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Registered Dental Practitioners: A New Way To Fill The Need For Dental Care?

KDHE report on Kansas dental workforce

Analysts have known for years that Kansas has a severe shortage of dentists -- and that shortage is getting worse.  

The problem is greatest in rural Kansas, especially in the western part of the state.  One idea under consideration is the creation of a mid-level dental provider.  This would be a person whose training and skills fall somewhere between those of a hygienist and a full-fledged dentist.  But the proposal to create such a position remains bogged down in the Kansas Legislature.

You don’t have to be in poverty, or even uninsured, to run into trouble trying to access dental care in western Kansas.  Just ask Fort Hays State University President Ed Hammond…

“I can’t get dental services where they accept our Delta Dental Blue Cross/Blue Shield plan,” says Hammond. “As a state employee, I get—and pay for—dental insurance, but the dentists in western Kansas don’t accept it.”

Hammond says he’s had to switch dentists three times to find someone who would accept his dental insurance.  There are 13 primary care dentists in the Hays area, but Hammond says only two or three accept Delta Dental.

 “The shortage is impacting not just the indigent, not just the children,” says Hammond. “It’s impacting all of Kansans in western part of the state.”

A report published last fall by the Kansas Department of Health and Environment and the University of Kansas Medical Center counted 11-hundred 59 primary care dentists in the 105 counties of Kansas.  However, roughly half of them are located in metropolitan Kansas City and Wichita.  Add in Topeka and Lawrence, and more than 700 of the state’s dentists are in just four communities.  Most counties in the western half of the state have only one or two dentists, if any.  A dozen counties, plus three more in eastern Kansas, have no dentist at all.  Hammond says it’s not hard to understand why dentists are reluctant to set up shop in frontier counties.

“The problem is, the people graduating from dental school are coming out with tremendous debt,” says Hammond. “and then they have to get a lot of equipment, and their practice has to generate a certain amount of resources in order for it to make sense, and so they don’t go to western Kansas and the smaller towns.”          

Hammond thinks the solution is to create a so-called mid-level dental provider, comparable to the mid-level providers who are already helping meet the need for medical care in rural Kansas.

“We train nurse practitioners that go out to the various different communities throughout the state, and provide medical services,” says Hammond. “We’re proposing to do the same thing with a mid-level professional in the area of dentistry.”

Hammond says Fort Hays State University is prepared to begin training this new class of dental providers as soon as the legislature approves the proposal.  That may be awhile.  A coalition called the Kansas Dental Project submitted a plan last year.  It would create a new type of provider with more training than a dental hygienist, but not as much as a dentist, called a Registered Dental Practitioner, or RDP.  But the Kansas Dental Association has fought this idea all the way.  Kevin Robertson heads the Association.

 “The overwhelming majority of dentists are opposed to the registered practitioner model,” says Robertson. “And it’s not like 99%.  It’s 99.9%.”

Robertson says the proposal goes too far by allowing RDPs to perform procedures which are, by definition, considered surgery.

“Anything that includes the cutting of the hard surfaces of the tooth is considered surgery,” says Robertson. “The bill is written to allow the extraction of all primary teeth, or meaning baby teeth.  Now, a lot of listeners might think, well, baby teeth, well I’ve pulled out my son’s or my daughter’s baby teeth.  Well, there’s nothing in the proposal that says it has to already be loose.”

And Robertson says what sounds like a simple procedure can suddenly become more than a registered dental practitioner is trained, or licensed, to do…

“Maybe you’ve snapped off a tooth.  Maybe the root’s wrapped around the nerve, and you didn’t know it at the time.  Those are the types of things that we think could occur, that we’re concerned about,” says Robertson.

Robertson predicts that mid-level providers would actually make it more difficult for dentists to make ends meet in rural areas.  He says that would create a two-tiered system of dental care in Kansas—dentists for those in the more-populated areas, and mid-level providers with a lower level of training for rural Kansans.

