level provider with a defined clinical lane that varies by state, working under general supervision in certain cases with no dentist required on site. Keep that in mind as we move forward.
So now, where are they actually working right now? Dental therapists are currently authorized in 14 states, with roughly another dozen states with bills in motion, getting closer with each legislative session. There are about seven training programs, in states like Alaska, Minnesota, Oregon, Washington, and Wisconsin, with more in development.
Usually, they're fenced in. They're only allowed to practice in areas considered underserved, meaning a federally designated area where the doctor-to-patient ratio is too high, if I'm not mistaken it's roughly one dentist to 5,000 patients. So if you're in an area with very few dentists and a lot of people, that's underserved, and that's where a dental therapist, if licensed in that state, is allowed to practice. You're not going to see a dental therapist setting up shop in Manhattan, Los Angeles, or Miami, because there are already enough dentists there.
But here's the interesting part, and this isn't meant to be doom and gloom, because that's not my thing, and I don't think this is a doom and gloom situation. Consider the physician's assistant or nurse practitioner. Most of us have seen a nurse practitioner for primary care, maybe for something like bronchitis, and gotten a prescription from them. That's a relatively newer development, and it started out very similarly to this, limited to just a few providers, initially restricted to underserved areas only. Now there are hundreds of thousands of nurse practitioners and physician's assistants across the country.
So right now, dental therapy has a fence around it, certain states where it's licensed, but in a few states that fence already has gaps. In Arizona and Michigan, for example, the law was written without confining dental therapists to safety-net settings only. That's a policy choice, and it matters.
This connects to something I covered last week. Right now we're on a trajectory where dental school output hasn't kept pace, though that's improving, with more programs opening and more graduates coming out. But a large share of the profession, dentists 55 and over, is on track to potentially retire over the next 10 to 15 years. That's a significant exit of experienced doctors, and the number of new doctors entering doesn't fully replenish those numbers. We're projecting the total number of dentists will actually dip slightly by 2028, a bit under 200,000, we're at about 202,000 now, before recovering to a modest surplus of around 204,000 by 2033.
Here's where it gets more interesting with dental therapy specifically: remember, they practice in underserved areas, meaning the dentist-to-patient ratio is already out of balance. In an average urban area, the ratio is somewhere in the 60s per 1,000 people, meaning 60-plus dentists for every thousand residents. In the average rural area, that number is roughly half, around 32 or 33. So rural areas are already underserved right now, before you even factor in retirements.
Now imagine that a large share of practicing dentists are 55 and over, and a lot of those doctors own their practices. Ownership skews heavily toward the older end of the profession: the highest ownership rates are among dentists 45 to 54 and 55 to 64. At the other end, dentists under 30 owned about 25 percent of practices back in 2005. Today that number is closer to single digits, and it keeps trending down.
So picture this: young doctors coming out of school aren't buying practices the way they did 20-plus years ago, and the doctors who own the majority of existing practices are heading toward retirement over the next 10 to 15 years. That means fewer practice owners overall. Based on this trajectory, we estimate that over the next 10 years, roughly 36,000 practices will change hands. Not all of them will sell in the traditional sense, some will be bought by DSOs, some by other practitioners carrying the torch forward, but we estimate around 17,000 of those practices will simply disappear over the next 10 years. They'll either sell their patient charts to another office or hand the keys back to the landlord, because there's no one to buy them.
So it's a bit of a perfect storm: younger dentists not buying practices, experienced dentists retiring and selling or closing up, and rural, already-underserved areas becoming even more underserved as a result. That's the dynamic that opens the door wider for the dental therapist position.
There was a bill in the Florida legislature this year to legalize dental therapists in Florida, and other states are considering similar legislation, largely because there simply aren't enough doctors in certain areas. You can walk down a street in a dense metro area and see a dental office on nearly every corner, then drive out to a rural area with plenty of people but no dentists at all.
My first piece of advice to any young doctor asking where they should practice: look outside a major city. In the US, outside maybe Miami, you can get in a car and be in a rural area fairly quickly. If I were a young doctor going out on my own, that's where I'd look. I'm not saying you can't succeed in an urban area, some of our most successful clients practice in cities, but a rural area removes a lot of headwinds. Less competition, plenty of patients.
As a matter of fact, ADA data shows average revenue in a rural practice tends to be higher than in an urban one, simply because there are fewer dentists competing for the same patient base. And interestingly, DSOs generally don't open in rural areas, they target urban markets. Given that roughly a third to a quarter of graduating dental students say they want to work for a DSO, that pulls a meaningful share of new graduates into urban practice by default, which only widens the rural gap further.
So let's look at how this position develops going forward. First, how a private practitioner might use it. Say you're in a state where dental therapy is already approved, or likely to be. What does a dental therapist typically earn? That figure is harder to pin down than dentist salary data since there isn't a robust body of formal studies yet, but from what I can gather, it's roughly 80,000 to 100,000 dollars a year. And remember, they're not carrying three, four, five hundred thousand dollars in student debt, more like tens of thousands. Compare that to a new associate walking out of dental school with 300,000 to 500,000 dollars in debt, earning 130,000 to 160,000 dollars a year. Lower debt load and a leaner income requirement gives a dental therapist a real structural advantage in certain settings.
