Progress Continues on the Legislative Front
The past year has seen the expansion of the midlevel practitioner and scope of practice for dental hygienists.
The year 2019 has been full of forward momentum for dental therapy, which has gained legislative traction as states grapple with issues of accessibility. Despite often deep-rooted intransigence, dental hygiene as a profession continues to make inroads into areas of dental practice that were previously off limits. Most notably, increasing numbers of states are recognizing the midlevel profession of the dental therapist (DT). According to Director of Advocacy and Education for the American Dental Hygienists’ Association (ADHA) Ann Lynch, the big news this year is, in fact, the growth of dental therapy. “Several states have passed legislation pertaining to dental therapy in the past year—each a little bit different.” Lynch observes that there are currently 100 dental therapists licensed in Minnesota, which passed its own dental therapy legislation 10 years ago. “That’s significant,” Lynch says.
DENTAL THERAPY MILESTONE
Minnesota, the first state to legalize the practice of dental therapy, has now clocked in a decade’s worth of dental therapy practice within its borders. Christy Jo Fogarty, RDH, ADT, BSDH, MSOHP, was the first licensed advanced dental therapist (ADT) in the state—and in the entire country for that matter. She practices at the nonprofit Children’s Dental Services in Minneapolis, serves as president of the American Academy of Dental Therapy, and is the current president of the Minnesota Board of Dentistry.
In Fogarty’s opinion, dental therapists have made a tremendous impact as far as broadening access to dental care. “It has decreased wait times and travel distance for many patients in receiving quality dental care,” Fogarty says, adding, “Improved access to care is, hands down, the greatest benefit to those most in need.”
While acknowledging that dental therapy is still pretty hotly contested in some circles, Fogarty believes that is due to a lack of understanding about the profession and how it can help expand access to care. She believes this is most common in states with legislation still in the early stages, when misconceptions of what dental therapists do and how they are trained and supervised are prevalent. Fogarty explains, “I have never encountered a parent or patient who opposes our profession. In addition, many practitioners have said that the integration of dental therapists (DTs) and ADTs has made for a more collaborative environment that only benefits patients.”
Fogarty notes that any opposition she encounters tends to come from organized dentistry. But in her experience, once people have a better understanding of her profession and how these clinicians add to the dental team, opposition disappears. “I am surprised how quickly the Minnesota Dental Association has become supportive of our profession and how the overall controversy regarding dental therapy has turned into acceptance,” Fogarty notes. “It shows me that once people are able to see us integrated into practice and witness the safe, quality care we give, they are easily won over to become fans of DTs and ADTs.”
Though Minnesota was the first state to embrace dental therapy, it is not the last. When we left off last fall, Arizona had just passed legislation to allow dental therapists, joining Minnesota, Maine, and Vermont. Michigan was almost there. And in December 2018, Michigan passed SB541, authorizing the profession of dental therapy. The passage of SB 541 allows qualified dental therapists to provide preventive and specified restorative services, under the supervision of a dentist and within a written practice agreement, especially in underserved areas. It’s a major win in the face of sometimes intense opposition for stakeholders that have worked together to bring about the change to benefit at-risk and underserved populations in the Great Lakes State.1
Last year, several states, including Connecticut, Florida, Kansas, Maryland, Massachusetts, Michigan, Mississippi, Ohio, and Washington State introduced dental therapy legislation and seemed poised to take the next step of legalizing its practice in one form or another. Of these, Connecticut is the only one to have clinched the deal, passing SB 807 in May 2019. It was signed by the governor in June to establish dental therapy as a new type of practice in the state. The legislation allows dental therapists to offer preventive, therapeutic, and educational services in a range of settings. It is hoped that, working collaboratively with a dentist, dental therapists will help resolve oral health care access shortfalls in eight counties.2,3
Yet, while other states that were on the cusp of passing legislation last year continue to struggle against opposition, out of the blue, a handful of states that seemed nowhere close to passing dental therapy legislation at that time have managed to cross the 2019 finish line. In February, dental therapy legislation from the Coeur d’Alene Tribe passed the Idaho Senate Health and Welfare Committee. The governor signed it into law on March 25, authorizing dental therapists to practice on tribal lands in that state after graduation from a Commission on Dental Accreditation (CODA)-accredited program. Individuals are licensed by the dental board.4
In March, New Mexico’s governor signed HB 308 into law to allow dentists to hire dental therapists to provide preventive and restorative treatments. The move expands access to dental care into underserved communities and to as many as 900,000 New Mexicans.5
Nevada’s SB366 was signed into law in June. It green lights dental therapists to perform routine procedures such as basic extractions, restorative care, and applying sealants in underserved populations, such as low-income, rural, and tribal communities.6,7
Montana passed HB599 this year, initiating the creation of a community health aide program. Under this law, a dental health aide, dental health aide hygienist, or dental health aide therapist, working on tribal land, are authorized to provide dental health education and preventive care.8
SO WHERE DOES THE REST OF THE COUNTRY STAND?
