As reported by The Hartford Courant, December 17, 2004.

Dental Licensing Changes Proposed

Panel Backs Residency Program as Trade-Off for Test

By Garret Condon

Connecticut could join a handful of states that allow dental school grads to skip a skills exam now required for a state dental license in return for a year in the trenches. In addition, foreign-trained dentists would find it easier to get licensed here and dental hygienists could be allowed to administer Novocain if the legislature accepts the recommendations of a panel of dental health and policy experts.

The changes are intended to improve the education of dentists, expand the dental health workforce and improve access to dental care for low-income residents. But the licensing proposal already is causing some gnashing of teeth.

Dr. Roger Ostrander Jr., a Waterbury dentist who is chairman of the Connecticut State Dental Commission, said he worries that the least-talented dental school graduates will skip the exam in favor of the residency program. A standardized clinical test, he said, "levels the playing field for everybody" and is a better way to evaluate students.

Those who support the post-graduate year say that dentists who spend a year practicing in hospitals and clinics under careful supervision will be much better trained and evaluated than those taking a one-shot, one- to two-day test.

"Residency provides a year or two of additional training," said Dr. Monty MacNeil, vice dean of the University of Connecticut School of Dental Medicine in Farmington. "It fits more with the medical model, where students graduate from medical school and they must take a residency to qualify for licensure."

Currently, New York and Minnesota offer the post-graduate year as an option to the clinical exam, although the residency will become mandatory in New York in 2007. Delaware requires both the residency and the clinical exam. Other states considering a change to an optional post-graduate year are Ohio and California.

But Laura Neumann, associate executive director of the Chicago-based American Dental Association, said it's too early to tell whether the post-graduate-year option will become a broad, national trend. The ADA's current policy is to support an independent, third-party evaluation of new dentists - whether by clinical exam or through an accredited residency program.

Another proposed change would allow graduates of foreign dental schools to apply for a Connecticut dental license. To do so, they would have to complete at least a year of residency and two further years of work in a safety-net clinic. They would then be able to take national board exams and would also have to pass the clinical exam. At present, foreign-trained dentists must start over and get a degree from a dental school in the United States.

The committee also will recommend allowing dental hygienists to administer local anesthesia such as Novocain and will recommend further consideration of expanded duties for both hygienists and dental assistants. Although there is no proposal to create in dentistry the equivalent of a physician assistant or advanced practice nurse, the idea is the same: to move some of the routine procedures to mid-level clinicians so that dentists can focus on more medically challenging work.

It is a way to "expand the efficiency of the dental team," said Dr. Sheldon Natkin, a West Haven dentist who is on the committee.

Each of these proposals could address what many in public health feel is a major crisis in dentistry in the state and nationwide: the lack of access to dental care for the poor. A more efficient dental team in a clinic, for instance, could see more patients. And dental grads who pursue the post-graduate year will gain experience in hospital, school and neighborhood clinics with low-income patients and with individuals who have special needs, such as the elderly and the mentally or physically disabled.

"If you have experience in working in community health centers, you're more apt to volunteer or work as a part-time employee for them," said Dr. Peter Robinson, dean of the UConn dental school and a member of the committee, adding that he hoped that graduates trained in this way would create a "blended practice" that includes both for-profit dentistry and volunteering in dental clinics. He said that making it easier for skilled, foreign-trained dentists makes more dentist chairs available to state residents.

Robinson said that dentists from Peru, for example, may be more likely to serve Connecticut's Peruvian population.

Committee members were charged with making changes to the practice of dentistry in the state. Dealing with Medicaid was not on the table, although increasing Medicaid reimbursement is widely seen as a key to improving access to low-income residents.

Robert Slate, executive director of the Hartford-based Connecticut Oral Health Initiative and a member of the committee, said that less than 10 percent of the state's 3,120 dentists accept Medicaid patients because the reimbursements cover less than 20 percent of a dentist's costs. In 2000, attorneys for Connecticut Legal Services and Greater Hartford Legal Aid filed a class-action lawsuit against the state to improve dental care for Medicaid recipients.

Sen. Christopher Murphy, D-Southington, co-chairman of the legislature's public health committee, which will review the report beginning next month, said that some of the proposed changes seemed worthwhile, but that they're not going to dramatically improve dental health care for low-income residents.

"In terms of solving the access crisis in dentistry, this is playing around the edges," he said. "We're never going to get real dental care for poor people unless we increase the rates we're giving to dentists."