October 1, 2012
by Pat Foy, DDS
The State of Minnesota has finally licensed the first Dental Therapist and the whole world is watching this new dental experiment down in the Land of Ten Thousand Lakes.
The American Dental Association and the Minnesota Dental Associated were initially opposed to the new Dental Therapist Law, mainly because of concerns about patient safety and they had supported a different type of mid-level provider called an Oral Health Provider. Despite the opposition from the existing dental professional community in this state and parts elsewhere, the Dental Therapist Law was enacted in May of 2009. After a long, drawn out political process and heated debate, the current law established two levels of Dental therapists: a Dental Therapist and An Advanced Dental Therapist.
The concept of a dental therapist is supported by the Pew Foundation and the Kellog Foundation as a means to improve access with a possible reduced financial risk to communities. Also the Minnesota Dental Hygiene Association and Hygiene Educators had a very active role in establishing an educational model within the Community College system. This was supported more by their leadership than the dental community as a whole. They equated the Dental Therapist to that of a Physician’s Assistant. It was argued that more people will receive dental care and the professional providing care will demand less of a salary than a licensed dentist. The example they used was that a dentist could be paid roughly $75.00 per hour whereas a therapist would be paid approximately $45 per hour. Whether or not a dentist would agree to this level of remuneration would be up to the particular dentist involved.
As of December 1st, 2011, there have been only five licensed Dental Therapists in Minnesota according to Mr. Marshall Schragg, the Executive Director of the Minnesota Board of Dentistry. Dental Therapists now have the ability to drill and fill cavities, extract primary teeth, pulp cap, prepare and place pre-formed crowns, remove sutures, repair dentures and perform many other miscellaneous dental treatments under the general supervision of a collaborating dentist. (Please refer to table setting out the levels of supervision applicable in Minnesota.)
The collaborating dentist must be licensed in the state of Minnesota. A licensed dentist can sign, under contract, up to five Dental Therapists under a Collaborative Agreement at one time and then the dentist has the right to determine or limit what procedures each Dental Therapist can perform despite what is allowable by law. The dentist is ultimately liable for the outcomes of the procedures performed by the Dental Therapists under the dentist’s own malpractice insurance policy. There is only one Dental Therapist in the state that was hired by a private practice who provides for Public programs (Welfare or Medicaid). All others are employed by community clinics or county hospitals. There are also Federally Qualified Community clinics.
An Advanced Dental Therapist has to complete 2000 hours of clinical practice under direct or indirect supervision of a dentist, graduate from a master’s advanced dental therapy education and pass a board-approved certification as prescribed by the board. An Advanced Dental Therapist may perform nonsurgical extractions of periodontically diseased teeth with mobility of +3 to+4 under general supervision if authorized in advance by the collaborating dentist. The collaborating dentist is ultimately responsible for providing or arranging for another dentist or specialist to provide any necessary advanced dental care. The duties of the Advanced Dental Therapist should be clearly spelled out in the collaborating agreement with the contracting dentist.
Senator Lynch from Rochester, Minnesota was the author of the bill and she has been hired by the American Dental Hygienist Asssociation in Washington D.C. as a legislative consultant. It is apparent that the ADHA supports the expanding professional development of its members.
There are currently two educational facilities in Minnesota that are training Dental Therapists. The University of Minnesota Dental School, Minneapolis Campus, offers a Bachelor of Science in Dental Therapy and a Masters Program and the applicant does not have to be a dental hygienist to qualify for admission. Metropolitan State has an Oral Health Care Practitioner Master of Science Program that is delivered at Normandale Community College Campus in Bloomington, Minnesota, a suburb of Minneapolis. To qualify for the Metropolitan State Program one must already have graduated from a credentialed dental hygiene program and be licensed. This latter Program encourages licensed dental hygienists to expand their professional capabilities.
