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Minnesota proposal for new dental assistant sets dentists' teeth on edge

Faculty and students use the University of Minnesota School of Dentistry's high-tech dental simulation clinic.
Courtesy of the University of Minnesota School of Dentistry
Faculty and students use the University of Minnesota School of Dentistry's high-tech dental simulation clinic.

Minnesota dentists are all abuzz — and concerned — about the creation of a new mid-level job called oral health practitioner.

Legislation last session opened the door to creating the discipline, which is basically a step between a hygienist and a dentist. The practitioner would be licensed to pull teeth and fill cavities, something that today only dentists are allowed to do.


The new position wouldn't compete directly with dentists for business, but there has been opposition to the proposal, primarily from the Minnesota Dental Association, which has voiced concern about practitioners performing surgeries and other procedures without the direct supervision of a dentist.

Sen. Ann Lynch, DFL-Rochester, whose legislation created a work group to study the new dental position, says the association's resistance is reminiscent of arguments presented some 40 years ago on another health care assistant.

"It's like when we enacted mid-level nurse practitioners," says Lynch. "We had the same conversations, and now today the physician's assistant is an important, vital and widely accepted part of the health care team."

Practictioner would fill critical gap in dental care system
Lynch and other supporters say the new oral health practitioner position is a critical component in filling a gap in dental care access for what are called "underserved populations," which include the uninsured, low-income, mentally and physically disabled, and people living in homeless shelters, reservations, prisons, and nursing homes.

In short, under Lynch's legislation — and work group recommendations due to the Legislature this week — the oral health practitioner would be allowed to treat only underserved populations that most dentists refuse, or are simply not available, to treat.

There are nearly 4,000 licensed dentists in Minnesota. But, according to the Minnesota Department of Human Services, there are only about 180 dental practices designated as critical access dental providers.  That equates to about 450 dentists who treat enrollees in the state-subsidized Minnesota Health Care Program on a regular basis. And although about 2,500 dentists (in Minnesota and neighboring states) are authorized to treat Minnesota Health Care Program enrollees, fewer than half of them (48 percent) saw more than 50 underserved patients.

Michael Scandrett of the Minnesota Safety Net Coalition — a group of hospitals and providers who treat low-income and uninsured populations — says the dearth of dentists treating the underserved is a major concern.

"We can't get dentists to work with these patients," says Scandrett. "At low-income clinics, you can wait 7 to 9 months to get in to see a dentist because of the shortage. It's also an issue on Indian reservations, because there are no dentists practicing in those areas. In metro areas, there are long waiting lists because we can't find dentists willing to do that kind practice."

The need for dental care is also acute in nursing homes, according to Mick Finn, chief of operations for Ecumen, one of the state's largest providers of senior housing.

"We have trouble getting oral care for our residents," says Finn, "There aren't enough dentists out there who will see our residents. It's a supply-and-demand question."

Finn says many dentists aren't interested in specializing on the elderly who may have confusion issues or other complexities of an aging body.

And there's also a payment issue, which is no small problem.

"Many residents are on medical assistance," says Finn, "and the reimbursement rate isn't what [dentists] would like it to be."

For many in the field of dentistry and public health, the proposed oral health practitioner position helps bridge the dental access gap.

A similar discipline, called a dental therapist, is widely seen in dozens of countries, including Great Britain, New Zealand, and Canada.

When the oral health practitioner position is fully implemented here,

Minnesota would be the first state in the country to create the mid-level position (Alaska has something similar, but it's limited to the beneficiaries of the Alaska Tribal Health System).

"What we have before us is really leading, cutting edge," says Lynch. "That's really exciting and what a great opportunity."

Agreement on goal, opposition on answer
Although improving access to dental care is a key aspect of health reform and a goal just about everyone in the medical community can agree upon, not everyone is sure creating an oral health practitioner discipline is the answer.

The Minnesota Dental Association opposed the creation of the mid-level position last year when Lynch's bill was introduced.

And though the association had at least three representatives on the just-concluded work group of dentists, hygienists, higher education and health care policy experts, its immediate past president — Maple Grove dentist Jamie Sledd — says her membership is not happy with the way the practitioner role is being defined.

Sledd says her organization opposes a recommendation that a practitioner be allowed to pull teeth and perform other procedures without the presence of a licensed dentist onsite. Additionally, the MDA believes only a dentist should be able to diagnose conditions, prescribe drugs or create a treatment plan.

That's a position directly in opposition to the work group recommendations, which allow the practitioner to work more independently.

For Sledd, that independence raises patient safety issues.

"Another way to phrase it, is there should not be two levels of care," says Sledd. "Everyone has a right to the same safety and quality of care."

Sledd says even a routine extraction can turn into an emergency, and she is skeptical that practitioners would have the training to handle all the challenges that still test even dentists with years of experience.

Sen. Lynch says the MDA requirement that a dentist make the diagnosis and be present during a procedure, defeats the purpose of the position.

"This legislation wasn't designed, and was not for the benefit of, dentists or hygienists or the higher-ed institutions," says Lynch. "This legislation is to address a very serious unmet need in this state and this country."

