The midlevel practitioner model continues to gain momentum as more states consider the addition of new dental providers
The use of midlevel oral health practitioners can positively impact the United States’ access-to-dental-care crisis through the provision of safe, accessible, and high-quality care.1–4 And for some of the 185,000-plus dental hygienists in the US, the dream of taking their skills to the next level is becoming a reality. This year, Vermont became the latest state to recognize dental therapists, when Senate Bill 20 was signed into law in June. Under the new law, licensed dental hygienists who graduate from an accredited dental therapy program will be permitted to perform certain expanded duties (see sidebar on page 20).5–7
Vermont’s move follows a 2014 decision in Maine to recognize dental hygiene therapists. However, according to Ann Lynch, director of governmental affairs for the American Dental Hygienists’ Association (ADHA), prior to the bill’s signing, language was added stipulating that the new providers must be supervised by a dentist, potentially weakening the bill’s intended effect. While the Maine bill requires that dental hygienists with associate’s or bachelor’s degrees complete an additional four semesters of education, pass a clinical examination, and complete 2,000 supervised clinical hours, the state has yet to establish an accredited education program. In Vermont, however, Vermont Technical College in Williston plans to offer dental therapy education and training as an extension of its dental hygiene program. The result would be a 4-year program for the dental therapist credential.
The developments in Maine and Vermont follow Minnesota’s 2009 decision, which made it the first state to legislate licensed midlevel dental providers. This followed more than a decade of statistics indicating that Minnesota had the lowest dentist-to-population ratio in the US, with one dentist for every 1,670 Minnesotans.8 Midlevel practitioners began working in 2011, through either a dental therapist (DT) or advanced dental therapist (ADT) model. The DT holds a bachelor’s degree and practices with a dentist on-site, while an ADT, who holds a master’s degree, is allowed to work off-site under a collaborative agreement with a dentist. An ADT may perform oral evaluation and assessment; formulate an individualized treatment plan; perform nonsurgical extractions of periodontally diseased permanent teeth with Class III or Class IV mobility; and provide, dispense, and administer limited medications with a dentist’s authorization.
Currently, 63 licensed DTs and 25 certified ADTs are practicing in Minnesota, and judging from high program attendance, these numbers will grow. So far, the expanded workforce appears to be positively impacting accessibility in Minnesota. According to a 2014 report by the Minnesota Department of Health and the Minnesota Board of Dentistry, since dental therapists began practicing in Minnesota, no patient safety-related or disciplinary issues have arisen involving them. On the contrary, benefits attributed to these providers include reduced wait and travel times for patients, fewer dental-related visits to emergency departments, and improved access to care for patients covered by public health insurance programs (84% of patients out of 6,338 were enrolled in state/federal insurance programs). In addition, clinics employing dental therapists have experienced an increase in new patients—most from underserved communities—as well as a decrease in personnel costs.4
The aforementioned models are not the first successful uses of midlevel practitioners. This model has long been accepted in 54 countries across the globe.
In the US, the midlevel model has been employed in Alaska for more than a decade, though only on tribal land. Dental health aide therapists (DHATs) have been serving Alaska Native communities since 2004. This, however, was only after intensive legal wrangling. In 2006, the American Dental Association (ADA) and the Alaska Dental Society, expressing concerns about quality and safety, challenged the authority of the Indian Health Service (IHS) by filing a lawsuit to block certification of DHATs.9,10
That lawsuit ended in a settlement, favoring the IHS.11 DHATs are certified under the Indian Health Care Improvement Act (IHCIA). However, even though tribes are recognized as sovereign nations by the federal government, when the IHCIA came up for reauthorization, language was added to Senate Bill 1790, specifying that, with the exception of tribes in Alaska, those in the lower 48 states must get government approval to employ dental therapists, although community health aides are authorized.12
Under the Patient Protection and Affordable Care Act (HR 3590), a revision was added to allow a tribe or tribal organization “to elect the use of dental health aide therapist where such services are authorized under state law.”12 Most states do not currently authorize such services.
Earlier this year, the Swinomish tribe in the state of Washington exercised its right of self-determination and became the first Native American tribe in the lower 48 states to hire a dental therapist—after tremendous opposition from the ADA and state dental associations. This new professional, trained in Alaska, provides basic and preventive dental services (including fillings and simple extractions) in a population that not only lacks sufficient access to dental care, but whose children experience caries at a rate as much as five times higher than the national average.13,14
Because the IHS, a federal entity, can’t legally pay dental therapists without state authorization, private funding has been provided by the W.K. Kellogg Foundation. So far, organized dentistry has not challenged tribal authority.