 “I would describe no care as second-class care, and that’s the system we have in place now for many Kansans,” says Shannon Cotsoradis, head of the advocacy group Kansas Action for Children.  The group is spearheading the Kansas Dental Project -- the effort to create licensed, mid-level dental providers. 

“Our goal is to make sure that all Kansans, regardless of what kind of insurance they may have or whether or not they have insurance at all, can access care,” says Cotsoradis.  “And we believe that adding another member to the Kansas dental team will help ensure that.”

Cotsoradis says the opposition to registered dental practitioners is based on fear and misinformation.

“The research says very clearly that mid-level dental provides can provide the same quality and the same level of safety in the care they deliver as a dentist, within their scope of practice, and I would challenge the Kansas Dental Association to produce research that demonstrates something to the contrary,” says Cotsoradis.

Hays dentist Melinda Miner sees a lot of patients whom she believes could benefit from the services of a registered dental practitioner. One of the so-called “dental deserts” identified in the KDHE dental workforce report is just to the south and west of Hays.  It’s an area of approximately 500 square miles, where there are no primary care dentists at all.  Miner envisions being able to use registered dental practitioners to bring dental care to nearby Trego and Ness counties, which currently have no dentists.

“Our goal would be to open outreach clinics in the surrounding communities for preventive—for cleanings, for check-ups, for small fillings,” says Miner.

Miner says people will drive long distances for major dental problems, but they’re less likely to do so for the kind of routine care that can prevent more serious issues.

“You know, having to take your child out of school, take half a day off work, drive 30 minutes or more to go to the dentist for a routine checkup or preventive care is a lot less likely to happen than if you have a preventive person in your town,” says Miner.

The proposed law would require registered dental practitioners to spend their first 500 hours of practice under the direct supervision of a licensed dentist.  That means they’d start out in the Hays clinic, just down the hall from Miner and her husband.  Once they’re placed in the outreach clinics, they’d be under what’s called general supervision.  Miner says telemedicine makes it possible to supervise their work without being at the same location.

“All of our x-rays are on the computer,” says Miner. “They can send us a photograph or an x-ray, and ask us our opinion.  You don’t have to be there in person to watch over somebody.”

Miner sees mid-level providers not as a threat to her practice, but as a way to make it more efficient, and expand her patient base.

 “Every dentist can run their practice how they want to, and I don’t want to tell a dentist, hey, you have to take Medicaid or you have to see people for free, or you have to use a hygienist.  There’s dentists that don’t want to use hygienists.  That’s fine for their practice,” says Miner. “But I would prefer if they don’t tell me I can’t do something that would help my practice to be better.”

The Kansas Dental Association does support expanding the role of dental hygienists.  They’ve endorsed a bill to create what’s called an Extended Care Permit three.  It would allow specially-trained hygienists, under the sponsorship of a dentist, to provide temporary fillings, adjust dentures, and remove very loose baby teeth.  Their services would be aimed at underserved children, senior citizens, and people in various forms of state care or custody.  Those favoring creation of Registered Dental Practitioners say this bill would help, but it doesn’t go nearly far enough. 

The level of unmet dental need is clear to anyone who’s ever attended a Kansas Mission of Mercy event.  The Kansas Dental Charitable Foundation held its 11th free dental clinic in Kansas City, Kansas, last February.  As volunteers and patients filled a former Wal-Mart store, organizer Greg Hill described the turnout.

“At 8 p.m. last night, there were about 100 of them in line when we opened the doors,” says Hill. “They spent the night indoors, and by 5:30 there were 12-hundred people in the building.”

That’s when the parking lot had to be closed, because that’s all the patients that could be treated in a single day—even with 165 volunteer dentists, and many more hygienists and other support staff from all across the state.   Kansas is among 15 states where advocates are working to expand the dental workforce with mid-level dental providers.  So far, Alaska and Minnesota are the only states where these providers have been authorized. 


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