Oregon’s dental care landscape will change if lawmakers pass a proposal to let dental therapists practice in the state.
House Bill 2528 would establish dental therapists as an occupation and give them a scope of practice to provide much of the routine dental care that dentists now provide. Under the bill, dental therapists aren’t dentists, but they could fill minor cavities and perform simple extractions, as well as basic work, such as cleanings.
In the dental profession hierarchy, they are below a dentist and above a dental assistant.
Under the bill, they could work in a clinic with a dentist, or on their own without a dentist on site. Either way, they would need to be under the “general supervision” of a dentist in Oregon whom they could contact.
For supporters, dental therapists are a way to serve hard-to-reach and underserved populations who lack access to basic dental care, whether in rural or urban regions of the state. Other states in the Northwest allow dental therapists. In Alaska, dental therapists work in remote frontier regions. In Washington state, lawmakers passed a bill in 2017 that allows dental therapists to serve tribal communities.
The Oregon bill would allow dental therapists to work in the entire state.
“I see dental therapy as a really great way to increase access to safe care, and it’s evidence-based and I think it’s the best way to increase access for all the populations that need care,” said Dr. Miranda Davis, a dentist in Washington state and director of the Native Dental Therapy Initiative of the Northwest Portland Area Indian Health Board.
Many Oregonians struggle to access dental care. A 2019 study by the Oregon Health Authority determined that 45% of Medicaid members in the state did not have a regular dentist they went to for routine checkups or cleaning, or in the event of cavities or dental pain.
Oregon has the full-time equivalent of 0.49 dentists per 1,000 people, according to a 2019 report by the Oregon Office of Rural Health. The rates are higher in urban Portland and Eugene.
Oregon already has two pilot projects in place for dental therapists.
In one, HIllsboro-based Willamette Dental Group and Pacific University in Forest Grove are working together to train dental hygienists with the skills they need to become therapists. Through the pilot, they can work at clinics in the Portland area, Eugene, Central Oregon and other parts of the state that are affiliated with Willamette Dental Group or other participants in the study.
In the other, the Northwest Portland Area Indian Health Board, part of the Oregon Dental Access Campaign, is sponsoring a pilot project with three dental therapists working with tribal communities and groups, including the Confederated Tribes of Coos, Lower Umpqua and Siuslaw Indians, the Coquille Indian Tribe, and the Native American Rehabilitation Association. Two more dental therapists will join the pilot when a clinic for the Coquille Indian Tribe is built later this year. They are trained through a program in Alaska accredited by the American Dental Association’s Commission on Dental Accreditation.
Dental therapists have about three years of classroom instruction and training, which includes clinical experience.
The pilot project, overseen by the Oregon Health Authority, has input from supervising dentists. It has reduced wait times to see a dentist in tribal communities from 10 weeks to less than eight weeks in the first three years.
Dan Courtney, chair of the Cow Creek Band of the Umpqua Tribe of Indians, urged lawmakers to take action, as the pilot project ends in 2022.
“There is much work to be done to turn the tide on oral health disparities in Oregon, and dental therapy is one solution we urge you to support,” Courtney wrote in testimony to the House Health Care Committee. The committee heard testimony on the bill and a proposed amendment on Thursday but didn’t take action.
The bill is sponsored by Rep. Tawna Sanchez, D-North Portland.
Some Dentists Seek Restrictions
However, some Oregon dentists and the Oregon Dental Association, oppose the bill as written and want to reshape it to put dental therapists under closer supervision of dentists. Rep. Cedric Hayden, a dentist, introduced an amendment to the bill that would put dental therapists under tighter supervision by dentists, with less flexibility to do some of the procedures independently. The amendment would require dental therapists to purchase their own liability insurance coverage. It also would require at least 51% of a dental therapist’s practice to be devoted to underserved populations.
“It is more restrictive than the current base bill, but it is a pathway to dental therapist licensure in the entire state of Oregon,” Hayden, R-Roseburg, said in the legislative hearing. “It is a bill that would be applied to the entire state of Oregon. It is a pathway forward.”
Dr. Scott Hanson, a dentist in Milwaukie and chairman of the Oregon Dental Association’s legislative task force, said the proposed amendment is sufficient to get his organization to a neutral stance on the bill and drop its opposition.
He said some surgical procedures need to be done by the dental therapist under “indirect supervision,” which means a dentist needs to be in the same building, and dental therapists could perform other, less invasive procedures, under “general supervision” with the supervising dentist anywhere in the state.
Dentists, including Hanson, have previously testified against dental therapists performing procedures such as tooth extractions, with potential for complications, in remote areas without a dentist in the same community.
The original bill allows dental therapists to provide a variety of services, including simple tooth extractions and work on cavities under the “general supervision” of a dentist, who doesn’t need to be in the same building as the dental therapist. For proponents of expanded access, that’s a key selling point because it would put dental providers in locations that lack a dental office. Under the original bill, the dentist and dental therapist can do that only through a practice agreement that both parties have signed. That agreement would detail the procedures that a dental therapist can do and the level of supervision that is necessary for each procedure.
In comparison, the amendment would offer less flexibility for practice agreements and be more restrictive. For example, a dental therapist could do only limited procedures without the supervising dentist on site. Those procedures would include exams, X-rays, providing oral health instruction, preventative work and emergency palliative treatment for dental pain, which treats the pain but may not permanently address the underlying cause.
The amendment would require either indirect or direct supervision for other procedures, including simple tooth extractions and administering local anesthetic. Either indirect or direct supervision would require the dentist to be on site. Under direct supervision, the dentist is in the same room as the dental therapist during the procedure. Under indirect supervision, the dentist is in the same building, but doesn’t need to be in the same room. The agreement with the supervising dentist would determine the type of supervision.
Bill “Poses A Danger,” Dental Groups Say
In a joint letter to lawmakers, the Oregon Dental Association, Oregon Academy of Pediatric Dentistry and Oregon Society of Oral & Maxillofacial Surgeons opposed the bill in its original form.
In a letter, the groups wrote: “Our organizations are not opposed to the concept of dental therapy, but without adding sideboards around scope, training and supervision, the bill, as drafted, poses a danger to Oregon’s most vulnerable populations. We urge the committee to oppose the bill as introduced, and ensure the work on this bill moving forward is inclusive of the broader dental community.”
But some advocates of the original bill oppose the amendments as drafted.
Amy Coplen, program director at Pacific University’s School of Dental Hygiene Studies, is involved in the pilot project for dental therapists. Coplen urged lawmakers not to put further restrictions in place that would limit access to dental care. The original bill puts the level of supervision in the hands of the supervising dentist, Coplen said.
“Dental therapists are not independent practitioners,” Coplen said. “One of the things I really like about this bill, is that it requires a practice agreement that explicitly states the supervising dentist must designate the level of supervision for each and every procedure allowed under the practice agreement. We need to trust the competent and highly educated dentists of Oregon to delegate safely and to oversee the dental therapists work.”
Lawmakers considered similar legislation in the 2020 session and formed a working group to explore the issue more.