The North Dakota House of Representatives has rejected legislation that would have allowed dental therapists to operate in the state and permitted dentists to employ and supervise therapists as members of their dental teams.
Unlike dental hygienists and dental assistants, dental therapists train for two to three years to extract teeth and provide fillings, as well 80 to 90 other procedures only dentists may perform in most states. Therapists practice in Alaska and Minnesota and among tribes in Oregon and Washington State. Maine and Vermont allow therapists to obtain licenses, although none currently practice there.
North Dakota House Bill 1256, sponsored by state Rep. Bill Devlin (R-Finley), passed the House Human Services Committee 8–6 with amendments limiting dentists to hiring up to five therapists and requiring therapists to practice in the same building as their supervising dentists. The authors of “The Case for Licensing Dental Therapists,” published by The Heartland Institute, which publishes Health Care News, testified in support of HB 1256 in committee on January 18.
The House rejected the bill 32–59 on February 8.
Access Versus Authority
Representatives of the 17 North Dakota organizations supporting the bill, including the state’s AARP chapter and the North Dakota Dental Hygienists Association, argued licensing dental therapists would expand options for dentists to grow their practices, thereby increasing access for underserved rural and low-income patients.
The only two state groups opposing the bill, the North Dakota Board of Dental Examiners (NDBDE) and North Dakota Dental Association, argued therapists would provide inadequate care and HB 1256 would undermine the NDBDE’s authority.
The Big Short
Shawnda Schroeder, a research assistant professor at the Center for Rural Health at the University of North Dakota School of Medicine and Health Sciences, says a shortage of oral health care professionals takes a toll on the state’s rural population.
“North Dakota has fewer dentists per 100,000 people than the national average,” Schroeder said. “Dentists that do practice in the state are predominantly located in the four most urban counties, leaving residents in small rural and isolated rural communities without proximal access to a dentist.”
The state’s poor and ethnic minority populations are likeliest to suffer because of the shortage, Schroeder says.
“Our data suggest that Medicaid, low-income, and American Indian populations report worse oral health and are less likely to have access to or utilize dental services than those who are insured, middle- or high-income, or Caucasian non-Hispanic,” Schroeder said.
Minnesota’s legalization of dental therapy has expanded access for rural and poor populations in the state, which resemble North Dakota’s rural and poor, Schroeder said.
“Evaluations completed in Minnesota have described dental therapy as a solution to access concerns for rural residents and Medicaid enrollees, which are both populations experiencing oral health access and care disparities in North Dakota,” Schroeder said. “In [North Dakota] in 2015, 72 percent of Medicaid children went without a preventive dental visit. There were nearly 33,000 Medicaid children who went without any dental service at all in 2015.”
State Rep. Aaron McWilliams (R-Hillsboro) says his concern for patient safety exceeded his support for the free-market principles embodied in HB 1256.
“When I started to learn about dental therapists, I was open to the idea and supported a free-market approach,” McWilliams said. “Then I remembered that I’ve had seizures after receiving a local anesthesia. It is my understanding that if this would have happened under the care of a dental therapist, [he] would not have had the medical background necessary to handle the emergency.”
Dentists should find safer ways to expand patient access, McWilliams says.
“I believe North Dakota dentists will continue to find innovative ways to serve our community without putting the safety of patients at risk,” McWilliams said.
Dr. Karl Self, director of the Division of Dental Therapy at the University of Minnesota School of Dentistry, says dental therapists and dentists are equally equipped to provide local anesthesia and emergency care.
“The University of Minnesota School of Dentistry dental therapy students take the same local anesthesia and pharmacology courses and participate in the same medical emergency drills as the dental students,” Self said. “Therefore, if there is a concern about our dental therapy graduates, then folks should be concerned about our dentist graduates.”
Self says the NDBDE overstepped its bounds by arguing its authority would have been undermined by HB 1256.
“As with all professions, the legislature outlines the scope of practice and the level of supervision, and [NDBDE] oversees it,” Self said. “It is not in their jurisdiction to make those judgments independently.”
Dentists would have defined the specific procedures their dental therapist employees could have performed in a written collaborative management agreement (CMA), Self said.
“As for the specifics of the CMA, again, the legislature makes the rules, and the dentists have an opportunity to further restrict the rules based on the CMA,” Self said. “They are determining how they want to work with a [dental therapist] within the authorized scope of practice.”
Michael McGrady ([email protected]) writes from Colorado Springs, Colorado.
Michael T. Hamilton, Bette Grande, and John Davidson, “The Case for Licensing Dental Therapists in North Dakota,” Policy Brief, The Heartland Institute, January 13, 2017.
Michael T. Hamilton, “Testimony Before the North Dakota House Human Services Committee, The Case for Licensing Dental Therapists in North Dakota,” The Heartland Institute, January 18, 2017.
Mary Tillotson, “States Consider Authorizing Dental Therapy to Expand Access,” Health Care News, The Heartland Institute, October 3, 2016.
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