Minnesota governor signs dental therapist legislation

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armorshell

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Read the article before freaking out, the bill seems fairly nerfed:

St. Paul, Minn.—The legislative battle over what have come to be known as "midlevel providers" in Minnesota has come to a close.

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What dental therapists and advanced dental therapists in Minnesota can do

University of Minnesota reviewing applications for nation’s first dental school-based dental therapy program

What began as two distinct models of education and practice emerged as one with the state creating a new position—the dental therapist—who will provide care for underserved patient populations in the state.

Gov. Tim Pawlenty signed Senate File 2083 May 16, creating the dental therapist, a licensed provider with a bachelor's degree in dental therapy who will work with Minnesota-licensed dentists to provide preventive dental services, restoration of primary and permanent teeth, extraction of primary teeth and select other dental treatments.

"Regardless of the procedure or setting where care will be provided, it will be the dentist who completes the examination, makes the diagnosis and formulates the treatment plan," said Dr. Lee Jess, Minnesota Dental Association president. "For restorative and surgical procedures, the dentist must be on-site to provide intra-operative diagnoses and to assist when treatment complications arise."

Added Dr. Jess: "We are confident that with this well-defined scope of practice, level of supervision and patient population, dental therapists will help contribute to addressing the access to dental care challenge faced by many in Minnesota."

SF 2083 also creates a second level of dental therapist, the advanced dental therapist. To become an advanced dental therapist, one must have a bachelor's degree in dental therapy, practice for at least 2,000 hours as a dental therapist, graduate from a master's level advanced dental therapy program and pass a board-approved exam to demonstrate competency.

Advanced dental therapists will be able to practice off-site without a dentist present but are still required to obtain the approval of a supervising dentist prior to performing restorative and surgical procedures. They also will be able to perform nonsurgical extraction of advanced periodontally involved permanent teeth but only with the approval of the supervising dentist.

SF 2083, say officials from the Minnesota Dental Association, ultimately creates an integrated member of the dental team who cares for patients with dentists—as opposed to other proposed legislative models that had little or no interaction between a "midlevel" provider and a dentist.

"The MDA and its member dentists have worked hard for nearly a year advocating for principles of appropriate education, supervision and scope of practice," said Dr. Jess. "We are pleased that our concerns were heard and that this new position is a workable program to reach those in need while helping to ensure quality care."

Striking a legislative agreement that MDA could support would not have been possible without several things happening, said Dr. Jess, including the University of Minnesota School of Dentistry announcing a plan to start its own dental therapy education program (see story, page five), February's Dental Day at the Capitol which resulted in a strong showing of grassroots support from 150 MDA dentists and dental students, and a last-minute public awareness campaign.

"Particularly important to the MDA's efforts were well-considered positions on behalf of patients, effective lobbying at the state capital and extensive grassroots contact with legislators by MDA members," said MDA Executive Director Dick Diercks.

MDA and other stakeholders succeeded last year in opposing a legislative proposal to create the advanced dental hygiene practitioner with the authority to perform a wide array of surgical procedures without on-site supervision or preauthorization by a dentist. The legislature eventually dropped the ADHP proposal but passed a law authorizing creation of an "Oral Health Practitioner" without specifying the scope of practice or degree of supervision for the position, calling instead for a Department of Health work group to develop them and report back to the legislature. The work group failed to reach consensus on all critical issues but narrowly approved OHP guidelines close to those of the ADHP, that included—over strong objections from MDA—unsupervised surgery and a fragmentation of the dental team. Early in the process of considering the OHP's supervision and scope of practice, the U of M School of Dentistry introduced its own dental therapist model, the basis for which eventually passed into law.

With the 2009 legislative session drawing to a close, MDA launched a public awareness campaign with the theme, "The last thing you want to hear when you're getting dental care is uh-oh." TV, radio, print and banner ads online alerted patients of the legislative proposal to allow unsupervised workers to perform dental surgical procedures.

"The public awareness campaign was big," said Dr. Jess. "It brought attention to the issue of patient safety and created momentum for the dental therapy bill that we were supporting, which eventually prevailed."

The ADA provided legislative consulting, research and communications assistance to the Minnesota Dental Association through the State Public Affairs Program. Now, as the state moves forward with the dental therapist model, the MDA remains committed to upholding patient safety.

"Ultimately, Minnesota must find the political will to fund a dental health system in which the people in greatest need, and who also have the most complex oral health needs, can get care from fully trained dentists," Dr. Jess wrote in an op-ed distributed to statewide media May 22.

Members don't see this ad.
 
This legislation is obviously a travesty and insanity. Pediatric dental patients are among the most critical and sensitive populations. Drug dosages especially local anesthetic can be very critical in a child. Yet this legislation provides that the dental therapist is to extract primary teeth and do restorations on primary teeth. So why shouldn't the highest trained practioner be the one to treat children? Why a barely trained "dental therapist"? Also...notice dental hygiene is specifically excluded from their training. What special interest did that cater to? If the skill sets are vastly different from hygiene and therapy...why is it that a DH can apply for advanced standing in this legislation? This was obviously a way for a DH to practice dentistry without becoming a dentist. Minnesota Legislators must have a very low opinion of the dental profession to allow a very vulnerable and critical population (the young and the old) to be treated by a vastly undertrained practitioner. This was not well thought out. Also...is Minnesota going to create a bunch of mini dental schools to train these people? What faculty will do the training? What cost will it incur to create a bunch of little dental schools? Would not a better model have been to created subsidized scholarships (like military scholarships) with paid tuition and mandatory service years for DDS candidates? Or would it have been better to create a new dental school, tuition free, but with mandatory service in underserved areas of Minnesota for a prescribed period of time(let say 6 yrs)? This is total nonsense, it endangers the public health, it erodes and dilutes the dental profession. We are not tradesman. We are health professionals. We are Doctors not Misters. Why does Minnesota think we are but trained monkeys that anyone can do our job? I am waiting for that pediatric death from local anesthetic overdosage by these dental therapists. Maybe then Minnesota will open their eyes. Maybe then ADA will defend our profession.




The Minnesota Dental Therapist
Minnesota Governor Tim Pawlenty signed legislation creating a “dental therapist” on May 16. With that act a two year legislative struggle came to a close. The dental therapist, upon completing a bachelor’s level program in dental therapy will be able to practice in underserved locations and perform a range of procedures, including restorations and primary extractions with the indirect supervision of a dentist
The unfortunate reality is that the state government has given with one hand while taking with the other. Proponents of mid-level dental providers may celebrate. But, funding for the state’s dental Medicaid program continues to languish. While the declining economy has created more enrollees and accompanying demands for service, the state has provided no additional funding and may in fact institute cuts to dental Medicaid in the near future. Without a commitment to pay for the dental care for Minnesota’s neediest citizens, new members of the dental team can have little impact. If low-income Minnesotans are to have greater access to dental services, the state must increase financial support for programs like Medicaid and SCHIP, along with proven disease prevention initiatives like community water fluoridation, school sealant programs and oral health literacy efforts
The Minnesota Dental Association did everything possible to achieve the “least-worst” legislative outcome, including extensive grassroots efforts, lobbying and an intensive public affairs campaign, supported largely by the ADA State Public Affairs program.
Below are answers to some of the questions likely to arise about the developments in Minnesota. The ADA will distribute any new information as it becomes available.

