Mid-level Providers: Why Membership in the ADA Matters

By Cesar R. Sabates, DDS, FACD, FPFA, FICD

“Access to dental care” has been a growing concern for many years. Foundations and many other individuals have frequently used the same catchphrase to propose a new provider be introduced within the dental team to meet the challenge. “Mid-level providers” (aka “dental therapists”) are being touted as the solution to this nation’s access-to-care problem. The W. K. Kellogg Foundation has committed millions of dollars to advocate and promote this “solution.”

The American Dental Association (ADA) remains steadfast in opposition to the mid-level provider. ADA Policy on the Mid-Level Provider (Trans. 2008:439) states: “Resolved, that the ADA’s position on any proposed new member of the dental team shall be an individual supervised by a dentist and be based upon a determination of need, sufficient education and training and of scope of practice that ensures the protection of the public’s oral health.”

Many who advocate for mid-level providers use the argument that “there is a shortage of dentists.” A recent report by the ADA Health Policy Institute demonstrates that the number of dentists practicing per 100,000 people today has climbed more than 4 percent from 2003 to 2013, is projected to increase by 1.5 percent from 2013 to 2018 and 2.6 percent by 2033.

However, such arguments are simply not valid. Consider an article from the ADA Health Policy Resource Center, written by authors Thomas Wall, MBA, Kamyar Nasseh, PhD and Marko Vujicic, PhD, “U.S. Dental Spending Remains Flat Through 2012.” The article contains invaluable results of extensive research and is extremely effective in countering such inaccurate claims made by others. The highly acclaimed ADA Resource Center, in doing expansive research and sharing of such important information, is yet another membership value and benefit of belonging to organized dentistry.

In spite of the ADA’s opposition to the mid-level provider, the Commission on Dental Accreditation (CODA), an independent entity recognized by the U.S. Department of Education as the national accrediting agency for dental, allied dental and advanced educational programs, adopted standards by which programs that educate mid-level providers can apply for accreditation.

To give you an idea of what the scope of practice of a mid-level “dental therapist” would be, I ask you to read the following, taken directly from a document entitled, “CODA Accreditation Standards for Dental Therapy Educational Programs.”

At a minimum, graduates must be competent in providing oral health care within the scope of dental therapy practice with supervision as defined by the state practice acts, including:

a. identification of oral and systemic conditions requiring evaluation and/or treatment by dentists, physicians or other health care providers, and managing  referrals
b. comprehensive charting of the oral cavity
c. oral health instruction and disease prevention education, including nutritional counseling and dietary analysis
d. exposing radiographic images
e. dental prophylaxis including sub-gingival scaling and/or polishing procedures
f. dispensing and administering via the oral and/or topical route non-narcotic analgesics, anti-inflammatory and antibiotic medications as prescribed by a licensed health care provider
g. applying topical preventive or prophylactic agents (i.e., fluoride), including fluoride varnish, antimicrobial agents, and pit and fissure sealants
h. pulp vitality testing
i. applying desensitizing medication or resin
j. fabricating athletic mouth guards
k. changing periodontal dressings
l. administering local anesthetic
m. simple extraction of erupted primary teeth
n. emergency palliative treatment of dental pain limited to the procedures in this section
o. preparation and placement of direct restorations in primary and permanent teeth
p. fabrication and placement of single-tooth temporary crowns
q. preparation and placement of preformed crowns on primary teeth
r. indirect and direct pulp capping on permanent teeth
s. indirect pulp capping on primary teeth
t. suture removal
u. minor adjustments and repairs on removable prostheses
v. removal of space maintainers”

All of this can be accomplished by an individual with just three years of post-secondary education! A bit alarming, wouldn’t you say? How about “m. simple extractions”? Who can define the term, “simple?” I can remember one of my oral surgery professors telling me, “Son, you can only say it’s a simple extraction once you have that tooth sitting on the bracket table.”

It is time that we all wake up! Those of you who are members of the ADA, I applaud you for your investment in your future. Those of you who are non-members I simply ask you: “What are you waiting for?!” Your profession needs you! Don’t wait until it’s too late.

In a recent commentary published in Dental Abstract, Vol. 60, Issue 1, 2015, Dr. Frank Catalanotto states that, “Organized dentistry at the state and national level has opposed virtually all efforts to expand access to care to underserved individuals. And, in many cases, the Federal Trade Commission [FTC] has stepped in to help prevent this restraint of trade. Great examples of FTC intervention in the past decade or so can be found in Alaska, Alabama, Minnesota, South Carolina, Louisiana and Florida. Dentistry PACs [political action committees] are in full battle mode. Just get a copy of ‘The Dental Workforce Cook Book,’ if you can. I have only heard about it, but have not seen it.”

