Minnesota Graduates First Class of Dental Therapists

Laird Harrison

June 02, 2011

June 2, 2011 — Christy Fogarty will always remember the man whose wedding she saved. "His front teeth were so decayed he literally couldn't smile," she told Medscape Medical News. Fogarty restored all 6 of the man's front teeth and sent him beaming to his bride. It is the kind of happy ending that many dentists like to reminisce about, but with one key difference: Fogarty is not a dentist.

A dental hygienist in practice as an independent contractor for 7 years, Fogarty, 41, is about to obtain her master of science in oral health care practitioner through a controversial program at Metropolitan State University in Minneapolis, Minnesota. Her class of 7 will graduate June 23, adding a new category of dental practitioner to the state, with duties falling between those of a dentist and those of a hygienist.

The program, enacted into law in 2009 despite continuing opposition from the Minnesota Dental Association (MDA), is only the second in the United States that licenses such dental therapists. Compared with the dental health aide therapist program in indigenous Alaska communities, the Minnesota therapists, who are also being trained at the University of Minnesota, will have more education and more limited capacities.

They will be able to prepare teeth and place all types of direct restoration, as well as stainless steel crowns; do pulpotomies; make prostheses; and extract primary teeth. They will do this work only under the indirect supervision of a dentist, meaning that the dentist must be on the premises — but not necessarily in the operatory — when the work is done.

With 2000 more hours of clinical practice, and after passing an examination that is as yet to be devised, these dental therapists can become advanced dental therapists, who will also be able to extract mobile permanent teeth and work under a dentist's general supervision — meaning the dentist could be miles away from the therapist when the work is done.

"It's very exciting," said Suzanne Beatty, DDS, curriculum and clinical coordinator of the Metropolitan State University program, which has allowed the therapy students to see patients at clinics operated by Normandale Community College. "They have served exactly the groups intended by the legislation, and it's been very gratifying to see the great care that these midlevel providers can bring to these populations," she told Medscape Medical News.

Advanced Dental Therapists Serve Wide Range of Patients

Among the patients served by the therapists in training have been veterans from the Iraq and Afghanistan wars, people who have lost their jobs, the elderly, medically compromised patients, children, patients who want to participate in diabetes studies but need dentistry first, and patients with mental disabilities, said Dr. Beatty.

The bridegroom Fogarty treated, for example, was unemployed and had not had dental benefits even before he lost his job as a carpenter.

Five of the 7 graduating therapists worked as hygienists in nonprofit public health clinics and plan to return to the same, or similar, settings, Fogarty said. The other 2, including Fogarty, have not yet settled on jobs.

Even as they begin their job search, the therapists are defending the program from skeptical dentists. Fogarty herself went back before the legislature earlier this month to argue against a bill advanced by the MDA to modify the law. "Before we start taking this apart, let's see how it works," she said.

Also testifying was Jamie Sledd, DDS, a Maple Grove, Minnesota, general dentist and past president of the association. "The concern that the MDA has is allowing the patient to be seen by advanced dental therapists without being seen by a dentist," she told Medscape Medical News. "They don't have the education to diagnose and make a treatment plan."

The MDA bill would require that therapists confer with dentists before taking these steps, even if the consultation was only by telephone or email.

"Our concern is that this really is not going to address the overall issue of access," Dr. Sledd said. People who have gone for a long time without dental care often have the most complex and challenging oral health needs, so working with a dentist is particularly important in treating underserved populations, she noted.

Rather than relying on dental therapists to address these needs, Dr. Sledd said the legislature should increase Medicaid reimbursement for dentists, which is currently only 35% of usual and customary fees.

American Dental Association, MDA Prefer Dental Coordinators

She also endorsed community dental health coordinators, a new category of dental professional advocated by the American Dental Association. These practitioners would not treat patients but would provide education and help them negotiate the healthcare system. "It's a multifaceted problem," she said. "There can be language barriers, and there can be cultural barriers."

The MDA bill was tabled for this legislative session, but Dr. Sledd said the MDA plans to try again to get the law changed.

Therapists such as Fogarty believe their education is perfectly adequate to help the patients they are seeing. She will have more than 6 years of training in dentistry by the time she starts her practice as a dental therapist. In contrast, dentists have 8 years, but 4 of these are undergraduate studies that could be in any field.

In the meantime, both Metropolitan State University and the University of Minnesota are continuing to educate new therapists. The schools have taken slightly different approaches. Although the Metropolitan students must start as licensed hygienists, the University of Minnesota students can enter with high school diplomas on a 40-month baccalaureate track, or with bachelor's degrees on a 28-month master's track.

University of Minnesota Dental School Dean Patrick Lloyd, DDS, emphasizes that the 9 students graduating from his school in December will be the only dental therapists in the country trained in a dental school, having taken many of the same courses as dental students.

"We were so worried that we were creating a second tier that we worked really hard to make sure we weren't," he told Medscape Medical News. "We believe we are going to graduate a new member of the dental team that the public can trust and dentists can have confidence in."

Therapists graduating from both Minnesota universities will have more education than Alaska's dental health aide therapists, who get only 2 years of training after high school, but who can perform any type of extraction. The Alaskan therapists, however, operating under a federal program, can only work through programs for indigenous people.

At least 50% of the Minnesota therapists' patients must be from underserved populations, but they are otherwise free to treat anyone in the state.

Fogarty, for one, believes the program can serve as a model. "I think we're going to see state after state follow suit," she said. "I think we're going to show them it's a safe way to provide dental care."

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