Revised legislation would give practitioners latitude
Lynch plans to introduce a revised version of last year's legislation that reflects work group recommendations that allow the practitioner to pull teeth and do other procedures independently. The practitioner would have what's called a "collaborative management agreement" with a dentist and be under his or her general supervision, but a dentist would not be required to be onsite when a practitioner is working.

The MDA's Sledd says her organization will fight for greater supervision and a narrower scope of practice for the new position. She says the association may introduce its own, competing bill.

"We want to make sure we're at the table and addressing the needs of Minnesotans," says Sledd. "We want to make sure the practitioner works in a safe, healthy, economically feasible way."

Most people in the dental community are optimistic that a compromise can be reached this session between the work group recommendations and the MDA concerns, and that questions about the scope of practice, education level and supervision of the new position will all be answered.

Academic programs gearing up
Meanwhile, the University of Minnesota and Metropolitan State University are creating separate academic programs in anticipation of training students to become oral health practitioners.

Both schools plan to enroll students this fall.

The U of M is creating both a bachelor of science degree and a master of dental therapy degree.

Practictioners would have two years of specialized training, while after college, dentists have four years of dental school and could have two or three additional years of study for a specialty.

Metro State, part of the Minnesota State Colleges and Universities (MnSCU) system, has designed a master's program geared toward licensed dental hygienists who want the expanded training and are willing to work with underserved populations.

"It's really about access," says Tom Cook, Metro State's director of governmental relations, "In the broad sense, that's part of MnSCU's DNA and the university's charge. That's our approach to enrollment, and this service to the community is a natural step to take it on as well."

There are some who fear Metro State's program could be Bigfooted by the U of M's School of Dentistry, which also wants a piece of the action. It is the only dental school in the state and has the support of the Dental Association, which believes the U of M's program would provide the narrower scope of training that it wants to see for oral health practitioners.

In any case, the School of Dentistry's dean, Patrick Lloyd, is excited about the new program.

"This is a huge deal for us," says Lloyd. "We'd be the first dental school in the country to do this. I get a call every week from dental schools asking me about it. It could be a Minnesota model picked up by other states."

Lloyd says one of the best outcomes of the coming legislative debate over the issue will be increased public awareness of the range of problems contributing to the barriers to dental care access.

Marisa Helms writes about politics and other topics. She can be reached at mhelms [at] minnpost [dot] com.

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Comments (7)

Our government has chosen to give dentists an absolute monopoly on dental work. Given how our government works, we should probably be happy that the dentists haven't asked the legislature to build them a domed stadium yet.

The average overhead for a dental office around the nation is 65%!! Thsat is the expense before the docto is paid anything, covers staff salaries,, fixed and variable expenses. The Minnesota State legislature and the Federal Government reimburse dentists about %40 of their usual and customary fees. In other words, it costs the dentist %25 of their production to see these patients assuming they show up. Can you say unrepresented taxation?? I am tired of th government and other organizations bashing dentists for years because we refuse to see Medical Assistant patients. It's n ot our fault. It is a pure business problem and the government is to blame for the state of the welfare system, not the providers. Raise reimbursement rates to cover the overhead of practitioners(65%) and the Access to Care Problem will disappear!!

If you think that's wild; consider this. This is how the new administrations plan on "creating jobs"... They will be the same old jobs but "divvied" up and legal requirements added to them so you have to attend special schools to be able to do those jobs. This I can see coming.

I wish we could create an "education practitioner" in order to under-cut the union education monopoly.

Wow! My health care takes care of the bones in my body and my dental insurance which few people are likely to have then medical insurnace takes care of the bones int my mouth ? What's up with that ? It doesn't seem like the dentists are the ones sending up the standards. Looks like those good old insurance companies are at it again. I'm tellin ya single payer !

It really does come down to an economic issue. As Fuller in post #2 said, there is a ~65% overhead cost in dentistry and the state of MN only reimburses 40% of the cost of MA patients. When these new OHPs get out and start opening practices, I am not sure how their overhead will be any less (the materials will not be cheaper for them, and they wont get a discount on rent or get to pay their assistants any less). So unless the state is planning on paying OHPs (someone with less experience and who is not a doctor) more than they pay dentists, the OHPs will not be any more motivated to treat the underserved than dentists currently are. Because there is no provision in Sen. Lynch's bill that actually requires OHPs to serve these underserved populations (at least there was no provision last session, and no provision was recommended by the work group), this new dental provider will have very little if any real impact on access to care, and only serves to "dumb down" health care.

By the way, I am a dental student (who has spent many hours at the capital talking to Sen. Lynch and others), and I have the time to write this this morning because my clinic schedule has openings in it that MA patients could have (the U of MN has no limit on the # of MA patients we accept) but many of us don't have enough patients! It is not like we are turning patients away or we are getting lots of requests for care - we want to see MA patients but there does not seem to be a great deal of extra un-met need. I understand that this is not the case everywhere (especially outstate MN), but there are also no provisions in the OHP bill that requires (or even encourages) new OHPs to go to outstate MN.

Getting changes to the dental regulations is like pulling teeth.