A not for profit 501C3 Corporation

A Study of Denturitry

Directed by the

1998 General Assembly

Prepared by

Michael Greer

Ann Mayo Peck

Research Report No. 292

Legislative Research Commission

Frankfort, Kentucky

January 2000

Paid for from state funds.

Available in alternative form upon request

i

FOREWORD

The 1998 General Assembly enacted SB 65 relating to dentistry. As part of that legislation the Legislative Research Commission was directed to conduct a study of denturitry. This report is the result of that directive.

Michael Greer and Ann Mayo Peck prepared the report. Progress reports were made to the Interim Joint Committee on Licensing and Occupations in July and October of 1999, and findings and recommendations were submitted to the 2000 General Assembly.

Robert Sherman

Director

January 2000

ii

iii

TABLE OF CONTENTS

FOREWORD....................................................................................................................... i

TABLE OF CONTENTS............................................................................................................ ii

CHAPTER I. INTRODUCTION ....................................................................................... 1

Study Methodology .........................................................................................................1

CHAPTER II. EVOLUTION OF DENTAL PRACTICE ................................................. 3

Occupational Regulation..................................................................................................3

Dentistry.........................................................................................................................5

Denturitry.......................................................................................................................6

The Canadian Experience.................................................................................................7

CHAPTER III. DENTURITRY IN OTHER STATES ..................................................... 9

Authorization.................................................................................................................. 9

Supervision.................................................................................................................... 11

Oral Health Certificate................................................................................................... 11

Range of Services .......................................................................................................... 11

Type of Regulation ........................................................................................................ 12

Regulating Authority and Composition .......................................................................... 12

Required Training .......................................................................................................... 13

Continuing Education .................................................................................................... 13

Grandfather Clause ........................................................................................................ 13

Other States................................................................................................................... 14

CHAPTER IV. DENTURITRY IN KENTUCKY.................................................................... 15

Legislative History......................................................................................................... 15

Study Resolutions.......................................................................................................... 16

Current Kentucky Law .................................................................................................. 16

CHAPTER V. ECONOMIC ISSUES....................................................................................... 19

Overview....................................................................................................................... 19

Cost of Dentures............................................................................................................ 20

Insurance Coverage ....................................................................................................... 21

Government Savings...................................................................................................... 22

CHAPTER VI. PUBLIC HEALTH ISSUES............................................................................ 25

Overview....................................................................................................................... 26

Competency................................................................................................................... 26

Analysis of Risks ........................................................................................................... 27

Oral Health.................................................................................................................... 29

CHAPTER VII. POLICY OPTIONS .............................................................................. 33

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Summary....................................................................................................................... 33

Policy Options ............................................................................................................... 33

ENDNOTES.................................................................................................................... 37

BIBLIOGRAPHY........................................................................................................... 37

1

CHAPTER I

INTRODUCTION

There are over 50 million people in the United States who are missing all of their

permanent teeth, a condition known as edentulism.1 Most of these people have dentures or will receive dentures, but many do not. Those that are without dentures do not have them for a variety of reasons, but two primary reasons are availability of denture services and cost. In an effort to reduce cost and increase the supply of denture providers, six states and Canada have legalized "denturists," non-dentists who provide dentures directly to the public. Other states, including Kentucky, have attempted to recognize denturists but such efforts have failed. The 1998 Kentucky General Assembly enacted SB 65 which directed a study of the denturitry issue, and this report is the product of that study.

Study Methodology

This study provides information that may be useful in determining whether denturists

should be legally recognized and allowed to practice independently in Kentucky.

Occupational regulation invokes the police power of the state to restrict the people who

can perform certain functions, in order to protect the public health, safety, or welfare. To explore the impact on the public health of allowing denturists to practice, researchers for this study looked at the public health risks presented and at the actual incidence of public harm documented in other jurisdictions where the practice of denturitry is allowed. An extensive literature search was conducted via the internet. A particular effort was made to identify research conducted by organizations with no vested interest in dentistry or denturitry. Input was requested and received from various professional organizations representing proponents and opponents of denturitry.

Inquiries were made of officials from other states and Canada that recognize denturists. Some of the research reports referenced in this study are dated, but they are used as sources because no subsequent research was found to dispute or update the data.

Chapter II looks at the historical background and evolution of the practice of dentistry and the emergence of denturitry. In Chapter III, denturitry laws enacted in other states are examined, and Chapter IV covers past attempts to legalize denturists in Kentucky. Relevant economic issues are explored in Chapter V, and public health issues are covered in Chapter VI. The final chapter, Chapter VII, summarizes the issues and looks at policy options that are available to the 2000 General Assembly to address the matter.

3

CHAPTER II

EVOLUTION OF DENTAL PRACTICE

Occupational Regulation

The emergence and evolution of an occupational group follows a standard pattern

regardless of the nature of the occupation. (The term "occupation" is used generically in this study in reference to both occupational and professional groups.) Understanding this process may be helpful in understanding the denturitry issue. First, the need for the occupation must be recognized. Then, individuals who have demonstrated some ability in performing the activities, generally through experience, find themselves in demand. Next, a body of knowledge is created and formal education programs developed to prepare persons to engage in the occupation. Finally, the practitioners within the occupation organize and seek government sanctions to permit exclusively their group to engage in the occupation and to prevent others from doing so in order to protect the public.

Generally, the "scope of practice" for the occupation is defined in very broad terms. If the

occupational group is the first within its field to seek regulation, the scope of practice usually includes any activity that might fall within that field. A broad scope of practice is not problematic as long as practitioners can keep pace with the evolution of the occupation. Often, when knowledge grows to the point where a practitioner cannot keep pace with changes, two things can happen. First, specialists within the occupation may begin to emerge, and second, auxiliary personnel not members of the original occupation may begin to perform discreet sets of tasks within the established scope of practice. These are usually tasks that practitioners do not have time to perform, or do not desire to perform and they normally require less knowledge and/or skill. Preparation for these emerging, task-oriented groups is usually less stringent and often outside the formal education paradigm recognized by the regulated practitioners and specialists.