Q: How did this happen?
A: Two years ago proponents of the American Dental Hygiene Associations’ Advanced Dental Hygiene Practitioner (ADHP) introduced legislation to create that position in Minnesota. As designed, the model provides for the ADHP to perform surgery without a dentist being on-site and with virtually no supervision.
The legislation gained momentum in the Senate, but an aggressive media and lobbying effort by the Minnesota Dental Association (MDA) stalled it in the House. The MDA strove to educate lawmakers about the shortcomings of the ADHP model. MDA built a coalition of oral healthcare providers to oppose the legislation and mobilized dental students and others to testify in hearings as well as attend lawmakers’ local meetings to speak out on the ADHP issue. A number of former hygienists who now are dental students were particularly effective in speaking to the dramatic differences between dental and dental hygiene education and training. To help shape communications efforts around these issues, the ADA conducted extensive qualitative and quantitative opinion research
MDA offered a variety of more realistic proposals to improve access to care, including the Community Dental Health Coordinator (CDHC) as a more integrated member of the dental team and an alternative to the ADHP. Ultimately, the MDA and its allies created enough controversy to scale back the legislation dramatically to the creation of a task force charged with making recommendations about an Oral Health Practitioner (OHP) for the legislature to consider in 2009. However, even this legislation was a turning point—the question was no longer whether to create midlevel providers, but rather how to do so.
The task force included representatives from the MDA, the University of Minnesota School of Dentistry, the Minnesota State Colleges and Universities, the Minnesota Dental Hygienists Association, the Minnesota Board of Dental Examiners and the Safety Net Coalition (SNC).
Unfortunately, the task force was unable to reach consensus. With the political and legal wind assuring the creation of a mid-level provider, the MDA put its efforts into ensuring patient safety and keeping the dentist as the head of the dental team. The state society made the difficult decision to endorse the alternative model proposed by the University of Minnesota School of Dentistry. The dental school’s plan provided for an integrated member of the dental team, educated in an accredited dental school, working with the supervision of a dentist. Any procedure permitted in the therapist’s scope would be taught to the same standard as a dentist.
The OHP Task Force narrowly approved recommendations that closely mirrored the ADHP design, and sent its report to the legislature. The MDA, the dental school and others offered alternative reports and findings that staked out the principles of one standard of education, patient safety and an integrated dental team as opposed to the fractured model offered by ADHP or OHP.
With the start of the 2009 legislative session both the OHP and dental therapist models garnered legislative support. Looking to avoid conflict, legislators put both provisions into the same bills and appeared poised to pass them both. With that prospect, MDA undertook a print, radio and web ad campaign with support from the ADA State Public Affairs program to raise public and policymaker awareness about the lack of supervision and varying standards of education that led to patient safety concerns in the OHP model. In the wake of that campaign, the Senate considered an MDA-supported amendment to remove the OHP scope, supervision and education requirements and replace them with those of the dental therapist. While that amendment failed by a single vote, it was a far closer outcome than anyone had predicted and provided real momentum heading into the House of Representatives.
In the House the Speaker decided to direct a negotiated settlement. Ultimately the result of that process very closely tracked the School of Dentistry model and the MDA principles.

Q: What exactly will the dental therapist do, and under what level of supervision?
A: The basic dental therapist will qualify for licensure upon graduation from a Bachelor's degree dental therapy program. The University of Minnesota School of Dentistry has stated that it will offer the program as of September 2009, but other institutions may develop them as well. A concern is that the Minnesota State Colleges and Universities system (MnSCU) which had originally agreed to host the ADHP program is exploring advanced placement for dental hygienists with a Bachelor’s degree in their version of the dental therapy program (Bachelor’s level). The extent, to which the Dental Board will authorize that process without placing the program at risk of not being approved by the Board, remains to be seen.
The Dental Board will grant a therapist license to a candidate who has successfully completed the program and passed a clinical exam, The therapist will work in a dental office with the indirect (on-site) supervision of a dentist, and will be able to provide a range of dental services for the underserved including restorations and extraction of primary teeth. The supervising dentist must authorize any surgical procedures before treatment may commence. Further, the supervising doctor will be on site to deal with any complications or emergencies.
After practicing as a dental therapist for at least 2000 hours, a candidate may choose to pursue a two-year Master’s degree in advanced dental therapy. Upon successfully completing that program and passing a clinical exam, an advanced therapist could practice in a separate site from the supervising dentist. However, any surgical procedure would still have to be specifically approved and authorized by the dentist prior to treatment. The advanced therapist also could extract permanent teeth with a mobility factor of +3 to +4, but only with preauthorization from the supervising dentist. By retaining a level of supervision by the dentist, the MDA has to the extent possible kept the dental team intact, with the dentist as the comprehensive leader of that team.
The law requires the dental board to report to the legislature in 2014 about the safety of dental therapists, the cost-effectiveness of the program and its impact on access to dental care.

Q: What about dental hygiene?
A: The dental therapist program excludes much of the dental hygiene scope of practice. Dental therapists will not perform prophys. The skill set required for a dental therapist is different than that of a dental hygienist.
Claims that the dental therapist law is a breakthrough for proponents of the ADHP model are overstated, to say the least. To become a basic dental therapist one must complete a dental therapy Bachelor’s degree. Whether one holds a degree or license in another allied dental profession does not matter. Without the dental therapy degree, one cannot be licensed and cannot practice as a dental therapist. The requirements for admission to the Master’s level program are completion of the Bachelor’s level therapist program and at least 2,000 hours of practice as a therapist. While someone holding a different type of allied dental professional degree will be free to apply and enroll in either dental therapy program, they will have to complete the appropriate dental therapy degree to practice as a therapist.

Q: How will dental therapists be limited to caring for the underserved?
A: The law sets strict guidelines for the patient base therapists can serve and the areas in which they can practice, including:
• Critical access dental clinics (which are operated by dentists who receive enhanced reimbursement from Medicaid because they treat a high volume of Medicaid patients);
• The usual assisted living facilities, FQHCs, etc.;
• A collaborative hygiene setting (although this would only apply to an advanced therapist, because a basic therapist could not perform surgical procedures with no supervising dentist on the premises);
• Military and VA facilities;
• Dental or dental therapy schools; and
• Any other setting where at least 50 percent of the therapist’s patients are among the following groups:
o Enrollees of a state publicly funded health care program,
o Having no private or public dental coverage and are at 200 percent FPL or below; or
o The patients or practice is in a designated DHPSA.

For more information: Jon Holtzee, [email protected], (312) 440-3520
May 20, 2009
 
Members don't see this ad :)
frickin' liberals, man.


"A Liberal is a person who will give away everything they don't own."



Furthermore, this is a perfect description from Panda Bear, MD

"sort of a metaphor for Obamerica, a country that is rapidly turning into a crappy third-rate nursing home where nothing is made, nobody does anything of value, and the only growth industry besides government are breathless special interest groups working hard at the kind of socially conscious jobs beloved of neighborhood organizers, vying for and spending money we borrowed from the Arabs and Chinese to mold another generation of Americans into beggers, whiners, and shrieking social parasites. The country is kind of peeling at the edges and fading, so to speak. Even the Russians are laughing at us, completely baffled at our headlong rush into Marxism, statism, socialism, and all of the other -isms that once, long ago when we were men, we defeated handily."

http://www.studentdoctor.net/pandabearmd/
 
I didn't read 3/4 of the above, but I feel we dentist brought this on ourselves.

We got greedy and forgot about those that couldn't afford our services but wanted to get dental work.

Some people are plain lazy and don't brush and bring dental disease on themselves. Others are just poor and try hard to keep a good mouth but can't because of other aliments.

If we dentist just donate one day a month of our time to a community center, a lot of these problems will be solved.

If we dentist don't fix the problem the gov't will step in, as they are in Minn, and tell us what to do!!!

I'm a far right guy. I hate the thought of national healthcare. I have a ton of student loans to pay, but I will give time back to the community. I know one day a month is nothing, but if EVERY dentist did that the gov't would get off our backs and that is what I want!
 
"A Liberal is a person who will give away everything they don't own."



Furthermore, this is a perfect description from Panda Bear, MD

"sort of a metaphor for Obamerica, a country that is rapidly turning into a crappy third-rate nursing home where nothing is made, nobody does anything of value, and the only growth industry besides government are breathless special interest groups working hard at the kind of socially conscious jobs beloved of neighborhood organizers, vying for and spending money we borrowed from the Arabs and Chinese to mold another generation of Americans into beggers, whiners, and shrieking social parasites. The country is kind of peeling at the edges and fading, so to speak. Even the Russians are laughing at us, completely baffled at our headlong rush into Marxism, statism, socialism, and all of the other -isms that once, long ago when we were men, we defeated handily."

http://www.studentdoctor.net/pandabearmd/

We had conservative republicans governing over the country for 8 years, yet manufacturing didn't grow and the number of whiners increased. Ever heard of the second rule of thermodynamics? The world is going toward disorder, and no one (even the conservatives) can stop it. So suck it up, and try to adapt (The other option would be moving to China or Russia).
 
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I didn't read 3/4 of the above, but I feel we dentist brought this on ourselves. ....

We got greedy and forgot about those that couldn't afford our services but wanted to get dental work....

I'm a far right guy. I hate the thought of national healthcare. I have a ton of student loans to pay, but I will give time back to the community. I know one day a month is nothing, but if EVERY dentist did that the gov't would get off our backs and that is what I want!



I am with you on being free of government and I'd love to tell you you're right on more volunteering but I just can't. The rise of liberalism isn't solving the problem, its creating more dependency. Look around at the arrival of liberalism/Obama and you'll see more and more people, car companies and institutions all becoming more dependent, not independent. Liberalism rewards losers. This is exactly what they have always wanted, more people dependent on government. That's liberalisms entire playbook.

As the family crumbles, marriage gets dumbed down from a man and a woman in a presumably generative relationship to "all you need is love" and religion is driven out of polite society, the institutions that produced strong individuals in who will marry and are capable of providing for their family's healthcare are fading.

I plan to volunteer my time, cuz I actually do care, but so long as society slides into oblivion under secular liberalism it won't be long before its two days a week. But why stop at doctors? Why doesn't AT & T give 2 free days of cell phone service? Why doesn't Comcast offer a no pay day?

