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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.
read article HERE

Wow not April fools:(
 
Jul 13, 2009
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sometimes you need to register to see it so here it is

Midlevel provider debate roils North Carolina
By Laird Harrison
Senior Editor
February 22, 2010

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.
.pullQuoteCredit { align:right; text-align:right; font-family:arial, sans-serif; font-size:11px; line-height: 16px; font-style: normal; padding-top:2px; } “It's a turf war. That's the underlying thing.”
— Steven Slott, D.D.S.
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.
 

SeattleRDH

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sometimes you need to register to see it so here it is

Midlevel provider debate roils North Carolina
By Laird Harrison
Senior Editor
February 22, 2010

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.
.pullQuoteCredit { align:right; text-align:right; font-family:arial, sans-serif; font-size:11px; line-height: 16px; font-style: normal; padding-top:2px; } “It's a turf war. That's the underlying thing.”
— Steven Slott, D.D.S.
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.
For the record, the Washington State Dental Hygiene Association does not support the "expanded functions" dental assistant that was just allowed in the state. I believe that legislation was proposed by the WSDA.

Also, the ADHP model proposed by the ADHA involves education at a Master's level. I don't see how an ADHP could open a private practice and be successful (crowns and bridges would not be allowed) so they will mostly be working for larger clinics (or you someday!). I bet an ADHP would demand a lower salary than an associate dentist and not leave you after a few years when they want to start their own practice.
 

Simiam

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The only way any of this should ever be considered is under direct supervision of a Dentist. Even then, their argument is very misconceiving. They say Mid Level Providers will solve the issue of access to care and more dentists will not. I would like to see some proof behind that statement. Americans are based off of a sense of honor and self interest. MLP will be just as disheartened to take medicaid as a dentist. Who would perform a procedure that costs $100 in materials in return for $70 payment and a massive risk of bureaucracy if some politician disagrees with the procedure performed? They will all most likely set up shop in minimalls, walmarts, or the like in suburban areas where they want to live and make money. They lack the education to be able to diagnose, treatment plan, and preform irreversible procedures. If anything like this were to ever be considered I still think there should be two heavy restrictions placed on them. 1)They must work under the supervision of a dentist or 2) They must reside in a city with no dentists in a rural area or at least some ratio of dentist to population.

Thats my 2 cents at least.
 
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The only way any of this should ever be considered is under direct supervision of a Dentist. Even then, their argument is very misconceiving. They say Mid Level Providers will solve the issue of access to care and more dentists will not. I would like to see some proof behind that statement. Americans are based off of a sense of honor and self interest. MLP will be just as disheartened to take medicaid as a dentist. Who would perform a procedure that costs $100 in materials in return for $70 payment and a massive risk of bureaucracy if some politician disagrees with the procedure performed? They will all most likely set up shop in minimalls, walmarts, or the like in suburban areas where they want to live and make money. They lack the education to be able to diagnose, treatment plan, and preform irreversible procedures. If anything like this were to ever be considered I still think there should be two heavy restrictions placed on them. 1)They must work under the supervision of a dentist or 2) They must reside in a city with no dentists in a rural area or at least some ratio of dentist to population.

Thats my 2 cents at least.
hah Whoa there Simiam, I like the idea of the MLP's having to work under a dentist but no one should ever be able to dictate where you have to work or liive.. do you really want to give the govt. that sort of power over you (the only way this is cool is if they are paying you, like the military or indian services deal) I know I certainly don't want to let the govt. determining where anyone can work because you may be next. However, we are in agreeance that MLP's should be under a dentist. What do we do about the access gap tho? As we have seen with our medical brethren, if to many people aren't receiving care the govt. will step in and fill that gap with mandates. I for one don't want it to come to that, so we must lobby our legislature for increased medicaid reimbursement rates, I have written at least three letters on this matter to my congressman and I suggest you do the same and get your dental class to contribute to it. Power in numbers my friend.
 

