The acronym KPIs has only drifted into view for many dentists with the recent imposition of the “PDS plus” contracts under the watchful eye of Dr Mike Warburton who is seeking to bring the same harmony to GDPs that he has to their medical colleagues.

A part of Peter Drucker’s philosophy of management by objectives, KPIs arrived along with the mantra “no management without measurement”. I firmly believe that there are certain basic parameters that must be measured and monitored in order that the performance of the business can be assured.

However, I know that measuring everything without regard for quality, the individuals involved and their understanding of the systems in which they work can lead to a target driven environment. This can rob the organisation of leadership, remove its flexibility and its ability to adapt to a changing environment.

So KPIs are important as a tool and a means to an end but not an end in themselves.

Figures highlight mounting expenses of dental practice warns BDA

New figures published by the NHS Information Centre today highlight the increasing expense of providing dental care, the British Dental Association (BDA) has warned. The Information Centre’s report, Dental Earnings and Expenses, England and Wales 2008/09, shows expenses borne by dental practices escalating at a faster rate than incomes were increasing during the period it details. It also highlights an increase in the average self-employed dentist’s taxable income of just £500 during the year.
The average taxable income for all self-employed primary care dentists in England and Wales in 2008/09 was £89,600, compared to £89,100 in 2007/08, according to the report.
The expenses borne by dentists – the costs of providing the building, equipment, staff and materials necessary to provide patient care – increased rapidly during 2008/09. Practice principals saw their expenses rocket by 7.6 per cent from £218,000 in 2007/08 to £235,500 in 2008/09.
John Milne, Chair of the BDA’s General Dental Practice Committee, said:
“These figures underline what the BDA knows from its own research and talking to members: that the costs associated with providing high street dentistry have risen dramatically. Changes in the exchange rate have had a pronounced impact on the costs of equipment imported from overseas and costs associated with compliance with a variety of regulatory requirements.
“Trends in expenses will need to be monitored carefully to ensure that dental practices are properly supported and are able to provide the resources they need to continue providing high-quality care to patients. The Doctors’ and Dentists’ Review Body will clearly need to consider the issue of expenses carefully this year and the BDA will be requesting it does so.”
Notes to editors
1. The report is available at: www.ic.nhs.uk/statistics-and-data-collections/primary-care/dentistry/dental-earnings-and-expenses-england-and-wales-2008-09

DDRB role on GDP pay in England suspended

The Doctors’ and Dentists’ Review Body (DDRB) will play no role in determining the remuneration of independent contractor general dental practitioners (GDPs) and general medical practitioners (GMPs) in England for the financial years 2011/12 and 2012/13, it has been announced. The decision has been taken in light of the current financial climate and the previously announced pay freeze that will affect public sectors workers earning over £21,000 a year.
Instead, the government will determine any gross uplift for GDPs and GMPs directly. It is understood that any uplift will be determined based on the efficiency assumptions government wishes to apply and evidence on non-staff expenses. The government has said it will enter into dialogue with relevant professional bodies about expenses. The BDA will be contacting the Government to take forward that dialogue.
At the time of writing, it is unclear whether the governments in Northern, Scotland and Wales will mirror the decision made by the administration at Westminster.
The announcement comes just days after an NHS information Centre report showing that the 2008/09 financial year witnessed an average 7.6 per cent increase in practice principals’ expenses across England and Wales.

www.medicalnewstoday.com/articles/196667.php

Pilots and dentists have more in common than one might think: Both jobs are highly technical and require teamwork. Both are subject to human error where small, individual mistakes may lead to catastrophe if not addressed early.

A dental professor at the University of Michigan and two pilot-dentists believe that implementing a checklist of safety procedures in dental offices similar to procedures used in airlines would drastically reduce human errors.

Crew Resource Management empowers team members to actively participate to enhance safety using forward thinking strategies, said Russell Taichman, U-M dentistry professor and director of the Scholars Program in Dental Leadership. Taichman co-authored the study, “Adaptation of airline crew resource management (CRM) principles to dentistry,” which will appear in the August issue of the Journal of the American Dental Association.

Airlines implemented CRM about 30 years ago after recognizing that most accidents resulted from human error, said co-author Harold Pinsky, a full-time airline pilot and practicing general dentist who did additional training at U-M dental school.

