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 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.