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Veterinary regulators poised to define parameters of lay dentistry

Stakeholders across America watch as Texas takes on controversial issue


September 9, 2010
By: Jennifer Fiala
For The VIN News Service


Texas is ground zero in a battle between lay dentists and the veterinarians who want to stop or at least regulate the unlicensed practice of equine dentistry.

The conflict, raging via lawsuits and in the court of public opinion, is destined to reach a pinnacle tomorrow when the Texas State Board of Veterinary Medical Examiners (TSBVME) decides whether to amend the definition of veterinary practice in Texas to focus specifically on the floating of teeth. Right now, the state’s licensing act defines dentistry to be within the purview of a licensed veterinarian — a classification that Texas authorities insist has always covered teeth floating but lay dentists have been able to skirt the law due to a lack of oversight and its broad nature.

The proposed regulation would allow lay practitioners to manually float teeth using hand tools only, leaving all other means of dental care including the use of power tools under the scope of a licensed veterinarian. The advent of motorized tools such as electric drills have brought with them a need to sedate animals, and that involves drugs that require a medical license to purchase and prescribe.

Sedation by those without a medical license is illegal in Texas.

“It’s now the standard of care for a veterinarian to sedate the animal so you can do a proper visualization of the mouth and perform proper dental work. That’s what the profession has evolved to in 2010, and the regulations should reflect that,” explains Dewey Helmcamp III, a lawyer and TSBVME executive director.

Lay dentists and those who support them vehemently disagree that the job should be restricted to veterinarians. Non-veterinarian teeth floaters have been around for decades, touting varying degrees of skill using manual and power tools, with or without the support of drugs to anesthetize or sedate equine patients. The process involves filing the molars to smooth or contour them, and short courses at various institutions teach aspiring lay dentists. Many supporters of the practice, including some veterinarians, believe that benignly rasping the points off a horse’s teeth should fall below the practice of veterinary medicine.

Despite diverse viewpoints, most agree that when it comes to lay dentistry there's a lot at stake and some big names at play. On the side of lay practitioners is the Institute for Justice, a civil liberties law firm, and perhaps even the Federal Trade Commission (FTC), which earlier this year began inquiries into the state board’s structure as well as its potentially conflicting dual roles as a regulatory body and an enforcement agency. The FTC's investigation, still open, also focuses whether the board's actions to curb lay dentistry violates the Sherman Antitrust Act — a federal statute designed to limit abusive monopolistic behavior in favor of competition.

Consumer demand — some of which is believed to stem from a lack of veterinarians performing the procedure — reportedly keeps the salaries of lay floaters in the range of six figures.

TSBVME officials say that the FTC met with them in January to get information on the makeup of the board, which has six veterinarians and three public members, as well as background concerning its stance on the lay practice of equine dentistry. The board hasn't heard from the FTC since.

Yet Helmcamp expects that the agency will be paying attention to Friday's decision. Veterinary regulators contend that lay floaters go beyond hand filing and often get access to sedation and anesthesia drugs from a small pool of DVMs or pharmaceutical companies that work with them.

In 2007, the TSBVME began its campaign to stop unlicensed equine dentistry and has since issued more than 30 cease and desist letters to lay floaters around the state. Regulators claimed it was a first step toward cracking down on the illegal practice of veterinary medicine in Texas.

With no state-supported certification process, regulated licensure or standardized testing and training to protect animals and their owners, officials in veterinary medicine consider the skills of lay floaters to be erratic. Lay floaters often claim professional titles such as "certified equine dentist" or "equine dental technician" based on their completion of a variety of dental programs not sanctioned by the American Veterinary Medical Association (AVMA), such as the Academy of Equine Dentistry in Idaho or the Texas Institute of Equine Dentistry near Dallas. Some lay floaters are members of non-professional groups like the National Association of Equine Dentistry.

"I call it certification by indoctrination," says Dr. Lynn Caldwell, chairwoman of the American Association of Equine Practitioners' dentistry committee. "There are all sorts of proprietary schools that certify people and anoint them in two or three weeks."

But lay floaters make a similar argument about veterinarians. In response to veterinary medicine's move to curtail lay practice, unlicensed floaters have been fighting back by pushing for the formal deregulation of equine dentistry. Last month, they faced off with veterinarians at a rally and public hearing in Austin, where supporters of unlicensed practice likened the profession’s stance to war against “a small group of entrepreneurs.” Non-veterinarians schooled in the art of floating teeth believe that they are highly qualified to do the job compared with veterinarians who might receive little formal instruction in equine dentistry amid years of basic medical training.