“Using checklists makes for a safer, more standardized routine of dental surgery in my practice,” said David Sarment, a third co-author on the paper. Sarment was on the U-M dental faculty full-time before leaving for private practice. He is also a pilot and was taught to fly by Pinsky.

CRM checklists in the dentist’s office represent a major culture shift that will be slow to catch on, but Pinsky thinks it’s inevitable.

“It’s about communication,” Pinsky said. “If I’m doing a restoration and my assistant sees saliva leaking, in the old days the assistant would think to themselves, ‘The doctor is king, he or she must know what’s going on.’” But if all team members have a CRM checklist, the assistant is empowered to tell the doctor if there is a problem. “Instead of the doctor saying, ‘Don’t ever embarrass me in front of a patient again,’ they’ll say, ‘Thanks for telling me.’”

At each of the five stages of the dental visit, the dental team is responsible for checking safety items off a codified list before proceeding. Pinsky said that while he expects each checklist to look different for each office, the important thing is to have the standards in place.

Studies show that CRM works. Six government studies of airlines using CRM suggest safety improvements as high as 46 percent. Another study involving six large corporate and military entities showed accidents decreased between 36-81 percent after implementing CRM. In surgical settings, use of checklists has reduced complications and deaths by 36 percent.

Many other industries: hospitals; emergency rooms; and nuclear plants look to the airline industry to help craft CRM programs, but dentistry hasn’t adopted CRM, said Pinsky.

For the next step, the co-authors hope to design a small clinical trial in the dental school to test CRM, Taichman said.

Source:
Laura Bailey
University of Michigan

www.medicalnewstoday.com/articles/196667.php

A Dentist’s View of Baghdad

Two recent stories from an Iraqi blogger provide an interesting snapshot of Baghdad as the city catches its breath.  He is a dentist who has a hard time practicing his profession because his clinic has no electricity.  Electricity is still minimal in most of Baghdad, and this is normal.  It is also normal for there to be endless traffic jams interrupted by checkpoints, manned by Iraqi soldiers who are often overwhelmed, as reported in this story from another Baghdad dentist.

Even with all of this, Dr. Mohammed runs into a different kind of inconvenience that he had not expected.  He goes for a bite to eat, only to find the corner store next to his clinic closed for renovations, paid for by the US Army.  In the big picture, the store is part of an on-going effort by the US military to rebuild Iraq, or at least lend a hand.  The overall impact of these projects is questionable, though there have been some prominent successes, such as the US-funded rebirth of Abu Nuwas street.  In Dr. Mohammed’s view, in a city where progress is often hard to see even a small step forward is a good thing.  The rebuilding projects create jobs, improve the neighborhood’s appearance, and indirectly reduce the chances of violence.

But as the local pharmacist describes the project to Dr. Mohammed, he becomes angry.  In his view, the Americans are paying for it with Iraq’s oil money, which they stole.   For him, nothing can overcome this perceived injustice, not even the fact that the supposedly stolen money is being re-invested where it can help Iraqi people.  Dr. Mohammed disagrees, but does not challenge the pharmacist’s main perception-that the US is stealing Iraqi oil.

The pharmacist’s information is wrong, of course.  Though there has been much talk of using Iraq’s oil revenues to fund reconstruction, the effort has been funded almost entirely by the US taxpayer so far.  In the meantime, the only oil production contract Iraq has signed since 2003 is with a Chinese company.  Overall there is very little evidence that the US as a whole has profited financially from its involvement in Iraq.  The perception, however, is difficult to defeat.  From an Iraqi perspective, for the US to occupy their country and not profit simply does not make sense.  They cannot see the powerful internal political forces which have mostly driven US decisions.  Perceptions like these make it hard for some Iraqis to accept successful US aid projects for what they are-help in a time of need.
In another entry the dentist shares some of his experiences as a patient, and his assessment that all is not well with the Iraqi health services.  Many clinics lack the basic equipment they need to help patients, and an almost impossible beauracracy prevents them from getting what they need.  More serious than these material shortages is the lack of good doctors, many of whom have fled or been killed.  These factors have created a dangerous situation where even a dentist has great trouble finding proper care for his infected tooth and his pregnant wife.  Dr. Mohammed’s prognosis for ordinary citizens in this system is not good.
These stories and others like them, while only snapshots, show a scarred city with many wounds left to heal.