SeattleRDH

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The only way any of this should ever be considered is under direct supervision of a Dentist. Even then, their argument is very misconceiving. They say Mid Level Providers will solve the issue of access to care and more dentists will not. I would like to see some proof behind that statement. Americans are based off of a sense of honor and self interest. MLP will be just as disheartened to take medicaid as a dentist. Who would perform a procedure that costs $100 in materials in return for $70 payment and a massive risk of bureaucracy if some politician disagrees with the procedure performed? They will all most likely set up shop in minimalls, walmarts, or the like in suburban areas where they want to live and make money. They lack the education to be able to diagnose, treatment plan, and preform irreversible procedures. If anything like this were to ever be considered I still think there should be two heavy restrictions placed on them. 1)They must work under the supervision of a dentist or 2) They must reside in a city with no dentists in a rural area or at least some ratio of dentist to population.

Thats my 2 cents at least.
Really? Walmart? Come on. We aren't a bunch of idiots.

Can someone define Mid-Level Provider please? There are so many opinions of what this means!

If it's a dental professional with education beyond RDH but below DDS then how can we say that they are not trained to diagnose? There isn't even a defined standard of education for these individuals. And when it comes to perio, the majority of dentists I have worked with ask me to diagnose the patient.

Ya'll should take the hygiene boards, see how easy they are. You know half of the test is case studies right?
 

Simiam

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hah Whoa there Simiam, I like the idea of the MLP's having to work under a dentist but no one should ever be able to dictate where you have to work or liive.. do you really want to give the govt. that sort of power over you (the only way this is cool is if they are paying you, like the military or indian services deal) I know I certainly don't want to let the govt. determining where anyone can work because you may be next. However, we are in agreeance that MLP's should be under a dentist. What do we do about the access gap tho? As we have seen with our medical brethren, if to many people aren't receiving care the govt. will step in and fill that gap with mandates. I for one don't want it to come to that, so we must lobby our legislature for increased medicaid reimbursement rates, I have written at least three letters on this matter to my congressman and I suggest you do the same and get your dental class to contribute to it. Power in numbers my friend.

I was trying to imply that, in my opinion, access to care simply can't be solved via a mid level provider. In most cases they will graduate and do exactly what most dentists do. Move to areas where they can produce a steady income in order to repay their loans and be comfortable. Whether that be private practice or for a chain dental clinic (I like to think of them as Walmarts, they will slowly corrode and gobble up all the small businesses.)

It seems like the two areas where access to care is an issue is extreme low income areas (where they only have Medicaid) and rural areas. The first could be solved with an increase in medicaid payments and the second is an issue of debt more than dentist vs MLP.

I think we'd be better off increasing Medicaid payments, and increasing NHSC and IHS grants. We need to create incentive for recently graduating dentists to go to the more rural areas. They have to be able to afford to be able to go. I feel like it isn't a matter of desire but the daunting loan payment due every month. It sucks, but in reality private practice is a business first. If you can't pay your bills, then you can't treat your patients. I think this prevents a lot of practitioners from practicing in their rural hometowns.

You also have to factor in that what one sees as an access to care issue others will see true utilization rates.

I definitely believe that government should NOT be dictating where one lives or works. Government is already trampling on too many of our rights. I kind of misspoke on that point. I'm not very eloquent, but hopefully you'll see my point a little better. I should probably avoid posting in the middle of the night:sleep::sleep:
 

Simiam

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Really? Walmart? Come on. We aren't a bunch of idiots.

Can someone define Mid-Level Provider please? There are so many opinions of what this means!

If it's a dental professional with education beyond RDH but below DDS then how can we say that they are not trained to diagnose? There isn't even a defined standard of education for these individuals. And when it comes to perio, the majority of dentists I have worked with ask me to diagnose the patient.

Ya'll should take the hygiene boards, see how easy they are. You know half of the test is case studies right?

Mid Level Provider can mean many something completely different and be called something different state to state. Minnesota and Alaska are the two biggest front runners in this so far as I know. Here's an article by the ADA on Alaska's DHAT:

http://www.ada.org/sections/about/pdfs/position_dentalaide_alaska.pdf

Here's one on the Minnesota version called the Oral Health Practitioner:

http://www.ada.org/news/2177.aspx



It's a very tricky situation, but I feel that creating a new level of provider is the wrong answer. There are studies going on across the country to determine the best solution, whether it be MLP or not..
 