Following the Washington tribe’s lead, the Northwest Portland Area Indian Health Board, which helped the Swinomish secure funding for its DHAT, is now working in partnership with the Swinomish Indian Tribal Community to bring the DHAT practice model to Oregon native communities. Backed by state Senate Bill 738—which gives the Oregon Health Authority permission to approve dental health pilot projects—the Confederated Tribes of Coos, Lower Umpqua, and Siuslaw Indians, and the Coquille Tribe of Southern Oregon are launching pilot programs that will train dental therapists to work in their communities.15 These developments are just the start. The IHS recently released a draft policy statement aimed at expanding community health aide program opportunities, including DHATs, at IHS facilities nationwide.16
Outside of tribal borders, expanded duties account for most of the recent advances in the dental hygiene field. For instance, Arizona, Colorado, Indiana, Illinois, Maine, Oregon, Utah, and Washington passed bills in 2015 confirming or expanding the scope of practice for dental hygienists. States allowing direct access to patients by dental hygienists, without the authorization or presence of a dentist, now total 39 with this year’s addition of Illinois and Utah. Eighteen states now allow direct Medicaid reimbursement to dental hygienists, with Rhode Island as the most recent entry.17,18
Indeed, more states are edging ever closer to the midlevel practitioner model, as the list of states working to create this niche grows. States such as Kansas, Massachusetts, Michigan, New Mexico, and Ohio are actively floating legislation or other kinds of proposals that would make dental therapists a reality within their borders. Other states working on midlevel practitioner legislation include Connecticut, Georgia, Hawaii, North Dakota, South Carolina, Texas, and Washington.17,18
To bolster these efforts, after the Commission on Dental Accreditation (CODA) voted 22 to 6 to adopt national training standards for dental therapy education programs, the accreditation process was set into motion in 2015. It is anticipated that the commission will begin accreditation of existing or developing programs this year.19
This legislative activity is aimed at resolving the crisis in access to oral health care, which some believe is due to a shortage of dentists. Others blame it on an uneven distribution of dentists, in which they are concentrated in more lucrative areas, while poorer and rural communities go without. Most dental organizations attribute this to staggering student debt loads shouldered by dental school graduates, who simply can’t afford to work in low-income settings.
The most common problem cited stems from shortcomings surrounding Medicaid. Recent figures indicate that more than 72.5 million people were enrolled in Medicaid and the Children’s Health Insurance Program as of May 2016.20 But up to one-third of all US dentists do not accept patients covered by Medicaid due to low reimbursement.21 According to the Pew Charitable Trusts, 48 million people live in dentist shortage areas.21 Unfortunately, dental associations often see the push to develop midlevel dental practitioners as an impediment to “the mission of bringing real solutions to those who are in need today.”22 Opposition to potential competition has been cited as another reason that dental organizations oppose midlevel practitioner models.
State laws are deeply influenced by state dental boards, which are charged with administering state dental practice acts and licensure. These boards are mostly composed of practicing dentists, and state dental associations influence the makeup of state boards. The associations also hire lobbyists to promote their agendas and influence legislation. Self-regulation of this nature opens the possibility for the creation of policies that discourage competition. This is the very action that can lead to the suppression of proposals aimed at creating a dental therapist niche.23
A 2015 US Supreme Court ruling on a case brought by the Federal Trade Commission (FTC) against the North Carolina Board of Dental Examiners determined that state licensing boards are not exempt from antitrust laws. The decision stems from a 2010 case in which the FTC asserted that the board was illegally preventing nondentists from providing tooth-whitening services, in order to block potential competition. Although whitening is not specified as a dental practice in North Carolina, responding to complaints from dentists that these providers were undercutting them with lower prices, the board issued dozens of cease-and-desist letters to nondentist providers, warning that “the unlicensed practice of dentistry is a crime.”23,24
The Court held that if “a controlling number” of the board’s members are “active participants in the occupation the board regulates,” it can only receive antitrust immunity if it was subject to active supervision by the state, which was not found to be the case in North Carolina.24 The case has led to the reexamination of licensing boards in general, as well as other state dental licensing board practices, many of which have served to block the creation of midlevel practitioners.23 The FTC supports the development of dental therapists in the interest of creating a competitive environment, which could lead to lower prices.
POSSIBLE STRATEGIES TO ADDRESS THE ISSUE
While the access-to-care problem is documented, there is little agreement on how to solve it. Opponents to the midlevel practitioner model cite fears of a two-tiered system, in which the poor receive second-class care. A common rationale is that nondentists should not perform irreversible procedures. The possibility of unforeseen complications that can only be resolved by highly trained hands is also frequently raised. In the opinion of the ADA, “The nation will never drill, fill, and extract its way out of what amounts to a public health crisis among some populations. Throwing more ‘treaters’ into the mix amounts to digging a hole in an ocean of disease.”25Instead, the ADA emphasizes prevention through solutions such as its community dental health coordinators (CDHCs), who provide patient education and act as patient navigators to help underserved populations make and keep dental appointments.25 Another solution often suggested by dental associations is offering debt relief for young dentists willing to work in underserved areas. Some, however, don’t feel these solutions go far enough.