LDC Conference chairman, Richard Emms received a standing ovation after his speech to the pre-Conference dinner. He called for consistency from Primary Care Trusts and honesty from the Department of Health. He called on the chief dental officer for England, Barry Cockcroft to trust the profession. ‘If our patients trust us to do the right thing why can’t the department, I think we’ve earned it’, he said.

“Distinguished guests, ladies and gentlemen. It is a great honour to stand before you this evening and to welcome you to this, the pre-conference dinner of the 59th Annual Conference of Local Dental Committees.

There is a mixture of emotions as I stand here, firstly pride… I’m proud to be on my home patch, very proud of the fact that you have elected me chair of this important body, and proud to be the third member of North Yorkshire Local Dental Committee to address you in this role, and I’d like to crave your indulgence to take this opportunity to thank two of my predecessors as conference chairs Stuart Robson and John Renshaw for the support and encouragement they have given me over the years since I joined the LDC as a fresh faced young pup almost twenty years ago.
As I look down and see John and Stuart’s name on this chain of office, it’s quite a humbling experience to read the other illustrious names of those that have gone before and to consider the contribution they have made to the profession, and the leadership that they have given.
The overwhelming emotion this evening however, is one of nervousness as one realises the fact that the audience at conference is traditionally, shall we say opinionated, and not one that will readily stand any bullshitting!
In recent years this seems to have been coupled with a predeliction for the ancient sport of chairbaiting, a situation that leads me to the feeling so quaintly described by Sir Alex Ferguson as teams approach the business end of the football season as, “squeaky bum time”.
And yet, and yet, I do feel a little more secure in having home advantage, as it were, and safe in the knowledge that I have played this venue previously, though it was a slightly different gig.
I appeared on the stage behind me here a few years ago in the Ripon Amateur Operatic Society’s 2002 production of Sound of Music so if things do go all a bit pear shaped this evening and I experience a Robert Green moment, I can always fall back on an impromptu Karaoke evening of such sing- along favourites as “How do you solve a problem like a Warburton contract” and that classic made popular by the PCTs “16 going on 17 pounds a UDA”
When you look around this magnificent auditorium you wouldn’t guess that when I was treading the boards up there as the Nazi butler of Captain Von Trapp, the building was close to being condemned, (unlike the performance I hasten to add). After 100 years the place was facing wrack and ruin, it was no longer fit for purpose. The Grand Circle behind you was unsafe, the roof leaked, and the dressing rooms, which are below us, were a hard hat area. A situation that was OK for the men playing the German soldiers, but it was hell for the nuns! I think we were the last company to perform here before it was closed for repair and refurbishment. After much thought and planning and several millions of pounds of investment, it was reopened last year and I’m sure you’ll agree it’s pretty impressive.
Around the same time I was elected to serve on the newly constituted GDPC where we soon began discussing another edifice that many thought was coming to the end of its usefulness, namely the old NHS contract.
Aha I hear the more astute and perhaps more sober members of the audience murmuring, he’s using the successful rebuilding of this auditorium as a metaphor for the reconstruction of NHS dentistry.
Would that I could. For while we began to put the foundations down for the new system, the plans suddenly changed and we were left with a structure vastly different from the one that had been envisaged. I’m sure you will remember those early days, Darrin Robinson, who was then with the Dept, was giving roadshows likening the new PDS system to a football match where we could stand on the sidelines to watch the early enthusiasts playing the game until we felt it was so good that we too were ready to participate.
You can picture the scene, the sun was always shining, the skies were blue, the grass was green, jumpers for goalposts, marvellous. Sadly just as we were all getting ready to join in, the park-keeper came along and not only moved our jumpers but told us all that from now on we would be playing a very different game.
Suddenly everything changed.

