As a Future Dentist, What Should You Know About Midlevel Dental Providers? A Review of the 2017 Landscape – David Danesh (Harvard ’20, National Editorial Board)

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What are dental midlevel providers?
“Dental midlevel providers” is a broad term that generally describes clinicians that provide dental care, but do not have the authority or training to provide the full breadth of procedures that dentists and dental specialists do. Depending on the definition being used, dental midlevel providers may include all members of the dental team, including dental hygienists and dental assistants. A type of dental midlevel provider that has been a topic of controversy and debate for the past few years in the United States has been the dental therapist.

What are dental therapists?
Dental therapists are trained to provide a limited number of diagnostic, preventive, and restorative dental services, including patient education, dental exams and screenings, x-rays, fluoride treatments, cleanings, sealant placement, fillings, and simple extractions. In some states, dental therapists can perform pediatric pulpotomies. Furthermore, dental therapists are permitted to supervise dental assistants and dental hygienists. ASDA defines a midlevel provider as, “An individual, who is not a dentist with four years of post-collegiate education (three years in the case of University of the Pacific School of Dentistry), who may perform irreversible procedures on the public.” ASDA’s definition has two unique points of emphasis: midlevel providers do not receive the traditional dental school training of dentists, and midlevel providers can perform procedures that previously only dentists have been allowed to perform.

Oversight of dental therapists
Dental therapists must practice under the supervision of a licensed dentist. They are also limited and restricted in their delivery of care through a written agreement under the supervising dentist. The agreement clearly defines almost every aspect of dental therapists’ care, including the procedures they may perform, practice settings, and patient populations served, as well as any limitations on the services based on procedure-specific or patient-specific factors.

In addition to restrictions on practice, dental therapists are allowed to practice only under the indirect or general supervision of dentists. “Indirect supervision” means the dentist is in the office, authorizes the procedures, and remains in the office while the procedures are being performed by the dental therapist. “General supervision” means that there is not a dentist in the office or on premises to supervise any of the procedures, but the dentist must have knowledge of and have given consent to the procedure being performed.

Dental therapists in the US 
Access and cost barriers are the two main impedances to receiving dental care in the US. Access barriers could include living far away from the nearest dentist or not having a means of transportation to a dentist. Cost barriers include not having dental insurance, having inadequate dental insurance when out-of-pocket costs are too high, or not having a dentist that accepts one’s dental insurance. Furthermore, for individuals living in states where Medicaid insurance covers dental services, coverage is only available for a limited scope of procedures and not all dentists accept Medicaid. The creation of the dental therapist role seeks to address these two barriers. It has been proposed that dental therapists restrict their practice to underserved areas with few dentists, which aims to address the geographic maldistribution of dentists. Dental therapists require shorter and less expensive training with a smaller scope of procedures compared to dentists, which may allow for lower reimbursements for care than dentists. This could alleviate financial barriers to dental care.

Dental therapists are utilized in some form in more than 50 other countries, but the training and scope of practice varies significantly. In the US, Alaska, Minnesota, Oregon, Maine and Vermont are the only states that have currently passed legislation granting dental therapists the right to practice in these states. Important to note is that there are significant differences in the roles and responsibilities of midlevel dental providers between these states. Alaska and Minnesota currently have practicing dental therapists (called dental health aide therapist in Alaska). Maine and Vermont have recently passed legislation authorizing midlevel providers, but the legislation has not been implemented yet, so there are no practicing midlevel providers in Maine or Vermont as of now. Oregon passed legislation permitting dental therapy pilot programs, and two American Indian tribes in Oregon have sent students to train in dental therapy.

Positions of some of the big players in dentistry
Both ASDA and the American Dental Association (ADA) have clear policies opposing dental midlevel providers. ASDA’s policy on dental providers states “only a qualified dentist should perform the following functions, including but not limited to examination, diagnosis and treatment planning; prescribing work authorizations; performing irreversible dental procedures; and prescribing drugs and/or other medications.” The ASDA position highlights the concerns with quality of care provided by midlevel providers that have not completed traditional dental school training.

The ADA notes its “unequivocal opposition” to non-dentists performing surgical or irreversible procedures in a 2011 ADA news release and strongly opposes any dental therapist or dental midlevel provider models. The ADA comments in a 2012 ADA news release that proposals like midlevel providers will take years to implement and require large financial commitments, and they suggest that these programs will return questionable results. The ADA believes that solutions to the access/cost barriers should focus on providing care now to those already suffering from dental disease, strengthening and expanding the public and private safety net, and brining dental health education and disease prevention into underserved communities.

The American Association of Oral and Maxillofacial Surgeons outlines their policy on dental midlevel providers in an Advocacy White Paper, stating that, “The addition of midlevel providers who have less education and training than dentists will not improve the situation and, in some instances, may actually exacerbate the problem.” The White Paper further describes how comparing dental midlevel providers to physician assistants or nurse practitioners is not accurate and that only licensed dentists with the appropriate education and training should provide care.

The American Academy of Pediatric Dentistry (AAPD) details in a Dental Workforce policy statement that it does not support dental therapists because there is, “Inadequate evidence [that] supports its benefits to children’s oral health in the U.S.” The AAPD believes that resources to implement dental therapists, “Should be directed to existing proven care methods.”

In an older policy statement, the American Association of Public Health Dentistry (AAPHD) advocates for the “expanded use of new and emerging types of dental personnel,” including the Alaska Dental Health Aide Therapist.

However, dentists across the US differ on opinions regarding the role of dental therapists. The National Dental Practice-Based Research Network released a November 2016 poll gauging dentist and dental hygienist opinions on dental therapists. Among 504 votes, 49% opposed dental therapists being allowed to work in their state, and 48% supported allowing dental therapists to work in their state. Of note, 63 percent of respondents had specific concerns about the care provided by dental therapists.