Right now this is a fairly limited opportunity because of the underserved-area fence, but as more states approve the position and that fence loosens, dental therapists could end up practicing more broadly, depending on the state and whatever tiered structure it adopts, similar to Minnesota's DT and ADT system.
It's worth comparing this to the nurse practitioner trajectory. The role was created in the 1960s, initially limited, supervised, and restricted to filling gaps in underserved areas due to doctor shortages, access problems, and healthcare costs. State by state, those restrictions came down. The first five states granted full independent practice authority in 1994. Medicare started reimbursing nurse practitioners directly in 1997. Today there are over 460,000 nurse practitioners in the country, and 27 states plus DC grant full practice authority, meaning no physician supervision is required at all. What started as a supervised, underserved-only role became independent nationwide over a few decades, not because of one sweeping decision, but because provider shortages kept eroding the restrictions bit by bit.
If you're a politician and your constituents are telling you there's no dentist in the area, and a bill comes up to authorize dental therapists for underserved areas, faster to train, capable of rudimentary procedures, one supervising dentist overseeing several of them, that's a fairly easy vote. I'm not saying that's exactly how it plays out everywhere, but it's a plausible path.
Now, if you're a private practitioner with one of these providers on staff, this could be a real force multiplier. They handle basic operative procedures, simple extractions, and hygiene-adjacent work, freeing you up for more complex cases, at a lower cost than hiring a full associate, since you're paying 80,000 to 100,000 dollars a year instead of 120,000 to 160,000. I was talking with one of our clients about this: you could have a dental therapist essentially working alongside you on complex cases, prepping temporaries and fillings while you move to the next patient. There's real utility here, and it could genuinely improve access to care in a private practice setting.
Now, the flip side. Picture a rural area with a real doctor shortage, and a public-private partnership forms to address it: a DSO and a government agency team up, government funding helps establish a location, and the DSO opens several offices staffed with a roving dentist for complex procedures and dental therapists handling the simpler work. Because the whole operation is in-network and running at scale, they can make lower reimbursement rates work in a way an independent practice with a full staff of associates and hygienists generally cannot.
So this position could be good or bad for private dentistry, depending on how it plays out, and that circles back to something I discussed last week: dentistry is developing into three tiers. Tier one is the independent practitioner, out of network, not insurance-driven, charging standard fees, patient-centered, and profitable. Tier two is the DSO and public-private partnership model, heavily insurance-based, potentially expanding into rural areas using dental therapists exactly as I just described, and I wouldn't be surprised to see more of that. Their scale lets them make lower in-network reimbursement work.
Tier three is the problem: the average doctor in the country today, 60 to 70 percent in-network, collecting anywhere from 600,000 dollars to a million a year, who has watched reimbursements decline while expenses have climbed with inflation. We estimated the average doctor has seen roughly a 35 percent drop in purchasing power over the past several years. If that's your situation, doing the same work you were doing four or five years ago but netting less because reimbursements dropped while costs rose everywhere, it's worth asking honestly where that trend goes over the next five to ten years. I don't see insurance companies deciding on their own to start paying dentists more.
So here's what I'd actually do in the face of all this. If you're a young doctor considering picking up a practice, look rural, there are going to be plenty available regardless of location over the next five to ten years. If ownership has ever been on your radar, now is genuinely the time. If you're an entrepreneurial dentist thinking about multiple locations, now is the time to start looking. You have to know what you're doing, if your primary location is already struggling, adding a second one isn't the fix. But that's exactly where our clients excel, they know how to scale a practice while actually improving patient care, which is what lets them take on that second, third, or fourth location and build something real.
So the first recommendation: if you're in a position to acquire, now is the time. But if you're in the squeezed middle, heavily in-network, profitability isn't where it should be, and you're not sure how to fix it, that's exactly what our Independent Practice Blueprint consultation is built for. We'll look at where your practice currently stands and map out what it would take to move toward that tier one independent model, since that's where the opportunity is over the next five to ten years.
A lot of people depend on you, not just yourself, but your family, your staff, and your patients, so it's worth making sure you're positioned well to navigate what's coming. And to be clear, dental therapists may end up being a genuine asset for your own independent practice as a force multiplier. This doesn't have to be a scenario where they only end up staffing DSO locations, though I could see that happening too in certain markets.
Anyway, this was a bit of an oddball episode, it was originally going to be an appendage to last week's episode, but there wasn't room for it at the Owners Conference briefing given everything else on the agenda. I thought it deserved its own episode because it's something worth being aware of. Laws get proposed and passed, and when it touches your profession or your livelihood, it's worth knowing what's happening, even if you're not glued to the news generally. It's worth at least checking what's on your state's legislative docket, since there's a real chance dental therapy legislation is somewhere in your state's pipeline.
If I saw a bill like that in my own state, I wouldn't necessarily be against it. In Florida, the state dental association was the only real opposition to the recent bill, so I'd call myself neutral on the underlying question. But the first thing I'd want to know is why. Because if a bill like that is moving, it tells you there's a real shortage, and that's something worth understanding, both as a potential opportunity to get more care to more people, and as something to watch closely if quality of care is a concern.
Anyway, an oddball episode, but I hope it helps. Don't forget to check out the Independent Practice Blueprint consultation, there's a link on the episode webpage. Otherwise, folks, that's all I have for you this week. If you want to learn more about MGE, you can find us online at mgeonline.com, or call us at 800-640-1140. Have a great week, and we'll see you at the next episode.