SeattleRDH

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Mid Level Provider can mean many something completely different and be called something different state to state. Minnesota and Alaska are the two biggest front runners in this so far as I know. Here's an article by the ADA on Alaska's DHAT:

http://www.ada.org/sections/about/pdfs/position_dentalaide_alaska.pdf

Here's one on the Minnesota version called the Oral Health Practitioner:

http://www.ada.org/news/2177.aspx



It's a very tricky situation, but I feel that creating a new level of provider is the wrong answer. There are studies going on across the country to determine the best solution, whether it be MLP or not..
I was born and raised in Alaska and I'm related to one of the 'four dental experts' referred to in this article. The DHAT's are very scary and I fully agree that mid-level providers like this should not be allowed. The only prerequisite requirement for training in the DHAT program is a high school education (less than a dental hygienist).

The problem that lies with Alaska is that there are very few schools and many communities are isolated. The only way to get in and out of my hometown is by boat or plane. To get to the nearest city, the ferry takes 2 days, and a flight costs upwards of $400 roundtrip. And the weather..... let's just say Seasonal Affective Disorder is a problem. So, unless the NHSC raises it's tuition reimbersement, very few dental school graduates are going to practice in these areas.

The problem is that if there is no dentist in town the members of the community who can't afford to travel get no dental treatment.

A prevention focused mid-level provider would benefit these communities. As a hygienist, I can't legally take xrays, perio chart, or start a prophy without a dentist's exam first. If a nurse practitioner type provider (ADHP) were in existence then at least their patient's could get preventative care, an exam, and a referral so that when they travel to the city they can get the treatment they need.
 

txlonghorn

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I was born and raised in Alaska and I'm related to one of the 'four dental experts' referred to in this article. The DHAT's are very scary and I fully agree that mid-level providers like this should not be allowed. The only prerequisite requirement for training in the DHAT program is a high school education (less than a dental hygienist).

The problem that lies with Alaska is that there are very few schools and many communities are isolated. The only way to get in and out of my hometown is by boat or plane. To get to the nearest city, the ferry takes 2 days, and a flight costs upwards of $400 roundtrip. And the weather..... let's just say Seasonal Affective Disorder is a problem. So, unless the NHSC raises it's tuition reimbersement, very few dental school graduates are going to practice in these areas.

The problem is that if there is no dentist in town the members of the community who can't afford to travel get no dental treatment.

A prevention focused mid-level provider would benefit these communities. As a hygienist, I can't legally take xrays, perio chart, or start a prophy without a dentist's exam first. If a nurse practitioner type provider (ADHP) were in existence then at least their patient's could get preventative care, an exam, and a referral so that when they travel to the city they can get the treatment they need.
ADHP is a useless concept, because it does not address the issue of access to care at all. The ADHA is trying to create a new provider to get under their belt that is not needed.

A new provider pitched by the ADHA is suppose to work in areas where dentist do not go, but in reality this will not happen. Most ADHPs will end up working in city environments, just like dentist. The only way an ADHP will go to rural areas is if they were mandated by law to do so. If this is what the ADHA proposes, then I am fine with it. Still, for more complex cases, a dentist will be needed, which again shows that the access to care problem is not solved.

Instead of creating a new class of practitioner, why does Alaska just not build a new dental school there and only accept in-state students? OR create a join program to train dentist at other dental schools and require a time payback for instate students by covering their costs. This way most of the people that attend dental school from Alaska will remain in Alaska. Also, travel reimbursements can be provided for travel to rural areas for dentists. This way a person who really needs dental care can be seen by a dentist rather than a half-dentist that is being proposed by the ADHA.

The problem with dental care is not that there are not enough dentist, but that there are not enough dentist in rural areas. Incentives need to be provided for dentist to move to the rural areas. I actually like the program being proposed by the ADA of a community dental worker. They can mandate these people to only see low income, rural area, etc patients and refer them to dentists for work.
 

SeattleRDH

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ADHP is a useless concept, because it does not address the issue of access to care at all. The ADHA is trying to create a new provider to get under their belt that is not needed.

A new provider pitched by the ADHA is suppose to work in areas where dentist do not go, but in reality this will not happen. Most ADHPs will end up working in city environments, just like dentist. The only way an ADHP will go to rural areas is if they were mandated by law to do so. If this is what the ADHA proposes, then I am fine with it. Still, for more complex cases, a dentist will be needed, which again shows that the access to care problem is not solved.

