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Mo. dental board endorses midlevel provider proposal
By Donna Domino, Features Editor

June 8, 2011 -- Despite opposition from the Missouri Dental Association (MDA), the Missouri Dental Board has become the first dental board in the U.S. to endorse a proposal for midlevel providers.

The proposal, submitted to the board by the Greater Springfield Dental Society, calls for the creation of licensed dental therapists and advanced practice dental hygienists, both of whom would be allowed to perform surgical and irreversible procedures, including some extractions and restorations. The state dental board voted May 27 to endorse the idea, according to Brian Barnett, executive director of the dental board.

The recommendation will be forwarded to the state Legislature, but state lawmakers have adjourned for the year so no action can be taken until the Legislature reconvenes next year. It is expected that a bill creating dental therapists and advanced practice dental hygienists will then be introduced.

“Dental associations exist to advocate for dentists; dental boards exist to protect the public.”
— Brian Barnett, executive director,
     Missouri Dental Board

The fact that the proposal comes from a state dental board may provide the measure with greater traction than has been the case with similar proposals in other states. It also highlights disparate attitudes within the dental profession regarding workforce models.

"Dental associations exist to advocate for dentists," he told DrBicuspid.com. "Dental boards exist to protect the public."

MDA President Mark Zust, DDS, said his group opposes the creation of midlevel providers as outlined in the new proposal because it focuses too much on restorative dentistry and not enough on prevention.

"We believe any new dental workers would be most effective by addressing the root of oral health problems: working to encourage regular preventive care and providing basic preventive services to those who need it most," he wrote in an email to DrBicuspid.com. "We cannot simply drill and fill our way out of the access-to-care problem. At the same time, we also want to ensure any new workforce model protects the safety of the patient."

Access to dental care is a multifaceted issue, he added. "Adding a new provider to the dental team is not a cure-all for solving the access problem, but rather needs to be part of a larger, more comprehensive approach that also places heavier focus on prevention efforts," Dr. Zust noted. "The dental association has their views, and the dental board does not necessarily always agree with them on the best course of action."

The MDA supports the development of a community dental health coordinator and an oral preventive assistant to provide care in underserved communities, he added.

The ADA and most state dental associations have adamantly opposed the concept of midlevel providers, and have fought legislation that would expand the scope of duties of hygienists and set up new categories of midlevel providers who would be allowed to do extractions and restorations.

Related Reading

5 states battle over dental therapist legislation, April 19, 2011

State dental groups question dental therapist qualifications, December 8, 2010

Pew report finds economic upside to midlevel providers, December 7, 2010

More states moving forward with midlevel providers, November 17, 2010

2-year study finds in favor of U.S. dental therapists, October 26, 2010


Copyright © 2011 DrBicuspid.com

Last Updated hh 6/8/2011 9:37:09 AM
Forum Comments
42 comments so far ...
6/8/2011 2:16:50 PM
S. Hwang		 I went to a dental school for 4 years and did residency that was surgery intense.
I do almost all dental surgeries in my office now but I still run into some teeth once in a while that humble me.
I feel this way after 7 years out of residency program.
I wonder how well the dental therapists will be prepared. Financially, it makes sense to provide mid level care so that people get more access but more access doesn't mean better care.
Makes me feel horrified actually....
6/8/2011 4:28:42 PM
WhiteLake69		 If you were taught critical analysis/thinking in dental school and in your residency, you are encouraged to use i. The data is overwhelmingly demonstrating appropriate safe and effective care provided by DTs, within their scope of practice. This track record continues in to this day, with DTs performing five basic and very needed services in Bush Alaska.  They could be doing the same things in inner city schools, other areas where dentists have not been effective, or cost far too much to train for the role that is needed. No one is teaching them to perform complex extractions, nor does anyone propose it. In all cases, DTs are supervised closely by dentists with training very much like that which you have.

If you feel horrified, it is only because of lack of knowledge, not that organized dentistry, including many dental educators, have informed dental students of what such personnel have been doing worldwide during the past 90 years.

I can only encourage you to seek evidence. It is all too easy to adopt a belief system and defend it against all comers. American dentistry has served 2/3 of America admirably for more than a century. That it has failed to improve access for the lowest 1/3 is not entirely its fault, however its blindness to possibilities should be embarrassing to us all.

Consider the following quote, from perhaps the greatest Executive Director in the history of the ADA:
"When the dental history of our time is eventually written, I believe the New Zealand Dental Nurse program will be considered one of the landmark developments in the practice of dentistry and dental public health."
 
Harold Hillenbrand
Distinguished and esteemed Executive Director
American Dental Association, 1947-1969 





6/8/2011 7:53:53 PM
drmo		 Supposedly the midlevel provider position is being created to create greater access to care for low income populations, but does this bill stipulate that they can only treat that population? So what is to keep a licensed DT from opening a practice right next door to yours, and start offering lower priced restorative and preventive services that you claim to be of equal caliber to yours? The DT model works in Alaska because there is truly an unequal distribution of dentists, but most urban areas with these "inner city schools" you speak of have plenty of dentists, the problem is those dentists don't get reimbursed enough to see medicaid/chip patients or they just plain don't want to see them. I am all for removing barriers to care, but I don't think creating a midlevel provider is the solution.
6/9/2011 7:09:52 PM
SwanO		 WhiteLake, you are being rude.  Even if a less trained practitioner were just as safe and effective, it does not make any economic sense.  How much do you think the price of dentistry will drop?  The only difference will be the salary of the actual practitioner.  Overhead will stay exactly the same.  Let's say that it's slashed by 75% so from say 100/hr to 25/hr because the midlevel provider will work for less money.  I'll keep the numbers simple.

Now, follow along.  These are all simple numbers and may not represent the real time needed for procedures.  A crown that once cost $1000 for 2 hours of work (at the 100/hr rate) will now cost $850 (at the 25/hr midlevel rate).  Do you really think you are helping the less fortunate and by charging them $150 less with a less-experienced and less-educated practitioner?  Do you really think the same person that couldn't afford the $1000 crown will be able to afford the $850 crown??!!  The overhead will be exactly the same, UNLESS there is a government handout to help subsidize the crown.  This government handout would do the same in both scenarios, as I'm sure you can conjecture. 

This is purely a political power issue, and everyone knows it, but politicians have found an easy way to win some votes.  If you really want to solve the access to care issue, support a model that focuses on prevention.  Diluting the overpopulation of dentists and creating a two-tier system of healthcare will not change anything.  Do you not see what has happened with nurse practitioners and physician's assistants?  You can't find an American medical student that will become a GP.
6/9/2011 7:46:25 PM
mcentiredds		 WhiteLake, do you not extract many teeth?...or are you a hygienist...or maybe in public health....or a DHAT yourself?? Just curious, because your comments are ignorant. The point S. Hwang is making is that the "simple" extraction can often quickly become more difficult than one anticipates. Just as the routine restorative procedure can often become more difficult. Having an undertrained individual performing IRREVERSIBLE procedures, without the training to "bail themselves out" is reckless and a poor service to the public. We are dealing with caries, A 100% PREVENTABLE DISEASE. The key to better oral health in our country, much like type 2 diabetes, is all in prevention.

WhitLake, just stop and ask yourself: would YOU want an undertrained provider with little more than technical school training doing an irreversible procedure in YOUR mouth?

Conversely, would you want someone with a technical school program under their belt doing surgery on any other part of your body??....I'm sure appendectomies or cataract surgery are routine and can be learned with 6 months of training. This is a slippery slope to creating a two-tier system where part of the population gets subpar care.
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