Mid-level Providers Unqualified to Treat Patients

I recently wrote a commentary in this journal about the numerous dangers I see associated with mid-level dental providers. Dr. Frank Catalanotto subsequently rebuked my views in his harsh and unprofessional “counter-commentary”. Dr. Catalanotto’s position is sharply out of step with The American Dental Association[1] and other prominent dental professionals, including Dr. Gordon Christenson.[2]

My primary opposition to mid-level providers is that they are providing irreversible surgical care on patients without the supervision of a licensed dentist. Dr. Catalanotto is quite misleading in his commentary by consistently referring to dental therapists as part of the “dental team”. This implies supervision, when in reality, an advanced dental therapist and Alaska’s dental health aide therapist can and do treat patients without a dentist on site.

Dr. Catalanotto also denies that politicians[3] [4]are pushing this agenda forward, as though there is a ground swell of support for untrained “providers” doing oral surgery for the poor. I’ve treated many, many indigent people in my career, and I don’t recall them wanting the least trained person available for their care. While I admit there may be some portion of the population without convenient access to dental care, to say it’s 50-60% is ludicrous. Dr. Catalanotto quotes an ADA study in 2009 where only 40% of people had a dental visit. Is it possible that most of the other 60% in that year were simply putting the dental visit off, had no perceived need, were fearful, or lacked dental insurance?

Incredibly, Dr. Catalanotto, a Professor and Chair at the University of Florida Dental School, praises the superior training of dental therapists compared to dental students regarding the making of stainless steel crowns and motivational interviewing of patients. Even though I question the validity of that assertion, I wonder if Dr. Catalanotto has done anything about this problem in his capacity as a professor in a dental school? He could spend some time lecturing at other dental schools about how they need to improve their curriculums to achieve the “high standards” set by the training of mid-level providers. I’m sure that would be well received.

Perhaps the most disturbing thing I read in Dr. Catalanotto’s post was his critique of how a patient with an MI should be managed. No dentist, not in Bensalem, PA or anywhere would just call for emergency support for a patient who is having an MI at his or her office. Initial management would include giving the patient a chewable baby aspirin, supplemental oxygen, and have an automated external defibrillator (AED) out and ready as a staff member called for “emergency support“. That’s a key difference, I would think, between what a competent dentist would do, as apposed to what a mid-level provider would do.

Dr. Catalanotto tries to slam the door on the debate about this topic by citing his personal experience with mid-level providers and their enablers and his so-called evidence about their competency. The problem is that the bulk of his “evidence” was provided by the Kellogg Corporation[5], who has invested millions of dollars in grants for mid-level provider programs and has an obvious conflict of interest in the outcome of these dubious ventures. While it true I have not seen mid-level providers in action, I don’t think I need to get into the pigpen to know it’s dirty in there. Although beyond the scope of my previous commentary, I personally support a community outreach program that helps poor children in my area, and would encourage others to do the same.[6] Another common sense approach would be to allow expanded function dental assistants (EFDA) to practice in every state in the country. The EFDA can place fillings and do many other ancillary procedures that expand treatment delivery in a responsible way under the supervision of a dentist. The bottom line is simple; it is unethical, immoral, and irresponsible to allow mid-level providers the scope of practice now allowed by law.

[1] ADA Current Policies (p. 220) http://www.ada.org/~/media/ADA/Member%20Center/FIles/2013%20Current%20Policies%20Final.ashx

[2] Dr. Christenson on mid-level providers http://www.dentaleconomics.com/articles/print/volume-104/issue-12/practices/ask-dr-christensen/midlevel-dental-practitioners.html

[3] http://www.pewtrusts.org/en/about/news-room/news/2015/02/06/washington-state-legislators-support-dental-therapists

[4] http://www.prnewswire.com/news-releases/minnesota-passes-legislation-allowing-mid-level-oral-health-provider-61903022.html

[5] http://www.wkkf.org/grants#pp=10&p=1&q=midlevel

[6] http://www.bchip.org