What is it with change – we’ve just been through an election campaign where two of the parties’ slogans, not surprisingly perhaps, focussed on change. Its true that we are not happy with things the way things are and that something needs to be done, but why do we have to have so much change, so quickly and so all consuming. The only constant seems to be keep changing.
Confession time. I’m a bit of a traditionalist; I’m comfortable with the familiar and quite like the status quo. I like old fashioned musicals, test cricket and the fact they still sing Abide with Me at the cup final. There’s a line in that hymn which seems appropriate for dentists at this time and in the situation in which we find ourselves, ‘Change and decay in all around I see”
Was it always so, – did we ever face such changes in our working lives in such a short period of time. I suppose it’s inevitable that at these sorts of events one looks back before looking forward.
When I qualified in the early eighties the only acronyms required were MOD, ELA and RCT plus the occasional, not politically correct, tongue in cheek ones that suggested perhaps that a condition was “normal for norfolk”. Any jargon we used was purely clinical, Mandibular, maxillary, extraction, oro-antral fistula.
In the new NHS it’s so much more complicated. If you wish to open a practice you contact the PCT with an EOI. They will then give you a PQQ before an ITT where you can consider the KPIs and the QOF after which, if you are successful, you will need to register with the CQC. One needs to look at the dashboard and check the metrics, observe the traffic light system and allocate to Red Amber or Green.
If you want advice, it’s a toss up whether you call the BDA or the RAC. We seem to be talking a different language these days where just like Humpty Dumpty in Alice in Wonderland words can mean anything they choose them to mean.
How can all practices have an average value? By its very definition some must be better and some must be worse. I must have treated thousands of patients but I don’t think I’ve ever seen an average patient; I’ve certainly never seen one and only provided the average of 1.4 restorations. To criticise a practice for not having an average return is about as sensible as castigating a PCT for not having all their workers of average intelligence.
Ask any clinician about quality and you will get a range of answers but I guess some would include the margins on a crown, the longevity of a restoration, or the radiographic appearance of a completed root filling.
What you wouldn’t hear amongst the answers would be the number of new patients seen, the presence of a swanky NHS logo or the percentage re-attending within nine months.
And at what point did nine become a magic number. How can only one interval from NICE Recall Guidelines be taken, Recall Guidelines remember, and then that be misinterpreted and the meaning changed and re-attendance pattern used as a measure of quality. I’m sorry, that’s not quality, that’s rationing.
And its not just recall intervals. We seem to have entered a world that wants to measure everything. We forget that very often the things that can be counted don’t count and the things that do count can’t be counted.
Real quality is any number of timeless classics, reassuring the patient, continuity of care, time spent in communication, a willingness to go the extra mile. Which box do I tick for that data set? We are facing a steady erosion of what we have traditionally recognised as professional responsibility, “doing the right thing when nobody is watching” as Susie Sanderson quoted at last years conference. An erosion of the discernment that our professional education and experience has brought us. Most practices that are not achieving their UDAs are not doing so because they are slacking but because they ARE being professional and, despite the system, are trying to do what’s best for their patients.
I qualified at the end of the paternalistic era, the era of doctor knows best and patients were expected to have done to them what the dentist felt was best for them. We moved through to the phase, quite rightly, of agreeing options with the patient and listening to their wishes.
It’s a great privilege to metaphorically take a patient by the hand (CRB and ISA checks permitting of course) and lead them through an agreed treatment plan, and it’s why patients stay with us because they trust us to inform them and to do the right thing.
But that’s going, its been replaced with a ‘PCT knows best’ mentality with their hard enforcement of clinical data sets without the knowledge of the circumstances of the patient sat in the chair in front of us. Where there is a greater concern with structures and process than care. We heard just a few days ago that there’s to be a public enquiry into last year’s tragic events in Mid-Staffordshire when the quest for target achievement became paramount and patient care suffered.
I think it’s Goodhart’s law that states that when a measure becomes a target it ceases to become a measure. So, in the target driven NHS, its starting to get somewhat soul destroying, and I’ve lost count of the number of colleagues who have said to me that they are glad that they are at the end of their careers and not at the beginning.
That’s a sad indictment on a system that, when it was being discussed back in 2004, was supposed to be good for patients, good for the department and good for dentists. It took a special skill to get it wrong on all counts. But what can we do –
We have a new coalition administration and I understand they want to focus on outcomes. Ok that’s fine, but it will require a deal of thought and work not only by GDPC but also by practitioners like those in this room, those who are at the tooth face, to come forward with suggestions so that appropriate outcomes can be determined and how they can best be evaluated.
And yes at the moment we have Steele with his recommendations on a new way of working, and it will be interesting to hear Jimmy again tomorrow, one year on, as to his take on the state of change, and I am sure that there will be strong opinions expressed from delegates on the direction of travel.
But is it enough, have we gone down the road we’d rather not journey, too far away from our practice independence toward micro management ever to return. Perhaps.