The law states that a Dental Therapist must limit his or her practice in settings that serves the low income and the underserved community. In effect, this mean that only dentists who treat these types of patients in their practices are able to hire Dental Therapists. The objective is to help increase the access to dental care in areas where such access has traditionally been perceived to be inadequate. Since it is also perceived that there are many dentists who are struggling in this down economy, there is a potentially large capacity to produce dentistry which could meet all the dental needs in the state, but the barrier stopping this is a huge mal-distribution of supply problem. Dentists commonly place their dental practices in larger cities and not enough are practicing in the less populated areas. It is hoped that the use of Dental Therapists under this model will be successful in helping to address community needs.
There is language in the law that will have the Board of Dentistry and the Health and Human Services sectors revisit the outcomes in a few years to see if the law has accomplished what it was intended to do, namely if there has been more access to dental care for rural areas and poor underserved areas. This includes medical facilities, assisted living facilities, federally qualified health centers, qualified community clinics, educational facilities, mobile clinics and populations who are on public programs or in areas that qualify as a professional shortage area.
The question of access to dental care in the rural regions of Minnesota and the mal-distribution of dental professionals may be a geographic hurdle that may only be solved by transportation solutions in the future. It may not ever be feasible (in some remote regions of the state) to have a dental professional nearby. The density and the distribution of the population can be limiting factors on the economics of operating a rural practice in rural communities.
There currently is not a shortage of dentists or a lack of capacity in the dental offices throughout the state of Minnesota, especially over the last few years as result of a struggling economy. Many dentists would be willing and able to serve more patients but the low re-imbursement rates of State of Minnesota programs without any other subsidies makes it financially impossible for most private practitioners to provide dental care at the currently inadequate re-imbursement rates.
This subject has garnered attention from the media. For instance, a television program on C-span was sponsored by The Robert Wood Foundation and the panel included an ADA spokesperson, the Pew Foundation, a Minnesota Dental Therapist, and a federal government spokesman. The Dental Therapist from Minnesota presented the rationale for dental therapist treatment; the ADA and MDA presented the perspective of the dental profession including concerns with the cutting of hard or soft tissue by anyone other than a licensed dentist.
It has yet to be seen how this new provider will impact access to care in Minnesota. Will this new model be accepted by the patients? Will there be enough positions available to new graduates? Will it create a new standard of care? Will Public Program patients be relegated to Dental Therapists in the future? Will Dental Therapists b
e allowed to treat all patients, not just low income and underserved patients and be able to practice as independent, self-regulated dental health care professionals in the future? Already, there is discussion emerging on websites open to the public suggesting that such legislation be created in the future. It is noteworthy that in President Obama’s Healthcare Reform there is language that alludes to the use of a Mid-level provider.
The issue of how increased access to dental care should be provided and by whom in the best interests of the public should be a priority and concern to all of us in the dental profession. There are many questions that are currently left unanswered here in Minnesota, but with time and experience, light will be shed revealing success or failure of this new experiment.
The horse of the Dental Therapist has barely left the barn, so sit up, pay attention and don’t miss the ride. The future of dentistry as we know it may be at stake.OH
Patrick J. Foy, D.D.S., received his dental degree at the University of Nebraska Dental School and completed a General Practice Residency at the VA Medical Center in Minneapolis. Active for many years in several levels of organized dentistry, he currently serves on the ADA’s Council on Ethics, Bylaws and Judicial Affairs and the Minnesota Dental Association’s Taskforce on Evidence-Based Dentistry. Dr. Foy practices general dentistry in Minneapolis and has become an enthusiastic spokesperson promoting the value and exciting possibilities of getting involved in Evidence-Based Dentistry and dental practice-based research networks. His commitment to the concept led him to become a Practitioner-Investigator in a 67 million dollar National Dental Practice-Based Research Network project funded by NIDCR, one of the National Institutes of Health. He currently serves on the NDPBRN Executive Committee for that project. His first book “Architect of Smiles” can be found on Amazon.com, He can be reached at firstname.lastname@example.org.
Chart reprinted with permission, Minnesota Board of Dentistry. www.dentalboard.state.mn.us