Health Care

Dentists block proposal to allow licensed dental practitioners

In 2012, nearly 68,000 adults went without dental care because they could not afford it, according to the advocacy group Vermont Oral Health Care for All.

That group is behind a push to create a state license for a mid-level dental practitioner position that would be a step above a dental hygienist and a step below an actual dentist.

Such positions exist in Minnesota and Alaska, and there are bills to license so-called dental therapists or dental practitioners in several other states. Legislation to license dental practitioners in Vermont stalled in the House last biennium, but was reintroduced this year in the Senate.

Sen. Claire Ayer, D-Addison, is chair of the Senate Committee on Health and Welfare. Photo by Roger Crowley/for VTDigger
Sen. Claire Ayer, D-Addison, is chair of the Senate Committee on Health and Welfare. She is the sponsor of a bill that would provide for the licensing of dental practitioners. Photo by Roger Crowley/for VTDigger

Advocates say that the state’s access problem stems from a shortage of dentists, especially in rural areas.

The bill would require dental practitioners to be employed by a dentist; that would allow a practice to serve more patients.

The dental practitioner’s scope of care would be limited by a contract with the supervising dentist.

The Vermont Dental Society opposes the bill. Vaughn Collins, the organization’s director, said Vermont’s issues with access to oral care don’t stem from a shortage of dentists, but rather how dentists are distributed geographically and how Medicaid compensates them.

In addition, Collins and the Dental Society have raised concerns about whether dental practitioners would get sufficient training to perform certain surgical dental procedures.

The advocates counter that dentists would define the dental practitioners’ scope of practice, allowing dentists final say over what procedures they could perform.

The most recent figures from the state show the state has 368 dentists, or roughly 59 per 100,000 residents, nationally the rate is only slightly higher at 61 per 100,000, according to data from the federal Centers for Disease Control and Prevention.

However, some counties such as Rutland and Chittenden have plenty of dentists, Collins said, while there are only a handful in the entire Northeast Kingdom.

“There’s nothing in the bill that says whether they (the dental practitioners) would be required to go out to these rural areas,” Collins said.

Vermont Technical College, which currently trains dental hygienists, has signed on to provide the curriculum for the dental practitioners as well.

“They have curriculum ready, just waiting to get started,” said Sheila Reed, of Vermonters for Oral Health Care for All.

It takes a three-year program to become a hygienist, and the certification for a dental practitioner would require an additional year of classes and 400 hours of clinical training.

While nothing in the bill requires they practice in an underserved part of the state, Vermont Technical College’s graduates are predominately local, according to Reed, and that increases the odds they would return home to practice.

Hiring dental practitioners could also help dentists accept more Medicaid patients, Reed said.

Medicaid reimburses dentists at half of what commercial insurance pays.

The same is true for providers of medical care, but the different economies of scale in dentistry force dentists who accept Medicaid patients to treat them at an even greater loss.

Dentistry is a cottage industry compared to the rest of the medical professions, with dentists typically operating freestanding practices that nonetheless have higher fixed costs than most independent physician practices, Collins said.

“Dentists are basically dental surgeons and their offices have to be operatory,” Collins explained.

Dentists are forced to evaluate how many Medicaid patients they can treat without losing money, he said.

Just under half of Vermont dentists didn’t take a single new Medicaid patient in 2011, according to a Green Mountain Care Board report.

Employing dental practitioners would allow practices in Vermont to expand their Medicaid patient population, because they would make less than dentists but be able to provide many of the same services, Reed said.

Collins said he would prefer to see the state increase Medicaid reimbursement rates for oral health services. Increasing rates from 50 percent of commercial payments to 75 would cost Vermont between $4.2 and $13.8 million more than what it currently spends on Medicaid depending on the corresponding spike in use of services, according to the Green Mountain Care Board report.

Though expensive, Arthur said raising the reimbursement rate has increased the number of Medicaid patients dentists will see in other states.

The Department of Health favors licensing dental practitioners, Arthur said, in large part because if Vermont doesn’t have a shortage of dentists currently, it will in the next decade.

Vermont has the oldest dentists in the United States, with 34 percent over age 60 and many are likely to retire over the next decade, Arthur said.

With only roughly 4,000 people graduating from dental school nationally each year and no dental school in Vermont, it’s difficult to imagine the state maintaining an adequate number of dentists through recruitment alone, Arthur said.

