The Legalization of Denturism: a Fight Led By Few
Posted Apr 28, 2011 in Management
Denturism is now legal in six states: Arizona, Idaho, Maine, Montana, Oregon and Washington--and denturists say more legislation is right around the corner. Read on to learn how they did it and if your state may be next.
Since it was first legalized in the United States in 1977, denturism has evolved from an unregulated movement of technicians--whom many considered to be renegades--into a more widely accepted, reputable profession. In their quest to expand patient access to affordable, quality dentures by servicing the public directly, denturists have fought long, hard battles at the grass-roots level. Despite limited manpower and financial resources, they've successfully taken on the powerful, wealthy lobbying efforts of opposing dental associations and made significant--albeit slow--legislative and professional inroads in the last 27 years.
Denturism is legal in Arizona, Idaho, Maine, Montana, Oregon and Washington click here for chart, Denturism: legal in Arizona, Idaho, Maine, Montana, Oregon and Washington. While it hasn't been legislated in Colorado, there is a formal agreement that allows denturists to practice under the direct supervision of a dentist. There are approximately 400 licensed denturists practicing in these states and they work directly with the public to perform the entire restorative procedure, from taking impressions and fabricating the appliance to seating the final restoration. They are also paid directly by the patient or, in some states, by the patient's dental insurance company.
With six states under their belts, denturists continue to actively pursue legislation to both change existing laws and legalize the profession in additional states. For example, the original legislation in Oregon only allowed denturists to offer complete upper and lower dentures, relines and repairs. To expand the scope of its practices to include all removable prosthetics, the Oregon State Denturist Association (OSDA) formed a Political Action Committee, Citizens for Affordable Denture Care, and took the issue to the Oregon public. A coalition effort of the OSDA and senior and consumer organizations, the PAC raised $225,000--much of which came from denturists who took out business loans and second mortgages on their homes--for radio and newspaper advertising to raise consumer awareness of denturism. The campaign worked: in 2002, Ballot Measure 24 was passed by a 76% to 24% vote, giving denturists the right to offer complete dentures, partials and implant-retained dentures.
Similar efforts are being made in Maine where denturists also want to expand their scope of practice and change their oversight board. Currently, they fall under the auspices of the Maine State Board of Dental Examiners comprised of five dentists, one denturist, one dental hygienist and one lay person. "Given the ratio of dentists to denturists on the board, it's difficult to make changes. We'd like a board that offers a more level playing field so we can have more impact," says Austin Carbone, Jetport Denture Center, South Portland, Maine, who is the president of the National Denturist Association (NDA).
Legislation is currently in various forms of development in California, Massachusetts, Minnesota and Pennsylvania. For example, in Massachusetts Bill #2961 is being reviewed by the House Healthcare Committee in preparation for sending it to the state legislature later this year. The bill--initiated by Ron Fine, a licensed denturist in York, Maine, who also has a home in Massachusetts--proposes two types of licenses: Limited Scope which covers complete dentures, denture relines and denture repair services and Full Scope which also includes partial denture services. The requirements outlined in the bill are similar to legislation passed in other states. Some of the stipulations include:
Five years of experience as a dental technician or a two-year dental technology degree.
Completion of--or current enrollment in--a curriculum that is approved by the American Denturist Society Council of Denturitry Education. It must include at least one post-secondary course in each of the following topics: head and neck anatomy and physiology, oral pathology, CDC guidelines for disinfection, clinical removable prosthodontics, temporomandibular joint disorders, principles of dental radiology, and ethics and jurisprudence.
Passing denturitry-board approved written and practical exams that are specific to the limited scope and full scope licenses.
At least six months of clinical practice under the supervision of a licensed denturist or a dentist.
Allies and adversaries
Denturists charge an average of 30 to 50% less than dentists and, because of the cost-effectiveness and specialized nature of their services, the dental consumer has been denturism's greatest ally. This is why public initiatives and referendums have typically been the more successful route to legalizing denturism. "When the issue goes to the public, that's when it wins," says Paul Levasseur, Standish Denture Clinic, Standish, Maine, who is president of the International Federation of Denturists.
Dentists, on the other hand, have traditionally been denturism's greatest adversary and their opposition is the main reason legalization has been such a slow-paced process. They cite concerns for public safety, quality of care and limited training as reasons to block denturism legislation. However, denturists feel these concerns are unfounded, especially given the current state of removable prosthetic training in dental schools.