Advocates of midlevel practitioner models believe that regardless of the reasons behind the lack of access in some areas, the individuals in those locations need help now. They believe that limited care is better than no care. Advocates also point out that midlevel therapists receive highly concentrated training on the select procedures they are allowed to perform, work in collaboration with dentists, and that no known serious negative effects have occurred in those states that allow midlevel practitioners.4,26–28
Proponents maintain that dental therapists can actually be a boon to the practice bottom line, allowing more patients to be seen at a lower cost. They may also make it easier to take dental care off-site, to expand practice hours, and to allow dentists to focus on more complex procedures.
The midlevel practitioner trend is not likely to disappear as more states decide that improving the oral health care of their most vulnerable populations is well worth the addition of a new dental provider.
FOCUS ON VERMONT | By Ellen B. Grimes, RDH, MA, MPA, EdD
On June 2, 2016, Vermont became the fourth state to approve a new dental provider as a means to alleviate the access-to-dental care issue plaguing the state. Senate Bill 20 was sponsored by the Vermont Oral Health Coalition, which is composed of more than 40 organizations representing a wide array of constituents including children, the disabled, and the elderly. The bill was opposed only by the Vermont State Dental Society. With the passage of the legislation, dental hygienists with additional education will be able to perform the following specific restorative techniques:
- Placement of temporary and preformed crowns
- Emergency palliative treatment of dental pain
- Formulation of an individualized treatment plan, including services within the dental therapist’s scope of practice and referral for services outside the dental therapist’s scope of practice
- Minor repair of defective prosthetic devices
- Recementation of permanent crowns
- Placement and removal of space maintainers
- Prescription, dispensing, and administration of analgesics, anti-inflammatories, and antibiotics, except Schedule II, III, or IV controlled substances
- Administration of nitrous oxide
- Fabrication of soft occlusal guards, but not for treatment of temporomandibular joint disorders
- Tissue conditioning and soft reline
- Tooth reimplantation and stabilization
- Extractions of primary teeth
- Nonsurgical extractions of periodontally diseased permanent teeth with tooth mobility of Class III or greater
- Cavity preparation
- Restoration of primary and permanent teeth, not including permanent tooth crowns, bridges, veneers, or denture fabrication
- Preparation and placement of preformed crowns for primary teeth
- Pulpotomies on primary teeth
- Indirect and direct pulp capping on primary and permanent teeth
- Suture removal
To become a dental therapist, an individual must be a dental hygienist who has graduated from a Commission on Dental Accreditation Dental Therapy program. Once startup funding is secured, Vermont Technical College plans to offer dental therapy curriculum that will last a minimum of 1 year and will culminate in a baccalaureate degree. The college expects to begin the program with a class of 10 students. After dental therapists have graduated from the program and passed a clinical licensing examination, they can practice under direct supervision in a dental office.
Once dental therapists have practiced under the direct supervision of a dentist for 1,000 hours, they will then be able to practice under general supervision through a collaborative agreement with a supervising dentist. Schools, nursing homes, and hospitals are traditional locations where dental therapists might provide care under general supervision.
- Hammons PE, Jamison HC, Wilson LL. Quality of service provided by dental therapists in an experimental program at the University of Alabama. J Am Dent Assoc. 1971;82:1060–1066.
- Trueblood G. A Quality Evaluation of Specific Dental Services Provided by Canadian Dental Therapists. Ottawa, Ontario, Canada: Epidemiology and Community Health Specialties, Health and Welfare Canada; 1992.
- Nash DA, Friedman JW, Kardos TB, et al. Dental therapists: a global perspective. Int Dent J. 2008;58:61–70.
- Minnesota Department of Health and Minnesota Board of Dentistry. Early impacts of dental therapists in Minnesota. Report to the Minnesota legislature 2014. Available at:mn.gov/boards/assets/2014DentalTherapistReport_tcm21-45970.pdf. Accessed September 20, 2016.
- American Dental Hygienists’ Association. Dental Therapists Now Recognized in Vermont. Available at: adha.org/resources-docs/adha_dental_therapists_now_recognized_in_vermont_press_release_6-20-2016.pdf. Accessed September 20, 2016.
- Vermont General Assembly. S.20 (Act 161). Available at: legislature.vermont.gov/bill/status/2016/S.20. Accessed September 20, 2016.
- Pew Charitable Trusts. Vermont Passes Legislation Authorizing Dental Therapists. Available at: pewtrusts.org/en/research-and-analysis/analysis/2016/06/20/vermont-passes-legislationauthorizing-dental-therapists?sl&utm_campaign=2016-06-20+DEN&utm_medium=email&utm_source=Pew. Accessed September 20, 2016.