These new occupations are usually accepted and even encouraged by the original

practitioners if they meet a demand that the practitioners cannot meet, and if the original

practitioners retain control over the full "scope of practice." In many cases, the emerging group will ultimately want to practice independently which usually precipitates scope of practice disputes. There have been many long, hard-fought battles in most occupational fields for independent practice, and these will continue as long as occupations continue to evolve.

The practice of medicine is a good example of how this evolutionary process works.

Doctors have been practicing medicine since recorded time. An early doctor learned by

apprenticing with another doctor who had acquired the skills also by apprenticeship. Over the years a scientific body of knowledge developed which in turn led to the establishment of medical schools. It was not until the mid 1800's, however, that formally trained doctors organized to have states regulate the practice of medicine to keep untrained, incompetent persons from practicing. In regulating physicians, the scope of practice for medicine was defined broadly. The current definition of medicine in Kentucky law still reflects the breadth and depth of the scope of practice:

Practice of medicine and osteopathy means the diagnosis, treatment, or correction of any and all human conditions, ailments, diseases, injuries or infirmities by any and all means,

methods, devices, or instrumentalities. (emphasis added) [KRS 311.550]

Since the initial licensure of physicians, many ancillary medical occupations have emerged and each has had to define its scope of practice within the broad definition of medicine. These groups include podiatrists, chiropractors, optometrists, nurses, physician assistants, nurse practitioners, nurse anesthetists, nurse midwives, emergency medical technicians, and a burgeoning number of practitioners in behavioral medicine. Some of these have acquired the ability to practice independently, while others have not.

Dentistry

Dentistry itself is an occupation that has emerged from medicine even though the practice

of dentistry may indeed be as old as humanity. Cro-Magnon skulls show evidence of tooth decay, and the earliest recorded reference to oral disease is from an ancient Sumerian text that describes "tooth worms" as a cause of dental decay. As early as 700 BCE the Etruscans were able to make dental appliances. They consisted of wide bands of pure gold that were soldered together to fit over natural teeth and a substitute tooth made of ivory or bone inserted into place.2

[L1]

During the Renaissance in Europe, dentistry was not considered a separate area of

practice. It was the province of physicians and surgeons and remained so until the "Father of Dentistry," Pierre Fauchard, wrote a comprehensive work in the 18th century detailing the practice of dentistry. It was within this document, Le Chirugien Dentiste, that the term dentist was applied to those medical professionals that dealt almost exclusively with teeth. Fauchard wrote that surgeons did not wish to practice dentistry and that the technical training required to fill and replace teeth was not to their tastes.3 Dentistry then became a specialty of medicine.

During this period, medicine was self-regulated by professional associations that

functioned as guilds. The power of these groups to control the practice of medicine fluctuated with political and social circumstances. After the French Revolution, for example, controls over all medical professions were removed and anyone who wished to practice could do so. This resulted in egregious harm to the public, and Napoleon Bonaparte in 1802 imposed controls to resolve the problem including making the practice of dentistry in France a specialty of surgery.4

6

As in Europe, surgeons originally pulled teeth in the United States, but as medicine

evolved, most surgeons turned to other procedures while a few specialized in tooth extraction. In the mid-1800's, this latter group split from the physicians and surgeons and formed the practice of dentistry. By 1889, Charles Gordon organized a dental congress in the United States and during this time, porcelain dentures became available in America.5 The first government regulation of dentistry did not occur until the 1920's.

The scope of practice for dentists is therefore a sub-set of medicine and the overlap from

time to time still causes problems. For example, in 1998 the Tennessee Board of Dentistry promulgated a regulation allowing oral surgeons to perform elective cosmetic surgery. The rationale behind this move was that oral surgeons were trained in facial reconstructive surgery and therefore competent to perform these expanded functions. The Tennessee Medical Association objected and filed suit to stop implementation of the regulation on the grounds only a graduate of a medical school with a license to practice medicine was competent to perform plastic surgery.

Denturitry

With the continuing evolution of dentistry, dentists have gravitated more to procedures for saving and restoring natural teeth than pulling teeth and making dentures. Technological advancements have given dentists new methods and materials to fill, cap, and bond teeth, and even dental implants as an alternative to dentures. While retaining the production of dentures as part of the practice of dentistry, dentists began to delegate certain functions such as the actual fabrication of the dentures to trained specialists. As the population of this country aged and the need for dentures increased, the practice of denturitry emerged. The practice of denturitry involves taking impressions of the upper and lower jaws, fabricating the dentures to complement the patient's facial features, and fitting the fabricated denture in the patient's mouth. It also involves, in most states and foreign countries that recognize denturists, the examination of the oral cavity to determine that no abnormalities exist and the mouth is fit for dentures.

In other countries, notably Australia, Denmark, Finland, Iraq, Israel, and Switzerland,

dentures are legally available through the services of denturists. In Denmark, denturists were never prohibited from providing services directly to the public and were formally licensed in 1976.

According to the World Health Organization's Division of Non communicable Diseases/Oral Health, in 1987, 60% of the world's population age 65-74 were edentulous. In 1990-91, there were 800 licensed dental laboratory technicians registered worldwide and of that number 650 of them served the public as denturists.6

The Canadian Experience

Canada has legally recognized denturitry since denturists were licensed in British

Columbia in 1958.7 The first attempts at legislation to enable denturists to deal directly with the public came in 1955 but were limited in scope to the repair of broken dentures. Public sentiment was the driving force behind the legislation to legalize denturitry, led by consumer advocates with support from the media.8 Even before the consumer push for legislation in British Columbia, denturists were practicing illegally. This was accomplished by practicing without publicly advertising services, to avoid the charges of practicing dentistry without a license.

