MLPs could change the dental landscape

2013 12 23 15 23 25 385 Second Opinion 200

I'm 100% in favor of midlevel providers (MLPs) and have been for years.

Personally I don't understand why all dentists are not in favor of MLPs. Professionally, I understand why the vast majority of nonspecialist dentists oppose MLPs as they see them as a threat but don't understand why specialists are opposed to MLPs (other than needing to agree with general practitioners to get referrals).

First and foremost, we dentists are supposed to serve the public good to enhance prevention and access to care for all patients. Midlevel providers would do that by allowing hygienists with additional training to render the most basic care unsupervised. Things like scaling, extraction of primary teeth, sealants, and even basic fillings.

Benjamin Burris, DDS.Benjamin Burris, DDS.

What's that you say, doctor? Hygienists are not adequately trained to do these things, and a little extra training does not an independent provider of dental services make?

From where I sit, this is the same argument that specialists make against general practitioners taking a weekend course and proclaiming themselves proficient, but that doesn't stop it from happening.

Next, MLPs would level the playing field and provide patients access to the best care possible without allowing pesky self-interest to interfere. What do I mean? At present, the majority of the new-patient flow is controlled by general dentists; in effect they are the gatekeepers. This is compounded by the fact that hygienists, though they do almost all the work at regular cleaning and exam appointments, are currently forced in most states to work under the license of a general dentist.

This is all well and good except the gatekeeper has a monetary incentive to keep all the work in-house (so they can get paid for the work irrespective of the difficulty of the case or the skill of the general practitioner). That is not to say that all general dentists keep work in-house that they should not, but a lot do and most are happy to "try the case themselves" knowing that if something goes wrong "the specialist will bail them out because they want the referrals."

I know this sounds perfectly logical to most general dentists in my experience, but I object and patients would too if they knew the lay of the land. Don't patients deserve the best chance for a positive outcome the first time?

I'd ask where did you send your kids and your spouse for any kind of specialty treatment such as braces, aligners, or gingival grafting? That's what I thought. Any of you who sent your family members to a specialist but treat other people's kids for fun and profit are proving my point to the detriment of patients and the profession.

As an aside, many want to argue this point about hygienists doing the work at cleaning appointments, but I know better. I've been to hundreds of offices and talked to enough hygienists and patients to know that this is the case at the average office. Hygienists are basically indentured servants and cash machines for the dentists who employ and could easily do what they do now on their own.

Access to care

The most appealing aspect of the advent of MLPs is that they will increase access to the most basic dental care both geographically and financially. This is great not only because of our obligation to the public good but it is also good for dentistry and dentists.

“Midlevel providers are coming to dentistry just as surely as physician's assistants came to medicine.”

As patients take better care of themselves, they want to take even better care. The better their teeth look, the more particular they get. This leads to more dental work for all of us. Right now, the vast majority of Americans don't have ideal dental health or anywhere close to that. Education, access, affordability, and convenience are the keys. Midlevel providers will move us in the right direction for prevention, awareness, education, and access to the best possible care for each individual patient.

Midlevel providers are coming to dentistry just as surely as physician's assistants came to medicine. Arguing against MLPs as a profession (they way we are now) puts us on the wrong side of a public access-to-care debate, and it makes us, as a profession, look like a bunch of money-grubbing turf-defending jerks. We will ultimately lose as the advent of MLPs is inevitable.

Democracy has no dominion over truth. Think about this issue from the point of view of a nondentist. Ask people not associated with your office what they think. Understand what is happening with or without you and, most important, understand that change is coming. To survive and thrive we must change "the way we have always done it" or suffer the consequences individually and as a profession.

Ben Burris, DDS, is an orthodontist, writer, speaker, philanthropist, activist, and patient advocate. He can be contacted at

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.

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