North Dakotans’ teeth are the root of the issue − specifically, the ability of those teeth to receive proper care.
For the third session in a row, legislation authorizing practice by dental therapists − a level of certification above dental hygienist but below dentist – is on the table at the Capitol. Similar legislation was defeated in the Senate in 2015 and in the House in 2017.
House Bill 1426’s proponents say it would increase access to care in rural and tribal areas across the state. Opponents, including the North Dakota Dental Association, say they are concerned it would lower the quality of care for vulnerable populations.
Emily Mallory, president of the state Dental Hygienist Association, said she believes most of the opposition to the bill comes from a fear of change. Only eight states allow dental therapists to practice in any capacity.
As a dental hygienist at a federally qualified health center in Grand Forks, Mallory said she sees many cases exacerbated by a lack of access to dental services.
“What we see is a lot of patients come through that have a lot of decay, a lot of healthcare needs, and you can’t get it all in a timely manner just because of a shortage of providers,” Mallory said. “It’s not uncommon for patients to come in in their late 20s, early 30s (and) have never been to a dentist.”
This bill, Mallory said, would not only free up dentists’ schedules to perform more complex work, but also make it easier to open health care centers in underserved areas. There are 429 practicing dentists in the state, according to the state Board of Dental Examiners.
The primary concern of William Sherwin, executive director of the North Dakota Dental Association, is that the legislation allows too much autonomy on the part of dental therapists.
While the bill limits dental therapists to working only in federally qualified health care centers, federally qualified health care center look-alikes and nonprofit health care centers under the supervision of a dentist, it also specifies that the supervising dentist only has to be available for consultation though electronic means and does not have to have previously examined the patient or facility.
“The dentists, so long as they have a cellphone, they could be anywhere in the world,” Sherwin said. “That is a massive concern to us.”
Sherwin also expressed frustration that the efforts to bring dental therapy into the state have been partly funded by out-of-state interests such as Pew Charitable Trusts, a nonprofit, independent research institution based in Philadelphia.
A Pew report issued Jan. 15 noted that Arizona and Michigan authorized dental therapy in 2018, “joining six others where dental therapists are allowed under state law, practice through pilot programs, or work on federal tribal lands.” The report noted that North Dakota and four other states are considering legislation this year.
“Dentists report that low payment rates keep them from accepting more Medicaid patients,” the report states. “With wages significantly lower than those of dentists, dental therapists are seen as an affordable way for practices to treat more Medicaid patients and a cost-effective means to deliver care in dentist shortage areas.”
In July 2018, the Center for Rural Health at the University of North Dakota and the state Department of Health produced a map identifying “dental health professional shortage areas” by county.
One legislator who opposes dental therapy is Sen. Brad Bekkedahl, R-Williston, a dentist himself in North Dakota for 35 years. According to Bekkedahl, the dentistry labor shortage in the state is “not as acute as it’s painted to be.”
He and Sherwin said North Dakota leads the country in in-migration of dentists, and the primary barrier for care is lack of education about access to dental services, not lack of services themselves.
Rep. Bill Devlin, R-Finley, said he believes this is a narrow view of the issue and downplays the challenges particular populations face.
“The Medicaid population is not being served and I don’t think the tribes are being served,” Devlin said. He said he first learned about dental therapy while on a trip to Alaska, where dental therapists are “doing a phenomenal job” serving native tribes.
The Spirit Lake Tribe, Standing Rock Sioux Tribe, the Mandan, Hidatsa and Arikara Nation and the Turtle Mountain Band of Chippewa Indians have all officially voiced support for dental therapy in North Dakota.
House Bill 1426 has been discussed in committee but no vote has been taken.
Devlin is hopeful the legislation will pass this session. The major difference between this bill and previous attempts is that it limits dental therapists to working in certain designated kinds of health care centers focused on serving poorer communities. He believes it has widespread support.
“The only people that are against it are dentists,” Devlin said.