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Charting the Confusion Around 'Midlevel' Dental Practitioners


Dental assistants, hygienists, and technicians have been around for decades, but the terms used to categorize them and the regulations limiting what they can and can't do vary greatly by state.

For most of his career, Gordon Christensen, DDS, MSD, PhD, a practicing prosthodontist in Provo, UT, has been a proponent of expanding the clinical responsibilities of dental assistants, hygienists, and technicians under dental supervision.

The term often used to categorize those dental professionals as midlevel practitioner, though much more in an unofficial rather than official capacity. That’s because only two states, Minnesota and Maine, have officially embraced this new category. And according to Christensen, confusion reigns in those states.

“They have these unknown auxiliaries and they don’t know what to do with them,” he says. “Where do they fit in? What are they paid? Are they paid similar to a dentist, or to a hygienist? It’s not clear.”

And therein lies Christensen’s frustration.

What’s in a Name?

Christensen explains that dental hygienists have been around for 70 or 80 years. Use of dental assistants and laboratory technicians is also widespread. All three of those categories have different kinds of expanded clinical functions that they can do legally—depending on the state.

“And the spread of how liberal a state is, is unbelievably wide,” Christensen says. “In some states you practically have to have a PhD to do anything, and other states are wide open.”

In other words, a ball of confusion. And what’s adding to the confusion, Christensen says, is a lack of vision and leadership.

“I sat with the leadership in Minnesota a year ago and asked what are you doing with these [midlevel dental practitioners]?” he recalls. “They have them, but they don’t know what to do with them.”

What politicians are doing, or want to do, Christensen says, is move these auxiliary dental professionals into geographic areas of need. But he points out that those locations are populated with the most extreme kind of patients: those with the most extreme level of neglect.

“Sticking a midlevel person, who had half the knowledge or a quarter of the knowledge, in these areas makes absolutely no sense to me,” Christensen says. “You must send a dentist there to supervise.”

Resistance Despite Benefits

Christensen says that, almost without exception, the concept of expanding the clinical responsibilities of dental assistants, hygienists and technicians has been successful—for patients, dentists, and dental staff members. And yet there is considerable resistance up and down the industry.

According to Christensen, the American Dental Association and the American Student Dental Association have both been negative on the concept of midlevel dental practitioners. And that negativity has more than trickled down to state leadership.

For example, at a recent meeting in Vermont, Christensen presented 18 expanded functions for already identified and current dental staff that translates into 25 methods of increasing practice productivity. He says it was “interesting” to see how few were ready to jump on the bandwagon.

“They’re in a rut, and they want to stay in a rut,” he explains. “That’s the level of resistance that you see.”

The other major issue, Christensen says, is lack of education. He says that young dentists come out of school having never been taught how to use an assistant.

“Many years ago I got federal grants to bring in an assistant for every senior dental student,” he says. “Today, I doubt there’s a school in this nation that has any program to educate dentists on how to use an assistant.”

And with average dental school debt ranging between $300,000 and $350,000, Christensen believes that being educated on how to use expanded staff functions would not only help these graduates overcome the negativism they feel, but be more productive in their respective practices.

But the education challenge isn’t limited to new dentists.

“You ask older guys to have a dental assistant do something and they flip out,” Christensen says. “There are all kinds of challenges. Some financial, and some educational.”

Moving Forward

Christensen says what’s needed to clear up this confusion is a group of real world people.

“Not the Pew Research Center,” he says. “I respect them, but they’re usually academics or administrators, not people on the firing lines.”

He advocates for a more holistic approach—academics teamed with real world practitioners as well as administrators and public health professionals.

“Let’s get this group together, and get some equitable solution rather than have the politicians dominate the people who are actually doing the work,” Christensen says. “There’s nothing wrong with expanding the functions of staff. As I said, I’m the most liberal one in the country. However, not in the way they want to do it, through political channels. Let’s get them out in the field and work a day rather than sit at a desk and prognosticate.”

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