“I’ve floated the teeth of more than 100,000 horses,” says Carl Mitz, who bills himself as an equine dental technician who's been floating the teeth of horses and cattle for 25 years. He claims to not use drugs for sedation. During the public hearing, Mitz demonstrated for the TSBVME his skills wielding the air-driven and motor-driven power devices designed to float teeth. Of the tools, he stated, “I know how to use them.”

Many veterinarians, in turn, argue that what lay floaters don't know is the medical care that goes hand-in-hand with dentistry, including teeth floating. They believe that a veterinarian's medical license provides the background needed to safely use sedation and anesthesia drugs, examine animals and perform dental care. The opposition to lay practice is rooted in a desire to protect the health and welfare of horses as well as horse-owning consumers from fraud; it is not merely an attempt to corner the equine dentistry market, leaders in the profession contend.

Dr. Lori Teller, a practitioner in Houston and president of the Texas Veterinary Medical Association (TVMA), shuns the notion that organized veterinary medicine is motivated by business rather than the health and safety of animals: “Our association’s position is the same as that of the American Association of Equine Practitioners: only veterinarians should be performing this. We’re willing to fight for these horses until the bitter end.”

Widespread estimates put Texas’ equine population at roughly a million. No one has a good read as to how many veterinarians actively float teeth, yet regulators believe that the manpower exists to provide the state’s horses with dental care. Numbers concerning lay dentists are equally vague. The nation’s largest trade association, the International Association of Equine Dentistry (IAED), reports just 300 members.

Some veterinarians, especially those who enable lay dentists to operate by providing them with sedatives and employing their services, believe that unlicensed dentistry has its place. Lay floating has proliferated for decades without much fanfare, supporters argue, and with 50 different states enforcing 50 different laws, it’s difficult to grasp the nuances of what constitutes legal practice.

Still, most of the veterinary profession argues that dentistry — including teeth floating — calls for medical training and education.

Dr. Stephen Galloway, an equine practitioner in Tennessee who once worked in the Texas Panhandle, is lobbying to start an equine specialty within the American Veterinary Dental College. He performs teeth floating procedures daily and describes it as “a service that should at least be done under the direct supervision of a veterinarian.”

“It seems everyone wants a piece of the animal health pie,” he contends.

There appears to be real truth in that statement. While the ultimate outcome for Texas veterinarians, horses and lay floaters remains uncertain, stakeholders expect the upshot to have a ripple effect nationally as other states deal with similar challenges to the scope of veterinary practice. Acupuncturists, physical therapists, chiropractors and massage therapists are known to illegally dabble in animal health care, arguing that they have more knowledge and training to perform their respective complementary and alternative modalities than average veterinarians.

Yet lay dentistry seems to trigger the most divisive debates with powerful arguments coming from the Institute for Justice, a group of civil rights litigators that have caught the public’s attention. On behalf of lay floaters, the firm has filed lawsuits in Texas and Minnesota that accuse state regulators of engaging in monopolistic behavior by limiting equine dentistry to veterinarians via a system likened to a state-run “cartel” that infringes on the rights of non-veterinarians to earn a living performing their craft.

The lawsuit in Texas makes two allegations: that attempts by the board to control unlicensed teeth floaters violates the state’s constitution and that regulators have not gone through proper channels to impose a crackdown on unlicensed practice. Filed in 2007, the case is being held in abeyance in anticipation of tomorrow's ruling by the TSBVME.

Meanwhile, Texas isn’t the only state grappling with the issue. Organized veterinary medicine scored a major win in 2008 when a Minnesota judge upheld the state’s veterinary regulations pertaining to teeth floating and dismissed the Institute for Justice’s allegations. More recently, Oklahoma became the latest state to feel the pressure of lay practitioners and the civil rights litigators who lobby on their behalf.

In 2009, a rodeo cowboy was arrested in Oklahoma for floating equine teeth, which was then a felony in the state. Earlier this spring, the battle between veterinarians and lay floaters intensified as lawmakers mulled creating a certification mechanism for “non-veterinary” dental providers. The measure, opposed by the Oklahoma Veterinary Medical Association, allows lay persons to perform teeth floating on horses and other livestock, defines equine dentistry as animal husbandry rather than veterinary medicine and removes animal husbandry from the state’s veterinary practice act.

Gov. Brad Henry signed the bill in April, which forced the Oklahoma State Board of Veterinary Medical Examiners to enact a certification mechanism to license lay floaters by Aug. 28. Now, lay floaters are permitted to practice if they provide the board with proof of either 80 hours of hands-on training in equine teeth floating at a recognized dentistry school and certification by a trade group. While state veterinary regulators are charged with issuing licenses to those who meet the requirements, the Oklahoma Department of Agriculture, Food and Forestry will enforce the law and address public complaints tied to lay dentists.

