Dentistry and Health Care Reform in the USA

What will the practice of dentistry look like in the United States when the health care delivery systems are changed? This question makes two likely assumptions. One assumption is that the health care systems are going to change. It is hard not to see the wave of demand for improvements in this sector. The other is that it is hard to imagine that some of the very significant changes under discussion will not impact dentistry and orthodontics.

We all know that potential contentious issues are best addressed before they are encountered. We also know that orthodontics draws many of the finest minds in dentistry. It is human to lean toward favoring the status quo when we are doing well, but it is time that we begin to look at the effect some of the proposed changes can make on our discipline.

The buzz I hear these days' is about the presumed efficiency and cost savings inherent in the transfer of many patient care duties to a lesser trained person. This arises from the concept of a transfer of the medical nurse practitioner concept to dentistry. The concept is tantamount to saying that a portion of health care is technical in nature and can be properly and more economically delivered by someone with lesser education and training. The debate is largely focused on capturing the economy of such a shift with the resistance citing the need to guarantee the patients' quality of care.

While there are undoubtedly many approaches being discussed in various states, the one I hear most commonly cited is the Minnesota proposal. This is where I live and the facts are that the Minnesota legislature did address this question in 2008. The first proposal to enlarge upon dental hygiene education for certain hygienists was replaced by a second bill that is now law. This second bill provides for the creation of a new level of dental care provider, the oral health practitioner. Under the new legislation, The Board of Dentistry will license the new oral health practitioner and the oral health practitioner will work under the supervision of a dentist. The details of the final bill can be seen at LAWS of MINNESOTA for 2008.1

This bill that passed the Minnesota legislature authorized licensure of what has been termed a midlevel dental provider. The legislation also left many of the specifics to be developed by an oral health work group. This group is charged with developing recommendations and proposed legislation for the education and registration of these oral health practitioners. They are charged to report the group's recommendations and proposed legislation to the Minnesota Legislature by January 15, 2009.

Dr. Patrick Lloyd, Dean of the Dental School at Minnesota, explained that the School of Dentistry together with a 12-member delegation of Minnesota dental educators, dental professionals and regulatory agency representatives went to New Zealand to visit the decades old dental therapist training program at the University of Otago in Dunedin.2 This was one of several site visits to recognized dental therapist training programs. Other visits have been to First Nations University in Prince Albert, Canada, the Eastman Dental Hospital in London and the School of Clinical Dentistry at the University of Sheffield.

The visits were in preparation for the school's launch of a mid-level provider training program scheduled for the fall of 2009. This requires decisions on the details of the training program, level of supervision, licensure requirements and all of the other decisions needed for a major change such as this. Dean Lloyd sees this program as the creation of a new member of the dental team that will work in concert with existing personnel.

So the facts are there has been legislation passed for of a new level of training to create a new person prepared to perform some of the duties that here to fore have been solely the responsibility of the dentist. Most of these such programs have been proposed have been based on needs in underserved populations. There is currently a version of such a program now operating for one population group in Alaska. There is legislative support for change in this area and the next legislative session promises to again address this issue.

What are the implications? Are there substantial amounts of unmet dental needs in the population that a lesser trained person can properly perform? How much purely technical training is required for treatment without a basic education? Has the rapid rise in digital technology automated dental skills? Does the whole question arise because public financing of existing delivery systems is inadequate and additional public money to create a new system is redundant and wasteful? If the situation moves forward, what are the details of training, quality control, the specific tasks delivered, professional life expectancy vis-à-vis cost of preparation, and many more yet undefined issues?

There are more questions than answers, but it is clear that change is an ever constant. Dentistry is much changed from what it was when we went to school and it will be so for the Class of 2008 graduates several decades from now. The critical feature is to have rational heads guiding whatever change emerges and not let it become a political or turf war. Orthodontics may appear to be peripheral to this hot button question, but we will inevitably be very much affected. Stay tuned and become involved!