Proposed bill would ease shortage of dental care in rural ND, supporters say
Post Date: Feb 07 2015

By Patrick Springer - The Forum
February 7, 2015
BISMARCK – North Dakota legislators will decide whether to allow certified “advanced dental hygienists” to perform certain procedures now done by dentists to fill a gap in dental care that is acute in rural areas and Indian reservations.
Proponents of Senate Bill 2354 held a news conference Thursday in the Capitol to promote the measure as a way to address a shortage of dentists that now affects 40 percent of North Dakota’s counties and is expected to worsen as dentists retire.
Sen. Dick Dever, R-Bismarck, the proposal’s primary sponsor, called it a “common sense North Dakota solution to increasing access to affordable, routine dental care for all North Dakotans.”
But dentist groups in the state oppose the bill, and say other legislative funding measures could help their profession attract more dentists to the state to address the issues.
Under the proposed bill, dental hygienists who receive advanced training – which is not defined in the bill – would be allowed to perform certain procedures under a dentist’s supervision.
If the bill passes, North Dakota would be the fourth state to allow mid-level dental providers. Minnesota is one of three states that allow mid-level dental providers. 
Dr. Donald Warne, a physician who heads the master of public health program at North Dakota State University, is a vocal supporter of the bill, which he said will help alleviate the severe shortage of dental care on the state’s Indian reservations.
“We have the worst disparity of access of any group in North Dakota,” said Warne, who is a member of the Oglala Lakota tribe.
Poor oral health not only makes maintaining proper nutrition difficult, but can elevate risks for diseases including diabetes, studies have shown. American Indians are twice as likely to develop diabetes and six times more likely to die from the illness than the general population.
“Right now, people are suffering unnecessarily,” Warne said. “If the dentists could solve this that would be great,” but it’s a decades-old problem that hasn’t yet been solved, he said.
The North Dakota State Board of Dental Examiners, which licenses dentists, dental hygienists and dental assistants, would draft the education requirements for advanced dental hygienists.
The board, dominated by dentists, voted to oppose the bill. Instead, it is moving ahead with proposed administrative rule changes to expand tasks dental hygienists and dental assistants can do to make dentists more efficient.
“Evidence supporting the safety or efficacy of a mid-level provider is incomplete,” said Dr. Rob Lauf, a dentist in Mayville and president of the North Dakota State Board of Dental Examiners.
“We are not for surgical procedures being done other than by trained dentists,” he said.
Some of the services and procedures that advanced practice dental hygienists would be able to perform: 
  •  Oral evaluation and assessment of dental disease and formulating a treatment plan.
  •  Cavity preparation and restoration.
  •  Tooth extraction.
  •  Pulpotomy, or removal of diseased pulp tissue from a tooth.
  •  Preparation and placement of a crown, replacing a permanent crown.
  •  Tooth reimplantation.
  •  Emergency palliative treatment of dental pain and management of dental trauma.
Rachelle Gustafson, president of the North Dakota Dental Hygienists Association, which supports the bill, said mid-level dental providers have worked well in Minnesota, helping to expand care and make dentists more efficient.
“We still need the dentists,” she said. “They’ll still be our supervisors.”
Supervision, which must include a collaborative agreement, could involve video links, so a dentist could see inside a patient’s mouth while advising a hygienist, Gustafson said.
Although the education requirements for an advanced-practice dental hygienist aren’t specified, she said her group would like to see a master’s degree requirement. Hygienists can have either a two-year associate or four-year bachelor’s degree.
Possible alternatives
Resistance from dentists to allowing mid-level practitioners is similar to opposition from medical doctors when nurse practitioners and physician’s assistants were initially proposed several decades ago, Warne said.
“I cannot imagine a medical system without nurse practitioners and physician assistants,” he said. “As a clinician, I relied heavily on them,” allowing him to focus more on patients presenting more complex cases.
The North Dakota Dental Association is pushing alternatives to the mid-level practitioners, including expanded dental loan repayment programs, improved dental Medicaid coverage and expansion of nonprofit dental “safety-net” clinics.
“This one-size-fits-all approach fails to take into account the unique needs of North Dakotans,” said Paul Tronsgard, a Fargo dentist and president of the dental association.
The bill has its first hearing Tuesday before the Senate Human Services Committee.

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