But its no good just moaning about it and throwing our hands up in despair. Some LDCs have not joined us this year as they feel that some of our meetings and conferences are pointless, we never change anything, and that it is just one big whinge fest. I’d like to hope that surely we could be more than that. Yes, things are now more locally and regionally focussed, and we are building a strong network of regional LDC groupings, but it is still centrally where the big decisions are made and it is only through national gatherings such as this that we can hope to influence policy.
In the film Network, Peter Finch plays a grizzled cynical anchorman in a US news station who eventually has had enough. He goes on air and announces to his audience that “I’m mad as hell and I’m not going to take it anymore” a mantra that is taken up by the viewing public.
Perhaps that’s what we need to do. We need to stop our whinge fest and say we’re mad as hell and we’re not going to take it anymore. We need to retake a hold on our professional lives and livelihoods and articulate our thoughts, and our concerns, to put forward our ideas for change because that surely is the function of this conference.
Where can we start. Flippantly, I could suggest at the very beginning. It may not be raindrops on roses or whiskers on kittens but perhaps I can share with you some of my favourite things!
How about some consistency from PCTs?
How can it be that using the same guidance, one PCT does one thing and another takes a contrary view? One willingly collecting LDC levies whilst another refuses. I’m all for local solutions, but for one PCT to say that practice transfers are not allowed whilst another encourages it is unfair, confusing for everyone and breeds uncertainty.
How about some honesty from the department? We might not like what you have to say but at least we would know where we stood.
· if you don’t like the idea of independent contractors – say so.
· if you want a service to be purely access driven – say so
· if you want limited treatments and a core service – say so
but please – don’t pretend to us or our patients that in the current climate you can provide all of the treatment, to all of the people, all of the time. That fools nobody.
And what about trust?When this place was a wreck and PDS was on the horizon, we were promised, don’t laugh, a high trust environment.The Chief Dental Officer believes we should have ‘earned autonomy’ in other words we should show that we can be trusted. Well I’m sorry Barry but we have been educated over many years to think, to diagnose and to treat on an individual basis. Yes we are mindful of the wider aspects of health care but our responsibility lies with the patient in front of us. Their needs and yes their demands are paramount.
If our patients trust us to do the right thing why can’t the department, I think we’ve earned it. So here we all are, gathered on the eve on conference. We come from the four corners of the country, from the North of Scotland, from Southern Cornwall, from East Anglia and from West Wales. We come to represent our constituents, their practices and their patients and it’s an opportunity to make known their feelings as to what is happening and to present our ideas for change, in a constructive fashion I hope, with knowledge and with passion. I hope we will have robust debate and by the close of conference have articulated not only the personal views of the delegates but of those we represent.
I started this evening with a theatrical allusion and I’d like to close with one. Towards the end of Howard Barker’s play Victory, which is set in the aftermath of the English Civil war and the restoration of the Monarchy, one of the characters has this line, he says; “You have nowhere to go to in the end but where you come from”
I hope that during the debates tomorrow you too will remember where you come from and what our purpose is. Enjoy the rest of the evening, I shall be able to now, and have a great conference. Thank You”

The latest NASDA survey in which Alan Suggett, partner in charge of the unw Dental Business Unit and editor of the quarterly survey, comments on the continuing rise in the goodwill value of dental practices.

NASDA goodwill survey reflects rising dental practice values

The goodwill value of dental practices continues to rise according to the figures gathered in the quarterly survey of deals and valuations by NASDA, the National Association of Specialist Dental Accountants. The average figure for both valuations and deals is now back near 100 per cent, the kind of level last seen before the recession struck in 2008.

Alan Suggett, a partner in unw LLP and the NASDA technical committee member responsible for gathering the figures, said that while the figures were snaking back up, the amounts achieved by dental practice vendors lacked consistency. It would be difficult to draw any conclusions on regional trends or on the merit of private versus NHS as an income source.

“As always,” he said, “this is very much a snapshot in time which reflects the general trend of the marketplace. The corporate chains are still buying, which helps keep dental practice values buoyant, although the big groups are more interested in NHS or mixed practices.”