The average dental student graduates with $200,000 in student loan debt, and the financial pressures facing them is likely to make rural Vermont a difficult option. Allowing dental practitioners to train in the state is one way Vermont could help existing dental practices expand, Arthur said.

The Senate bill was passed out of the Government Operations Committee earlier this session, but landed in the Finance Committee because of the fees involved with issuing licenses.

There was not sufficient support from his committee to pass the bill before crossover, according to Sen. Tim Ashe, D/P Chittenden, the committee chair.

It’s still possible the committee could pass the bill on its own under suspension of the rules or tack it onto other legislation, but its sponsor, Sen. Clair Ayer, D-Addison, was not sanguine about its prospects.

“I’m thinking it’s kind of late to do anything now,” she said.

One step the Legislature may take to improve the oral health of Vermonters is aimed helping people on WIC – the federal assistance program for women infants and children – learn better oral health practices, Ayer said.

There is legislation to expand the number of Agency of Human Services offices assisting people on WIC that employ dental hygienists to work with beneficiaries. The Senate would need to fold the appropriation into the larger budget bill for it to pass at this point in the session, Ayer said.

Each year there are over 400 children age 5 or younger admitted to emergency rooms for dental surgeries. That costs the state over $2 million per year in hospitalization costs alone, and the state spends another $1 million on routine dental problems for young children, Arthur said.

The bill calls for $375,000 to put eight additional part-time public health dental hygienists in district offices across the state.

“That’s really high impact for low cost,” Ayer said.

Half of Vermonters don’t have dental insurance

Vermont may have one of the smallest uninsured populations in the United States, but the health insurance residents have typically doesn’t provide dental coverage.

More than half of Vermonters don’t have dental insurance, according to a recent study of oral health in the state commissioned by the Green Mountain Care Board.

While that’s not out of line with statistics nationally, Vermont’s covered population isn’t getting the oral health coverage they need either, the report concludes.

“Significant numbers of adults 18-64 have lost all their natural teeth to decay or disease and do not access recommended preventative services,” the report states.

In some areas of the state as high as 9 percent of the total population have lost all their natural teeth to disease or decay.

Oral health impacts overall health and is known to affect or contribute to a variety of conditions and diseases including diabetes and heart disease.

People who don’t receive regular oral health services are more likely to end up requiring costly hospitalizations or procedures.

The status of oral health in Vermont doesn’t rise to the level of a public health crisis, said Dr. Steve Arthur, director of the Health Department’s Oral Health Office, but the state would do well to take steps now to avoid it becoming one in the future.

Statewide less than 50 percent of Medicaid beneficiaries accessed oral health services, and for the privately insured it was just over 60 percent, according to the Green Mountain Care Board report.

Part of the problem is that people just don’t go to the dentist, even if they’re covered, but for some it’s unaffordable or difficult to find an appointment.

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Morgan True

Recent Stories

  • David Healy

    The link to the interactive maps contained in the Green Mountain Care Board’s Vermont Dental Landscape Study can be found here:

  • Barbara Morrow

    Dentists get a bad rap. Dental ins riders are expensive, there’s usually pain involved in an office visit, and I dunno, dentists don’t get the respect they deserve in the system. But resistance to this bill reminds me of the difficulty midwives had when OB-GYNs thought they take away business.

    Dental health is so important. Dental orgs need to do more education of the public, etc. Collective efforts, not just independent offices

  • Sarita Khan

    The Vermont Dental Society also insists that you have to have an Xray to have even a dental cleaning which not only makes a dental visit even more expensive but no consideration is given to the unnecessary exposure to radiation. You wonder why there are so many brain issues….mental health problems. Dentists cover other organs – lungs, reproductive with a lead coat but then direct the radiation directly into the mouth and brain….For starters, stop with the unnecessary dental xrays for cleanings.

  • ruth sproull

    If dentists were forced to take dental emergencies, regardless of whether or not they were paid like hospital emergency rooms, I think that they would allow this. As it is, they are able to transfer the cost of expensive, difficult cases relating to dental issues to the hospitals. This allows the dentists only to take the cases that are profitable, skimming the cream from the top.