Other Canadian provinces shortly followed suit: Alberta, 1961; Manitoba, 1970; Quebec,

Nova Scotia, and Ontario, 1973; and New Brunswick, 1978.9 By 1979, there were only two provinces in Canada that prohibited denturist's services. The Denturist Association of Canada states that as of September 1999, denturists have been recognized by legislation in every jurisdiction in Canada except for Prince Edward Island. The dentists and denturists in Canada work closely together to provide denture services to the public. Thirteen percent (13%) of Canadian denturists' patients are referred by dentists, and the public has been generally supportive of denturitry.10

In the beginning of legalized denturitry in Canada, denturists were grandfathered in by

examination. This was done so that people who were trained and/or practiced denturitry prior to the enactment of the law could be licensed.11 This practice was discontinued in 1981. To be a certified denturist in Canada, applicants must now submit academic credentials and proof of graduation. In the academic year 1974-1975, the only education program for denturists was a five semester program at George Brown College of Applied Arts and Technology in Toronto. Today, there are five colleges of denturitry operating in Canada.12

9

CHAPTER III

DENTURITRY IN OTHER STATES

In the United States, dentures are still provided almost exclusively through dentists. Most dentists make impressions in their offices and then send them with instructions to a dental laboratory where a dental laboratory technician actually fabricates the dentures. A dental laboratory technician receives certification based upon training or practical experience in either a licensed dentist’s office or in a commercial dental laboratory, or by having a degree from a two year course of study. The dentist later fits the finished product but may send it back to the lab for further alterations. By contrast, denturists deal directly with the patient by making the impressions, fabricating the dentures, and providing alterations after the fittings.

There are six states that currently allow the practice of denturitry in the United States:

Arizona, Idaho, Maine, Montana, Oregon, and Washington. A breakdown of major provision of denturitry laws in these states contained in Table 1.

Authorization

Maine enacted the first denturitry law in 1977. Two states, Arizona and Oregon, followed

suit in 1978. Denturitry laws were then enacted in Idaho in 1982 and Montana in 1984. The

most recently enacted law was in Washington in 1994. In four of the six states that have enacted

denturitry laws, public initiative or referendum has been the medium through which it has been

accomplished, indicating a similar grass roots consumer support that drove the legalization in

Canada.

10

TABLE 1

STATE DENTURITRY LAWS*

ARIZONA IDAHO MAINE MONTANA OREGON WASHINGTON

Date

Authorized

1978 – Arizona

By Legislation

1982 – Idaho

By Initiative

1983 – Maine

By Legislation

1977

By Legislation

Amended 1994

1984 – Montana

By Initiative

1985

By Legislation

1978 – Oregon

By Initiative

1994 – Washington

By Initiative

1995

By Legislature

Required

Supervision

In dentist's office; under gen'l superv'n; initial & final

OK by dentist

None None None None None

Oral Health

Certificate

Required

No No Yes--by DDS

<30 days

No Yes--by MD or

DDS**

No

Range of

Services

Make/repair

full & partial

Make/repair

full; repair

partial only

Make/repair

full only

Make/repair

full & partial

Make/repair

full & partial

Make/repair

full & partial

Type of

Regulation

Certification Licensure Licensure Licensure Licensure Licensure

Regulating

Authority

Board of Dental

Examiners

Board of

Denturitry

Dental

Examiners

Dental Board State Advisory

Council on

Denture

Technology

Board of Denture

Technology

Composition

of Authority

6 dentists

2 hygienists

3 denturists

2 lay members

5 dentists

1 hygienist

1 lay member

6 dentists

1 denturist

1 hygienist

2 lay members

1 dentist

4 denturists

2 lay members

1 dentist

4 denturists

2 lay members

Required

Training

2 yr degree

exam

2 yr degree

exam

2 yr internship

2 yr degree

exam

2 yr degree

exam

1 yr internship

2 yr degree

exam

2 yr internship

2 yr degree exam

Continuing Education Required

None 12 hrs/yr 20 hrs/2 yrs 36 hrs/3 yrs 30 hrs/3 yrs None

"Grandfather Clause” (original)

None 5 yrs experience 10 yrs experience; 5 years Practical experience

4,000 hrs Practical experience graduate of denturism program; exam

Number of Denturists

12 29 15 13 130 103

* Statute analysis and table preparation completed by LRC staff.

** No oral health certificate required if the denturist has completed additional training in oral pathology

11

Supervision

Only one state that has legalized denturitry requires supervision by a dentist. In Arizona,

the denturist must practice in a dentist's office under the general supervision of the dentist. The

dentist must give the initial okay for denture procedures to be done by the denturist and must give

the final authorization for the completed procedures. In the remaining states where denturitry is

legal, there is no requirement for any type of supervision of the denturist by a dentist.

Oral Health Certificate

Maine and Oregon both require that a patient present an oral health certificate obtained

from a dentist or a physician to the denturist before the denturist can provide services to the

patient. Generally an oral health certificate is valid for one year from the examination date. In

Maine, a patient must have an oral examination by a dentist within thirty days of using the services

of a denturist. Oregon requires that patients have an oral examination by a dentist or a physician

before denture services are obtained through a denturist. However, if a denturist has proof of

additional training in oral pathology, the oral health certificate requirement does not apply. The

supervision requirement in Arizona makes the requirement of an oral health certificate redundant,

but the remaining states of Idaho, Montana and Washington have no oral health certificate

requirement.

Range of Services

Four states--Arizona, Montana, Oregon, and Washington--have the same requirements for

the types of services that a denturist can provide to the public. They all allow for the construction

and repair of full and partial dentures. In Idaho, the denturist can make and repair full dentures,

12

but may only repair partials. In Maine, the statutory definition of the practice of denturitry allows

the denturist to make and repair full dentures only.