Instead of creating a new class of practitioner, why does Alaska just not build a new dental school there and only accept in-state students? OR create a join program to train dentist at other dental schools and require a time payback for instate students by covering their costs. This way most of the people that attend dental school from Alaska will remain in Alaska. Also, travel reimbursements can be provided for travel to rural areas for dentists. This way a person who really needs dental care can be seen by a dentist rather than a half-dentist that is being proposed by the ADHA.

The problem with dental care is not that there are not enough dentist, but that there are not enough dentist in rural areas. Incentives need to be provided for dentist to move to the rural areas. I actually like the program being proposed by the ADA of a community dental worker. They can mandate these people to only see low income, rural area, etc patients and refer them to dentists for work.
Though your solutions to the access problem in Alaska sound wonderful, they are unlikely to happen. Aside from the costs of building a school, tuition reimbursement, and travel vouchers, there are only so many people that can stand living in Alaska. Spend a winter there and you'll see why. Two people that I went to highschool with are now dentists and neither of them plan on returning.

It's a sad state, but the main reason why the DHAT came about.

From my knowledge of the politics in Washington with the ADHP, I doubt it will come into existence any time soon, but in the meantime professions like the DHAT will pass through legislatures. And neither the dental hygiene community nor the dental community want that.

So what's worse?
 

mike3kgt

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Ya'll should take the hygiene boards, see how easy they are. You know half of the test is case studies right?
So those are questions like, "if you were to clean the distal surfaces of #14, what instrument would you use?"

Or maybe "you have a patient that is unable to floss underneath a PFM bridge, what could you recommend to them to cleanse properly?"

I want my hygienists cleaning teeth and being patient advocates as part of a dental team. While it's huge to be part of patient education and facilitation, in no way should my hygienist be picking up a highspeed, forceps, or anesthesia syringe.
 

SeattleRDH

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So those are questions like, "if you were to clean the distal surfaces of #14, what instrument would you use?"

Or maybe "you have a patient that is unable to floss underneath a PFM bridge, what could you recommend to them to cleanse properly?"

I want my hygienists cleaning teeth and being patient advocates as part of a dental team. While it's huge to be part of patient education and facilitation, in no way should my hygienist be picking up a highspeed, forceps, or anesthesia syringe.
Wouldn't it have been nice if the questions were so simple.

This is from www.ada.org on the NBDHE. I encourage you to look into the exam as it has changed quite a bit over the last 20 years.

"Component B includes 150 case-based items that refer to 14 to 15 dental hygiene patient cases; these cases present information dealing with adult and child patients by means of patient histories, dental charts, radiographs, and clinical photographs. Each examination includes at least one case regarding patients of the following types: Geriatric, Adult-Periodontal, Pediatric, Special Needs, and Medically Compromised. The case-based items address knowledge and skills required in: 1. Assessing patient characteristics 2. Obtaining and interpreting radiographs 3. Planning and managing dental hygiene care 4. Performing periodontal procedures 5. Using preventive agents 6. Providing supportive treatment service 7. Professional responsibility"

The NBDHE covers material that applies to hygienists practicing in all states so it is mainly preventive hygiene. In states (like mine) where RDHs are licensed in restorative and/or anesthetic there is a separate written and clinical board exam.

I don't believe that hygienists should be prepping or extracting teeth but with two more years of school (at a Masters level) they would be a better choice to practice in rural Alaska than the DHAT.
 
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Though your solutions to the access problem in Alaska sound wonderful, they are unlikely to happen. Aside from the costs of building a school, tuition reimbursement, and travel vouchers, there are only so many people that can stand living in Alaska. Spend a winter there and you'll see why. Two people that I went to highschool with are now dentists and neither of them plan on returning.

It's a sad state, but the main reason why the DHAT came about.

From my knowledge of the politics in Washington with the ADHP, I doubt it will come into existence any time soon, but in the meantime professions like the DHAT will pass through legislatures. And neither the dental hygiene community nor the dental community want that.

So what's worse?
Hey Seattle,

lets just do a small questionaire if you will.. it looks like you are pre dental now so congrats on choosing to move up the dental ladder, but I have a few questions about that exact process.