After going through 4 years of d school I have come to change my mind on somethings I thought before I went to school.
1) Until sexual ethics, marriage and the family is fixed, there will always be generations of chronically poor people lining up in our clinics. This is a relatively new phenomenon that started in the 1960s.

2) Dental schools and GPRs alone do tons of low cost work for poor people and a basic menu of extractions, prophys and fillings are within reach for 90% of the country.

3) The insurance companies and liberals politicians are driving the mid level forward.

4) Lastly, I'm going to pay my dues to the ADA to make sure it doesn't get real bad.
 
We had conservative republicans governing over the country for 8 years, yet manufacturing didn't grow and the number of whiners increased. Ever heard of the second rule of thermodynamics? The world is going toward disorder, and no one (even the conservatives) can stop it. So suck it up, and try to adapt (The other option would be moving to China or Russia).
Wait, you're saying the second law of thermodynamics dictates that every nonequilibrium physical event in the universe results in a net increase in socialism?

I must have skipped that lecture.
 
Okay, everyone needs to take a step back and take a deep breath and really think about what this now signed legislation means and why this is about as good a 1st state mid level practitioner legislation as we could hope for.

I will fully admit that I have a bit of different perspective as to what this bill SAYS and means, simply because my business partner is one of the national experts on mid-level care and is not only a member of multiple national ADA committees/tasks forces on this topic, but is also asked to speak at multiple national meetings about this topic.

First off, generally speaking the knowledge of dentistry that our elected officials have is rudimentary at best (plug for getting involved after graduation in organized dentistry and having/going to "political nights" at the component society levels where you can very often talk face to face with your elected officials to educate them - WE NEED TO GET OUT OF OUR OFFICES). Our elected officials can see how mid-level medical providers (Nurse practitioners, etc) work successfully for increasing access on the medical side of things, and plain and simple many legislators think something similar must therefore work on the dental side of things. Plus, to many a legislator, we as dentists, are just viewed as "those rich people" and they hear far less from us than the masses of their constiuents on welfare who may very well not be able to get into be seen by a dentist that accepts medicaid - that's the reality we're dealing with. Basically, completely squashing a mid-level practitioner just wasn't going to happen for very much longer.

Here's what Minnesota passed and what it actually means, and why very likely it will have many economic problems with succeeding long term.

First off, it says that the courses will be taught through a dental school, thus giving the profession more control then say if it was taught through a local college. Also, the first class won't be matriculating until the fall of 2010.

Second, to practice as a mid-level you need to complete 4 years of this yet to be fully determined curriculum and then you can practice ONLY under direct supervision of a licensed dentist. To practice under "in-direct" supervision of a dentist, you need to complete a total of 6 years of training, and then in-direct supervision will basically be that mid-level presenting their finding via a presumably webcam based link to a licensed dentist before starting treatment.

Now you need to find a potential student for this program that wants to go through the time + expense of atleast 4 years of education (probably at atleast 20-25 thousand a year) to practice fully supervised at a salary likely not very much more than what a fulltime hygienist is currently earning. Even more daunting time + expense wise for the 6 year version.

I don't think that they'll be too many existing hygienists/assistants lining up for this program, and if there some folks that didn't get into a dental school and decide to try for this as an alternative, well then in the big scheme of things, them practicing under supervision as opposed to independently is likely a GOOD thing.

Bottomline, is this piece of legislation(which ended up being much more in the way of requirements than the original hygienists backed proposal was) sets the bar for the inevitable passage in other states, and what the requirements will be.
 
We had conservative republicans governing over the country for 8 years, yet manufacturing didn't grow and the number of whiners increased. Ever heard of the second rule of thermodynamics? The world is going toward disorder, and no one (even the conservatives) can stop it. So suck it up, and try to adapt (The other option would be moving to China or Russia).

I have not heard of the 2nd rule of thermo related to this context. Further explain.
 
First off, generally speaking the knowledge of dentistry that our elected officials have is rudimentary at best .... Our elected officials can see how mid-level medical providers (Nurse practitioners, etc) work successfully for increasing access on the medical side of things, and plain and simple many legislators think something similar must therefore work on the dental side of things.

Not to mention that many people outside of our field, including legislators believe what we do is "just putting fillings in" and "how hard can that be, just get somebody else to do it like EFDAs (Ohio)!"

It really burns me how people can view what we do as so simple yet we are held to the highest standard of law if God forbid we fail to accurately explain a patient's "Gingivitis [ GUM DISEASE.... aaaaaah!]" to them so they can understand. Trust me on this one.


Plus, to many a legislator, we as dentists, are just viewed as "those rich people" and they hear far less from us than the masses of their constiuents on welfare who may very well not be able to get into be seen by a dentist that accepts medicaid - that's the reality we're dealing with. Basically, completely squashing a mid-level practitioner just wasn't going to happen for very much longer.

And many in organized dentistry honestly believe that increasing numbers of medicaid providers will solve the access to care issue. I saw a post (I think on Dentaltown??) indicating that there was a provider that was denied for pedo medicaid because there were too many providers?! Comprhensive adult Medicaid is absolutely, positively, the most egregious system right now in our profession. If it were forced upon me for legislative purposes (without government audit/fraud/malpractice protection) for getting my license, I'd turn it in and teach or retire on my sailboat or even work at Dunkin Donuts rather than practice Medicaid-based dentistry.
 
This piece of uh legislation sounds awful. It seems like the people who would be doing this sort of thing are those that couldn't get in to dental school in the first place. Just like what is happening with the dental mills popping up, someone is going to find a way to turn this into big business.
 
So I would ask every legislator who supported this "mid-level provider" would they allow their own children or their grandparents to be treated by this "mid-level provider"? What exactly is the point?

Americans will need to decide exactly what type of health care they want in this country and who they expect to provide it. Americans want the best care, the most technologically advanced, the best and the brightest providers BUT don't want to pay for it. They don't want healthcare providers to make a living or make a profit after years of sacrifice and exorbitant debt. Yet they have no qualms about seeing ball players being paid 20 million dollars a year to hit a little round ball and round around some bases. If the people do not want a dedicated fully trained professional to deliver quality dental care, then there is a need for the "mid-level provider". Sure it'll be cheap. But there is the adage "You get want you pay for". The best and the brightest will NOT go into healthcare if you cut reimbursements. The best and the brightest WILL NOT be these mid-level providers. That eventually endangers the public health and endangers the profession of Dentistry.

And this attitude "Oh well, this is the best we could have hope for" is not going to cut it. Organized dentistry has dropped the ball here. This idea of "mid-level providers" threatens your profession. It relegates dentistry to a trade...to vocational training. It will mean that you are no better than an auto mechanic or a plumber or an electrician. Crank up the Political Action Committee, hire some high level lobbyists. This fight is for the soul and heart of Dentistry. DO NOT BE FOOLED!

And this attitude "oh you don't do enough free dentistry"...well I cannot tell you how many times I had to get up the middle of the night and treat a broken jaw and not be compensated in any way. Oh...but that is Fraud and Abuse that I am perpetrating on the health care system...at least that is what Obama's healthcare advisers say...So don't tell me that I have not done enough...
 
Members don't see this ad :)
Everyone seems to be threatened by these therapists. Would you change your mind if you, yourself, can turn it into a major business that would rake in cash like crazy?

Suppose for a minute you're a GP. You hire 5 therapists to perform the dental work for you, while you just supervise. You do the exams and make the diagnosis. The therapists perform all the preps based on the criteria you give them. Now you've just multiplied your business productivity by roughly 3-5 times. It's like dental school, having each clinic instructor supervising 10 dental students.

With these therapists, every GP can now have the lifestyle of an orthodontist.
 
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Everyone seems to be threatened by these therapists. Would you change your mind if you, yourself, can turn it into a major business that would rake in cash like crazy?

Suppose for a minute you're a GP. You hire 5 therapists to perform the dental work for you, while you just supervise. You do the exams and make the diagnosis. The therapists perform all the preps based on the criteria you give them. Now you've just multiplied your business productivity by roughly 3-5 times. It's like dental school, having each clinic instructor supervising 10 dental students.

With these therapists, every GP can now have the lifestyle of an orthodontist.

I would assume that this is the way it would start, profiteers, during their implementation, would bank serious cash. The problem will be that these mid-level providers would gain experience and/or hubris and then believe they are just as good as dentists and form PACs to lobby congress to become independent and expand "scope of practice."

I have worked with EFDAs (those that place, contour and adjust restorations) and know what I'm talking about here. There are some good ones that I would MAYBE let touch my mouth and there are others that make me cringe. While one can argue the same about dentists, at least I know there is a national and regional basic skills assessment/standardization in combination of at least 4 years of intense didactic and clinical education to back up their degrees. You think that you can just hire 5 "therapists" to work for you making serious money for you, well, the states will regulate the numbers you can employ as they regulate EFDAs (max 2 per dentist/practice).