Type of Regulation

Arizona is the only state that certifies denturists rather than licensing them. However, the

term certification used in the Arizona statutes may be misleading since denturists are specifically

told that to practice their trade they must be certified; hence the model becomes in actuality a

licensing model. In all the remaining states that have legalized the practice of denturitry, the

regulatory model used is licensing.

Regulating Authority and Composition

In Arizona the regulating authority is the State Dental Board composed of six dentists,

two dental hygienists, and three lay members. Idaho has a Board of Denturitry composed of three

denturists and two lay members. Maine is regulated by the Dental Examiners Board consisting of

five dentists, one dental hygienist, and one lay member. In Montana denturists operate under the

auspices of the Dental Board, which consists of six dentists, one denturist, one dental hygienist,

and two lay members. Oregon has a State Advisory Council on Denture Technology as the

regulatory authority. It consists of one dentist, four denturists, and two lay members.

Washington has a Board of Denture Technology comprised of one dentist, four denturists, and

two lay members.

There is some disparity between the memberships of the boards regulating the practice of

denturitry in the states where the practice is legal. Arizona and Maine have no denturists as board

members but include dental hygienists, and Idaho operates the Board of Denturitry without the

benefit of dentist members or dental hygienist members. All boards include lay members.

13

Required Training

The educational requirements for licensing are fairly consistent throughout the six states

where denturitry is a legal practice. All six states require a minimum of a two year degree plus an

examination for licensing or certification. In addition to those requirements, Idaho and Oregon

require a two year internship with a licensed denturist and Montana requires a one year internship.

Continuing Education

Arizona and Washington are the only states that do not require continuing education for

denturists. Idaho requires proof of 12 hours of continuing education each year. Maine requires

proof of twenty hours of continuing education every two years. Montana denturists must have 36

hours of continuing education within a three year period and Oregon requires denturists to show

proof of 30 hours within three years. Thus, Idaho and Montana have the highest continuing

education requirements of all six states where denturitry is a legalized practice.

Grandfather Clause

Five states allow for the grandfathering in of denturists. Arizona is the only state with no

provision for grandfathering. Idaho requires five years experience. Maine allows denturists to be

licensed with ten years experience. Montana requires five years practical experience. Oregon

requires 4,000 hours and Washington requires graduation from a formal "denturism program" and

successfully passing a board-approved written and clinical examination.

14

Other States

In addition to these six states, there are other states that have provisions for various

auxiliary dental personnel to perform denture related functions. In Colorado, current law

provides that certain tasks related to denturitry may be performed by auxiliary personnel under the

dentist's direct supervision; that is, the dentist must authorize the procedures but need not be

present on the premises while the procedures are performed. Furthermore, the dentist must

certify the oral fitness of the patient before the auxiliary personnel proceed with any work

pertaining to dentures. (Colo. Rev. Stat. sec.12-35-109, 1999)

The state of Florida allows dentists to delegate the task of taking preliminary impressions

to auxiliary personnel, but the final impressions and any other denture fitting procedures are

reserved for the dentist.13 In 1996, Florida introduced legislation to legitimize and regulate the

practice of denturitry in that state. Although it was placed on the calendar, the bill died when the

legislature adjourned without taking action 14

Other states have tried to legalize denturitry and have failed in those attempts. Most

recently, Mississippi introduced legislation to license denturists in the 1999 General Assembly.

The title of the introduced bill was the "Mississippi Freedom of Choice Dentures Act." This title

seems to reflect the trend in legislative attempts to legalize the profession of denturitry. This

attempt failed in committee.15

15

CHAPTER IV

DENTURITRY IN KENTUCKY

Legislative History

The first attempt to license denturists in Kentucky was HB 336, introduced in the 1978

General Assembly. While this bill did not pass, it marked the beginning of a twenty year period

during which unsuccessful attempts would be made to recognize denturists during each legislative

session. These attempts took the form of denturitry bills, denturitry amendments, and study

resolutions. Bills included HB 541 in 1980, HB 563 in 1982, SB 355 in 1986, HB 130 in 1988,

HB 421 in 1992, HB's 805 and 827 in 1994, HB 86 in 1996, and HB 182 in 1998. These bills

ranged from the establishment of a comprehensive regulatory process to license denturists to very

brief, simple bills which merely defined denturitry and exempted it from the practice of dentistry.

All of these bills failed, as did amendment attempts.

In 1986 Senate Bill 46, a bill to license professional geologists, passed both houses with

the house committee substitute. The committee substitute created a new section of KRS Chapter

411 which prohibited a person from being prosecuted or enjoined from performing acts he or she

is authorized to perform, even if the acts are included in the practice of another profession.

Denturitry opponents realized that this provision could be interpreted as indirectly authorizing

denturitry, or at the very least removing it from any enforcement jurisdiction. The opponents

prevailed on the Governor to veto the bill, and she did so, and the veto was not overridden.16

16

Study Resolutions

In addition to the attempts to license denturists, there have been several resolutions to

study the subject. House Concurrent Resolution 130, introduced in the 1988 session, directed the

Legislative Research Commission to "conduct a study of the practice of denturists and dental

laboratories and examine the merits and risks to the general public of them either to continue to be

regulated by the board of dentistry, to establish their own licensure board, or to be regulated in a

different manner." HCR 82 was introduced in the 1996 session directing the Interim Joint

Committee on Licensing and Occupations to conduct a similar study. Neither of these resolutions

passed, but the 1998 General Assembly enacted SB 65, which became the authority for this

study.17

Current Kentucky Law

Current Kentucky law specifically prohibits the practice of denturitry. Any person who:

..takes impressions of the human teeth or jaws to be used directly in

the fabrication of any intraoral appliance, or shall construct, supply,

reproduce or repair any prosthetic denture, bridge, artificial

restoration, appliance or other structure to be used or worn as a

substitute for natural teeth, except upon the written laboratory

procedure work order of a licensed dentist and constructed upon or

by the use of casts or models made from an impression taken by a

licensed dentist, or who shall advertise, offer, sell or deliver any

such substitute or the services rendered in the construction,

reproduction, supply or repair thereof to any person other than a

licensed dentist..." [KRS 313.010(2)]

is considered as "practicing dentistry."

