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By Karen Fox

St. Paul, Minn.—The legislative battle over what have come to be known as "midlevel providers" in Minnesota has come to a close.

What began as two distinct models of education and practice emerged as one with the state creating a new position—the dental therapist—who will provide care for underserved patient populations in the state.

Gov. Tim Pawlenty signed Senate File 2083 May 16, creating the dental therapist, a licensed provider with a bachelor's degree in dental therapy who will work with Minnesota-licensed dentists to provide preventive dental services, restoration of primary and permanent teeth, extraction of primary teeth and select other dental treatments.

"Regardless of the procedure or setting where care will be provided, it will be the dentist who completes the examination, makes the diagnosis and formulates the treatment plan," said Dr. Lee Jess, Minnesota Dental Association president. "For restorative and surgical procedures, the dentist must be on-site to provide intra-operative diagnoses and to assist when treatment complications arise."

Added Dr. Jess: "We are confident that with this well-defined scope of practice, level of supervision and patient population, dental therapists will help contribute to addressing the access to dental care challenge faced by many in Minnesota."

SF 2083 also creates a second level of dental therapist, the advanced dental therapist. To become an advanced dental therapist, one must have a bachelor's degree in dental therapy, practice for at least 2,000 hours as a dental therapist, graduate from a master's level advanced dental therapy program and pass a board-approved exam to demonstrate competency.

Advanced dental therapists will be able to practice off-site without a dentist present but are still required to obtain the approval of a supervising dentist prior to performing restorative and surgical procedures. They also will be able to perform nonsurgical extraction of advanced periodontally involved permanent teeth but only with the approval of the supervising dentist.

SF 2083, say officials from the Minnesota Dental Association, ultimately creates an integrated member of the dental team who cares for patients with dentists—as opposed to other proposed legislative models that had little or no interaction between a "midlevel" provider and a dentist.

"The MDA and its member dentists have worked hard for nearly a year advocating for principles of appropriate education, supervision and scope of practice," said Dr. Jess. "We are pleased that our concerns were heard and that this new position is a workable program to reach those in need while helping to ensure quality care."

Striking a legislative agreement that MDA could support would not have been possible without several things happening, said Dr. Jess, including the University of Minnesota School of Dentistry announcing a plan to start its own dental therapy education program, February's Dental Day at the Capitol which resulted in a strong showing of grassroots support from 150 MDA dentists and dental students, and a last-minute public awareness campaign.

"Particularly important to the MDA's efforts were well-considered positions on behalf of patients, effective lobbying at the state capital and extensive grassroots contact with legislators by MDA members," said MDA Executive Director Dick Diercks.

MDA and other stakeholders succeeded last year in opposing a legislative proposal to create the advanced dental hygiene practitioner with the authority to perform a wide array of surgical procedures without on-site supervision or preauthorization by a dentist. The legislature eventually dropped the ADHP proposal but passed a law authorizing creation of an "Oral Health Practitioner" without specifying the scope of practice or degree of supervision for the position, calling instead for a Department of Health work group to develop them and report back to the legislature. The work group failed to reach consensus on all critical issues but narrowly approved OHP guidelines close to those of the ADHP, that included—over strong objections from MDA—unsupervised surgery and a fragmentation of the dental team. Early in the process of considering the OHP's supervision and scope of practice, the U of M School of Dentistry introduced its own dental therapist model, the basis for which eventually passed into law.

With the 2009 legislative session drawing to a close, MDA launched a public awareness campaign with the theme, "The last thing you want to hear when you're getting dental care is uh-oh." TV, radio, print and banner ads online alerted patients of the legislative proposal to allow unsupervised workers to perform dental surgical procedures.

"The public awareness campaign was big," said Dr. Jess. "It brought attention to the issue of patient safety and created momentum for the dental therapy bill that we were supporting, which eventually prevailed."

The ADA provided legislative consulting, research and communications assistance to the Minnesota Dental Association through the State Public Affairs Program. Now, as the state moves forward with the dental therapist model, the MDA remains committed to upholding patient safety.

"Ultimately, Minnesota must find the political will to fund a dental health system in which the people in greatest need, and who also have the most complex oral health needs, can get care from fully trained dentists," Dr. Jess wrote in an op-ed distributed to statewide media May 22.