Other states actively exploring dental therapy include: Kansas, Florida, Massachusetts, North Dakota, Washington State, and Wisconsin.1 While dental therapists are still not recognized in these states, there has been some, if not always forward-leaning, action in them.
Kansas’ dental therapy bill SB 312 passed the Senate last year only to die in the House. In the beginning of this year, SB 11, a bill establishing education, licensure, and practice parameters for dental therapists, was introduced in the Kansas legislature and was last reported to have been referred to the Committee on Public Health and Welfare in January.9
Three counties in Florida reportedly do not have any licensed dentists.10 And more than 5.5 million Floridians are said to live in dental care health professional shortage areas.11 Yet, SB 684, introduced to the senate on February 15, 2019, and heard by Children, Families and Elder Affairs in May, and the similar HB 649, last seen in the Health Quality Subcommittee, both died in committee.12,13
In an interesting turn, the Massachusetts Dental Society and proponents of a bill to allow the practice of dental therapy came up with a compromise last year. In its new form, the bill would require dental therapists to have a master’s degree and pass a clinical exam.14 Such requirements, however, are not aligned with CODA standards. The legislation, S1215, introduced as “An Act to Improve Oral Health for All Massachusetts Residents” was most recently referred to the Joint Committee on Public Health.15
North Dakota’s SB1426, which would have authorized dental therapists to practice in the state under a dentist’s supervision, was introduced in January and shot down in a 62 to 31 vote in February.16 Similar bills have failed in 2015 and 2017. But broad-based support for dental therapy has continued to grow. In fact, a coalition composed of 24 organizations in the state support the legislative initiative to establish dental therapy in the state. In addition, in 2018, the Tribes of North Dakota passed resolutions in support of the new profession, with plans to reintroduce a version of SB 1426. The state legislature, however, does not meet again until 2021.17
As for Washington State, introduced early this year, HB 1317 would establish and regulate dental therapists throughout the state—not just on tribal land. The introduction came on the heels of a 2017 University of Washington study that confirmed the multiple benefits of the long-term use of dental therapists in Alaska.19,20 The bill has passed two committees and is pending in the Rules Committee at this writing.
In Wisconsin, 64 out of 72 counties experience dental shortages. The state is currently considering a bill aimed at licensing dental therapists to fill those gaps by providing routine care. Two bills, AS81 and SB89 are currently working their way through the legislative process.21
THE LATEST ON TRIBAL LAND PRACTICE
As mentioned above, Idaho and Montana join Alaska, Washington, and Oregon in allowing midlevel dental practitioners to practice on tribal lands. Within these parameters, variations exist. In the case of Idaho, dental therapists have just gained approval. The latter four states, instead, employ the dental health aide therapist (DHAT) model—as part of pilot projects in the case of Oregon. Alaska’s DHATs, unlike in the other states, are not state regulated. A primary difference between DTs and DHATs lies in the fact that the latter are certified to practice, but are not licensed and are not graduates of CODA-accredited dental therapy programs.
Recently, the first round of funding has been secured to start Washington’s program at Skagit Valley College. In fact, last April, the Swinomish tribe broke ground for clinic expansion to accommodate the program, which will incorporate both Community Health Accreditation Partner (CHAP) standards and Commission on Dental Accreditation (CODA) requirements.22
Oregon’s dental therapy pilot projects are being conducted on Oregon’s tribal lands, in conjunction with various public and private entities, according to the Oregon Health Authority. Among these is a project sponsored by the Northwest Portland Area Indian Health Board. The first report from this project is due in the spring of 2021.
In May, an additional pilot project, proposed by Pacific University and the Willamette Dental Group, to examine the feasibility of adopting the dental therapist model in Oregon was being considered by the Dental Pilot Project Program Technical Review Board.
On another front, Lynch relates that there have been increasing developments regarding licensed portability for dental hygienists. “It’s similar to nurses, who have an interstate licensure compact. That means that by virtue of having a nursing license in one of 34 states, they can practice in any of the states included in the compact,” she explains.