In 1974, this statute was amended to include the definition of a dental laboratory

technician, substantially legitimizing the profession and providing for its regulation in the

17

Commonwealth. (1974 Acts ch. 303, sec. 1) In order to qualify for a certificate of authority from

the Board of Dentistry in Kentucky as a dental laboratory technician, one must complete two

years of training or acquire two years of practical experience in dental laboratory technology by

employment in either a dentist's office or commercial dental laboratory, or have a degree in dental

laboratory technology from an accredited school with a two year course of study.

Even though Kentucky law explicitly prohibits the practice of denturitry, denturists have

operated in Kentucky for more than twenty-five years and continue to operate. The Kentucky

Board of Dentistry has successfully prosecuted denturists for practicing dentistry without a

license. The more prominent denturists have continued to practice by employing a licensed

dentist to perform the denture functions still reserved for dentists. Other denturists continue to

operate illegally, and for this reason the total number of denturists in Kentucky is not known.

18

19

CHAPTER V

ECONOMIC ISSUES

Overview

Edentulism results from oral diseases, such as dental caries (cavities) and periodontal

disease. But edentulism also reflects attitudes toward oral health, availability and accessibility of

dental care, the prevailing standard of care, and availability of health insurance. 18 Other factors

that play a role in the prevalence of edentulism are education level, income, residency

(urban/rural), and age.

Age is a primary factor. In the United States, 23% of the population aged 65 to 74 is

edentulous and of the 75 or older group the rate climbs to nearly 27%. A recent poll of 46 states

conducted by the Centers for Disease Control and Prevention found that 44% of Kentuckians 65

or older were edentulous. Kentucky had the second highest rate, ranking behind only West

Virginia with 46%. Hawaii had the lowest rate at 13.9%. 19

The high incidence of edentulism in the 65 and older age range can be partially attributed

to the fact that preventative tooth loss measures now in place were not available to that age group

in their younger years. Also, a generally held misconception years ago was that tooth loss was an

inevitable consequence of the aging process, and dentists were more apt to remove teeth than to

restore them.20 The prevalence of edentulism among persons age 65 and over will probably

continue to decline in succeeding generations.21 However, the United States is an aging

population so the number of edentulous people in the 65 or older age range will likely rise in the

foreseeable future.22

20

Cost of Dentures

A Federal Trade Commission Report cites several issues to be addressed in researching

the unmet dental needs of the population. This report was drafted by the San Francisco office in

1978 and issued by the full commission in 1984. While it is more than 20 years old, it remains the

most comprehensive treatment of denturitry issues yet produced. Among the issues contained in

this report are certain barriers to obtaining denture care, and price is one of the primary barriers.

This report concludes that one of the major reasons for failure to obtain denture care is the high

cost of that care, especially for the elderly.23 Denturists believe that they can competently provide

dentures directly to the public for up to half the price charged by a dentist. Denturists maintain

that their overhead is lower than dental office practice overhead and that they do not sacrifice

quality to keep their prices low.

The effect of the legalization of denturitry upon the cost of dentures to the public can be

reviewed in the light of the Canadian experience, since denturitry has been legal in that country for

a little over 40 years. Although the cost of dental services responds to overall inflation, the

consumer in Canada continues to realize approximately a 50 percent savings in the cost of

dentures from a denturist as compared to the cost from a dentist.24

Another example of economic impact is seen in the state of Oregon, where a review of

dental insurance data shows that the costs of dentures, which had been rising at the same rate as

other dental services, had a much lower rate of increase after passage of the denturitry initiative.25

A study conducted in the State of Michigan by the Office of Health and Medical Affairs

found that after comparing the cost of obtaining dentures from a denturist in Oregon, Idaho, and

Canada with the cost of obtaining dentures from a dentist in Michigan, dentures obtained from a

denturist cost about half of those provided by a dentist in that state. This study also notes that the

21

evidence that denturists provide dentures at a lower cost is important when the "side effects" of

state regulation of dental personnel and dental care are considered such as the issue of dentist

supervision and dental auxiliary personnel:

Dr. John E. Kuchman, an associate professor at the University of

California at Davis and a consultant on dental care economics to the

Federal Trade Commission, has examined the implications of

denturist competition. Dr. Kushman's research found that

denturists offer lower prices and concludes that 'the economic

advantages of introducing competition are great, and significant

impairments in quality would be required to offset them.' Dr.