    • kristina goslin

      Speaking as the office manager of my husband’s small practice, I take particular offense at this comment. Our office has never turned away an emergency case and to suggest we pick and choose our patients by their ability to pay or the reimbursement of their necessary treatment is insulting to the oath my husband took when he chose to spend his career helping people achieve better health. A general practice operates under a significant burden of overhead costs, providing livable wages to staff, paying for equipment and materials, paying back large educational loans among many other expenses. Under Vermont’s current rate of Medicaid reimbursement we cannot accept any more Medicaid patients without changing our current level of care to all.

  • Rilla Murray

    I am very disappointed to see this proposal die once again. We have wasted a timely opportunity to get ahead of the inevitable oral health workforce demographics in order to protect an outmoded model of practice. Oral health, like mental health, needs to be fully integrated into our health care delivery system and preventive health services.

  • Kathy Boyle

    I am not sure the licensing of dental practitioners is the answer to reaching the populace that is currently underserved. One of the drawbacks that I see is the outfitting of the physical setting to be used. If you send these practitioners to rural areas, where are they going to practice? The equipment alone is astronomically expensive and will likely be the responsibility of the supervising dentist. If it is not, then the new practioners will be responsible. How would they pay for it? Certainly not with medicaid reimbursement. The key, I believe, is in educating the populace and providing PREVENTATIVE care. Hum…. sounds like a job for a dental hygienist. Practitioners would most likely be of greater value in an existing office where they could be scheduled with some of the simpler therapeutic procedures thereby freeing the dentist to see more complicated cases and increasing production. As a retired hygienist, I can firmly say that the profession is underutilized to begin with. I would have loved an additional year of training to become a “dental practitioner”. Just don’t think it will solve the upcoming shortage of dentists. State may want to think about offering incentives to dentists willing to move to this state.

  • More bloated Government/Corporate gobble-de-goo. Oh, poor Dentist! Really! THEY HAVE PUT A HUGE PRICE ON EACH AND EVERY TOOTH IN OUR MOUTH. An exray before ANY work can be done, really!

    Once again we have bureaucrats gumming up the access and telling us they are trying to fix it.

    How about DEREGULATING Dental Hygienist. Preventative maintenance has always proven to be worth it’s weight and to let Hygienist open practices to clean and evaluate dental health would save everyone time, pain and money.

    Once again we have Government, Dental Associations and insurance companies causing mayhem and out of control cost.

    I really like my Hygienist. She does a wonderful job and I trust her with my dental health. The problem is, Hygienist, being gummed up and controlled by ‘regulation’, we always get a visit from the “Dentist’ for an “exam” which takes two minutes and cost $50 – $75 depending on who you see. This is outrageous! So, along with the mandatory exray then the “exam” from the ‘Dentist’ we are nearly broke before we get started.

    Yes, let’s let Hygienist open shop and provide people with “Preventative Dental Care”. Even if a good cleaning cost $100 – $150 we would still be ahead in the long haul.

    • Kathy Boyle

      Dear Ray,

      Glad you like your hygienist. I am sure she is great. There really is nothing to prevent a hygienist from “setting up shop” as you say. Profession is ruled by general supervision meaning the dentist does not have to be present for a hygienist to render hygiene treatment, only available. So, why don’t hygienists do this here? A hygienist would just have to find a dentist willing to represent him/her. Simply put, it is not cost effective. Would need a great amount of trust on the part of the dentist too since they are shouldering the liability. As I said in earlier post, running a practice is expensive. I was also never comfortable seeing patients without a doctor actually IN the office. Never failed to run into circumstances that required more than I was capable of treating. P.S. We also need those radiographs. It would be like navigating a minefield with no map. The dentist needs to see the patient also. No matter how great the hygienist, the doctor is rendering further treatment if needed and needs “the skinny” so to speak.

      • Kathy – I respectfully completely disagree with your statement.

        • Kathy Boyle


          Which part do you disagree with? I actually contemplated this arrangement years ago. Unfortunately the fixed costs are just that FIXED. And who needs the headaches of actually running an office? As for the need for radiographs – you can always opt out. After all, the patient is the final decision maker. Practice would just have to put it the your chart. ( So when you develop that cavity, tumor, abscess, they are not held accountable.) IF a hygienist “opened shop”, they too, would have to document everything including the need to seek restorative care- which would most likely require two trips to the restorative dentist. Provided the patient goes. (Again the need to document by the hygienist.) The first appointment to assess the scope of the work, and the second to accomplish said work. There is always the thought of “contracting” hygienists”. I don’t know how many are here. They lease the space at the dental office. Somewhat like hairdressers lease a chair at a salon and are self employed. There are many different arrangements out there. I don’t know how many dentists utilize contract hygienists. They are more probably more expensive. They have to pay taxes and social security since they are self employed. So their rate would have to be higher.