As a hygenist you have your reasons for becoming a dentist, but would you still do this if the ADHP option existed?

since the ADHP option is being proposed to fix access problems by sending you out to rural or urban areas, would you go if you weren't forced? More importantly why?

How will you be able to charge lower fees than me?

I really don't want to come across like I am challenging you.. but if you can answer these simple questions then maybe it would explain why the ADHP or any MLP for that fact is an answer to the access issue; which is exactly what the MLP is supposed to address.

cao
 
Aug 20, 2009
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Though your solutions to the access problem in Alaska sound wonderful, they are unlikely to happen. Aside from the costs of building a school, tuition reimbursement, and travel vouchers, there are only so many people that can stand living in Alaska. Spend a winter there and you'll see why. Two people that I went to highschool with are now dentists and neither of them plan on returning.

It's a sad state, but the main reason why the DHAT came about.

From my knowledge of the politics in Washington with the ADHP, I doubt it will come into existence any time soon, but in the meantime professions like the DHAT will pass through legislatures. And neither the dental hygiene community nor the dental community want that.

So what's worse?
Exactly! Seattle RDH you nailed it!

And ADHP trained people are more likely to go to Rural Alaska compared to dentists?
At least DHATs are people originally from the villages they go back to serve.
 

SeattleRDH

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Exactly! Seattle RDH you nailed it!

And ADHP trained people are more likely to go to Rural Alaska compared to dentists?
At least DHATs are people originally from the villages they go back to serve.
No, but the people from these villages could more easily obtain the ADHP than the DDS. DHATs are people with a highschool education that are sent overseas to train for two years in dentistry. When they come back they don't even pass a board exam before they start practicing - this is not good.

I don't have all the answers. I just think that if there is going to be a mid-level provider it needs to be someone with at least a masters degree.
 

SeattleRDH

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Hey Seattle,

lets just do a small questionaire if you will.. it looks like you are pre dental now so congrats on choosing to move up the dental ladder, but I have a few questions about that exact process.

As a hygenist you have your reasons for becoming a dentist, but would you still do this if the ADHP option existed?

since the ADHP option is being proposed to fix access problems by sending you out to rural or urban areas, would you go if you weren't forced? More importantly why?

How will you be able to charge lower fees than me?

I really don't want to come across like I am challenging you.. but if you can answer these simple questions then maybe it would explain why the ADHP or any MLP for that fact is an answer to the access issue; which is exactly what the MLP is supposed to address.

cao
Honestly, I would just do the ADHP. My hygiene program was not free. Neither was my bachelor's degree. So with my prereqs that I'm taking at UW plus four years of dental school, I plan on being further in debt than most people on this site. In fact, I will be so far in debt that I'll be in my 50's before I am making more than I would if I had just stayed a hygienist.

Personally, I would go out into rural areas but I can't speak for all people. I'm from rural Alaska so I'll be going back as a dentist. (I wish more people would).

As far as independent practice... there's really no way to support the overhead without high-production procedures like crowns. But the ADHP could be employed by a community clinic similar to a nurse practitioner in a hospital or medical group. The problem with access to care is that most people in rural areas and poor urban areas don't get bi-annual exams. I don't see the ADHP performing irreversible procedures, I see them as a source of referrals. Prevention is key. The two year masters degree could focus solely on diagnosing. The DDS would still be the Doctor of Dental Surgery. Just my idea.

As far as lower fees... when I'm working a restorative day the patient is paying the same whether I fill the tooth or the dentist. Does medicine have a different fee scale for a nurse practitioner versus a physician? If so, I would assume that this would carry over to the ADHP in the same way.
 

txlonghorn

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Jun 29, 2009
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No, but the people from these villages could more easily obtain the ADHP than the DDS. DHATs are people with a highschool education that are sent overseas to train for two years in dentistry. When they come back they don't even pass a board exam before they start practicing - this is not good.