Kushman notes that such impairments in quality have not been

documented. He dismisses denturists working under the

supervision of a dentist as not providing the greatest consumer

benefit, since the denturist can be considered another office dental

auxiliary.26

Insurance Coverage

The Centers for Disease Control and Prevention found that in 1997 edentulism was more

prevalent among those persons without dental insurance (27.0%) than among those who had

dental insurance (18.3%).27 In a note to the study by the Center for Disease Control and

Prevention the editor states:

...the higher prevalence of total tooth loss among persons without

dental insurance than among those with dental insurance may, in

part, result from reduced use of preventive and restorative dental

services. however, dental insurance in the Untied States is almost

entirely employment-based, and Medicare does not cover most

dental procedures; therefore, relatively few persons aged >65 years

have dental insurance.28

A special commission of the American Dental Association also noted that : "there are

members of the edentulous public who have gained only limited access or no access to the denture

22

care they desire or need. The cost of denture care places this health service beyond the reach of

many individuals of low and low-middle income."29

Opponents of legalized denturitry note that Kentucky has two dental schools and a

relatively good per capita rate of dentists in its urban areas. They maintain that the competitive

market already operates to keep down the price of dentures and that dentures also are available

through low-priced services and pro bono programs operated by dentists. Proponents argue that

any advantages gained by competition between dentists are nonexistent outside of the state's

largest cities. The FTC report notes that "while the emerging advertising of low-priced denture

services will have an important impact on the accessibility of denture care, it is likely to be

engaged in by too few dentists in too few locations to potentially reach the 13 million Americans

who presently have unmet needs for denture care."30

Government Savings

Obtaining dentures through the services of denturists could have an economic impact on

the state budget since under the current Medicaid program complete upper and lower dentures are

an allowable expense. [KRS 205.560(1)] A study by the state of Michigan found that in the fiscal

year 1983-84 Michigan Medicaid paid $4.1 million for upper and lower dentures. Even though

the projected cost for the fiscal year 1984-85 was $3.4 million due to reduced number of

Medicaid eligible people, the study indicates the overall savings to the state of Michigan could

amount to as much as $1 million if dentures were available through denturists.31

A study by the Washington State Health Coordinating Council of the bill to certify

denturists in that state shows that the Medicaid program in that state would be impacted by the

legalization of denturitry by a savings of up to 50% of Medicaid expenditures for dentures. "In

fiscal year 1985 the state purchased 5,694 complete dentures at a cost of $1,752,320. The state

23

paid $513,926 for partials, $14,267 for adjustments, $73,227 for repairs, and $204,798 for

duplicates."32 This made the Medicaid expenditures for Washington slightly over $2 million. The

study says that "Dealing directly with denturists and their laboratories could save the state close to

a million dollars per year."33

24

25

CHAPTER VI

PUBLIC HEALTH ISSUES

Overview

Advances in medical science and technology are allowing people to keep their natural

teeth longer. Fluoridated water supplies, fluoride in toothpaste, and fluoride treatments in schools

are examples of interventions that have been highly successful. There is even a vaccine in trial

stages that causes the body to produce high levels of an enzyme in saliva that destroys caries, the

bacteria that causes cavities.

But there is still that group of people who have not had the advantage of these

breakthroughs and who have lost or will lose their natural teeth. Some of these with sufficient

means can still benefit from modern medical advances such as dental implants, but the remainder

will need dentures if they are to realize a satisfactory quality of life.

Losing one's natural teeth can have a significant impact on both the physical and

psychological health of the edentulous person. People may face traumatic experiences when they

lose their teeth, such as rejection in the job market where personal appearance can be crucial in

obtaining employment. "Tooth loss is associated with advancing age. The loss of one's teeth can

precipitate an emotional crisis. The belief that tooth loss will result in a decrease of family love

and affection is widespread."34 In a report that charted behavioral changes in a six year period

after good dentures were obtained by a group of 64 patients of various ages, it was discovered

that obtaining dentures, "...has had an identifiable impact on the several behavioral variables for

which changes were predicted before the study began. There has been general improvement in

self-image, confidence, and relaxation...."35

26

While the cultural context of wearing dentures is cosmetic, there are some definite effects

on physical health as well, especially for the elderly edentulous. Their food choices may be

dictated by the fact that they have either no natural teeth or ill fitting dentures. Poor nutrition

may in turn result in a myriad of nutrition-related health problems. In addition, the simple

pleasure of eating may be diminished.

In regard to public health issues, opponents of denturitry maintain that if dentures are

provided directly by denturists, consumers may be injured by ill-fitting dentures, unsanitary

facilities will spread diseases, and the rate of edentulism will increase.36 These issues are explored

in the following sections.

Competency

Public health and safety are always the key issues in whether the denturitry should be

regulated at all. The first public health question is whether denturists are competent to perform

the functions they seek to perform. Opponents of denturitry claim "...denturists know nothing

about the practice of dentistry nor the treatment of patients and have no training in the provision

of health services."37 Proponents of denturitry maintain that they are competent by virtue of

either formal training or years of experience, some of which have been in a clinical setting with a

dentist, or both. Proponents further contend that the only way they can prove their competency is

to be given an opportunity to practice.

There is no formal training program for denturitry in Kentucky. Kentucky schools do

offer training in dental hygiene and dental assisting, and the Lexington Community College offers

a two-year program in dental lab technology. The absence of formal programs in denturitry is not

unusual, however, since Kentucky does not officially recognize denturists. Denturitry proponents

27

point out that there were no programs in Canada prior to the legalizing of denturitry, and now

there are five programs. For example, the George Brown College of Applied Arts and

Technology in Toronto, Canada offers a six semester degree program in denturitry that includes

on-campus classes as well as courses available through distance learning. The George Brown

program is flexible and will give credit for community college dental technology courses as well as

credit for actual practice experience.

Analysis of Risks

To fully understand the other public health issues with respect to denturitry, one must first

look at the functions involved in the practice of denturitry. There are four basic functions:

1. Examination of the oral cavity to determine suitability for dentures;

2. Making of impressions from which the dentures will be fabricated;

3. Fabrication of the dentures; and

4. Fitting and adjustment of the finished dentures.

What public health risks are involved in denturists performing these functions? The third

function, fabrication of dentures, does not involve patient contact so there is essentially no health

risk. In addition, it is a technical function that is currently performed by dental lab technicians and

denturists and, therefore, is not an issue.

The second function, making impressions, does involve patient contact and working in the

oral cavity. There is some risk of spreading infectious disease when performing this function

unless sanitation standards are applied and enforced. There does not appear, under normal

circumstances, to be any health risk related to the actual making of impressions. This is a

28

technical procedure that dentists currently are required to perform but frequently delegate to

auxiliary personnel.