    • kristina goslin

      suggesting that a dentist diagnose or evaluate the health of your teeth and mouth without taking a diagnostic image (x-ray) is akin to asking your mechanic to look at your car from across the street and assure you that it doesn’t need an oil change or a belt replaced. It’s sad and a disservice to the men and women who dedicate their professional lives to caring for your oral health to suggest they are all just out to soak you for every cent, and dishonestly to boot. My husband is a dentist and has spent many a late night, weekend and holiday in his clinic treating emergency cases without an “after-hours” charge. He calls his patients in the evening after big procedures to ask how they’re feeling. He will give consults and post-op checks without charging anything extra. He does this because he values the trust his patients put in him. He earns their respect and treats everyone to the very best of his ability. He has diagnosed oral cancers and other severe conditions during his exams and through routine x-rays that would otherwise gone undetected, to the great relief of those patients. the many years of education both in dental school and in the years since have equipped him to know what to look for and how to approach complex issues. That is the value of being seen by a dentist. People too often don’t consider that until they or their spouse or child is the one affected.

  • Nancy Baer

    Why not MANDATE that ALL dentists take medicaid patients like we used to? WHY do you deserve any less better dental care because you are POOR????!!! I now have bad peridontal disease and will lose most of my teeth all because some JERKS in Montpelier
    lobbied against EQUAL DENTAL CARE FOR ALL!! I can’t go to my dentist of 40+ years because I AM POOR NOW AND HE REFUSES TO ACCEPT MEDICAID!!!!! And I’m NOT going to a so called MEDICAID dentist that doesn’t even have a hygenist to clean teeth or a sink to spit the bacteria in!!! Way to go lawmakers in Montpelier!!!! YOU SHOULD BE ASHAMED OF YOURSELVES!!!!!!!

    • Jordan Posner

      Unfortunately, The mid level would bill at the same rate as a dentist. This will not solve your problem. However, the creation of a CDHC, whose sole job would be to coordinate care for Medicaid recipients, would be a huge step in the right direction. Unfortunately, the CDHC bill was voted down in Sen.Ayer’s committee in favor of this

    • Cheryl Pariseau

      I am wondering why your dental woes are not your fault? Even if your dentist will not except Medicaid I can bet he will except cash. If you have been a loyal patient for so long perhaps a deal can be worked out. While I do not consider myself poor I am far from being considered rich. I have been with out dental care for the past 22 years yet I make it a point to get dental care. It is all about priorities and my dental health is right up towards the top. Also if you are refusing to except the care that is being provided to you via Medicaid then that is your choice. As Ben Franklin said “Any fool can criticize, condemn and complain – and most fools do.”

  • rosemarie jackowski

    What a mess!!! We need talented ethical dentists, but I am not sure that pressuring them is the answer.

    Imagine the lack of quality of the dental work and real damage that could be done by an ‘unhappy’ dentist. Think about what it would be like to have the wrong tooth pulled. Think about having root canals done without any anesthesia. Think about all the unnecessary X-rays done for billing purposes only.

    Maybe the answer is to educate more so that the number of dentists will increase. In the meantime, we need to set up dental clinics in underserved areas… and we need to do that ASAP.

  • Vaughn T Collins, Executive Director of VSDS

    Thank you for a balance article, but many questions still remain. The Office of Professional Regulations issued in a recent report that raised 64 questions that need answering before legislators should consider creating a new type of practitioner in Vermont. Additionally, I would ask supporters of this bill, if this new practitioner effectively cures the problem Vermonters have accessing dental care? Will the rural areas of Vermont that truly have limited access to dental care, actually be served? Does this bill address the cost barrier? Will this bill expand our health safety net (Medicaid) to allow more Vermonters to be seen by more dentists?

    Vaughn Collins, VSDS
    Executive Director

  • Dr. Chuck Seleen, Vermont Dental Care, Winooski


    Nice article but there are many things to be considered. The problem is ACCESS so that is what needs to be solved. Get the patient who is in need to a provider. Cost, transportation, unperceived needs, prevention etc.

