Wash. lawmakers mull dental therapist bills

Will Washington become the next U.S. state to adopt the midlevel provider (MLP) model?

Washington lawmakers will decide in the next few days whether to pass proposed legislation that would allow MLPs to do irreversible procedures with offsite supervision by a dentist.

HB 2226 and SB 6126, introduced in early January as revised versions of HB 1310 (which was defeated a year ago but automatically reintroduced in this legislative session), would create a dental hygiene practitioner and a dental practitioner, both of whom would be allowed to provide various levels of dental care "pursuant to a written practice plan with a dentist."

The dental hygiene practitioner would require licensed hygienists to get a Bachelor of Science degree, followed by specialized training and a 250-hour internship with a dentist. The dental practitioner also requires specialized training after completing high school and a 400-hour internship with a dentist.

Dental hygiene practitioners would expand the scope of practice of the state's hygienists, who can now place fillings after a dentist has done the prep work. They would receive specialized training to do extractions, handle medical emergencies, and administer some drugs. In addition, they would be able to do extractions.

Dental practitioners would be permitted to do everything that hygienists can do except scaling and cleanings. They could also do restorations, administer anesthesia, and extract primary teeth and also loose permanent teeth (+3 to +4 mobility).

Both types of MLPs could work with offsite supervision if approved by their supervising dentist, but neither could do crowns, bridges, or complicated procedures.

February 3 deadline

Lawmakers have until February 3 to get the bills out of policy committees; the current legislative session ends March 8. Sources have told DrBicuspid.com that the House of Representatives bill probably will not be approved, but that the Senate version may get committee approval on February 1.

The Washington State Dental Association (WSDA) and the Washington Academy of General Dentistry (WAGD) oppose the bills. Representatives for WSDA voiced their concerns to legislators on January 27 during Dental Action Day at the state capitol in Olympia.

WSDA President Rod Wentworth, DDS, said his biggest concerns about MLPs are the lack of direct supervision and insufficient training for diagnosis.

"My hygienist has a B.A. in hygiene, but one year of training is not enough for diagnosis," he told DrBicuspid.com. "Dental students spend a whole term getting experience in diagnosis."

Dr. Wentworth also challenged the notion that MLPs cost less. "Regardless of who's providing the care in an independent facility, the overhead is the same, so the cost should not be any different," he said.

But many facilities already exist that could be used by MLPs, according to Lynn Stedman, RDH, president of the Washington State Dental Hygienists' Association (WSDHA) and director of the dental hygiene program at Columbia Basin College. Community colleges and clinics that already provide cleanings and restorations could house such providers, she noted.

The curriculum for such MLPs has already been developed at Eastern Washington University, where the dental school's faculty would provide training, Stedman added.

"I think there are a variety of settings where these people can work, and they also could be an extension of the private practice structure," she told DrBicuspid.com. "They can work in off hours when the dentist isn't working, without having to take on the cost of setting up a practice."

But Bryan Edgar, DDS, the state legislative director of the WAGD, doesn't believe MLPs will lower the cost of dental care for the underserved, and said that ongoing Medicaid cuts have gutted programs at the state's dental schools that provided free care to poor residents.

"To say that people can come to a school for free care is not a valid argument; they can't," Dr. Edgar said. "Somebody is subsidizing that cost."

He also questioned the MLPs' ability to handle the cases they would probably face while treating underserved populations.

"If it's anything like my practice, they'll be going out of their scope of practice almost on a daily basis. They'll be going into pulps with decay because this population tends to have a lot more severe problems and deeper decay than most; therefore, they can't operate," Dr. Edgar explained. "They'll have to refer the patient to a dentist, and that's not really a good patient care model in my mind."

Community health centers

But Alex Narvaez, DDS, the dental director of Sea Mar Community Health Centers, believes MLPs would provide care to children and adults who now have no access and often show up at emergency rooms with urgent problems such as abscesses.

Dental emergencies accounted for 54,000 emergency room visits and more than $35 million in expenditures in Washington between January 2008 and June 2009, according to the WSDHA.

According to Dr. Narvaez, only about half of the state's children received dental care in 2011. His clinics treated more than 52,000 patients, half of them children, last year.

"I'm concerned about the ones who aren't receiving dental care because they can't afford it, and that's where the midlevel [provider] would be very helpful. People need an alternative," Dr. Narvaez told DrBicuspid.com. "We need to educate organized dentistry, because their arguments really don't make sense. They need to come to the realization that this is what the community needs."

Dr. Narvaez said he has spoken to many WSDA members who support the concept of MLPs. He estimates that 40% of the association is open to the idea.

"I don't want to wait until these patients come in with urgent problems," Dr. Narvaez said. "Midlevels do a very good job of treating the technical aspects of dentistry; drilling and filling are the technical aspects of dentistry. Where we act as doctors is when we manage the disease."

MLPs would allow him to treat major problems and difficult surgeries, he said.

Hiring such providers would be much cheaper than dentists, Dr. Narvaez asserted, noting that 76% of his clinics' expenses go toward salaries.

"Why pay a dentist two to three times as much for work that a midlevel [provider] can do?" he asked. "When they do the same procedure over and over, they become very proficient."

As alternatives, Dr. Edgar suggested offering loan reduction programs to lure dentists to underserved or remote areas.

He also supports expanding postgraduate residency programs that would allow licensed dentists to treat underserved populations. Such a program has been operating in five locations in eastern Washington, Dr. Edgar noted, and about 40% of the dentists have chosen to stay and practice there.

"I believe that a dentist who is trained to do everything is a better person to be in that kind of environment, because many cases in these populations are complicated," he said.

Treating patients in pain

Dr. Narvaez and Stedman eschew concerns by the ADA and most state dental associations that MLPs would pose a danger to patients because they lack sufficient training.

"There are no studies that have shown it to be dangerous, partly because it's a very narrow scope of practice," Stedman pointed out. "It is evidence-based to be a safe way to deliver dental care, but I know the dentists don't want to believe that."

Dr. Narvaez agreed.

"If organized dentistry is not going to do enough to meet the community's needs, they should let other community leaders meet the needs of people who aren't receiving dental care because they can't afford it," he said. "I feel passionate about this because I see patients in pain every day."

Stedman promised to continue the fight, no matter what happens to the bills being considered this week. "Even if it doesn't get passed this year, whatever happens, we'll be back," she said.