To that effect, Lynch notes the advent of the Coalition for Modernizing Dental Licensure, of which ADHA is a member. She says that two stated goals of the organization are to “achieve adoption of valid and reliable examinations for dental licensure that do not include the use of single encounter, procedure-based examinations on patients; and achieve portability of dental licensure among all licensing jurisdictions in the US for the benefit of the public and the profession.” The coalition’s intended mission is to work to “ensure patient safety, increase access to care and promote professional mobility… .” For more information, visit: dentallicensure.org/en.
EXPANDED SCOPE OF PRACTICE FOR DENTAL HYGIENISTS
There are currently 42 direct access states—unchanged from last year. But despite the trend to expand the role of dental hygienists, roadblocks, especially in some states, remain. These are often based in entrenched reluctance. A chief concern surrounding expanded scope of practice voiced by many in the dental community appears to revolve around whether the work is irreversible. But even preventive measures, the dental hygienist’s stock-in-trade, are being hamstrung in some jurisdictions. Much of this stems from questions of supervision.
For instance, studies show that dental sealants are a major component in prevention of decay, reducing incidence of permanent molar caries by as much as 80% within 2 years of application.23–25 But when a state requires dentists to examine kids prior to sealant application by a dental hygienist, that can quickly become a quagmire for off-site oral health care, such as in schools—where the dentist is typically not present.23,26
In the past 10 years, all but about 10 states have repealed prior exam rules for such treatments. This allows dental hygienists to use their expertise to care for more patients, while helping to lower treatment costs.27 Recently weighing in on these kinds of issues, the US Department of Health and Human Services, U.S Department of the Treasury, and US Department of Labor, in collaboration with the Federal Trade Commission, formulated a set of recommendations pertaining to improving health care markets through choice and competition.
These agencies recommend, in part, that:
- All health care providers be allowed to practice to the top of their licenses, utilizing their full skill sets
- States consider permitting nondentist providers to be directly reimbursed for their services
- Requirements for rigid collaborative practice and supervision agreements between dentists and dental hygienists that lack justification in regard to health and safety be eliminated
- States evaluate emerging occupations such as dental therapy to help increase access and drive down costs, while providing safe, effective care
- States consider adopting interstate compacts and model laws that improve license portability28
Despite concerns cited by dental organizations, ranging from those of supervision and scope of practice to those of creating a tiered system of care, it is hard to overlook the impact made by midlevel practitioners, whether they be dental therapists or dental hygienists with expanded scopes of practice. With their help, access to care is delivered to those who would otherwise not have it at all—on any tier.
- American Dental Hygienists’ Association (ADHA). ADHA applauds passage of dental therapy in Michigan.) Available at: adha.o/g/resources-docs/_I_SB_541_Press_Release.pdf. Accessed October 15, 2019.
- O’Leary J. Senator Abrams leads senate passage of bill creating practice of dental therapy. Available at: http://senatedems.ct.gov/abrams-news/2506-abrams-190510#sthash.S8puj787.dpbs. Accessed October 15, 2019.
- TrackBill. Connecticut SB807. Available at: https://trackbill.com/bill/connecticut-senate-bill-807-an-act-concerning-the-legislative-commissioners-recommendations-for-revisions-to-the-public-health-statutes-dental-assistants-and-dental-therapy/1674850/. Accessed October 15, 2019.
- Russell BZ. Bill to authorize dental therapists on Idaho’s tribal reservations passes House, heads to governor. Available at: idahopress.com/eyeonboise/bill-to-authorize-dental-therapists-on-idaho-s-tribal-reservations/article_a63c3295-30ad-5ad1-b3e0-dd9464986730.html. Accessed October 15, 2019.
- New Mexico Dental Therapist Coalition. Legislative update. Available at: nmdentaltherapists.org. Accessed October 15, 2019.
- Messerly M. Midlevel dental providers to only practice in underserved areas under amended legislation. Available at: https://thenevadaindependent.com/article/mid-level-dental-providers-to-only-practice-in-underserved-areas-under-amended-legislation. Accessed October 15, 2019.
- Steehler J. Nevada Governor signs law impacting Nevadan Indian colonies. Available at: ktvn.com/story/40614812/nevada-governor-signs-laws-impacting-nevadan-indian-colonies. Accessed October 15, 2019.
- Montana HB 599. Allowing for the community health aide program for tribal facilities. Available at: https://trackbill.com/bill/montana-house-bill-599-allowing-for-the-community-health-aide-program-for-tribal-facilities/1698317/. Accessed October 15, 2019.
- Bethell RG. Senate Bill No. 11. Available at: kslegislature.org/li/b2019_20/measures/documents/sb11_00_0000.pdf. Accessed October 15, 2019.