Excessive profiteering hurts our profession so much. All it takes is the public to perceive dentists as "money hungry." Then they tell their congressperson about how their dentist only cares about their bottom line and it goes from there.

Look at what's going around in the country besides MN:

- California going with EFDAs in Jan 2010:
New EFDA rules in CA
In theory in CA starting in 1/2010 you can walk in, prep a crown and never "see" [work on?] the patient again. The EFDA can take a final impression, make the temp, cement the temp, remove the temp at seat date, and adjust and seat the crown without needing the dentist. But what about "Direct supervision"?? Shouldn't the dentist supervise the EFDA? - hahaha, get real CA.

- Maine allowed independent hygiene and the hygiene association petitions to bill benefit plan companies independently:
http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=2998
http://www.drbicuspid.com/index.aspx?sec=sup&sub=hyg&pag=dis&ItemID=301935&wf=47This means that private practice guys will see their UCRs drop for prophies as independent hygiene competes to attract patients. The jury is out whether independent hygiene actually works, however!

Dental students on here, get your head out of the ground and look around. There are some serious things happening right now affecting our profession, with the ADA often times sitting in the middle of it with their hands tied (by their financial ties to insurance companies?, by their fear of public perception?). Give Kids a Smile is great, but do we need every ADA News front page covering this issue? The ADA got a lot of flack about this and in the last few issues is actually covering the important issues.

I don't know about everyone else, but I can see the insurance companies are, more often than not, the ones backing legislation and regulations such as these. They are the ones that will benefit from "access to care" issues because why should we reimburse dentists more money when a mid-level provider can do it cheaper? I find it disturbing that patients think dentists are money hungry and their "dental insurance companies" are out for their best interests? Man, that's a scary thought.

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Read this article, I was amazed:
http://www.startribune.com/lifestyle/health/39534012.html?elr=KArksLckD8EQDUoaEyqyP4O:DW3ckUiD3aPc:_Yyc:aUUss

"Dentistry's version of nurse practitioners, called dental therapists, might soon fill your cavities.

A Board of Regents committee on Thursday approved creating two dental therapy degree programs. Meanwhile, legislators introduced bills that would license the people who graduate from them.

A step between a hygienist and a dentist, a dental therapist would be allowed to pull teeth, place sealants and do some other procedures now only performed by dentists."

How insulting... like "filling or pulling" teeth is so damn simple and nothing bad ever happens. These are serious procedures that are easily trained to anybody, but that's not the idea. 4+ years of education prepares you for the time when your patient goes into syncope, has a potentially life-threatening allergic reaction, or an assistant faints, falls and cracks their skull and ends up going to the ER (contrary to what EMS said, I sent her). All of this has happened to me, thank God the patients had a doctor to be there for them, I feel for any patients that are in these clinics without a doctor.

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Congresspeople just don't understand, (nor care?) to take the time to understand, how serious our job is. If an EFDA impressed and also cements a crown and the occlusion way off, there can be some major implications for the patient / dentist. Most of the EFDA training in occlusion is: bite down, tap tap, feels ok? great. What they want is a two-tiered dental system without the public perception of two-tiered dental system, with the insurance reimbursements of a two-tiered system while claiming to be equal in providing care, while, somehow, all along maintaining "separate but equal." Hrm.....


This quote is one of the best I have seen:

So I would ask every legislator who supported this "mid-level provider" would they allow their own children or their grandparents to be treated by this "mid-level provider"?

Would you? I certainly would not.
 
I agree that mid-level providers are not a good thing for the profession--but claiming that more than a bare few dentists are adequately trained to manage, or even reliably recognize, medical emergencies is a fantasy. E.g., syncope is not a medical emergency; I seriously doubt you know how to administer and dose epinephrine for anaphylactic reaction versus code; and it doesn't require for years of professional school to say "go to the emergency room."

I want to make very clear that I'm not picking on you specifically, Mike; I'm indicting the broader principles, and you just happened to be the one who articulated them here. Perhaps you're one of the few dentists who *can* tell his head from a hole in the ground when it comes to patient medical issues, in which case I apologize for using you as a springboard here. Unfortunately, even if that's the case, it leaves you and me as remarkable exceptions to an unfortunate rule.

I can tell you anyone reading this, after a year of working in the OR at a level 1 trauma center, that a hyperoccluding crown will virtually never result in "major implications" for the patient, and to suggest otherwise, however well-intended, implies a profound lack of perspective of what truly constitutes a major health implication. It is the blessing and curse of our profession that many of us will spend our entire careers without ever coming face-to-face with a true medical crisis; this puts us under much less stress than many of our physician colleagues, but also allows us to easily lose perspective about the big-picture significance of the patient care issues we see on a daily basis.

I agree that dental auxiliaries are inadequately trained to be working independently, but we need to maintain a realistic perspective about exactly what we do for patients. If a mid-level can safely and effectively perform burn surgery on a critically ill patient from start to finish without her attending ever scrubbing or even spending more than ten minutes in the OR (happened to me last week), I think it says a great deal of unflattering things about our professional self-image to suggest that patients' lives hang on the decision of who can cement a crown that was prepared, impressed, prescribed, and approved by the treating dentist.
 
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To practice under "in-direct" supervision of a dentist, you need to complete a total of 6 years of training, and then in-direct supervision will basically be that mid-level presenting their finding via a presumably webcam based link to a licensed dentist before starting treatment.
Financially speaking, the advanced dental therapists (ADTs) will be able to practice off-site without a dentist present - although they need prior approval for perform certain treatments. These treatments include restorative and surgical procedures, including extractions. So more or less, these ADT's can set-up a shop and produce like any other GP office as long as they get their prior approvals in order.

I think this will be a window of opportunity for corporate dentistry, where they set-up shops for ADT's, and have a district dentist or two to supervise them.

The salary of ADT's will be determined by the market demand, specifically how corporate chains go about it. I don't see ADTs making as much as hygienists, I would say closer to a new associate salary. This is enough to create a demand for ADT programs, considering tuition will be much cheaper than a DDS or DMD program.

I see an invasion of corporate dentistry coming out of this bill.
 
Financially speaking, the advanced dental therapists (ADTs) will be able to practice off-site without a dentist present - although they need prior approval for perform certain treatments. These treatments include restorative and surgical procedures, including extractions. So more or less, these ADT's can set-up a shop and produce like any other GP office as long as they get their prior approvals in order.

I think this will be a window of opportunity for corporate dentistry, where they set-up shops for ADT's, and have a district dentist or two to supervise them.

The salary of ADT's will be determined by the market demand, specifically how corporate chains go about it. I don't see ADTs making as much as hygienists, I would say closer to a new associate salary. This is enough to create a demand for ADT programs, considering tuition will be much cheaper than a DDS or DMD program.

I see an invasion of corporate dentistry coming out of this bill.

new associate salary is higher than even most top end hygienists so i am confused about what you're saying. i think they will (and should) make more than hygienists but probly not by much. the top end of hygienists is south of 90k and the low end of starting dentists is def north of 90k (minus military dentists who have other perks). i think we should embrace this new position. most dentists seem to be against socialized medicine's universal healthcare but SOMETHING has to be done to get care to the underserved and this seems to be a kind of a comprimise in the issue. an increase of services provided w/o losing the autonomy of the profession. a win-win perhaps?
 
"Suppose for a minute you're a GP. You hire 5 therapists to perform the dental work for you, while you just supervise. You do the exams and make the diagnosis. The therapists perform all the preps based on the criteria you give them"

You can do this now...ever hear of Western Dental Clinics or SmileCare...that is the principle of Advertising Dentistry...just hire a bunch of recent grads, or foreign trained dentists...pay them crap and do a bang up business. You don't need dental therapists for that job.

The issue is not a high occluding crown, the issue is administration of drugs, identification of potential life threatening problems problems, knowing drug interaction, physiologic response. For example...what is your maximum dosage of 2% lidocaine in a 30 lb child? How many milligrams does a carpule hold? What if your nursing home patient is on an MAO inhibitor? What if your nursing home patient has a nitroglycerine patch on? What about the pediatric patient that has bleeding gums and really has leukemia, lymphoma, or Von Willibrand's? Dental education has this full curriculum for a reason...or do you think it is just to pass the NBDE? Why bother with a doctoral education then...why not do the British model and have a Bachelor's of Dental Surgery (BDS)?

Sure, I have seen many fine Nurse Anesthetist too. But I would not allow independent practice for them, just as I would not allow independent practice of Hygienist, or this proposed dental therapist (which they will be able to do independent practice). The is a reason for boundaries in professional health providers. That is why there are boundaries in OMS between the single degree and the dual degree. That is why there is a boundary between dentistry and medicine. That is why there is a boundary between nursing and medicine. The boundary has to do with training, experience, knowledge, and most important of all RESPONSIBILITY and ACCOUNTABILITY. I guarantee you the ass on the line for a nurse anesthetist will be the attending MD. As with a hygienist as too with these proposed dental therapist. It will be the supervising DDS whose ass will be in the sling if anything goes wrong.

