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Originally published April 20, 2012 at 4:13 p.m., updated April 21, 2012 at 8:31 a.m.
ATLANTA, Ga. Proponents in at least 15 states including Kansas are pushing their legislatures to license mid-level dental providers as a way to extend basic oral health care access to thousands who have none.
But those efforts are running up against a common obstacle: opposition from dentists.
Mid-level dental care was the topic today of a panel discussion at the Association of Health Care Journalists' annual conference in Atlanta.
Fear of the unknown is likely behind most dentists' opposition to mid-level providers, said panelist Michael Helgeson, a dentist in Minnesota. Alaska and Minnesota are the only two states that currently license mid-level dental providers.
"I think the fear that dentists have is that (mid-level providers) are going to be independent, they're going to get in deep and try to pull teeth that they're not able and licensed to pull, that they're going to get into lots of trouble. That's the fear that a lot of dentists have," Helgeson said.
He said licensing of mid-level dental providers in Minnesota ensures that doesn't happen. The key is oversight of their work by dentists, he said, which is required by the legislation passed in that state in 2009.
"They're not hanging up their own separate shingle. They don't on the nursing side either," Helgeson said of nurse practitioners, now commonplace in the U.S. since licensing began for them in the 1960s. "You can scour the literature and you won't find stories of people who went in for a throat culture and the nurse practitioner decided to do a tonsillectomy."
In Minnesota, dental therapists are required to have a management agreement with a dentist who oversees their work at remote sites sometimes via video telehealth connections. They are only allowed to practice in state-designated underserved areas, and their scope of work is limited. Further, Helgeson said, the dental therapists receive much of the same training as dentists, taking many classes side-by-side.
"I'm 100 percent confident that our dental therapists at Apple Tree know how far they can go, and when they're in a gray area we have telehealth," said Helgeson, whose nonprofit organization employs two registered dental therapists, as they're called in Minnesota. So far, there are 15 licensed in the state, he said.
Kevin Robertson, chief executive of the Kansas Dental Association, said dentists do not support the mid-level provider model simply because it would lower the standard of care to all patients.
"Why should the U.S. (or) Kansas lower the standard of care for oral care that is the gold standard for the world?" Robertson said.
Dealing with dental deserts
There's little dispute between dentists and advocates for mid-level providers that there is a pressing need to increase access to oral health care in Kansas.
At least 57,000 Kansans live in dental deserts, where there are no dental services and where the closest dental office is at least a half-hour drive from the resident's home, according to a report published last fall by the Kansas Department of Health and Environment and the University of Kansas Medical Center. KDHE officials project that number to increase as more dentists retire.
The report found that most counties in the western half of the state have only one or two dentists, if any. A dozen western counties, plus three more in eastern Kansas, have no dentist at all.
Roughly half of Kansas' 1,159 dentists are in metropolitan Kansas City and Wichita. Add in Topeka and Lawrence and more than 700 of the state's dentists are in just four communities.
But getting newly trained dentists to set up their practices in underserved areas is challenging. Fewer people are living in rural communities, and the high costs necessary to run and maintain a viable dental practice tend to steer recent graduates toward population centers.
Even where dentists are available, access to care is often limited by the small number of dentists who accept Medicaid. Less than a quarter of dentists statewide accept Medicaid because, among other reasons, reimbursements are so low that they lose money on each patient, according to the Kansas Dental Association.
Another member of the dental team
Helgeson said dentists shouldn't think of mid-level providers as encroaching on their turf. Instead, he said, they can extend a dentist's practice.
"It's a way that you can serve a group of people that are underfunded, low-income, uninsured or on Medicaid. If you want to be able to serve them, you have to be able to do it at a lower cost," he said.
Mid-level providers simply help with routine care, Helgeson said, which frees dentists to do more advanced care.
"Dentists can have another worker who they can delegate some of the most common procedures to, which are fillings. That's the main thing a dental therapist is going to do that's different," he said. "Just like a hygienist is part of your team, in Minnesota a dental therapist is part of your team. It's a way of extending the number and kind of workers that can work in your practice."