What are the requirements to become midlevel providers in Alaska and Minnesota?
Alaska
Dental health aide therapists (DHATs) were introduced in Alaska in 2003 through the Alaska Native Tribal Health Consortium (ANTHC), which is a non-profit tribal health organization that provides health care to over 150,000 Alaskan Native and American Indians. ANTHC sent students to train in New Zealand and they returned to practice as DHATs in Alaska until the University of Washington established a dental therapy training program in 2007. Starting in 2017, the DHAT training program has been moved from the University of Washington to a tribal college in Alaska, announced in a 2016 ANTHC press release. DHATs complete a two-year program, after graduating high school, with rigorous didactic, scientific, pre-clinical, and clinical education. This is in addition to requiring a 400-hour preceptorship under a supervising dentist.

2008 study in the Journal of the American Dental Association of quality of care found no significant evidence that irreversible dental treatment by DHATs differs from treatment provided by dentists. The introduction of DHATs has also expanded access to dental care for over 45,000 Alaskans, as described in an ANTHC report.

Minnesota
In Minnesota, legislation was passed in 2009 authorizing two levels of MLPs: dental therapists and advanced dental therapists. You can review the text of statue 150A.105 authorizing dental therapists and statute 150A.106 authorizing advanced dental therapists. The reimbursement for services provided by a dental therapist is the same as services provided by a dentist. Prior to January 2017, in order to practice as a dental therapist, one had to complete a bachelor in dental therapy degree. After completing the dental therapy degree, dental therapists could then complete a master in advanced dental therapy degree to become an advanced dental therapist. However, both of the universities in Minnesota that offered dental therapy programs combined their dental therapy program with a bachelor’s in dental hygiene and master’s in advanced dental therapy. Thus, the bachelor of dental therapy is no longer offered. The only option for dental therapy education in Minnesota is now completing a combined bachelor of dental hygiene degree and master of advanced dental therapy degree.

According to a 2014 report by the Minnesota Department of Health and Minnesota Board of Dentistry, dental therapists were serving predominantly low-income, uninsured and underserved patients in rural and underserved urban settings. The report also said that the care provided by dental therapists is safe and quality, and clinics with dental therapists are seeing more new patients.

Maine and Vermont
Maine and Vermont have both passed bills authorizing dental therapists and defining education requirements and scope of practice for dental therapists. However, no dental training programs have been implemented and there are no dental therapists practicing in these states. In Maine, LD 1230 is the bill that authorized dental hygiene therapists in April 2014. In Vermont, S.20 (Act 161) is the bill that authorized dental therapists in June 2016.

However, a key point is that the Vermont legislation does not restrict dental therapist practice to underserved areas or to clinics serving underserved populations. The Maine legislation includes several limitations on the settings in which dental hygiene therapists are able to practice. They can work in a private dental practices that serve a population of “underserved adults” or that is at least 25% MaineCare (Medicaid in the state of Maine).

Oregon
The Oregon legislature passed Senate Bill 738 in 2011 permitting dental therapy pilot programs. The Coquille Tribe and the Confederated Tribes of Coos, Lower Umpqua and Siuslaw Indians will have members of their tribes trained as dental therapists and will return to practice in tribal communities.

Which states currently have legislation up for consideration?
Washington, Massachusetts, New Mexico, Kansas, Ohio, and Michigan are some other states that are actively considering or have considered dental therapist legislation.

The Washington legislature has introduced dental therapist legislation every year for several years, including in the 2015-2016 legislative session with Senate Bill 5465, but no action has been taken beyond introducing legislation. However, the Swinomish Indian Tribal Community in Washington state hired a dental health aide therapist trained in Alaska who began providing dental care in 2016, further detailed in a New York Times article. In Massachusetts, Senate Bill 1118 and Senate Bill 2076 were introduced in 2015, which would establish dental hygiene practitioners that would complete a year to a year-and-a-half of training to perform the functions of a dental therapist. In early 2016, legislators in New Mexico introduced House Bill 191. In Kansas, Senate Bill 413 was introduced in 2016. In Ohio, Senate Bill 330 was introduced in 2016. In Michigan, Senate Bill 1013 was introduced in 2016. A Pew Charitable Trusts Map, “States Expand the Use of Dental Therapy,” also summarizes legislation regarding dental therapists in 2016. However, while legislation has been introduced in these states, what this means is that a senator or state representative wrote and introduced a bill, but nothing more. These bills failed and there has been no implementation yet. The future of dental therapy still remains unclear.

To learn more about the current status of dental therapy, the following journal publications provide an overview the current status of dental therapist legislation throughout the US and in Native American communities:

Timeline of dental therapy in the US
ASDA summarizes the major events in implementing dental therapists across the US, with more information available at: http://www.asdanet.org/midlevel-providers.aspx.

Dental therapy moving forward
The expansion of the dental workforce to include new midlevel provider positions is a highly controversial issue facing dentistry that varies across the US. This article attempts to provide an objective, factual overview of this important topic in dentistry. I encourage you to check out the additional resources below to learn more about this issue, especially the ASDA and ADA resources. Only one thing is certain: MLP legislation will continue to be hotly debated for the foreseeable future. It is vital that we, the current and future leaders of the dental profession, remain informed about this topic and its potential effects on the changing landscape of dentistry.

Additional resources

Acknowledgments: Special thanks to Ryane Staples (UConn ’20), Kristen Yant (Harvard ’20), Kellie Moore (Harvard ’18), and Adam Patenaude (Harvard ’17) for their thoughtful feedback on this article.

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