Background: Dentistry Practice in Washington. Dentists practicing in Washington State must be licensed by the Dental Quality Assurance Commission (DQAC). The Commission also regulates the practice of dentistry in Washington. In Washington, Dentists may:

diagnose, treat, remove stains and concretions from teeth, operate or prescribe for any disease, pain, injury, deficiency, deformity, or physical condition of the teeth, alveolar process, gums, or jaw;
furnish, supply, construct, reproduce, or repair any prosthetic denture, bridge, appliance, or other structure to be worn in the mouth;
x-ray teeth, the alveolar process, maxilla, mandible or adjacent soft tissues;
perform any dental or oral and maxillofacial surgery; and
may prescribe or dispense any legend drug or controlled substance necessary in the practice of dentistry.

Other Dental Professions in Washington. Washington also registers dental assistants, and licenses expanded function dental auxiliaries, and dental hygienists. Each profession has a gradually increasing scope of practice. Dental hygienists have the most expansive scope for a non-dentist practicing in Washington. Dental hygienists may:

remove deposits and stains from the surfaces of the teeth;
apply topical preventive or prophylactic agents;
polish and smooth restorations;
perform root planing and soft-tissue curettage; and
perform other dental operations and services delegated to them by a licensed dentist.

Mid-Level Dental Providers in Other States. Other states have established mid-level dental providers who are authorized to provide a range of services. For example:

In Minnesota, dental therapists and advanced dental therapists are authorized to perform a variety of tasks under the supervision of a dentist, including the administration of certain legend drugs and certain types of extractions. Dental therapists must possess a bachelor's or master's degree and pass an examination. Advanced dental therapists must possess a master's degree, complete additional training, and pass an additional examination. Dental therapists and advanced dental therapists are limited to practicing in settings that serve low-income, uninsured, and underserved populations.
In Alaska, dental health aide therapists are authorized to provide a variety of services pursuant to an agreement with a supervising dentist, including fillings, preventive services, and uncomplicated extractions. A dental health aide therapist must have a high school education, complete a two-year educational/clinical program, and a perceptorship of at least 400 hours with a supervising dentist.

Summary of Bill: Two new dental professions are created in Washington: dental practitioners and dental hygiene practitioners.

Licensure. A person, to receive licensure as a "dental practitioner" from the Department of Health (DOH), must:

possess a high school education;
complete a dental health aide therapist education program;
complete a preceptorship of at least 400 hours under the supervision of a dentist;
pays applicable fees; and
pass an examination.

To receive licensure as a "dental hygiene practitioner" from DOH, a person must:

possess a license in good standing as a dental hygienist;
complete a post-baccalaureate advanced dental hygiene therapy education program;
complete 250 hours of advanced dental therapy clinical practice;
pays applicable fees; and
pass an examination.

Scope of Practice. Dental practitioners and hygiene practitioners may perform a broad scope of mainly noninvasive procedures, including charting, making radiographs, polishing, dressing changes, tooth reimplantation, emergency palliative treatment of dental pain, suture removal, and recementing permanent crowns. A full list of procedures is enumerated in the bill.

Dental practitioners and hygiene practitioners may dispense and orally administer, within the confines of their practice plan contract, non-narcotic analgesics, anti-inflammatories, preventative agents and antibiotics.

Supervision. Dental practitioners and hygiene practitioners must practice pursuant to a written contract with a dentist and must practice pursuant to the off-site supervision of the contracting dentist.

Practice Settings. Dental practitioners and hygiene practitioners may only practice in the following settings:

federally qualified health centers;
clinics operated by accredited schools of dentistry or dental hygiene;
clinics operated by a tribal health program or an urban Indian organization; or
any other clinic or practice setting in which at least 35 percent of the total patient base consists of Medicaid patients, patients with chronic conditions or disabilities that present a barrier to receiving dental care, or patients with annual incomes less than 133 percent of the federal poverty level.

Dental Quality Assurance Commission.

The DQAC is expanded from 16 to 18 members. One new member must be a dental practitioner and one new member must be a dental hygiene practitioner.

Study.

The American Dental Association and the Washington State Dental Association are encouraged to consult with practitioners, stakeholders and patient advocates to study programs in Washington that use volunteer dentists and oral surgeons to provide specialty care dental services.

Staff Summary of Public Testimony: PRO: There is experience in running this program in several states, including Minnesota. There is an access problem for Medicaid constituents. Minnesota and Washington have a ton of similarities. Working with Dental Therapists is absolutely safe. There are no reports of incidents in Minnesota or complaints lodged against Dental Therapists. Dental Therapists are tested side-by-side with dental students during the board exams, and examiners don’t know if they are testing a dentist or dental therapist. Dentists pay around $1000 a year for dental liability insurance, but Dental Therapists pay about $97 a year because of their safety. Oral healthcare is a health issue and should be a right. This would save money on emergency room visits and reduce dependence on painkillers. The American Dental Association, with dentists on its board, has developed a standard for Dental Therapist education. This is the same accrediting body that accredits dental schools and dental hygiene programs. These CODA standards will develop competencies under a 3-year academic plan. While there may not be a great physical distance to find access, there are still significant access issues for certain populations, including mentally compromised and disabled adults. Dental Hygienists may do 36 types of procedures, Dental Therapists may do about 54 procedures and Dentists may do about 600 types of procedures. In Minnesota, 50 percent of the patients that Dental Therapists serve must be low-income. The only way to make money serving Medicaid patients, is to see 40 to 60 patients a day. Emergency room visits for dental issues cost the state a lot of money. Forks has one dentist that comes in two days a week.

CON: There is concern that a supervising practitioner would not be available in emergency situations, since therapists can work under the off-site supervision of a dentist. There is not a shortage of providers, but a broken insurance system. The Swedish Dental Clinic provides millions of dollars in free dental care to underserved populations. Most procedures done on the Clinic's patients are well-beyond the scope of the mid-level provider. This bill discusses two different types of providers, one of which has a high school diploma and two years of training. Dental hygienists make about $50 an hour, and some entry level dentists make less than that. Why would someone want to get a mid-level credential to make less than just becoming a dental hygienist? There is an access problem for adults, but not children. We are training over 50 dental residents in Washington each year, and if programs are expanded, they would be able to serve more people in rural areas.