EDITORIAL

MIDLEVEL PROVIDERS

In 1980 I was getting ready to graduate from the Oregon Health Science University School of Dentistry. At the same time, a 31-year-old lawyer by the name of Ron Wyden was campaigning to win a congressional seat from Portland. He was promoting the “gray panthers”, a term he used to describe the elderly. Part of his platform to support the “gray panthers” was to legalize denturism in the state of Oregon. His proposal was to allow technicians who had been trained in providing the laboratory side of making dentures to provide dentures directly to the public without supervision by a dentist. They would not need to go to school but would-be grandfathered in. The reason he gave to support denturism was that it would be cheaper and improve access to care. Sound familiar? At the same time Portland was trying to pass a law to allow the fluoridation of its public water supply. The results of the elections were denturists could provide dentures directly to the public, but fluoride was not added to Portland’s water. Portland is still the largest city in America without water fluoridation. Dentists lost in both cases. Ron Wyden won his election and like most politicians has never left. Now he is a bald headed, old man who looks a little weird (to use his own term) and is in the U. S. Senate. Denturists can now practice indirectly in Oregon, Idaho, Montana, and Washington. They can practice under supervision in Maine, Arizona and Colorado. I learned early on that one politician can have a huge impact on dentists, that the slogan of “rich dentists need to be cut down to size by providing cheaper alternatives and allowing more access to care” could win votes.

Today we are facing a much bigger attack on our profession. They are called midlevel providers or dental therapists. The idea of having less trained individuals providing expanded dental care began in New Zealand in the 1920’s. Today 54 countries have dental therapists. As of August 2019 Alaska, Arizona, Connecticut, Idaho, Maine, Michigan, Minnesota, Nevada, New Mexico, Oregon, Vermont and Washington have authorized the practice of dental therapists. Minnesota seems to have been the most aggressive state in promoting dental therapists. They have a program to educate and license dental therapists and over a hundred of these midlevel providers are working in Minnesota. The only other school of dental therapy is in Utqiagvik (Barrow) Alaska, that is at least what was reported. Vermont is expecting to open a school soon. Outside of Minnesota, most dental therapists seem to be working on Indian reservations.

The two main organizations funding and promoting midlevel providers are the Kellogg and Pew Foundations. What is the scope of practice for a dental therapist? There are over thirty procedures that they can perform. They can provide all preventive and diagnostic procedures. They are allowed to administer nitrous oxide and prescribe certain drugs. They can perform cavity preparation and restoration of primary and permanent teeth. They can prep and place crowns on primary teeth and place temporary crowns on permanent teeth and recement permanent crowns. They can extract primary teeth and do “simple” extractions of permanent teeth. They can perform pulpotomies on primary teeth and pulp cap permanent teeth. They can reimplant and stabilize a fully avulsed tooth. They can make space maintainers and do denture relines. In my mind they are coming close to being general dentists. They use high speed hand pieces and elevators and forceps.

Why is there a demand for midlevel providers? Simple, the American public believes they will provide less expensive care and care to otherwise neglected people. Cost and access to care. The University of Minnesota school of dental therapy prints in bold lettering, “Dental Therapists work primarily in settings that serve low income, uninsured and underserved populations or in a dental health professional shortage area”. That is a hard combination for dentists to take on. We sound greedy and heartless. Personally, I do not think that they will be inclined to go to unattractive places or to provide services for less than they can charge.

Where will the dental therapists come from and how will they get training? I suspect that hygiene schools and hygienists will provide facilities, faculties, and students for schools of dental therapy.

In the future, I could see dental therapists providing much of what we call restorative dentistry. Dentists will need to become experts in advanced areas—taking on some of the work currently done by specialists and also new areas such as sleep apnea, occlusal therapy, laser dentistry, implant dentistry, wisdom teeth extractions and so on. This will require dental schools to become more demanding because graduating students who can’t do much more than a dental therapist would be of little value.

Over my time as editor, I predicted the coming of two dental schools, the coming of a pandemic and now the future of dental therapy. Utah will be slow to join the dental therapy bandwagon because we already have plenty of dentists and a low reimbursement rates. But remember, sometimes it only takes one goof ball politician to mess things up!!

Dr Drew Jones UDA Action Editor