One of the hot issues currently being addressed in dentistry is patients’ access to care. According to an ADA investigation, “The increase in dentists [entering private practice] may meet the continued demand, and perhaps create a surplus, in the private sector. However, there are not likely to be sufficient providers to meet the demand in the growing publicly insured sectors of the population.” Numerous solutions have been proposed to address this discrepancy, but one solution in particular seems to be gaining steam in multiple states. This solution is midlevel providers, also called Dental Therapists. A dental therapist is a licensed oral health professional who practices as part of the dental team to provide educational, clinical, and therapeutic patient services. A midlevel provider essentially works under the supervision of a dentist, much like a physician’s assistant, ideally in a setting that serves low-income, uninsured, and underserved patients. Currently, there are multiple dental therapist models being proposed. However, with the creation of any new healthcare provider, opposing ethical issues immediately arise. This discussion will focus on the ethical concerns brought up if dental therapist were to join the dental team.
In order to become a dental therapist (and depending on the program), one must complete at least two years of dental education beyond high school. The Commission on Dental Accreditation (CODA), which accredits dental schools and dental education programs, has also created a set of standards for dental therapist programs that must be met in order to
become accredited. In the state of Minnesota, dental therapists are taught side by side with dental students, taking the same courses, exams, and patient boards. The instructors are unaware of whether the prep being graded is from a dental student or a dental therapist.
Upon graduation, dental therapists have to work under a dentist’s direct supervision for an additional 500 to 2000 hours, depending on the state’s requirements. At this point the supervising dentist then decides which procedures he or she feels the therapist is competent to perform on their own. The dentist no longer has to be in the room while the dental therapist is treating patients. However, the dentist must provide either general supervision or, in some states, be available by “telecommunications.”
Currently, there are over 500 different procedural codes (CDT) a general dentist can perform and bill to insurance providers. Of these codes, dental therapists would be able to perform around 80 of these codes under the supervision of a dentist. This limits the dental therapist scope of practice to about 15% the scope of a general dentist, with a big chunk of procedures focusing on preventative and cleaning services. A dental therapist must also have his or her own malpractice insurance. When putting this into perspective, it is easy to see why some believe dental therapists might be the answer to our access to care problem.
One of the major concerns in the dental community concerning dental therapists is, “What happens if something were to go wrong?” Dental therapists perform irreversible procedures in locations where dental care is limited. This could also mean medical services and dental specialists are also limited, or even nonexistent for many miles. If a patient were to have a medical or even a dental emergency in the middle of nowhere, what happens then? Will a midlevel provider have the skills and/or training to deal with these unique situations when an emergency does occur? Is having a dentist available by Skype or telephone enough? Patients should not have to compromise care because of their location. The quality of care must be the same regardless of who is performing the procedure, and the patient must be well informed of the increased risk that might be involved when being treated by a midlevel provider.
What do you consider a complex extraction or a simple extraction? This is where the dentist’s role in supervision of a dental therapist becomes extremely important to ensure the patient’s safety and a high quality of care. The dental therapist needs to have the ability to know when a tooth is within his or her skill set and when consultation is necessary with the supervising dentist. Maybe one dentist doesn’t want their dental therapist to perform any extractions, while another feels very confident in their dental therapist’s skills. One thing is worth noting: In the state of Minnesota there has yet to be a safety or quality complaint since the first graduating class in 2011.
Many of my classmates feel dental therapists might not be needed, but will be unavoidable during our careers. We should be open to this idea and even play an active role in helping these programs come to life. As future dentists, we need to make sure dental therapist’s sole focus is not on treating disease but on prevention and education for the patient. It’s up to the dentist, as the captain of the team, to ensure all players are performing at their best and that patient’s health is at the heart of the game.
To learn more, check out Student Ambassador Lyn Wilson's blog on Midlevel Providers.