"The situation in Oklahoma is a disaster," says Galloway, who's co-authored published reports on unlicensed dental care for his colleagues.

Four equine veterinarians in Oklahoma apparently agree. In opposition to the bill, they took out newspaper advertisements claiming that if the measure passed, Oklahoma would be the first state to allow unlicensed floaters to possess drugs that could be used for abortions and date rapes. “Don’t let the drugs to treat her horse be the drugs used to rape her,” an advertisement in The Oklahoman stated. An accompanying graphic featured an unconscious woman on a horse.

The AVMA has expressed its opposition in a more customary fashion. A letter from AVMA CEO Dr. Ron DeHaven to Gov. Henry reads: “Veterinarians possess the knowledge necessary to administer the medications at the correct dosages, use the appropriate routes of administration, safely monitor animals while they are under the effects of the drugs, and immediately address potentially devastating or fatal side effects or adverse reactions.”

The AVMA’s stance allows for lay dentistry only by a trained veterinary health care worker as directed under the supervision of a licensed veterinarian and in accordance with state regulations. The AVMA’s policy, which merely serves as a guide with no regulatory teeth, is that veterinary dentistry is a function of veterinary practice and “includes the cleaning, adjustment, filing, extraction or repair of animals’ teeth and all other aspects of oral health care in animals.”

It requires “diagnosis and treatment, and, to be fully effective, demands extensive knowledge of anatomy, anesthesiology, pharmacology, physiology, pathology, radiology, neurology, medicine and surgery that is part of the graduate veterinarian’s training.”

Texas regulators will likely take the AVMA’s outlook into consideration. According to the AVMA, five states — Connecticut, Florida, Maryland, Oklahoma and Vermont — allow non-veterinarians to manually float teeth without a veterinarian’s supervision. Only in Oklahoma are lay floaters permitted to use power tools without any oversight by a DVM.

That hasn’t stopped Ron Johnson, a lay floater who advertises himself as an “equine dentist” in Tennessee. In an interview with the VIN News Service, he admitted to regularly using power tools and sedating animals.

“Veterinarians don’t know any more about floating a horse’s teeth than I know about flying a space shuttle,” he says. “There are as many people like me doing this as there are riders in a rodeo. I’m watching this case in Texas to see just what happens.”

Johnson says he gets his drugs from Dr. Ronald Baker, president and founder of Farmington Equine Services in Lewisburg. Baker did not return a request from the VIN News Service seeking more information.

Phone calls to two other veterinarians who reportedly work in a similar fashion with lay floaters also were not returned.

Galloway, also from Tennessee, says he's spent years watching what he believes is a “highly illegal” practice by non-veterinarians. "The use of sedatives by these people is unlawful, and the drugs are obtained through black-market sources," he says.

Regulators with the Tennessee Board of Veterinary Medical Examiners could not immediately be reached concerning Johnson's work with equines.

According to the TSBVME’s Helmcamp, the public in Texas has filed a handful of complaints against lay floaters, including one that involved a sedated horse that had to be euthanized as a result. But apart from issuing cease and desist orders, there isn’t much regulators can do to curb the practice of lay floaters because they do not have licenses at risk with the board. Not all state regulatory boards have the authority or financial means to enforce veterinary practice acts by prosecuting violators.

In Texas, some cases of unlicensed dentistry have been forwarded to the State Office of Administrative Hearings where the TSBVME has secured default judgments. “Then basically the next time we find them doing something, it becomes a violation of that order in a civil court of law. We can ask the Texas Attorney General to represent us and seek a civil penalty of up to $5,000 a day,” Helmcamp explains.

Though Helmcamp refutes it, insiders like the TVMA's Teller believe that the Texas Attorney General’s office is encouraging regulators to settle the issue amicably with lay floaters and deter any legal action by the FTC.

“The board is under a budgetary constraint,” she says. “It’s estimated that a lawsuit could cost approximately half a million dollars. Pressure has been put on them by the AG’s office to make the FTC go away.”

Helmcamp is among those who believe that collaboration between both sides is possible with the roles of lay practitioners clearly defined by the state.

"Personally, I think there should be a degree of cooperation between veterinarians and teeth floaters. It's what that relationship would look like that needs to be worked out," he says.
 




VIN News Service commentaries are opinion pieces presenting insights, personal experiences and/or perspectives on topical issues by members of the veterinary community. To submit a commentary for consideration, email news@vin.com.



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