Function four, the fitting and adjustment, does pose some public health risks. Opponents

contend that ill fitting dentures may lead to oral cancer and that only dentists are trained and

qualified to perform this function. Denturists argue that since they are the ones who actually

make the dentures, they are just as competent as dentists to fit and adjust them. They also

contend that the fit is usually better because the fitting is done where the dentures are made and

adjustments can be made immediately, saving the patient time and money.

There is also a potential health risk posed by a denturist performing the first function, the

initial examination of the oral cavity. Before dentures are made and fitted, an examination must

be conducted to determine that the oral cavity is fit to receive dentures. Teeth or pieces of teeth,

bone protrusions in the jaw or gums, and sores or lesions are examples of the abnormalities that

would make the oral cavity unfit for dentures. Dentists argue that their education and training

makes them the only group within the dental field competent to perform an oral examination.

Denturists counter that they are competent to perform this function through education and

experience. Some denturists have completed denturitry programs that cover mouth, neck, and

jaw pathology. Others claim that years of experience, including experience working with a

dentist, have prepared them to detect abnormalities. They say that they may not be able to

identify the specific pathology present but they are competent to detect abnormalities and will

make necessary referrals to dentists for proper treatment.

29

Oral Health

While there is some public health risk involved in the practice of denturitry, a review of the

actual documented incidence of public harm may be useful. There are three public health issues

that need to be examined:

1. The spread of infectious diseases through improper procedures or unsanitary facilities;

2. An increase in the incidence of oral cancer due to insufficient or improper diagnostic

screening; and

3. An increase in the incidence of oral cancer due to ill-fitting dentures.

With regard to the spread of infectious diseases, denturitry opponents point to incidents

where inspectors of the Board of Dentistry have observed sanitation violations. In one case a

practitioner was observed not wearing latex gloves, and in another case an improper appliance

was used to sterilize molds for making impressions. Proponents contend that they observe

general sanitation standards and that the citations for violations have been infrequent and

relatively minor. They also point out that since denturists are not now regulated, they are not

always aware of specific sanitation protocols and they would not object to appropriate standards

and training being required of them. According to the FTC report, there has been no increase in

the spread of infectious disease attributable to the practice of denturitry in the United States or

Canada.38

The issue of regular diagnostic examinations for denture wearers is another issue that has

public health impact. An argument for opponents of denturitry is that the rate of undetected oral

cancer will rise with the legalization of denturitry. They state that patients using the services of a

denturist will not have proper access to diagnosis and treatment for oral cancers. Proponents of

denturitry maintain that with legalization, a higher level of oral health may actually be attained.

They reason that the more mouths that are seen by denturists, the more referrals they can make to

30

dentists of patients exhibiting potential pathological conditions and with this cooperative approach

help protect the public's oral health.

The final public health issue is the link between oral cancer and the practice of denturitry.

Opponents argue that legalizing denturists will result in more ill-fitting dentures and an increase in

oral cancer. The relationship of dentures to oral cancer is based on the hypothesis that chronic

physical irritation of the oral mucosa (caused by ill-fitting dentures) is a contributing factor in the

incidence of oral cancers.

A scientific study conducted in 1984 on denture wearing and oral cancer found no

evidence that denture wearing, even wearing ill fitting dentures, is a significant factor in oral

cancer.39 The study was conducted on 400 patients with oral carcinoma seen in the Oral Medicine

Clinic, University of California, San Francisco, between 1968 and 1982. This study included

recorded data on tumor site and stage, smoking habits, and dental/denture status. "When denture

and non denture wearers were compared, there was no apparent risk relationship in regard to

tobacco use, tumor state, or delay in diagnosis."40 This study also concluded that "denture

wearing in a population of oral cancer patients does not appear to be associated statistically with

an increased risk of the development of a malignancy."41 The study concludes that there is no

correlation between the wearing of dentures and any specific cancer sites. Furthermore, there is

no difference between denture wearers and control groups in the occurrence of oral cancer.42

Similar results have been observed in certain denturitry jurisdictions. In Alberta, Canada,

where denturitry has been legal since 1961, there was no increase in the rate of oral cancer over

the next 15 years.43 According to the FTC report, there has been no increase in the incidence of

oral cancer in the United States or Canada associated with the practice of denturitry.44 In

addition, anecdotal evidence indicates there is no significant difference in the rates of oral cancer

when comparing denturitry states that require a certificate of oral health with those that do not.

31

32

33

CHAPTER VII

POLICY OPTIONS

Summary

Denturitry is a technical occupation that has evolved from the practice of dentistry. Six

states, Canada, and most western European countries allow denturists to practice independently.

Attempts to legalize denturists in Kentucky have been made every legislative session since 1978,

but none have been successful. The concern expressed by opponents of denturitry is that

denturists are not sufficiently educated to practice independently and that allowing them to do so

would be harmful to the public health. Competency of denturists and standards of practice do

raise issues for consideration. Available research on the public health issues suggests that health

risks are minimal and the actual incidence of health problems is not significantly different between

states that allow denturists and states that do not. In regard to economic issues, there is some

evidence that legalizing denturists does increase the availability of denture services and reduce the

cost.

Policy Options

There are three basic policy options that might be considered by the 2000 General

Assembly. The first option is not to license denturists; the option that has been exercised by

previous General Assemblies whenever the issue has been before them. This option preserves the

status quo, which is that all denture work is performed as part of the practice of dentistry and

under the aegis of a dentist. The argument for this approach is that it protects the public from any

health risks that might be posed by the independent practice of denturists.