I think you have not thought this through and see where truth lies.
 
The issue is not a high occluding crown, the issue is administration of drugs, identification of potential life threatening problems problems, knowing drug interaction, physiologic response. For example...what is your maximum dosage of 2% lidocaine in a 30 lb child? How many milligrams does a carpule hold? What if your nursing home patient is on an MAO inhibitor? What if your nursing home patient has a nitroglycerine patch on? What about the pediatric patient that has bleeding gums and really has leukemia, lymphoma, or Von Willibrand's? Dental education has this full curriculum for a reason...or do you think it is just to pass the NBDE? Why bother with a doctoral education then...why not do the British model and have a Bachelor's of Dental Surgery (BDS)?
1) Roughly 15kg at 5mg/kg, just to keep the math simple, puts you at about two 36mg carpules for a 30-pound kid. This is the kind of thing you do with a reference sheet and a $2 four-function calculator.

2) MAO inhibitors are a contraindication to epinephrine. But uh-oh, your hygienist just went and gave a bunch of epi before you could warn her. What do you expect to happen, and what do you plan to do about it? Call 911 and wash your hands of the matter? Time to show what you're made of, Doctor.

3) Lots of options here. Sedation, staged procedures, deferring treatment altogether. This patient's medical history deserves a close look to see whether the benefits of dental treatment outweigh the risks. They very well may, but they very well may not. Do you feel prepared to make that determination? If not, then you'll be calling the patient's PCP just like the dental therapist would.

4) You're talking about once-in-a-lifetime cases that, like it or not, dentists themselves frequently don't catch--not because they're bad dentists, but because they're not adequately trained to recognize the historical or physical signs of conditions like lymphoma, leukemia, or VW.

5) I encourage you to do some reading on the differences in academic convention between American and Europe. A British BDS and an American DDS are equivalent degrees.

Sure, I have seen many fine Nurse Anesthetist too. But I would not allow independent practice for them, just as I would not allow independent practice of Hygienist, or this proposed dental therapist (which they will be able to do independent practice).
Too late. CRNA's practice independently in a great number of locations around the country.
The is a reason for boundaries in professional health providers. That is why there are boundaries in OMS between the single degree and the dual degree.
This is flatly incorrect. As sarah_bellum indicates, there is no difference whatsoever in the scope of practice between single- and dual-degree oral & maxillofacial surgeons.
That is why there is a boundary between dentistry and medicine. That is why there is a boundary between nursing and medicine. The boundary has to do with training, experience, knowledge, and most important of all RESPONSIBILITY and ACCOUNTABILITY. I guarantee you the ass on the line for a nurse anesthetist will be the attending MD. As with a hygienist as too with these proposed dental therapist. It will be the supervising DDS whose ass will be in the sling if anything goes wrong.

I think you have not thought this through and see where truth lies.
I think you failed to verify your facts adequately before making this post, which somewhat weakens the impact of any guarantees you make.
 
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Oh, and the physician's assistant doing the burn surgery, did she independently and on her own authority determine that the burn patient needed the surgery,diagnosis the problem, decide what surgery to do, and then independently manage the post surgical care of this patient? I don't think so. Remember , a dental therapist in this legislation can get an "advanced" certification and will be able to do independent practice without any supervision or oversight by a DDS.

It is this issue of INDEPENDENT practice that strikes a dagger into your profession. "Why any monkey can work on teeth" "Why do you need all that basic science training?" "Anybody can work on children" "It's just baby teeth, right? They are just going to fall out" That will become the issue here. Why bother with a doctoral education? Why bother having GPA and DAT scores determine admission and require 3-4 yrs of undergraduate college? Why bother with Ivy League Dental school? Heck...Dentistry is vocational training right? Just like barbers right?

Wake up and see what is really there.
 
new associate salary is higher than even most top end hygienists so i am confused about what you're saying. i think they will (and should) make more than hygienists but probly not by much. the top end of hygienists is south of 90k and the low end of starting dentists is def north of 90k (minus military dentists who have other perks). i think we should embrace this new position. most dentists seem to be against socialized medicine's universal healthcare but SOMETHING has to be done to get care to the underserved and this seems to be a kind of a comprimise in the issue. an increase of services provided w/o losing the autonomy of the profession. a win-win perhaps?
I guess what I meant was that ADT's will make more than hygienists since their scope of practice falls somewhere between a dentist and a hygienist. We already have the "advanced hygienist practitioner" in the ladder, who make more than regular hygienist, so experienced ADTs will make at least $100k if they are doing EXT's, fillings, etc.
 
Oh, and the physician's assistant doing the burn surgery, did she independently and on her own authority determine that the burn patient needed the surgery,diagnosis the problem, decide what surgery to do, and then independently manage the post surgical care of this patient? I don't think so. Remember , a dental therapist in this legislation can get an "advanced" certification and will be able to do independent practice without any supervision or oversight by a DDS.

It is this issue of INDEPENDENT practice that strikes a dagger into your profession. "Why any monkey can work on teeth" "Why do you need all that basic science training?" "Anybody can work on children" "It's just baby teeth, right? They are just going to fall out" That will become the issue here. Why bother with a doctoral education? Why bother having GPA and DAT scores determine admission and require 3-4 yrs of undergraduate college? Why bother with Ivy League Dental school? Heck...Dentistry is vocational training right? Just like barbers right?

Wake up and see what is really there.
While I still think the second paragraph here contains much more fluff than substance, I agree with the first completely. Mid-level dental providers are inevitable, and trying to prevent them is a waste of valuable energy and resources. Where we now need to concentrate our attention as a profession is on keeping them mid-level and dependent on dentist oversight, where our professional judgment remains in the equation to ensure patients' well-being.
 
I beg to differ that there is no difference in practice of a single degree and a dual degree OMS. Just try getting a Facial Plastic fellowship without having a medical license. Just try getting a CranioFacial Fellowship without doing general surgery and a plastic residency. SHOW ME where you can get that training with a single degree. If you are talking just dental alveolar and orthognathic surgery sure...there is no difference. I have a single degree and I practice a pretty full scope and my American Board certification is just as good at the dual guy. But go ahead ...show me where you can do these fellowships without the 2nd degree. And I'll just bet you are taking the 2nd degree.

Where do CRNA do independent practice? Where are they NOT medically or dentally directed? You mean to say a CRNA can walk into any dental office or anywhere and administer an aneshetic? Not in California they can't. There is a difference between instruction and direction. Instruction is telling the CRNA you need to push that or push this, the blood pressure is too high give that...direction is saying this patient has been determined to need an anesthetic...put that patient to sleep by MY direction (but not by my instruction) but do it by your own training. So where in this country are CRNAs NOT directed? Or do you not see that difference. In California NO CRNA may perform dental anesthesia without the attending dentist having a sedation permit. And that anesthesia will be directed NOT instructed.

A BDS and a DDS are NOT equivalent. Otherwise why would you have 2 yr International Dental Programs? Also, in Britain, a BDS cannot become an OMS without taking the MD training. These degrees are NOT equivalent.
 
I beg to differ that there is no difference in practice of a single degree and a dual degree OMS. Just try getting a Facial Plastic fellowship without having a medical license. Just try getting a CranioFacial Fellowship without doing general surgery and a plastic residency. SHOW ME where you can get that training with a single degree. If you are talking just dental alveolar and orthognathic surgery sure...there is no difference. I have a single degree and I practice a pretty full scope and my American Board certification is just as good at the dual guy. But go ahead ...show me where you can do these fellowships without the 2nd degree. And I'll just bet you are taking the 2nd degree.

Where do CRNA do independent practice? Where are they NOT medically or dentally directed? You mean to say a CRNA can walk into any dental office or anywhere and administer an aneshetic? Not in California they can't. There is a difference between instruction and direction. Instruction is telling the CRNA you need to push that or push this, the blood pressure is too high give that...direction is saying this patient has been determined to need an anesthetic...put that patient to sleep by MY direction (but not by my instruction) but do it by your own training. So where in this country are CRNAs NOT directed? Or do you not see that difference. In California NO CRNA may perform dental anesthesia without the attending dentist having a sedation permit. And that anesthesia will be directed NOT instructed.

A BDS and a DDS are NOT equivalent. Otherwise why would you have 2 yr International Dental Programs? Also, in Britain, a BDS cannot become an OMS without taking the MD training. These degrees are NOT equivalent.
Doc Ock, I'm not going to argue about these points with you. These are questions of fact, not opinion, and you're obviously an intelligent, educated individual who cares about our profession. You can find the truth of these matters online very easily, and I encourage you to do so in order to settle your doubts.
 
Cop out.

TBLTB

The Blind Leading the Blind.

