Midlevel provider debate roils North Carolina

Alaska, Minnesota, Washington, Connecticut ... Will North Carolina be next? A dentist's proposal to start a midlevel dental care provider program in the Tar Heel State has touched off a heated debate in local newspapers and among state dental organizations.

"For too long we have depended on just a few dental leaders saying it can't work," Steven Slott, D.D.S., a Burlington general dentist who specializes in treating Medicaid patients, told DrBicuspid.com. "Well, why can't it work?"

Dr. Slott has approached members of the North Carolina General Assembly about setting up a commission to study whether the state should license a new category of dental professional with less training than a dentist to fill teeth and do extractions under direct supervision.

Because they would charge less for their services, such practitioners could help care for 1.5 million North Carolinians who can ill afford to see a dentist, Dr. Slott argues. With 4.1 dentists for every 10,000 people, the state has the third-lowest ratio among the 50 states.

Beyond the statistics, Dr. Slott draws his motivation from personal experience. His North Carolina Missions of Mercy program travels around the state providing free services for two days at a time. "Everywhere you go the lines are huge," he said. "They will start lining up at midnight to be seen at 7 in the morning."

Dentists riled

The Legislature has yet to act, but the proposal quickly caught the attention of the Raleigh News & Observer and other state newspapers, and their articles set the phones ringing nonstop for days at the North Carolina Dental Society (NCDS). But leaders there are cool to the idea. "Stop-gap solutions that rely on undereducated practitioners are not the answer," wrote NCDS President Dan Cheek, D.D.S., in a letter to the newspaper.

The state is already taking steps to address its access-to-care issues, according to M. Alec Parker, D.M.D., NCDS executive director. Next year, East Carolina University will admit its first class of 50 dental students in a new dental school that targets students with a commitment to underserved areas. At the same time, the state's existing school at the University of North Carolina (UNC) at Chapel Hill has expanded its enrollment.

Together these programs will increase the number of students graduating in North Carolina each year from about 82 to 150, Dr. Parker told DrBicusipid.com. Up to 85% of current UNC students end up practicing in the state.

"The General Assembly gave $150 million to each of these universities with the goal of increasing access to care," he said. "I don't think we have a lot of extra money [to spend] on a program that may or may not work. If we do have this extra money laying around, put it into prevention."

Last year the dental society officially passed a policy opposed to letting midlevel providers do irreversible dental procedures. That would rule out a dental health aide therapist program like the one now operating among villages of indigenous Alaskans, the dental oral health practitioners now being trained in Minnesota, or the advanced dental hygiene practitioner model being advanced by the American Dental Hygienists' Association. An ADA model, the community dental health coordinator who can perform some prevention, education, and referral -- but not extractions or drilling -- would be acceptable, Dr. Parker said.

He was skeptical that a North Carolina commission would find enough data to reach definitive conclusions. "To my knowledge, there are not any studies that talk about how midlevels have affected access in a positive way," he said.

In a study published in the Journal of the American Dental Association (November 2008, Vol. 139:11, pp. 1530-1535), a Baylor College researcher found that the outcomes of dental health aide therapists' work was as good as that of dentists in the short term but that long-term results were needed. Dr. Parker questioned the value of the study. "I'm not sure how it was set up," he said.

Alaska is the only state with midlevel providers who can extract teeth or place restorations outside the direct supervision of a dentist. Minnesota has not yet graduated its first class of oral health practitioners. The leading organizations of dentists and hygienists in Washington and Connecticut have asked their states to evaluate such models.

'We don't want to drill or pull'

But the North Carolina Dental Hygiene Association has not pushed for the advanced hygienist model. "North Carolina dental hygienists have no interest in drilling or pulling teeth," Sandy Boucher-Bessent, R.D.H., the organization's president, told DrBicuspid.com.

Instead, the hygienists have proposed legislation allowing them to provide hygiene outside of dentists' supervision in public health facilities such as nursing homes, group homes, schools, and Head Start centers. Such legislation exists in some other states, such as California. But the NCDS has blocked the hygienists' bills, Boucher-Bessent said.

Now, the two organizations are meeting to look for common ground, she said. One area in which they might collaborate is to try loosening up a state law that prohibits dentists from hiring more than two hygienists at a time. "There are a lot of unemployed dental hygienists who are well-qualified to fill the shoes of midlevel providers," Boucher-Bessent said.

Dr. Slott said he has no interest in the community dental health coordinator idea. "I don't see that helping the access situation because they can't do the work," he said. And just training more dentists won't make dental care available to everyone because only 22% of the state's dentists accept Medicaid as reimbursement, he added.

The dental society doesn't want to consider midlevel providers who can do restorations and extractions because it's protecting dentists' turf, he said.

Dentists should abide by the findings of a commission that could evaluate such evidence from other states, Dr. Slott argued. "If it's not causing problems to citizens in other areas, if it's improving access, then let's bring it on. If we find that it's detrimental or not improving access, then let's not," he said.

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