- Pew Charitable Trusts. The Minnesota Story: How Advocates Secured the First State Law of its Kind Expanding Children’s Access To Dental Care. Available at: pewtrusts.org/~/media/legacy/uploadedfiles/wwwpewtrustsorg/reports/state_policy/06010dent20the20minnesota20story20briefwebpdf.pdf. Accessed September 20, 2016.
- Cultural Survival. Lawsuit Puts Alaska Native Dental Care at Risk. Available at: culturalsurvival.org/news/lawsuit-puts-alaska-native-dental-care-risk. Accessed September 20, 2016.
- Gwozdek AE, Tetrick R, Shaefer L. The origins of Minnesota’s mid-level dental practitioner: alignment o problem, political and policy streams. J Dent Hyg. 2014;88:292 –301.
- Summary S.1790—Indian Health Care Improvement Reauthorization and Extension Act of 2009. Available at: congress.gov/bill/111th-congress/senate-bill/1790. Accessed September 20, 2016.
- National Indian Health Board. Summary of the Indian Health Care Improvement Act and Indian Specific Provisions in the Patent Protection and Affordable Care Act. Available at:nihb.org/search_results.php?cx=002676378880225752727%3Aimlpnzwsxcm&cof=FORID%3A10&ie=UTF-8&q=summary+of+the+indian+health+care+improvement+act&sa=Search&siteurl=www.nihb.org%2F&ref=&ss=9691j2606495j49. Accessed September 20, 2016.
- Brewer S. Swinomish Hires Dental Aide Therapist in Washington State, ADA objects. Available at: indiancountrytodaymedianetwork.com/2016/01/07/swinomish-hires-dental-aidetherapist-washington-state-ada-objects-162983. Accessed September 20, 2016.
- Nash DA, Nagel RJ. Confronting oral health disparities among American Indian/Alaska Native children: The pediatric oral health therapist. Am J Public Health. 2005;95:1325 –1329.
- Wahowiak L. Dental health therapists bringing oral health care to US tribal communities: opening up access. The Nation’s Health. 2016;46;5(1):25.
- Indian Health Service. IHS Initiates Tribal Consultation on Draft Policy to Expand Community Health Aide Program. Available at: ihs.gov/newsroom/pressreleases/2016pressreleases/ihsinitiates-tribal-consultation-on-draft-policy-to-expand-community-health-aide-program. Accessed September 20, 2016.
- ADHA. Bills Into Law 2015. Available at: adha.org/resources-docs/75110_Bills_Signed_Into_Law.pdf. Accessed September 20, 2016.
- ADHA. Direct Access States. Available at: adha.org/resources-docs/7513_Direct_Access_to_Care_from_DH.pdf. Accessed September 20, 2016.
- Commission on Dental Accreditation. Dental Therapy Implementation. Available at: ada.org/~/media/CODA/Files/Update%20on%20Dental%20Therapy_April2016.pdf?la=en. AccessedSeptember 20, 2016.
- Medicaid. Medicaid and CHIP Application, Eligibility Determination, and Enrollment Data. Available at: medicaid.gov/medicaid-chip-program-information/program-information/medicaidand-chip-enrollment-data/medicaid-and-chip-application-eligibility-determination-and-enrollment-data.html. Accessed September 20, 2016.
- Pew Charitable Trusts. 5 Dental Therapy FAQs. Available at: pewtrusts.org/en/research-and-analysis/q-and-a/2016/04/5-dental-therapy-faqs. Accessed September 20, 2016.
- Palmer C. Maine Therapist Bill Signed in April. Available at: ada.org/en/publications/ada-news/2014-archive/april/maine-therapist-bill-signed-in-april. Accessed September 20, 2016.
- ADHA. In Wake of Supreme Court Ruling, States Begin to Examine Licensing Boards. Available at: adha.org/stateline. Accessed September 20, 2016.
- Supreme Court of the United States. Syllabus: North Carolina State Board of Dental Examiners v. Federal Trade Commission. Available at: ftc.gov/system/files/documents/cases/150225ncdentalopinion.pdf. Accessed September 20, 2016.
- American Dental Association. Comment on the Kellogg Foundation Report: A Review of the Global Literature on Dental Therapists. Available at: ada.org/en/press-room/news-releases/2012-archive/april/american-dental-association-comment-on-the-kellogg. Accessed September 20, 2016.
- Nash DA, Friedman JW, Mathu-Muju KR, et al. A review of the global literature on dental therapists. Community Dent Oral Epidemiol. 2014;42:1–10.
- Alaska Native Tribal Health Consortium. Dental Health Aide. Available at: anthc.org/dental-health-aide. Accessed September 20, 2016.
- Bolin KA. Assessment of treatment provided by dental health aide therapists in Alaska. J Am Dent Assoc.2008;139:1530–1535.
From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2016;3(10):19-23.