Consumer Survey Triggers Midlevel Dental Provider Debate

Laird Harrison

October 20, 2011

October 20, 2011 — A survey suggesting that most Americans would support licensing a new kind of dental practitioner has touched off an argument between the survey sponsor, the W.K. Kellogg Foundation, and US dentists' groups.

"Millions of Americans cannot find affordable dental care in their communities and many want to explore mid-level providers as a way to improve their access to needed oral health care," Kellogg announced in releasing the survey October 4.

The American Dental Association (ADA) and Academy of General Dentists (AGD) quickly fired off critiques of the survey's methodology and of the concept of midlevel providers.

Although both groups agreed with the Kellogg findings that people need better access to dental care, ADA President Raymond F. Gist, DDS, explained in a press release that “[t]he Kellogg Foundation's narrow focus on a single idea — so called 'dental therapists' — and its claim that a vast majority of Americans favor creating dental therapists lacks credibility."

Hired by Kellogg to explore the public's experience with dental care, Lake Research Partners and Knowledge Networks administered an online survey to 1023 adults in July. The margin of error was ±3.1%.

One question on the survey read as follows: "Many efforts are going on to improve affordable access to dental care in our country. One effort is training licensed dental practitioners to provide preventive, routine dental care to people who are going without care. Would you support or oppose this effort to train licensed dental practitioners?"

The question avoided the terms "dental therapist" or "midlevel provider," which have become fighting words among some dentists who follow policy debates.

Seventy-eight percent of the respondents said they supported the idea, with 6% against and 15% neutral.

"Kellogg's survey question regarding dental therapists implied that care by therapists would somehow cost less than care by dentists, said Dr. Gist in the press release. "We know of no data to support this. If such data exists, Kellogg should release it."

Dr. Gist complained that the practitioners in the question were poorly defined. "Kellogg also declined to describe therapists' level of training, whether they would work with a dentist nearby in case something goes wrong, or what types of surgical procedures they would perform," he said. "Absent that information, the survey respondents could not provide informed opinions."

In a separate written statement, the AGD also criticized the way the question was posed, and expressed concern about the idea of nondentists doing "clinical dental procedures that may be irreversible."

"These midlevel providers could be putting the patient's oral and overall health at risk, and that is a concern to the AGD," said AGD President Howard Gamble, DDS, in the statement.

Survey taker Michael Perry, from Lake Research Partners, told Medscape Medical News he was surprised by the heated reactions of the dentists' groups. "It seemed so odd to me that those 2 organizations would target what seemed like a benign question," he said. "I think it's only those who are protecting the vested interests of dentists who will have that kind of reaction. To be that aggressive and try to shut down public conversation strikes me as not in the public interest."

He said he expected a future survey to probe more deeply into how the public would view a range of possible duties for a new midlevel provider.

At least 4 states are considering legislation to launch new midlevel provider programs, David Jordan, dental access director at Community Catalyst, told Medscape Medical News. Minnesota already has such a program, and dental therapists practice in Alaskan indigenous communities under a federal mandate.

The Kellogg survey also looked at other aspects of access to oral healthcare:

  • 41% of respondents reported that they, or someone in their household, had put off dental care in the previous 12 months because of cost,

  • 40% said they do not have dental insurance, and

  • 30% said they do not have a regular dental care provider.

To address such problems, the AGD called for "proven solutions," such as loan repayment programs for students serving the underserved; increases in community services, such as transportation and oral health education; unspecified changes in Medicaid; additional volunteer programs in impoverished areas; and "a stronger public health infrastructure."

Asked to elaborate its own solutions, an ADA spokesman provided Medscape Medical News a letter to US Sen. Max Baucus calling for "adequate" funding of Medicaid, federal programs that train dental professionals, Centers for Disease Control and Prevention oral health education programs, community water fluoridation, and research by the National Institute of Dental and Craniofacial Research.

The 2 dentists' groups said they could not provide spokespeople for interviews on deadline.

Mr. Perry has disclosed no relevant financial relationships. Mr. Jordan's employer, Community Catalyst, supports midlevel dental providers.

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