Dental practitioner proposals pose considerable health, financial risks

Re: “Our state’s dental system is letting too many patients down” (Viewpoint, 1-29).

Anita Rodriguez recently argued on this page for a new category of mid-level dental provider authorized to practice independently from a dentist.

Rodriguez explained that many dentists oppose this proposal because of concerns for safety and quality of care. She also argued that such practitioners are much the same as the nurse-practitioners of 50 years ago – a profession once opposed by the establishment and now embraced by it.

I wanted to provide some clarity on many dentists’ views on this matter.

Rodriguez is writing in particular about two bills that are currently being considered by our Legislature. Both would create practitioners who, with an unspecified amount of training after high school, could perform irreversible procedures that include drilling and extractions without the on-site supervision of a dentist.

We have three concerns with these bills.

 • We are concerned about the seriousness of the procedures these mid-level practitioners could perform. The measures would allow dental therapists to do surgical procedures including pulpotomies (root canals on primary teeth), drilling for cavity preparation and extractions.

These procedures are irreversible and could be performed by an individual with a GED, an unspecific amount of training and no competency testing. There is no precedent for this mid-level practitioner anywhere else.

To Rodriguez’s point about nurse practitioners: Nurse practitioners cannot perform surgical procedures, and in our state they are required to receive a master’s or doctoral degree.

 • We are concerned about fracturing the dental home for patients. Under the structure of these bills, a patient with complications from a practitioner’s procedure would need to rush to a dentist to address the issue or wait for the dentist to come to him or her. Nearly every dentist can tell a recent story of a procedure that was more complicated than he or she expected.

 • The model is not economically sustainable. Every other mid-level practitioner operating off-site from a dentist –whether located in Alaska, Europe or Australia – has required either government, private or tribal funding to survive.

That’s because the overhead of operating a stand-alone clinic for a mid-level practitioner is much the same as a dentist’s office: same equipment, materials and operating costs. The fees that a dental practitioner would charge would need to reflect these same operating costs.

The Washington State Dental Association has calculated that a practitioner operating off-site from a dentist, and treating only Medicaid patients, would earn $13.87 an hour – yet have about $150,000 in equipment and education loans. It’s a wage unlikely to attract many candidates, especially when it’s less than the current wage of a dental assistant.

That math explains why other mid-level practitioners who operate independently of dentists around the world have all received subsidies of one kind or another. Washington’s no-subsidies budget cannot accommodate dental practitioners.

The truth is, our state’s dentists do support mid-level practitioners. In 2009, we helped create another mid-level practitioner called the “expanded function dental auxiliary,” a profession that has helped expand capacity in community health centers and private practices.

Our concerns are with the way these specific bills would create and define this particular class of mid-level practitioners. Based on our experience, they would create a model that is not economically sustainable and that has no precedent in terms of scope of practice and amount of training required.

Sammy Pak is a Puyallup dentist and president of the Pierce County Dental Society.