I don't have all the answers. I just think that if there is going to be a mid-level provider it needs to be someone with at least a masters degree.
My question, again, is why create an ADHP? If you are creating a masters level program, then you might as well go to dental school. If you want to solve the problem, then create more dentist - not half dentist. I think the DHAT program would be fine for rural areas - be confined to this environment. The DHAT should, however, be working under a dentist - sending x-rays, etc to a dentist that diagnosed. This is similar to how radiologist can screen from home.
 

banana23

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I'm sorry but when was it conceded that there is an access to care problem? I have just finished my 8th week of community outreach rotations working on the very population’s mid-level practitioners are purported to serve and I have to say I don't see one. I have seen two types of patients. One group consists of those seeking emergency care which are indeed better served by community clinics than ERs from a cost/benefit perspective. The other group of individuals are those who utilize community clinics as a free or heavily discounted dental service often subsidized by grants and you the taxpayer. In speaking of the former group all these individuals seem to lack is a sense of personal responsibility when it comes to paying for their dentistry. According to the Heritage foundation which directly cites federal statistics:

Overall, the typical American defined as poor by the government has a car, air conditioning, a refrigerator, a stove, a clothes washer and dryer, and a microwave. He has two color televisions, cable or satellite TV reception, a VCR or DVD player, and a stereo. He is able to obtain medical care. His home is in good repair and is not overcrowded. By his own report, his family is not hungry, and he had suf*ficient funds in the past year to meet his family's essential needs. While this individual's life is not opulent, it is equally far from the popular images of dire poverty conveyed by the press, liberal activists, and politicians.

As I see it life is full of choices. If you choose to have cable with HBO and Showtime, and drink code red mountain dew with all your meals then that is your choice and I, nor anyone else, should be forced to subsidize that choice. Choosing to have cable overseeing the dentist does not make someone “underserved” it simply reflects a certain life choices. Living in a desert where there isn’t a dentist for a thousand miles would certainly result in an access to care problem, but I don’t think this is the kind of problem mid-level practitioners are meant to address.

Also, I don’t see how a mid-level provider could reduce the cost of dentistry for the “underserved”. Dentistry is expensive, and most of it goes towards paying overhead. Most overhead goes to staff and materials. Staff and materials are necessary regardless of who is practicing dentistry. All a mid-level practitioner does is reduce the cost of the individual providing care. Since community health dentists are paid around 100,000 or less out of school and hygienists are paid around 50,000 out of school, would the mid-level practitioner likely paid somewhere in between those figures realistically impact the cost of care? The difference would be cents on the dollar in terms of actual patient bills, regardless of how they are paid.

I am still waiting for a reasonable explanation of how a mid-level provider would solve any problems or accomplish anything meaningful.
 

DrJeff

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I'm sorry but when was it conceded that there is an access to care problem? I have just finished my 8th week of community outreach rotations working on the very population’s mid-level practitioners are purported to serve and I have to say I don't see one. I have seen two types of patients. One group consists of those seeking emergency care which are indeed better served by community clinics than ERs from a cost/benefit perspective. The other group of individuals are those who utilize community clinics as a free or heavily discounted dental service often subsidized by grants and you the taxpayer. In speaking of the former group all these individuals seem to lack is a sense of personal responsibility when it comes to paying for their dentistry. According to the Heritage foundation which directly cites federal statistics:

Overall, the typical American defined as poor by the government has a car, air conditioning, a refrigerator, a stove, a clothes washer and dryer, and a microwave. He has two color televisions, cable or satellite TV reception, a VCR or DVD player, and a stereo. He is able to obtain medical care. His home is in good repair and is not overcrowded. By his own report, his family is not hungry, and he had suf*ficient funds in the past year to meet his family's essential needs. While this individual's life is not opulent, it is equally far from the popular images of dire poverty conveyed by the press, liberal activists, and politicians.

As I see it life is full of choices. If you choose to have cable with HBO and Showtime, and drink code red mountain dew with all your meals then that is your choice and I, nor anyone else, should be forced to subsidize that choice. Choosing to have cable overseeing the dentist does not make someone “underserved” it simply reflects a certain life choices. Living in a desert where there isn’t a dentist for a thousand miles would certainly result in an access to care problem, but I don’t think this is the kind of problem mid-level practitioners are meant to address.

Also, I don’t see how a mid-level provider could reduce the cost of dentistry for the “underserved”. Dentistry is expensive, and most of it goes towards paying overhead. Most overhead goes to staff and materials. Staff and materials are necessary regardless of who is practicing dentistry. All a mid-level practitioner does is reduce the cost of the individual providing care. Since community health dentists are paid around 100,000 or less out of school and hygienists are paid around 50,000 out of school, would the mid-level practitioner likely paid somewhere in between those figures realistically impact the cost of care? The difference would be cents on the dollar in terms of actual patient bills, regardless of how they are paid.