As dentistry has shifted its emphasis to crown and bridge and implants to treat the edentulous population, there's been a trend in dental schools to reduce and even eliminate removable prosthetic coursework from their curriculum. Because of this limited training--plus the allure and higher profitability of C&B--fewer and fewer dentists are offering dentures. "The average dentist has 200 hours of experience with dentures whereas I have 4,000 hours. Dentists can't reasonably argue that they can provide better removable prosthetic care than I can. They don't have a leg to stand on," said Fine during his presentation at the Northeast Dental Technology Conference (NDTC) in Sturbridge, Massachusetts in April.
Another reason denturists are so determined to fight for their profession is the tremendous need to expand public access to cost-effective removable prosthetics, a need that according to industry analysts will only continue to grow. "The adult population in need of one or two complete dentures will increase from 33.6 million adults in 1991 to 37.9 million adults in 2020," writes Chester Douglass, DMD, PhD, in the January 2002 Journal of Prosthetic Dentistry article, "Will There Be a Need for Complete Dentures in the United States in 2020?"
From the denturist's perspective, this is a paradoxical situation. "Treating the edentulous population has become a serious national healthcare problem because of limited access and prohibitive costs to many patients, especially seniors and indigent people. Many dentists don't want to fabricate the dentures that the public so desperately needs and yet they have resisted giving control of removable services to denturists," said Ralph Dhuy, Ralph Dhuy Denture Arts, Medway, Maine, during his presentation at the NDTC.
However, this mindset is slowly changing, in part because of the more stringent educational requirements. "Years ago, denturists were licensed by grandfathering or mediocre testing procedures but now a diploma from a recognized college of denturism is required," says NDA President Carbone. "These curriculums offer a broad scientific background as well as real-life, clinical experience and competency that's superior to dentists' training."
The disparity of the situation--that the dental community is reducing its removable training as denturists are enhancing theirs--is becoming increasingly apparent to some dentists, including Dr. Carl Ebert, who has been a key player in trying to get denturism legalized in Minnesota. During his testimony before the Senate's health policy committee, he testified that "a denturist graduating from George Brown College in fact received far greater number of hours of both didactic and clinical instruction than dental students enrolled at the University of Minnesota's School of Dentistry."
Ebert works for Apple Tree Dental, which has clinics in Twin Cities and Hawley that provide services to low-income families and children, persons with disabilities and the elderly. Although he knew his stance in favor of denturism might be controversial among his peers, he felt compelled to support it because he's alarmed at the quality of care these populations have been receiving. The bill has not passed but a new version is being written and will be submitted to the next legislative session.
Dentists who've seen denturism in action and learned first-hand how it can create a win-win situation are also becoming advocates. For example, denturism was legalized in Washington in 1994 after a 15-year fight. "It was a turf war and many dentists took a very adversarial attitude," says Val Charron, Northwest Dental Services, Tacoma, Washington. "But after being legal for 10 years, there's a much greater acceptance of denturism. As our profession has brought the importance of routine dental care more into the public eye and as dentists and denturists have started working as a team--referring patients to each other for example--dentists' practices have grown as a result. There's a much greater sense of teamwork and compatibility." In fact, of the 120 licensed denturists in Washington, about 40 of them have dentists on staff.
Dhuy has seen a similar pattern in Maine. "Dentists were initially against denturism but now they're pleased that we're opening doors to patients that have been economically locked out and that we've taken away one of the most problematic services in the dental practice," he says.
Raising the bar
The denturist profession has come a long way. "When I was a kid, before denturism was legal in Washington, denturists worked out of their homes or garages. Now, we can put our names on the front door with pride. We've raised the bar. Being accepted as a licensed professional is phenomenal," says Charron, whose practice has grown from six to 13 employees in the past 10 years as a result of skyrocketing patient demand.
Looking ahead, they see a bright future. They're motivated by the face-to-face contact they have with their patients and the satisfaction of changing lives with quality dental care. They relish their independence from dentists and they're reaping the financial rewards as well. "Because demand is so great, it's possible to earn a six-figure income working two to three days a week," explains Dhuy.
Their long-term goal is to legalize denturism in every state and in doing so, continue to expand public access to their services. Some denturists would also like to establish reciprocity within the United States as well as Canada and Europe, meaning a denturist's license obtained in one state or country would be recognized and accepted everywhere. They look at the evolution of the medical profession and look forward to a time when the dental profession follows suit. "If you look at the history of medicine, physicians were given carte blanche; they handled everything. As they realized they couldn't do it all, complementary, support professions developed," explains Levasseur. "Just as this situation has worked well for the medical community, dentists and the government need to see how professional offshoots could benefit dentistry and--more importantly--the dental consumer."
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