34

The argument against this option is that the public will not realize the benefits that the

denturitry proponents contend will be available. The cost of dentures will not decline. Dentures

will not be made for more edentulous citizens. And fewer citizens will have oral examinations,

possibly resulting in oral pathology going undetected. The major drawback to this argument,

however, is that the question of whether denturists are qualified to independently practice

denturitry is still not resolved and the issue will continue to arise regularly as a legislative issue.

The second option is to license denturists. The pros and cons of this option are obviously

the reverse of those of the first option. Arguments for licensing would be that more denture

services would be available. The cost of dentures would decline and more oral pathology would

be detected and patients referred to a dentist. The argument against licensing is that the public

could be exposed to a greater health risk.

The third option would be to establish a "pilot project" through which qualified denturists

would be licensed for a set period of time and would be allowed to practice under controlled and

monitored circumstances. This option would allow denturists to prove their competence but at

the same time provide public protections to minimize any potential health risks. To assure a

successful outcome, the pilot project would need to be carefully structured. Practice standards,

including sanitation standards, would need to be established, and denturists would need to report

regularly on their activities. A complaint process would need to be put into place and complaints

investigated.

An oversight committee would need to be created to work with the Board of Dentistry to

monitor the pilot project. The oversight committee membership should reflect equal

representation of dentists and denturists, but should also contain persons not aligned with either

group to give representation to consumer interests and provide objectivity.

35

Denturists contend that they are sufficiently trained and competent to practice

independently. Opponents contend they are not. The pilot project approach would provide the

opportunity for denturists to prove their claim, but to do so under controlled circumstances

designed to protect the public. With a pilot project in place and operating for a period of three to

six years, sufficient objective data should be generated to allow a future General Assembly to

make an informed decision on permanent licensure.

36

37

ENDNOTES

1DDS-Online, "Mandibular Edentulism,", accessed 2 February, 1999, identifier, ddsonline.

com/fslide1.htm.

2Vilma Grobler, "The History of Dentistry 1652-1900," (unpublished masters thesis, Faculty of

Arts, University of Pretoria, 1974), p.9.

3Grobler, p. 21.

4Grobler, p. 21.

5Grobler, p. 23.

6World Health Organization, Division of Non Communicable Diseases/Oral Health, WHO

Collaborating Centre, Malmo University, Sweden, 1999, p.1.

7M.I. MacEntee, "Denturists and Oral Health in the Aged," The Journal of Prosthetic Dentistry

(1994), 193.

8MacEntee, p. 193.

9David I. Rosenstein, Lireka P. Joseph, Leslie J. Mackenzie, and Ron Wyden, "Professional

Encroachment: A Comparison of the Emergence of Denturists in Canada and Oregon,"

American Journal of Public Health, 70:6 (1980), 616.

10Herbert M. Hazelkorn and Tom Christoffel, "Denturism's Challenge to the Licensure System,"

Journal of Public Health Safety, 5:1, (1984), 108.

11State of Michigan, Independent Practice for Denturists: A Way to Provide Safe Dentures At a

Lower Cost to Consumers, Office of Health and Medical Affairs: Department of

Management and Budget, 1985, p. 4.

12George Brown College of Applied Arts and Technology, Profile-Facilities and Services, 1999,

database online. Available from Schoolfinder.com.

13Federal Trade Commission, :"The Sale of Complete Dentures: Effects of Present & Alternative

Regulations," 1980, p. 28.

14Federal Trade Commission, p. 28.

38

15State of Mississippi, 1999 Regular Session, Senate Bill 2788 (database online), accessed 7

October, 1999, identifier, billstatus.ls.state.ms.us/1999/pdf/history/SB/SB2788.

16Legislative Record, Summary of Kentucky Legislative Activities, Final Action, Legislative

Research Commission, 23:85 (1986).

17Legislative Record, Summary of Kentucky Legislative Activities, Final Action, Legislative

Research Commission , 23:95 (1998).

18Centers for Disease Control and Prevention, "Total Tooth Loss Among Persons Aged >65

Years - Selected States," Journal of the American Medical Association, 280:14 (1999),

1264.

19Centers for Disease Control and Prevention, p. 1265.

20Columbia Education online/Dental Education, "Common Oral Health Problems of the Elderly,"

accessed 25 February, 1999, identifier,

cpmcnet.columbia.edu/dept/dental/Dental_Educational_S.

21Centers for Disease Control and Prevention, p. 1265.

22Federal Trade Commission, p. 2.

23Federal Trade Commission, p.

24Rosenstein, et al. "Professional Encroachment...," p. 616.

25David I. Rosenstein, G. Empey, G.T. Chiodo, and D. Phillips, "The Effects of Denturism on

Denture Prices," American Journal of Public Health, .75:6, (1985), 671.

26State of Michigan, p. 10.

27Centers for Disease Control and Prevention, p. 1265.

28Centers for Disease Control and Prevention, p. 1265.

29Hazelkorn, p. 111.

30Federal Trade Commission, p. 11.

31State of Michigan, p. 8.

32State of Washington, Staff Analysis of Bill to Certify Denturists, State Health Coordinating

Council: Department of Social and Health Services, 1986, p. 14.

39

33State of Washington, p. 14.

34Federal Trade Commission, p. 17.

35Federal Trade Commission, p. 18.

36Federal Trade Commission, p. 57.

37Theodore, Logan, D.D.S., "Denturism: What went Right in Kentucky," Dental Management,

19:6 (1998), 50.

38Federal Trade Commission, p. 83.

39Meir Gorsky, D.M.D., and Sol Silverman, Jr., M.A., D.D.S., "Denture wearing and oral cancer,"

Journal of Prosthetic Dentistry, 52:2 (1984), 166.

40Gorsky, p. 165.

41Gorsky, p. 166.

42Gorsky, p. 166.

43Federal Trade Commission, p. 14.

44Federal Trade Commission, p. 14.

40

41

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