There is NO Independently directed CRNA practice in California as pertains to dental offices. I KNOW this as fact as I serve as an in office Evaluator for the Dental Board. I suggest you check your facts. Again the issue is Instruction vs. Direction.

Good bye.
 
Cop out.

TBLTB

The Blind Leading the Blind.

There is NO Independently directed CRNA practice in California as pertains to dental offices. I KNOW this as fact as I serve as an in office Evaluator for the Dental Board. I suggest you check your facts. Again the issue is Instruction vs. Direction.

Good bye.
Sir, I recognize this is an issue many Californians struggle with, but your local environment does not in fact generalize to the rest of the United States. Do the research and see for yourself. If that's still too much work, simply google "CRNA opt-out legislation" and see for yourself. Good night.
 
Let me explain this one more time.

Now since I know California, I will explain it how it is in California. Since there is a basic principle involved, watch the illustration carefully.

In California a CRNA may NOT practice independently in regards to a dental office. By this I mean a CRNA may not walk into any dental office and on their own initiative and volition deliver a anesthetic to a dental patient. The CRNA must be DIRECTED by a permit holding Dentist. That dentist MUST hold either a Conscious Sedation Permit or a General Anesthesia Permit. That dentist must pass an inoffice inspection (simulated emergencies, emergency and monitoring equipment, demonstrate a sedation or GA). The CRNA does not independently hold a permit.

Is the CRNA practicing independently? No. The CRNA works at the direction of the Dentist. In other words...the CRNA is told on whom to provide the anesthesia to.

Is the CRNA being instructed on how to do their job? No. The CRNA delivers the anesthetic at their own discretion. But Who, When, Where is being directed by the Dentist. NOT HOW.

Is the CRNA an employee of the Dentist? No. They are independent contractors and run their own business. But this IS NOT independent practice because they cannot decide on who will receive their services. The CRNA may not on their own volition provide anesthesia for a belly button ring for example.

Can the CRNA walk into any dental office and give the anesthesia for a dental problem? No. Only in an office where the Dentist holds a valid permit (either sedation or GA).

As you see, the Dentist holding the permit is the one who is RESPONSIBLE for the well being and care of the dental patient. That Dentist is ACCOUNTABLE for the well being and care of the dental patient. NOT the CRNA.

A dental anesthesiologist (DDS) or a medical anesthesiologist (MD / DO) CAN hold their own sedation/anesthesia permit. They can go to any dental office and deliver anesthesia to a dental patient at their discretion whether the operating dentist hold a permit or not. THAT is INDEPENDENT practice.

This is a basic principle of RESPONSIBILITY and ACCOUNTABILITY. The Minnesota legislation erodes this principle. And this principle is at the heart of any health care profession. There is a big difference in a healthcare professional called MISTER as opposed to the healthcare professional called DOCTOR. And that is this principle of RESPONSIBILITY and ACCOUNTABILITY. Where does the buck stop? Who takes charge? Who takes it upon them to deliver the best care and ensure the safety of their patient?

If you cannot see this...then I cannot make this more CLEAR. If you cannot see this...then I pity you.

Have a Great Career.
 
Oh... FYI a dental carpule contains 34 mg of 2% lidocaine not 36mg(20mg/cc x 1.7 cc). The manufacturers a while back changed the carpule from 1.8 cc to 1.7 cc. I suggest you get your facts straight and do the proper research before posting also.
 
Oh... FYI a dental carpule contains 34 mg of 2% lidocaine not 36mg(20mg/cc x 1.7 cc). The manufacturers a while back changed the carpule from 1.8 cc to 1.7 cc. I suggest you get your facts straight and do the proper research before posting also.
36 was actually a typo on my part. I meant to type 35 for the sake, as I mentioned in the post, of simplifying calculation in my head. Nonetheless, you are correct that a carpule of 2% lidocaine contains 2mg less drug than I indicated in my post. Thank you for the correction.
 
I agree that mid-level providers are not a good thing for the profession--but claiming that more than a bare few dentists are adequately trained to manage, or even reliably recognize, medical emergencies is a fantasy. E.g., syncope is not a medical emergency; I seriously doubt you know how to administer and dose epinephrine for anaphylactic reaction versus code; and it doesn't require for years of professional school to say "go to the emergency room."

I want to make very clear that I'm not picking on you specifically, Mike; I'm indicting the broader principles, and you just happened to be the one who articulated them here. Perhaps you're one of the few dentists who *can* tell his head from a hole in the ground when it comes to patient medical issues, in which case I apologize for using you as a springboard here. Unfortunately, even if that's the case, it leaves you and me as remarkable exceptions to an unfortunate rule.

I can tell you anyone reading this, after a year of working in the OR at a level 1 trauma center, that a hyperoccluding crown will virtually never result in "major implications" for the patient, and to suggest otherwise, however well-intended, implies a profound lack of perspective of what truly constitutes a major health implication. It is the blessing and curse of our profession that many of us will spend our entire careers without ever coming face-to-face with a true medical crisis; this puts us under much less stress than many of our physician colleagues, but also allows us to easily lose perspective about the big-picture significance of the patient care issues we see on a daily basis.

I agree that dental auxiliaries are inadequately trained to be working independently, but we need to maintain a realistic perspective about exactly what we do for patients. If a mid-level can safely and effectively perform burn surgery on a critically ill patient from start to finish without her attending ever scrubbing or even spending more than ten minutes in the OR (happened to me last week), I think it says a great deal of unflattering things about our professional self-image to suggest that patients' lives hang on the decision of who can cement a crown that was prepared, impressed, prescribed, and approved by the treating dentist.

Whoah! Man,

Seriously, tone it down a bunch and chill! I guess I struck a nerve on this topic for you. I am in no way trying to pick a fight, I really like what you often choose to post on SDN, as you often articulate yourself in a well-written and educated manner. You just came out at me with FLAMES on!! hahaha Remember, maybe I have a hyperinflated sense of what a dentist does but maybe it's also possible you share the same sense of a dental anesthesiologist? Just playing the "devil's advocate" here.

I will agree that a hyperoccluding crown will not result in a true medical emergency per se your definition. I suppose syncope was a poor choice of example, but certainly one can argue that anaphylaxis is more of an acute medical emergency. But what about extracting a "simple periodontally involved permanent tooth" and discovering that the patient won't stop bleeding because they doubled their dose of Plavix because they were concerned about their out of whack INR (that they didn't tell you about because you didn't ask) and you don't keep sutures or gelfoam available because you are a midlevel practitioner who is only performing "simple extractions."

You were probably mistaken with the focus of the point I was attempting to make. We can argue all day about the potential for risky medical emergencies that are cut & dry, but what I argue is the more insidious danger of allowing a person to perform irreversible dental procedures who does not have a full scope of the nature of what they are doing (or lack-thereof).

I purport that getting occlusion wrong can seriously affect the well-being of the patient from something as simple as introducing excursive or protrusive working interferences. We cannot ignore the dental/medical manifestations such as myofacial pain, migranes, TMD etc. resulting from being poorly restored or simply not paying attention to the whole picture and focusing solely on one tooth.

What I argue is not the fact that we receive our doctorate because we are aptly more able to handle a serious medical emergency, or only diagnose & treat caries, or only able to diagnose and treat oral cancer. What I argue is that implementing an "independent" mid-level practitioner erodes the confidence that the public expects in a dentist and the trust that a patient bestows upon us when they simple get enough courage to sit in our chair.

What we do, as dentists, is very serious stuff, and while we may not often hold a patient's life in jeopardy, I argue that it is the banter of those who feel what we do is inconsequential compared to that of a "risk of medical emergency" may be belittling the practice of dentistry and those who do argue this fact may be the ones who are truly disingenuous.
 
Whoah! Man,

Seriously, tone it down a bunch and chill! I guess I struck a nerve on this topic for you. I am in no way trying to pick a fight, I really like what you often choose to post on SDN, as you often articulate yourself in a well-written and educated manner. You just came out at me with FLAMES on!! hahaha Remember, maybe I have a hyperinflated sense of what a dentist does but maybe it's also possible you share the same sense of a dental anesthesiologist? Just playing the "devil's advocate" here.

I will agree that a hyperoccluding crown will not result in a true medical emergency per se your definition. I suppose syncope was a poor choice of example, but certainly one can argue that anaphylaxis is more of an acute medical emergency. But what about extracting a "simple periodontally involved permanent tooth" and discovering that the patient won't stop bleeding because they doubled their dose of Plavix because they were concerned about their out of whack INR (that they didn't tell you about because you didn't ask) and you don't keep sutures or gelfoam available because you are a midlevel practitioner who is only performing "simple extractions."

You were probably mistaken with the focus of the point I was attempting to make. We can argue all day about the potential for risky medical emergencies that are cut & dry, but what I argue is the more insidious danger of allowing a person to perform irreversible dental procedures who does not have a full scope of the nature of what they are doing (or lack-thereof).