With all due respect to Dr. Catalanotto, I would disagree with his statement: “Organized dentistry … has opposed virtually all efforts to expand access to care to underserved individuals.” As a past president of the Florida Dental Association (FDA), president of Florida’s Donated Dental Services, vice chair of the ADA’s Council on Access Prevention and Interprofessional Relations, and a general practitioner in private practice who has devoted most of his professional life advocating for access to the underserved, I could not be prouder of the ADA’s leadership role when it comes to advocating for “access to care.”

Please take time to look at the following publications by the ADA and the FDA Action for Dental Health initiative:

  • “Breaking Down Barriers to Oral Health for All Americans: The Community Dental Health Coordinator”
  • “Breaking Down Barriers to Oral Health for All Americans: The Role of Finance”
  • “Breaking Down Barriers to Oral Health for All Americans: The Role of Workforce”
  • “Breaking Down Barriers to Oral Health for All Americans: Repairing the Tattered Safety Net”
  • “Action for Dental Health: Bringing Disease Prevention into Communities”

… just to name a few.

I am almost certain that Dr. Catalanatto meant to say that the ADA has opposed all efforts to bring in mid-level providers/dental therapists. And, if that is the case, I would agree with him!

To quote the ADA president, Dr. Maxine Feinberg: “The ADA believes it is in the best interest of the public that only dentists diagnose dental disease and perform surgical and irreversible procedures. Through Action for Dental Health, the ADA and its member dentists are implementing solutions that have been proven to help address the multiple barriers that prevent many Americans from attaining better oral health.”

The issue of access to care is a complex one. I applaud and respect the efforts of anyone and everyone attempting to eliminate the barriers that prevent all Americans from suffering needlessly from a totally preventable disease. I hope and dream that, as a profession, we can continue to work to bring about the changes needed to provide the necessary education and care to those who need it.

This article first appeared the the South Florida District Dental Association’s Newsletter,  Volume 57, No. 2, Fall 2015.

Dr. Sabates can be contacted at fdacesar@gmail.com, or you can contact the FDA Governmental Affairs Office at gao@floridadental.org.



Providing Dental Services in the Hospital Setting

By Amy Wasdin, RN, CPHRM, Patient Safety Risk Manager II, The Doctors Company

Lack of familiarity with hospital systems can pose serious risk management implications.

Patients present to an acute care facility for a variety of reasons, such as emergency care, admission for ongoing treatment, surgical procedures and specialized nursing care. Unfortunately, appropriate dental care often is overlooked or not identified as a priority at the beginning of a patient’s course of hospitalization.

Good dental care is an important component to maintain overall health and well-being. When unchecked and untreated, bacteria that forms on teeth often can lead to more serious health problems. Poor oral care has been known to contribute to cardiovascular disease and respiratory infections, as well as other serious health conditions.

Dentists and oral surgeons often are credentialed and included in a hospital’s medical staff roster to provide dental services to emergency department patients and inpatients when needed. Providing dental care for a hospitalized patient is uncommon, and dentists and oral surgeons are not routinely consulted to provide dental services.

Because of the infrequency of providing dental care in the hospital setting, many dentists are unfamiliar with hospital and medical staff requirements that apply to the providers who examine and treat inpatients. The lack of familiarity with hospital systems and medical staff rules can pose serious risk management implications for the dental care provider.

Risk Management Strategies

  • Be wary of “curbside consultations” in which informal collaboration may find its way into the medical record. Consulting dentists have been sued by patients that they neither met nor examined because of inaccurate documentation by other providers in the medical record. If you are asked for input on a specific patient situation, it may be best to request a formal consultation so that you can document your thoughts and opinions in your own words.
  • Communicate clearly with other providers on the expectations regarding your involvement in patient care. Once you become a part of the care team, the lines often get blurred among providers regarding who is responsible for each aspect of care. Key information often can get lost in the transitions of care that occur in a hospital among caregivers. Clarify your role in the record, and communicate with other providers when there is confusion or cause for concern.
  • Familiarize yourself with the medical record beforehand — ask for training. Electronic medical records (EMRs) present unique nuances and special challenges to a user who is unfamiliar with the system. There may be templates or designated sections for your documentation. The EMR may not be easily navigated, so it is helpful to take the time to learn the various sections that you will need to use. It can be a powerful tool for provider collaboration if you know where to look for information.
  • Understand your documentation requirements. How often are you required to document your care of the patient? When does your documentation need to be finalized and available in the medical record? What do you need to include in your consultation notes? This information should be provided at the time of your appointment to the medical staff.
  • Request updates and revisions to processes and systems. Hospitals regularly update and revise facility operations as well as clinical policies and processes. Make sure that you periodically request updated information regarding any facility or patient care-related changes. Notice of physical plant changes may prove extremely helpful to you when you need to locate your patient to provide dental services. Notice of process changes will help you fulfill your obligation as a medical staff member to follow current policies and procedures.
  • Have a go-to person to contact for assistance when needed. Despite taking appropriate steps to be prepared to care for your patient, there are always unexpected challenges that may occur. Get to know your medical staff department coordinator or the facility risk manager. They can prove to be great resources when you need quick access to information. Also, if you can’t find someone for assistance after regular hours, reach out to the hospital administrator on call who will connect you with someone who can assist you.


Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

The Value of Your Current Patients

By Jackie Ulasewich, Founder, My Dental Agency

There are a lot of reasons to want to bring in new patients. Maybe you want to expand your practice enough to hire an associate, maybe you want to open a second location or maybe you want to make sure your practice is established enough for you to have a healthy retirement when the time comes. Whatever the reason, you need to remember the people who have already helped you grow your practice: your current patients. Bringing new patients through the front door is useless if your current patients are sneaking out through the back.

Why They’re Valuable
If you’re lucky, your patients are loyal to you. With patient loyalty comes regular visits, more involved treatments and those sought-after referrals. If you are not loyal in return, then what’s to stop them from switching to another practice?

How to Create Loyalty
Your patients have tons of dentists from which to choose. Some of those dentists may offer discounted treatments, some may be closer to home or work or some may have a stronger marketing game. What makes your practice unique is YOU, but you have to be willing to remind your patients that you’re there for them beyond their semi-annual appointments and you have to let them see who you are when they’re not in your chair. The following ideas will get you started.

  • Use Facebook multiple times a week. Only 20 percent of your posts should “sell” a service or product; the other 80 percent should be fun posts that show the personalities of both you and your practice.
  • Use targeted emails. Have you spoken with clients about a treatment such as implants or adult orthodontics who haven’t followed through? Reach out to those people via email to remind them of your discussion and encourage them to seek treatment.
  • Use email regularly. Once a month, reach out to your current patients via email. The content can be educational, but keep it fun; you’re trying to keep your patients informed and make them feel connected to the practice, not overwhelmed by information.
  • Use customized content. Nothing says “I’m just phoning it in” like mass-produced marketing content. Using customized content on your site, social networking platforms and emails is another way to set yourself apart from the other practices and let your patients know who you are.

There is nothing wrong with wanting to grow your practice. In fact, the same tricks that help your current patients feel connected to you also help potential patients know why your practice is unique. But instead of putting all of your efforts towards bringing in new patients, remember that you have current patients who need a reason to stay loyal.


With over a decade of experience in corporate dental laboratory marketing and brand development, Jackie Ulasewich decided to take her passion for the dental business and marketing to the next level by founding My Dental Agency. Since starting her company, she and her team have helped a wide variety of practices all over the nation focus their message, reach their target patients, and grow their practice through effective marketing campaigns. When she isn’t helping dental practices reach their full potential, she can be found at the beach with her three dogs or immersed in everything food-related with her large Italian family. For more information, call (800) 689-6434.

 This article originally appeared on DentistryToday.com

What is “Plan B?” The New Normal in a Post-Irma World

By a Fellow FDA Member

Call it intuition, but I had the feeling we —and the entire east coast of Florida — dodged a bullet last year with Hurricane Matthew. It just seemed like a matter of time before our 13-year dry spell was going to end.

I desperately wanted to be wrong, as I watched CNN every evening for the latest update on Hurricane Irma, and the National Hurricane Center for the more elaborate interpretation.

The memories of spending another post-Labor Day weekend away from home (Hurricane Frances, 2004) sadly is still too vivid in our memories. I worked as a dentist a total of four days that month, and two of those were without air conditioning — which is a testament to the determination of my staff and my patients to create a sense of “normalcy” in the aftermath, despite the obvious disruption to our personal lives.

Doctors, it is time for “Plan B.”

Depending on where you are in your practice career, it may not make economic sense to “build over” before or after your insurance adjuster has given you the final assessment. For dentists with more than 25 years of practice, the return on investment may not be in your favor at such a late period, as the current tax laws for business owners after 50 provide decent “catch-up” provisions in a defined benefit (like a government pension) and defined contribution (401K-type) plans that would be more beneficial.

For a mid-career solo practitioner, you have been faced with rising overhead costs since 2007, and along with diminished income (ADA Health Policy Institute has the data), the time is ripe for a multi-doctor practice formation, which should always be created with expert legal and financial advice.

Look “around the neighborhood” and reach out to other dentists who may share the same dilemma you do. If you have damage to your office, and someone nearby does not, now would be the time to construct a well-defined contract that outlines the term and time limit for this new arrangement. And if the relationship works on a limited basis, you may find the new arrangement something you want to solidify.

Likewise, if your office came out unscathed, reach out to your colleagues in this period and strategize. This is not a DIY project, so retain the professional advice you need to make this happen. Involve your bankers and financial advisors for expert advice.

In closing, I want you to know that I understand what you have gone through, and I look at 2004 as a defining year in my professional career. The decisions I made after these disasters guided me to where I am today, and my family is better for it.

Make the right choice for your loved ones and your staff members, and don’t be afraid to execute “Plan B!”