Dental Personnel in Washington.
Washington has a variety of credentialed dental providers who provide assistance to licensed dentists. For example:
Dental Health Aide Therapists.
The federal Community Health Aide Program (CHAP) is a workforce model available in tribal communities that includes three different provider types that act as extenders of their licensed clinical supervisor. The national CHAP currently includes a behavioral health aide, community health aide, and dental health aide.
As part of the CHAP, dental health aide therapists (DHATs) are authorized to provide a variety of services pursuant to an agreement with a supervising dentist, including fillings and preventive services. A DHAT may only perform pulpal therapy (not including pulpotomies on deciduous teeth) or extractions of adult teeth after consultation with a dentist who determines that the procedure is a medical emergency that cannot be resolved with palliative treatment. A DHAT may not otherwise perform oral or jaw surgeries other than uncomplicated extractions. A dental health aide therapist must have a high school education, complete a two-year educational and clinical program, and complete a preceptorship of at least 400 hours with a supervising dentist.
In 2017 the Legislature authorized DHAT services in Washington under the following conditions:
Dental health aide therapist services are exempted from licensing requirements for other dental professions. The Health Care Authority was directed to coordinate with the Centers for Medicare and Medicaid services to provide that DHAT services are eligible for federal funding of up to 100 percent.
License Requirements.
A person may not practice dental therapy or represent himself or herself as a dental therapist without being licensed by the Department of Health (DOH). The DOH must issue a license to practice as a dental therapist to any applicant who:
When considering and approving the exam required for licensure, the Committee must consult with tribes that license dental health aide therapists and with dental therapy education programs in Washington. The Secretary of Health (Secretary), in consultation with the Committee, may adopt rules to implement these requirements. The DOH must establish continuing education requirements for license renewal in rule.
Applicants holding a valid license and engaged in current practice in another state may be granted a license without examination, if the Secretary determines the other state's licensing standards are substantially equivalent.
Limited License.
The DOH must issue a limited license to any applicant who:
A person practicing with a limited license may perform only the procedures that the person was licensed or certified to practice in the jurisdiction they held an active license. A person who demonstrates competency in the scope of practice may apply for licensure as a dental therapist.
Scope of Practice.
A dental therapist may perform the following services and procedures under supervision of a licensed dentist to the extent authorized by the supervising dentist:
A dental therapist may only practice in federally qualified health centers (FQHCs), tribal FQHCs, and FQHC lookalikes.
Practice Plan Contract.
A dental therapist may only practice under the supervision of a dentist licensed in Washington or exempt from licensure under the Indian Health Care Improvement Act and pursuant to a written practice plan contract (contract) with a supervising dentist. In circumstances authorized by the supervising dentist in the contract, a dental therapist may provide services without prior examination or diagnosis of a dentist and without the dentist being personally on site when services are provided. The contract must be signed and maintained by both the contracting dentist and the dental therapist and must specify:
The supervising dentist must accept responsibility for all services and procedures authorized and provided by the dental therapist. A supervising dentist that is licensed in Washington who knowingly permits a dental therapist to provide a service or procedure not authorized in the contact, and any dental therapist who provides a service or procedure that is not authorized, commits unprofessional conduct. A supervising dentist may not supervise more than five dental therapists at any one time. A supervising dentist must:
A dental therapist may only perform the services authorized by the supervising dentist and contract, and must maintain an appropriate level of contact with the supervising dentist. A dental therapist must submit a signed copy of the contract to the Secretary at the time of licensure renewal and must submit any revisions.
Other Provisions.
The Washington State Dental Quality Assurance Commission (Dental Commission) membership is increased to 19 members, adding two licensed dental therapists. The Dental Commission is established as the disciplining authority for dental therapists for the purposes of the Uniform Disciplinary Act.
For purposes of the legend drug chapter, dental therapists are added to the definition of practitioner, to the extent authorized in the dental therapy chapter.
A dental therapist must complete a one-time training in suicide assessment, treatment, and management.
A dental assistant and an expanded function dental auxiliary may perform services under the supervision of a dental therapist. This act creates a new chapter in Title 18 RCW. The DOH must adopt any rules necessary to implement this act.
The substitute bill:
(In support) This bill is a small step to recognize that the state needs more dental providers. This bill is a scaled back from previous versions and is a smaller step to see if it can provide more access.
Everyone deserves a healthy smile no matter their race, where they live, or what dental insurance they have. However, that is not the reality. Many people have stories about the inability to access dental care. Dental therapy adds a member to the care team that can handle routine procedures and it has been found to improve outcomes and increase access to care. Oregon and Colorado have recently passed dental therapy without opposition from dentists. The experience in other jurisdictions has continually found that dental therapists provide safe and quality care.
Dental care is key to being able to eat healthy foods that allow everyone to stay healthy. Those who do not have access to dental care, particularly as a child, can have dental problems throughout life. Tooth decay is the most common childhood disease despite being completely preventable. Individuals who are low income, people of color, and non-English speakers have more cavities and more tooth decay. The current narrative around dental therapy is that it would create two tiers of care, but we already have two tiers of care in Washington, and it is not based on training, but on access. The question is who can access care and who cannot. In 2021 less than 20 percent of adults with Apple Health saw a dentist.
The expansion to allow dental therapy can resolve some of these shortages and gaps, increasing access to dental care. Dental therapists help dentists focus on more complex procedures and work at the top of their scope of practice. Dental therapists help address the gaps, diversify the dental workforce, and benefit all Washingtonians.
(Opposed) Dental therapy has been available in Minnesota for 13 years and it was not a silver bullet there and has not solved the access issue. The scope of practice in this bill includes procedures that some dentists would not perform themselves and would refer to a specialist. Simple procedures can become difficult due to unforeseen circumstances. Some of the procedures that dental therapists are authorized to perform are difficult, and just because a dental therapist is authorized to perform the procedures, it does not mean it will be more accessible.
The contract required in the bill is not well defined. There is no requirement to address any unmet needs of a patient that a dental therapist cannot handle. There is an ethical requirement to treat a patient once you have given them an exam, but dental therapists would then need to tell patients that they can only take care of the person's simple issues.
A patient with complex health issues should not be treated by someone with only two to three years of training after high school. Given the choice, how many people would choose the provider with less training? Patients in areas served by dental therapists have privately shared that they would rather see a dental student for care than a dental therapist. This is not a solution for Washington.
(Other) A tribe in Washington is grateful for the government-to-government partnership and the historic enactment of the 2017 dental therapist legislation recognizing inherent tribal sovereignty to license dental therapists. Dental therapists have broken the cycle of poor dental care provided by part-time traveling dentists that worked out of a broken down trailer. Tribes in Washington currently use dental therapy and one tribe has found that wait times were reduced from two months to one to two weeks. There has also been an increased focus on prevention and emergency care and outside referrals have decreased. Dental therapists bridge the gap and address recruitment challenges.
No new changes were recommended.
(In support) Dental healthcare is important, and this bill takes significant steps to increasing care by providing another option on a dental team for routine procedures. There are currently large barriers to getting sufficient dental services and care. Dental therapists have a positive impact on communities and allow for resources to be stretched further, which improves access to care. This bill will also reduce barriers to training for the workforce. Dental therapists are increasingly used in other states.
(Opposed) The conversation around dental therapists is not new, and is a work in progress. Some of the procedures covered under the bill are concerning, and many dentists would not perform them. The workforce issues in dental care are real, and there is interest in continuing this conversation.