- House of Representatives Staff Analysis. Summary analysis. Available at: flsenate.gov/Session/Bill/2018/683/Analyses/h0683a.HQS.PDF. Accessed October 15, 2019.
- Katebi C. Research and commentary: dental therapists can soothe Florida’s dental shortage pains. Available at: heartland.org/publications-resources/publications/research–commentary-dental-therapists-can-soothe-floridas-dental-shortage-pains. Accessed October 15, 2019.
- Florida State Senate. SB 684: Dental Therapy. Available at: flsenate.gov/Session/Bill/2019/684. Accessed October 15, 2019.
- Florida State Senate. HB 649: Dental Therapy. 2019. Available at: flsenate.gov/Session/Bill/2019/00649. Accessed October 15, 2019.
- McClusky PD. Compromise bill advances to allow dental therapists, a new kind of provider in Mass. Available at: bostonglobe.com/metro/2018/04/24/compromise-bill-create-new-kind-dental-provider-advances/7KsCYzb840sTnuW3QYXkQL/story.html. Accessed October 15, 2019.
- Massachusetts Dental Society. Midlevel Dental Professionals. Available at: massdental.org/Advocacy/Legislation/Midlevel-Professionals. Accessed October 15, 2019.
- North Dakota HB1426. Track Bill. Available at: https://trackbill.com/bill/north-dakota-house-bill-1426-a-bill-for-an-act-to-create-and-enact-four-new-sections-to-chapter-4320-of-the-north-dakota-century-code-relating-to-regulation-of-dental-therapists-and-to-amend-and-reenact-sections-432001-1-and-432008-of-the-north-dakota-century-code-relating-to-dental-therapist-definition-and-unlawful-practice-of-dental-hygiene-dental-therapy-and-dentistry/1629238/. Accessed October 15, 2019.
- National Indian Health Board; Tribal Oral Health Initiative. Tribal dental therapy legislation in North Dakota. Available at: nihb.org/docs/states/TOHI%20State%20Legislative%20Tracker%20Bill%20North%20Dakota.pdf. Accessed October 15, 2019.
- Laissle A. Scratch: could ‘dental therapy’ improve health care, cut costs in Ohio? Fresh Air. Available at: wyso.org/post/scratch-could-dental-therapy-improve-health-care-cut-costs-ohio#stream/. Accessed October 15, 2019.
- Chi DL, Lenaker D, Mancl L, Dunbar M, Babb M. Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim DeltaJ J Public Health Dent. 2018;78:175–182.
- High M. New bill to address the use of dental therapists.Available at: https://stateofreform.com/featured/2019/01/new-bill-to-address-the-use-of-dental-therapists-in-the-state/. Accessed October 15, 2019.
- Garrity M. Wisconsin legislature looks to license dental therapists. Available at: beckersdental.com/dentists/34644-wisconsin-legislature-looks-to-license-dental-therapists.html. Accessed October 15, 2019.
- Peters C. Oregon Pilot Project and DHAT Project Update. Northwest Portland Area Indian Health Board. Available at: npaihb.org/images/resources_docs/QBM%20Handouts/2018/July/6_C.Peters_July%20QBM%207%201718.pdf. Accessed October 15, 2019.
- Pew Charitable Trusts. When regulations block access to oral health care, children at risk suffer. Available at: pewtrusts.org/en/research-and-analysis/issue-briefs/2018/08/when-regulations-block-access-to-oral-health-care-children-at-risk-suffer). Accessed October 15, 2019.
- Griffin SO, Wei L, Gooch BF, Weno K, Espinoza L. Vital signs: dental sealant use and untreated tooth decay among US school-aged children. MMWR Morb Mortal Wkly Rep. 2016;65:1141–1145.
- Ahovuo-Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database Syst Rev. 2017;7:CD001830.
- National Network for Oral Health Access. Survey of School-Based Oral Health Programs Operated by Health Centers: Descriptive Findings. Available at: nnoha.org/nnoha-content/uploads/2014/07/SBHC-Report-FINAL_2014-07-28.pdf. Accessed October 15, 2019.
- Koppelman J. When regulations block access to oral health care, children at risk suffer. Available at: pewtrusts.org/en/research-and-analysis/issue-briefs/2018/08/when-regulations-block-access-to-oral-health-care-children-at-risk-suffer. Accessed October 15, 2019.
- The United States Department of Health and Human Services, US Department of the Treasury, and US Department of Labor. Reforming America’s healthcare system through choice and competition. Available at: hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf. Accessed October 15, 2019.
From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2019;6(11):8.