    These are social service problems. We need to connect patients with solutions and get them into the system. Also nothing in your article about EFDA’s and Community Dental Health Coordinators? I think you could have provided much more depth. Again the issue is ACCESS and connecting people to treatment.

    Chuck Seleen DMD
    Vermont Dental Care Programs, Inc.

  • rosemarie jackowski

    Are licensed dentists from other states still prohibited from rendering compassionate care in Vermont? If so, it appears that there is a turf war and the citizens in need of dental care are the victims.

  • Fragment the Dental Professions to Meet the Oral Healthcare Needs of Americans

    Too many Americans deal with little or no oral healthcare until the onset of aggressive periodontitis and pain; limiting their treatment options.

    We need dental hygienists at schools and public health facilities. We need independent practices for dental hygienists nationally, so hygienists can have the freedom to work independently on the public health level providing services where needed, especially for oral health education in the early years of the public school systems.

    We need dental therapists/dental health aide therapists for extended hands on dental procedures through dental teams working convalescent/retirement facilities, prisons, and Indian reservations.

    We need denturists, providing removable oral prostheses care and referral services; freeing up dental chairtime for children, emergency, and restorative care.

    We need more rural community health/dental clinics including mobile dental units traveling to rural areas.

    We need ADA to change its existing ill-fated and outdated polices currently in place on workforce issues and exchange them for common sense policy recommendations by the U.S. Surgeon Generals and other oral health organizations.

    Gary W. Vollan L.D. State Coordinator, Wyoming State Denturist Association,

  • Steven Farnham

    59 dentists per 100,000 people is one dentist for every 1695 Vermonters. I never get to see my dentist for more than fifteen minutes per checkup – the rest of the time is spent with the hygienist. The only time I see the dentist for more time is for “surgery” like fillings, etc.

    Is seeing ten clients a day a reasonable load? If a dentist can average ten clients a day, then they’d only have to work 170 days per year to serve 1695 people. Leaving aside two weeks for vacation, there are 250 work days per year.

    So why the “shortage”?

    • Matthew Choate

      Great question Steve. My own dentist is closed weekends, after 5, and Fridays. So they work M-Th, 50 weeks a year, or 200 days. If all of them are doing this, there is great underused capacity. I might also add the office rates have gone up about 300% over the past 15 years, a huge year-over-year increase. Dentists are doing just fine, and I have great respect for them a medical colleagues. But…yf you have money, you will get seen. If you don’t, good luck. I applaud Senator Ayers for trying to address that.

  • Anne Fleming, RDH

    I would love to see the state spend some money on public service announcements concerning the use of soda and sports drinks, and of course the 2X/2min/day brushing message. When I tell my patients that what they are drinking is dissolving their teeth the look at me like I am green because they have not heard it in the media. The younger generation distrusts anything that does not come over the media. What would it cost to run public service adds/infomercials? I work at a FQC in Franklin county and it is not unusual for a teen or twenty something to come in with 15 or 20 cavities- all because of what they are drinking. Reaching moms at WIC may help, but they may not trust the information they are receiving their either. I think media is the answer. They see it on TV or hear it over and over on their favorite radio station they believe it.

  • Matt Taylor

    The Vermont Dental Society opposes the bill – thats a big suprise since they don’t want anyone providing services that they can provide.

    Its very similar to the anesthesiologists vs the nurse anesthetists. The doctors want to keep their job whether someone without a MD after their name can do the job or not.

    This bill would open the door for later down the road, the middle provider to take away services from the Dentists that could provide similar care at a lower costs that they do want to match….without their oversight ie them getting a large chuck of the payment.

    • Kathy Boyle


      There is a big difference in anesthesiology and dentistry. Anesthesiologists work within a hospital setting. Dental personnel work within dental offices. In the case of anesthesiologists, hospitals provide the physical setting. You receive two bills when utilizing hospital services – one from the hospital itself, and another from the personnel involved in your procedure. In dentistry you get one bill combining both. SOMEONE has to provide the supplies and physical setting. These costs do NOT fluctuate. Practitioners would not get them at a reduced rate. There would be little in savings to the public after you factored in the cost. Practitioners would have these costs PLUS the added liability ins., administrative staff, etc. I just don’t see much cost savings to the public. And what makes you think that practitioners would charge a lower rate? You then get into the whole insurance fiasco and how rates are established.