I purport that getting occlusion wrong can seriously affect the well-being of the patient from something as simple as introducing excursive or protrusive working interferences. We cannot ignore the dental/medical manifestations such as myofacial pain, migranes, TMD etc. resulting from being poorly restored or simply not paying attention to the whole picture and focusing solely on one tooth.

What I argue is not the fact that we receive our doctorate because we are aptly more able to handle a serious medical emergency, or only diagnose & treat caries, or only able to diagnose and treat oral cancer. What I argue is that implementing an "independent" mid-level practitioner erodes the confidence that the public expects in a dentist and the trust that a patient bestows upon us when they simple get enough courage to sit in our chair.

What we do, as dentists, is very serious stuff, and while we may not often hold a patient's life in jeopardy, I argue that it is the banter of those who feel what we do is inconsequential compared to that of a "risk of medical emergency" may be belittling the practice of dentistry and those who do argue this fact may be the ones who are truly disingenuous.
Nope. Believe it or not, I think you and I are pretty much on the same page, actually. You and I both know the impact, for good or ill, we can have on our patients' health and well-being. I respect that as much as you do. There are a *lot* of things (like most of what we dentists do on a daily basis) that I strongly agree assistants and hygienists have no business touching.
Your example of a "simple" extraction going unexpectedly south is a great illustration. We've all had it happen, and it has the potential to cause real problems for someone who isn't adequately trained to handle the problem.

You're right, this thread touched on a couple of my pet peeves, so I apologize for coming on so strong. This thread got a little bit sidetracked, and instead of trying to rein it back in I got sucked into the mire. In the end, all my sound and fury in this thread can be boiled down to a simple statement of opinion: there are a number of fronts on which we can attack the problems here, and I believe we should concentrate on the ones on which our patients' welfare most depends. Friends? :p
 
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"What I argue is that implementing an "independent" mid-level practitioner erodes the confidence that the public expects in a dentist and the trust that a patient bestows upon us when they simple get enough courage to sit in our chair."

Well said. My point exactly.

Which is what I tried to show in my above illustration. It is not the creation of the mid level practitioner (although this has a lot of problems associated with it...for example no perio curriculum, no hygiene...no college pre-dental courses etc.) but the provision for independent practice and the chance for inadequate care for very vulnerable populations. That was my beef with Minnesota's legislation....I hope it is yours too.

Have a good life and a long career fellas.
 
Okay, everyone needs to take a step back and take a deep breath and really think about what this now signed legislation means and why this is about as good a 1st state mid level practitioner legislation as we could hope for.

I will fully admit that I have a bit of different perspective as to what this bill SAYS and means, simply because my business partner is one of the national experts on mid-level care and is not only a member of multiple national ADA committees/tasks forces on this topic, but is also asked to speak at multiple national meetings about this topic.

First off, generally speaking the knowledge of dentistry that our elected officials have is rudimentary at best (plug for getting involved after graduation in organized dentistry and having/going to "political nights" at the component society levels where you can very often talk face to face with your elected officials to educate them - WE NEED TO GET OUT OF OUR OFFICES). Our elected officials can see how mid-level medical providers (Nurse practitioners, etc) work successfully for increasing access on the medical side of things, and plain and simple many legislators think something similar must therefore work on the dental side of things. Plus, to many a legislator, we as dentists, are just viewed as "those rich people" and they hear far less from us than the masses of their constiuents on welfare who may very well not be able to get into be seen by a dentist that accepts medicaid - that's the reality we're dealing with. Basically, completely squashing a mid-level practitioner just wasn't going to happen for very much longer.

Here's what Minnesota passed and what it actually means, and why very likely it will have many economic problems with succeeding long term.

First off, it says that the courses will be taught through a dental school, thus giving the profession more control then say if it was taught through a local college. Also, the first class won't be matriculating until the fall of 2010.

Second, to practice as a mid-level you need to complete 4 years of this yet to be fully determined curriculum and then you can practice ONLY under direct supervision of a licensed dentist. To practice under "in-direct" supervision of a dentist, you need to complete a total of 6 years of training, and then in-direct supervision will basically be that mid-level presenting their finding via a presumably webcam based link to a licensed dentist before starting treatment.

Now you need to find a potential student for this program that wants to go through the time + expense of atleast 4 years of education (probably at atleast 20-25 thousand a year) to practice fully supervised at a salary likely not very much more than what a fulltime hygienist is currently earning. Even more daunting time + expense wise for the 6 year version.

I don't think that they'll be too many existing hygienists/assistants lining up for this program, and if there some folks that didn't get into a dental school and decide to try for this as an alternative, well then in the big scheme of things, them practicing under supervision as opposed to independently is likely a GOOD thing.

Bottomline, is this piece of legislation(which ended up being much more in the way of requirements than the original hygienists backed proposal was) sets the bar for the inevitable passage in other states, and what the requirements will be.
Not to mention the only state in the nation who at present recognize this profession is MN. I don't know if I would invest this kind of time and money to be limited so much in the job market.
 
"What I argue is that implementing an "independent" mid-level practitioner erodes the confidence that the public expects in a dentist and the trust that a patient bestows upon us when they simple get enough courage to sit in our chair."

Well said. My point exactly.

Which is what I tried to show in my above illustration. It is not the creation of the mid level practitioner (although this has a lot of problems associated with it...for example no perio curriculum, no hygiene...no college pre-dental courses etc.) but the provision for independent practice and the chance for inadequate care for very vulnerable populations. That was my beef with Minnesota's legislation....I hope it is yours too.

Have a good life and a long career fellas.
Agree completely.
 
Not to mention the only state in the nation who at present recognize this profession is MN. I don't know if I would invest this kind of time and money to be limited so much in the job market.

Technically they're not even recognized yet since they don't have a finalized curriculum, a license exam, a class of students, etc, etc. Right now it's just the legal right to allow this mid-level to happen. It will be atleast 5 years before we actually have a mid-level out in the workforce in MN.
 
True. UMn is adding benches in the preclinic lab this summer and we were told to expect 10 students starting in the fall of this year. Personally, I think this is an overly optimistic start date. Guess we'll see.....
 
For those of you interested in what is really going on with the DT program (versus mass panic based on assumptions), I interviewed for the Master's of dental therapy program at the University of Minnesota last week and would like to offer some insight.

There are approx. 50 applicants to fill 10 spots (at most) in the dental therapy program. The Masters of DT program will begin Sept. 2009 and will produce its first graduates after 6 semesters (2 years plus two summer semesters). That lands the first DT out in the field in the summer of 2011.

There are two DT programs offered at the University of Minnesota School of Dentistry: Masters of DT - 2 years (applicants must have a 4 year bachelors degree) and Bachelors of Dental Therapy - 4 years. Students in the dental therapy program are trained alongside the dental students and receive all of the DT education in the dental school by the same professors teaching the dental students, using the same dental SIM lab and working in the same dental clinic at the university. They also work alongside dental students when doing community outreach clinic, as a part of the dental team.

It is true that DTs will only have 2 years of training versus four years of training that DDS receive, but they are only performing a small subset of procedures, certainly less than half of what dentists perform. Therefore, two years should be a sufficient amount of time to master the subset of proceedures they are allowed to perform. Furthermore, DTs must work under the supervision of a DDS. If anything ever does go wrong, a DDS is onsite to use his/her further training to step in and help.

The standard of care provided by a DT will be the same as a dentist for those SPECIFIC procedures they are providing. For those of you who do not know what DTs will be allowed to do, they can do extractions and crowns on primary teeth, and fillings on primary and permanent teeth. They will also be able to do sealants and fluoride varnish without the supervision of a DDS. DTs will also be trained in public health aspects of dentistry and will (hopefully) do a lot of work on prevention.

This program was created by dentists and other professionals in the field of dentisty. For that reason, I believe it was well thought out and the interest of the dentists and the patients were all taken into consideration when forming the program.

I know there is a lot of judgement and misunderstanding about the program. I'll give you my own personal story on how I ended up applying for the masters of dental therapy program...

I applied to 5 dental schools last cycle, got an interview at one and ultimately ended up not getting in my first time applying. Excluded from my last application was my 3 trips to central america to provide dental care for rural areas of Costa Rica, Nicaragua and Panama as well as two consecutive summer internships with my state dental association. Besides that, I had a 3.54 GPA from the University of Wisconsin-Madison and an 18 on my DAT (23 on O.Chem and 14 on QR - To give you the summary). I am by no means too stupid to get into dental school. I am confident that if I reapplied after giving the DAT another shot, I could get in. After much thought and research into my options (dental school versus dental therapy) I decided that dental therapy might be a better fit for me. I am deeply involved with access to dental care issues due to my position at the dental association and I want my main FOCUS of dental care to be those who have trouble accessing dental care. Dental therapy provides the means to focus on treating those populations without having to focus on bringing in money to keep a dental practice afloat.