"If you have a well-oiled team, you are constantly routing people to the right level of care all the time. I'm more concerned, to be honest, about settings where there's an individual dentist on their own, where there's nobody else for miles around. That's part of why they have those fears, because most of them practice that way," Helgeson said.
Shortfall of the status quo
Panelist Shelly Gehshan, director of the Children's Dental Campaign at the Pew Center on the States, said mid-level practitioners are only a novel concept in the U.S. Internationally, she said, the position is common and comes with less training and oversight than bills in the U.S. propose.
Gehshan cited a report that analyzed mid-level provider care in 26 countries and found that they provide good quality, cost-effective care.
But U.S. dentists are content with the status quo, Gehshan said.
"Productivity and work hours have stayed virtually the same while net income has been going up and up," she said, pointing to numbers from The Journal of the American Dental Association. "They don't want change."
"We've got a system that serves two-thirds of the population really well, and the other third is more or less left out in the cold. Think about that. If you could say that about health care or any other service, there would be rioting in the streets."
"Dental is — statistically and emotionally — the biggest unmet health need among adults and children," Gehshan said. "If you care about education, you care about dental health. It's the biggest reason why kids miss school."
Unemployment numbers are also affected by lack of dental access, she said.
"One of the main reasons people on the bottom economic rung stay there is they have lousy oral health. You can't get a job if you won't smile or you can't eat," she said.
Further, lack of basic preventive care costs states and the health care system by burdening safety net clinics and hospitals with oral health problems that they are ill equipped to address.
Toothaches and other dental problems accounted for at least 17,500 emergency room visits in Kansas in 2010, according to a national report released in February by Pew.
"States spend tens of millions of dollars on operating room charges to take care of those patients. They put them under general anesthesia to try to fix things, but 50 percent of those kids are back in within a year or two because they don't get follow-up," Gehshan said.
Mid-level providers in Kansas
A mid-level dental provider's training places them between a regular dentist and a dental hygienist — able to fill cavities and perform simple extractions of teeth. Under proposed legislation in Kansas, the practitioners would be able to provide a list of routine dental services under the supervision of a dentist, but the dentist would not necessarily have to be present during the procedures.
Oral Health Kansas, the Kansas Health Foundation and other groups have supported the licensing of mid-level dental practitioners in Kansas. The Kansas Health Foundation is a major funder of the Kansas Health Institute.
But opposition from dentists in Kansas — much like in other states — has stalled the measure. Robertson of the Kansas Dental Association has said 99.9 percent of the state's dentists do not support licensing mid-level dental providers because doing so would endanger patients.
Robertson said the proposal in Kansas goes too far by allowing mid-level providers to perform procedures that are, by definition, considered surgery — that is, anything that includes the cutting of the hard surfaces of teeth.
"A maximum 18-month training is simply not adequate for a dental hygienist to learn restorative dental surgical procedures, science, anatomy and emergency treatments should complications arise during treatment while these (mid-level providers) are treating patients without dentist backup anywhere in the state – perhaps in clinics with limited or no medical support," Robertson said.
He said that extending Medicaid dental coverage to adults is among the approaches that would yield greater access to dental care in Kansas.
"Patients who cannot afford dental care from a dentist will not be able to afford treatment from a (mid-level provider) either without adult Medicaid," Robertson said.
Other approaches supported by the dental association include water fluoridation in all communities, the Level III extended care permit for hygienists, and programs designed to attract dentists to dental deserts through loan repayments and other means.
A four-hour roundtable convened earlier this year aimed at reaching a compromise on the Kansas licensing proposal failed to make inroads. Rep. Brenda Landwehr, a Wichita Republican who heads the House Health and Human Services Committee, said of the stalemate: "I don't like to see turf battles, and that's what this is."
In Minnesota, Helgeson said there was no shortage of controversy over licensing mid-level providers. It took three legislative sessions to reach an agreement.
"It took a number of key leaders — both public and private — to keep the two sides on this issue working together. Many compromises were reached to bridge differences," he said. "The pressing need to address dental access issues kept the process from stalling."
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