Several Great Bend dentists,Larry Kutina, Ross Hildebrand, Marc Hueslig, Keith Ritter and Mike Allison, and Blake Herres of Hoisington, met Friday at the Tribune offices to discuss House Bill 2157, which seeks to create a mid-level dental provider called a Registered Dental Practitioner. RDPs would be allowed to perform some dental procedures, including surgery, under general rather than direct supervision of a licensed dentist.
Today in the house, the bill was withdrawn from the Committee on Health and Human Services and referred to the Committee on Appropriations. It’s twin, Senate Bill 197, has been referred to the Committee on Public Health and Welfare.
While RDP’s could make it possible for dental practices to greatly expand their practices, these dentists fear it would be at the risk of the public health.
“Dentistry as a profession is not all about money. Most of us are drawn into this profession and art to serve people,” Dr. Hildebrand said. “Are (RDPs) the best way to care for a person and would I want my family members cared for in that way. My answer is no.”
The dentists instead voiced support of an additional level of Extended Care Permit (ECP III) for dental hygienists. The newly proposed permit would enable more patients to be seen, but would maintain direct supervision of patient care.
According to Kevin Robertson, CAE, Executive Director of the KDA, ECP III advanced dental hygienists would be able to use additional non surgical procedures to assist with the treatment of patients, such as:
* Assessment of the patient’s apparent need for further evaluation by a dentist to diagnose the presence of dental caries and other abnormalities
* Identification and removal of decay using hand instrumentation and placing a glass ionomer filling
* Adjustment of dentures,
* Placing soft reline in dentures and placing permanent identification labeling in dentures
* Smoothing a sharp tooth with a slow speed dental handpiece
* Use of local anesthetic, including topical, infiltration and block anesthesia, when appropriate to assist with procedures where medical services are available in a nursing home, health clinic, or any other settings. If the dental hygienist has completed a course on local anesthesia and nitrous oxide as required in this act
* Extract primary (baby) teeth that are naturally loose.
Those in favor of HB 2157 envision having “mobile dental” capabilities, in which RDPs could provide care in counties or cities where no dental practice now exists. Another use would be to have one or more operating in an existing location, allowing the dentist to concentrate on more challenging work while RDPs handle routine work. But Ritter and Hildebrand disagree with this thinking.
“I never agreed with the thought of passing off the little stuff to others,” Ritter said.
“Passing off what they call “little stuff” to a lesser trained technician will not cut it,” said Hildebrand. “There is nothing that I do that I would like to trust to someone with lesser training.”
Kutina agreed. Some procedures that look simple to start with can become something more complicated very quickly, he said. Problems like a fractured tooth, nerve involvement, and patient medical concerns can arise without notice, he said.
“This bill is allowing this person with minimal training to do these procedures, and that’s a real big difference from a physician’s assistant. That’s a real big concern of all of us here,” Kutina said.
Scope of care
In a recent story about HB 2157, Rep. John Edmonds compared physician’s assistants to RDPs, but Ritter strongly disagreed with the comparison.
In addition to difference in educational requirements, one key difference between PAs and RDPs ,is in the scope of their duties. While PA may diagnose and prescribe treatment for various conditions, they are only performing noninvasive treatment.
“I have friends that are midlevels, and I think they do a great job, but they aren’t using rotary instruments that are spinning at a half-million RPM on the human body,” Hueslig said. “There is a big difference. It’s surgery. It’s hard tissue surgery. That’s my issue.”
According to Ritter, a better comparison with a PA is the dental hygienist.
“Everything we do is invasive,” he said. “Is a PA going to take out an appendix? No. So why would an RDP take out a tooth? That’s like saying you’re a surgeon now.”
Unfortunately dentistry , can be very unpredictable, Hildebrand added.
“It can look very simple, and get very complicated in a hurry,” said Hildebrand. Even after 40 years in practice, he worries what would happen in those situations where no dentist was present on site to supervise. There are few things he would consider simple.
Following the money
The W.K. Kellogg Foundation is a big supporter of the HB 2157. The non-profit has been funding support for the creation of RDPs, claiming they are needed to provide dental care in underserved areas of rural Kansas and several other states where they claim there is a severe lack of trained dentists. It claims Americans in poor and isolated communities and tribal areas are at risk for poor oral health of children and families where there are not enough dentists and dental care is unaffordable for many. They look to Alaska, where dental practitioners operate, bringing dental care to remote communities and Inuit tribal lands, as proof the plan is a good one.
But the Kansas Dental Association, after the 2010 announcement of the Kellogg Foundation’s plan to meet these needs, did a study to determine how accessible dental care is to rural Kansans. It found that only about two percent of Kansans live more than 30 minutes from a dentist, and by adding as few as 14 dentists to the rural dental workforce, any shortage in access could be alleviated, according to the KDA’s Kevin Robertson in his Jan. 29 testimony at a House hearing on the bill.
“Kansans living in the western part of our state – they reported traveling an average of
21.2 minutes to the dentist,” he said. “This compared favorably to travel to other services like the grocery store, gas station, movie, shopping, etc.”
A representative from the Kellogg foundation could not be reached by press time to comment about if the foundation has read this report, and why it continues to support the addition of RDPs in light of this information.
Working on access
In addition to supporting the addition of the ECP III permit, the KDA also recently announced the first three recipients of KIND scholarships, created by the KDA and the Delta Dental Foundation. Kansas Initiative or New Dentists is a scholarship and loan repayment program. Thanks to a $450,000 grant from the Delta Foundation, the association will award up to $25,000 in scholarship and loan repayment money to dentists who are dedicated to practising in rural Kansas areas after their graduation from dental school.
Other measures recently took to ease access include the creation of a special volunteer dental license for retired dentists enabling them to provide care for the underserved. Also, the association pushed for acquiring additional seats for Kansas residents from dental schools in neighboring states, set aside specifically for those who promise to come back and serve in underserved areas of the state upon graduation. Currently, no colleges in Kansas offer a program for dentists, so Kansas students must compete as out of state students for a limited number of seats in Nebraska, Oklahoma, Colorado and Missouri, Kutina said.
But the number of dentists isn’t the only issue Kellogg is trying to remedy. The foundation believes by creating RDPs, they will be able to increase care for poor and indigent patients. Not only would the mid-level practitioners serve in regular dental practices that accept Medicaid patients, they would serve in public practices.
In response, Hueslig asked, “Just because a person is poor or lives in a rural area, do they have to accept mediocrity?”
For him and the dentists around the table, the answer is simple. No.