As for the Advanced Dental Therapist program, currently there is no program set in stone at the University of Minnesota School of Dentistry. From what I understand, that program could possibly still be repealed. In my opinion, I don't know why anyone would want to do that program over dental school because it will require 4 years of dental education at roughly the same cost as dental school but with a limited scope of practice. I brought this up with the interview committee at the U of M and they didn't seem anxious to argue for the program. That is all the information I have on ADT right now.

Hopefully, I was able to provide some useful information on the current mid-level situation in MN. I just wanted to provide some facts and a different view of the program since I am pretty involved with it.
 
Therefore, two years should be a sufficient amount of time to master the subset of proceedures they are allowed to perform.

After practicing for almost 2 years in private practice and surviving 4 years of dental school, I can, without hesitation, make a claim that this statement is absolutely not true. 2 years is clearly not enough to 1. learn the theory of dentistry, 2. study the biomechanics, physiology, and anatomy of the human body & oral cavity, 3. practice model based dentistry, and 4. practice on human patients. While many may argue that 2 years is enough for basic clinical comprehension (dubious), I doubt ANYONE can actually muster an argument that 2 years will allow for mastery of the procedures a DT will allowed to due.

Sorry, simply not true.

...DTs will also be trained in public health aspects of dentistry and will (hopefully) do a lot of work on prevention...

...Dental therapy provides the means to focus on treating those populations without having to focus on bringing in money to keep a dental practice afloat...

After working in public health dentistry and in private practice, I can assure you that the two above are extremely difficult to do. Prevention is key but very rarely, once reality kicks in, applies to public health dentistry. The reality is "drill, fill & return 2 months later, extract."

----

Badger, please understand that your statements, while well intentioned, are classic of a idealistic pre-dent or dental student. Do some more research before making this serious career decision. I love clinical dentistry, and I am often humbled by how easy some work is and others can seem easy but end otherwise. There is a reason why dentists endure so much academic, clinical, and board rigors.

I encourage you to keep at your dream of becoming a dentist and do not get caught up in this stuff. It may seem exciting to be the first of something new, but I can assure you that the road will be rocky. Take the year to study up, retake the DAT and bring up your scores.
 
After practicing for almost 2 years in private practice and surviving 4 years of dental school, I can, without hesitation, make a claim that this statement is absolutely not true. 2 years is clearly not enough to 1. learn the theory of dentistry, 2. study the biomechanics, physiology, and anatomy of the human body & oral cavity, 3. practice model based dentistry, and 4. practice on human patients. While many may argue that 2 years is enough for basic clinical comprehension (dubious), I doubt ANYONE can actually muster an argument that 2 years will allow for mastery of the procedures a DT will allowed to due.

Sorry, simply not true.



After working in public health dentistry and in private practice, I can assure you that the two above are extremely difficult to do. Prevention is key but very rarely, once reality kicks in, applies to public health dentistry. The reality is "drill, fill & return 2 months later, extract."

----

Badger, please understand that your statements, while well intentioned, are classic of a idealistic pre-dent or dental student. Do some more research before making this serious career decision. I love clinical dentistry, and I am often humbled by how easy some work is and others can seem easy but end otherwise. There is a reason why dentists endure so much academic, clinical, and board rigors.

Incredibly true statement:thumbup:
 
:mad: - got this in my e-mail today from drbicuspid.com

-----------------------------------

U.S. Senate bill favors midlevel providers
6/12/2009
By: Laird Harrison, Senior Editor

The first draft of healthcare reform legislation by the U.S. Senate moves toward assuring dental benefits for all U.S. children. It would also fund pilot programs for midlevel dental providers, such as the controversial new dental therapist programs in Alaska and Minnesota.

The bill, offered by the Senate Committee on Health, Education, Labor, and Pensions (HELP) under Sen. Edward Kennedy (D-MA), leads a series of three competing proposals expected out of Congress this summer. The Senate Committee on Finance plans to release its version next week, followed by a joint version from the corresponding committees of the House of Representatives in mid-July.

All these drafts were written under Democratic leadership whose majority gives them a firm grip; Republicans leaders have complained that the bills don't reflect their input.

In addition to the pediatric and midlevel provider provisions, the HELP bill would also do the following:

* Launch an oral disease prevention campaign
* Mandate more data collection on oral health epidemiology
* Boost programs to provide sealants to school children
* Increase support for dental schools
* Launch a study on caries management systems

The bill got a mixed reception from oral health advocates. "We have set the stage that any plan will have pediatric oral benefits," said Burton Edelstein, D.D.S., M.P.H., a Columbia University professor and founding chair of the Children's Dental Health Project. "We are so happy, because trying to get these provisions in later would be hard."

Others haven't yet had time to work out all the implications of the 615-page document. "We are still reviewing the bill with the goal of providing constructive comments back to the HELP Committee," said Bill Prentice, director of the ADA's Washington, DC, office.

He expected the Senate Committee on Finance to address changes in Medicaid that could include a key policy goal of the ADA: making dental benefits under Medicaid mandatory for adults. Currently, states can choose whether to provide them. Since the cost is split between the state and federal governments, many states struggling to balance their budgets this year have proposed to cut adult benefits.

Meanwhile, the American Dental Education Association (ADEA) is focused on an expansion of Title VII of the Public Health Service Act, which provides money for dental education programs. "Title VII reauthorization is in, but not exactly as we suggested," read one brief ADEA memo.

Many of the oral healthcare provisions in the HELP draft are indirect. For example, while emphasizing that the Senate wants everyone to be able to have health insurance equivalent to that enjoyed by federal employees, the bill doesn't explain how it would provide these benefits to all those who can't currently afford it.

The HELP committee at the last minute pulled out a provision that would have set up a public insurance program to compete with private companies, according to news reports.

The bill would expand Medicaid to 150% of the poverty level, and it would bar insurance companies from denying policies or charging more on the basis of pre-existing conditions. It would also let children stay on their parents' policies until age 26.

In addition, the bill sets up a council to study what benefits should be included in health insurance programs. Among the benefits the council would study are "pediatric services, including oral and vision care."

This is a roundabout way of stipulating that the Senate wants oral healthcare to be available for all children, Dr. Edelstein said. Mandating it directly would be a violation of states' rights, he noted. He added that he'd pushed to get adult benefits mentioned as well. "We couldn't get any traction," he said.

The bill would also set up 15 demonstration projects to explore alternative models for dental care providers. These could be used to test various proposals, such as the community dental health coordinator advanced by the ADA, the American Dental Hygienists' Association's advanced dental hygiene practitioner, and the dental therapists already approved in Alaska and Minnesota. Details would be left to states, since they, rather than the federal government, have the authority to license health practitioners, Dr. Edelstein said.

"The chief message of the first bill is that Congress is not framing this as healthcare reform but as health reform," he said. "That's why prevention and surveillance are included. Congress is trying to reduce the percentage of gross domestic product that goes to healthcare."

Copyright © 2009 DrBicuspid.com
 
Here we go, they have their foot in the door and it's down hill from here.
 
Holy mother of "you-know-what"!

I'm glad we don't have this in Canada.
 
An interesting and spirited discussion so far. Masseter, I assume you are joking, as both the Alaska program and the Minnesota program used the Canadian model in their designs.

I cannot speak the types of experiences the Minnesota program will offer their students. However in the Alaska model, I can comfortably say that all the therapists graduating from that school have at least as much experience with pediatric patients as dental school graduates. I work with dental students from many, many different dental schools, and I am always simultaneously intrigued and appalled to hear about what their requirements for graduation are. New grads or soon to be new grads.... any of you do more than 5 stainless steel crowns? Any of you graduate doing none? How about pediatric extractions? I would love to hear from a new dental school graduate with an extensive pediatric experience in school.

Many opponents of the therapy program do so reactionarily. Aren't we supposed to be evidence based? A pilot study has already appeared in the JADA documenting no statistical difference in adverse outcomes with dental therapists. It will be dismissed by most as too small or too narrow. Please, I'm waiting for any evidence to the contrary. Many of the arguments are emotional based. "You wouldn't want your children being treated by these people, would you?" For many people, the answer is already, "yes, I would." Access to care is an issue not readily understood by those who have not worked in it or lived in it.

Several previous posters have noted that it is too late now to stop the mid-level dental provider. They are correct. Dental therapists are coming to your state, with or without the support of organized dentistry. You can choose to put your head in the sand and fight all forms of it, or you can recognize the extremely limited chance organized dentistry has to be a part of forming it. The Alaska Dental Society will never be a part of the dental therapy program there. That program exists in spite of their efforts to stop it, and their defeat leaves them absolutely powerless to shape its direction. Minnesota and many other states are recognizing this and becoming a part of the process. I applaud them
 
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