I am still waiting for a reasonable explanation of how a mid-level provider would solve any problems or accomplish anything meaningful.
Stop being so rational about this issue ;) :laugh:

Great Post!

The underlying problem has to do with 2 things that you sum up wonderfully in your post

1) Many people just don't want to/won't make the tough descisions that come with being an adult and having personal responsibility

2) Politicians think they can solve every problem by just mandating something new and/or just throwing $$ at a problem, when often the current resources that are in place are able to handle an issue, IF THEY'RE USED PROPERLY
 
Jul 13, 2009
176
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Shebulba
Status
Pre-Dental
I'm sorry but when was it conceded that there is an access to care problem? I have just finished my 8th week of community outreach rotations working on the very population’s mid-level practitioners are purported to serve and I have to say I don't see one. I have seen two types of patients. One group consists of those seeking emergency care which are indeed better served by community clinics than ERs from a cost/benefit perspective. The other group of individuals are those who utilize community clinics as a free or heavily discounted dental service often subsidized by grants and you the taxpayer. In speaking of the former group all these individuals seem to lack is a sense of personal responsibility when it comes to paying for their dentistry. According to the Heritage foundation which directly cites federal statistics:

Overall, the typical American defined as poor by the government has a car, air conditioning, a refrigerator, a stove, a clothes washer and dryer, and a microwave. He has two color televisions, cable or satellite TV reception, a VCR or DVD player, and a stereo. He is able to obtain medical care. His home is in good repair and is not overcrowded. By his own report, his family is not hungry, and he had suf*ficient funds in the past year to meet his family's essential needs. While this individual's life is not opulent, it is equally far from the popular images of dire poverty conveyed by the press, liberal activists, and politicians.

As I see it life is full of choices. If you choose to have cable with HBO and Showtime, and drink code red mountain dew with all your meals then that is your choice and I, nor anyone else, should be forced to subsidize that choice. Choosing to have cable overseeing the dentist does not make someone “underserved” it simply reflects a certain life choices. Living in a desert where there isn’t a dentist for a thousand miles would certainly result in an access to care problem, but I don’t think this is the kind of problem mid-level practitioners are meant to address.

Also, I don’t see how a mid-level provider could reduce the cost of dentistry for the “underserved”. Dentistry is expensive, and most of it goes towards paying overhead. Most overhead goes to staff and materials. Staff and materials are necessary regardless of who is practicing dentistry. All a mid-level practitioner does is reduce the cost of the individual providing care. Since community health dentists are paid around 100,000 or less out of school and hygienists are paid around 50,000 out of school, would the mid-level practitioner likely paid somewhere in between those figures realistically impact the cost of care? The difference would be cents on the dollar in terms of actual patient bills, regardless of how they are paid.

I am still waiting for a reasonable explanation of how a mid-level provider would solve any problems or accomplish anything meaningful.
I agree that we don't need mid-level providers but the heritage foundation?? Come on man that is the most right wing think tank out there!! lol
 
Aug 20, 2009
152
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0
Status
Dentist
No, but the people from these villages could more easily obtain the ADHP than the DDS. DHATs are people with a highschool education that are sent overseas to train for two years in dentistry. When they come back they don't even pass a board exam before they start practicing - this is not good.

I don't have all the answers. I just think that if there is going to be a mid-level provider it needs to be someone with at least a masters degree.
I think the idea of a Midlevel provider is a RED HERRING. IMHO it will do little to solve access to care problems. Most of these mid levels will probably stay in cities.

There are many ways to deal with the purported issue of access to care:

1) More dentist need to volunteer their time to do charity dental work, not just GKAS. Get involved in community clinics that offer volunter dental work.

2) With regards to rural areas with no dentist wanting to practice, open community clinics and do student debt repayment for dentists willing to work there even for 1 or 2 yrs. This idea is not new but can be made more effective. Even if there is high turnover of dentists in these community clinics bottomline they will get the care.

noboday wants to live in rural Alaska but for only 1 or 2 yrs with enough incentive surely there will be takers esp new grads.

Now we as dentists need to care and volunteer and take our profession back.