The average goodwill valuations as a percentage of turnover during the quarter ended 30 April 2010 was 99.6%, while the percentage for actual deals done was slightly lower at 99.2%. This compares with valuations at 92% and deals at 86% in the last quarter of 2009 and a year ago, in the first quarter of 2009, the figures were as low as 71% and 75%.

If you would like to speak to Alan about the above or any other related matters, he can be contacted as follows:

Alan Suggett

Synchronicity strikes. There was A14 LUN priced at exactly the amount that I received for Dad’s Granada, so I did a quick “Well what about it Dad?” and, knowing that he would have enjoyed seeing a car with it, I went for it.

Yesterday morning I was driving through Knightsbridge on my way to the World Aesthetic Conference at the QE II Conference Centre when I let a BMW pull out from a side street. There in front of me was the dentist’s dream number plate – BDS 1. We crept along between traffic lights towards the restricted areas of central London (it was also the Changing of the Guard to celebrate the Queen’s birthday) for perhaps ten minutes. I was wondering whether I was going to follow BDS 1 to Westminster all the way to the Conference, presuming that it must belong to a dentist. I thought about the purchase cost & resale value, and whether there would be CGT to pay.

Eventually at Hyde Park Corner we went our separate ways and I was able to see there was a flag fluttering from the nearside wing. Flags on cars are not unusual at the moment, with World Cup fever around, but I didn’t recognise this one.

It was only when I got home that I realised that BDS 1 was the official car of the Barbadian Embassy – never presume.

Summary states:It is suggested that it makes sense for dentists providing care for individual patients to take account of caries risk (as assessed by presentation of active, non-cavitated lesions) when deciding how to allocate time and effort of themselves and their staff. However, there is a question as to how realistic it is to ask the dental team to provide a full diagnostic assessment and all the preventive treatment required for a patient for the payment provided by 1 UDA. It is to be hoped that one or more of the Steele pilots will come up with a practical solution for controlling caries in NHS practice.

One sentence towards the end sums up what most of the profession know about NHS dentistry in England & Wales: “It means that the whole UDA system is founded on something that is unattainable and therefore, we consider, unethical.”

These are three eminent dentists with between them decades of clinical practice and research. Where does that leave the main promoter of the current system, the Chief Dental Officer Barry Cockcroft whose career seems to have specialised in committee work and dental politics?

The new minister responsible for dentistry is Earl Howe it is known is against the fluoridation of the water supply.

Barry, on the other hand, said that fluoridation: “is the perfect public health measure because people with the greatest need benefit most and most people benefit to some degree”.

The Chief Medical Officer has gone already surely it’s time for Barry to consider his position, he’s got his gong, his pension is safe, unlike the committed NHS practice owners who have seen their businesses effectively stolen by HMG since 2006 under Barry’s watch.

Dentists’ group aims to limit midlevel providers
By Laird Harrison, Senior Editor, May 18, 2010

A new group of dentists from at least 15 U.S. states aims to put a stop to the spread of Alaska-style dental health aide therapists (DHATs) and similarly empowered midlevel providers.
“Each state must determine its own fate, but I submit to you that Texas is ready, willing, and able to slam the door and silence the drumbeat of non-professional providers performing irreversible procedures,” said Matthew Roberts, D.D.S., at a May 6 meeting of the Texas Dental Association (TDA) delegates.

Dr. Roberts, immediate past president of the TDA, convened the first meeting of what he calls the Austin Group (otherwise known as the States Strategy Conference) on March 4 and 6. Some 50 delegates from dentists’ groups in Alabama, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Louisiana, Mississippi, New Jersey, North Carolina, Pennsylvania, South Carolina, Texas, and Utah attended the meeting, according to Dr. Roberts. They drew up policy documents and planned to pressure the ADA to take a firm position on the issue, he said.

Asked in a DrBicuspid.com interview to define “irreversible procedures,” Dr. Roberts said he meant removing tissue from a patient’s mouth. He noted that he was not speaking for the TDA.

He said the Austin Group was concerned about dental care providers such as the Alaskan DHATs who, with two years of education after high school, are permitted under a federal mandate to extract teeth and place restorations in remote Alaskan villages. A new law in Minnesota also allows groups of midlevel providers to pull teeth and prep for restoration. Legislators and health advocates, including some dental groups, have proposed similar new licenses in other states, such as an advanced dental hygienist — a hygienist who, after additional training, could also extract teeth and place restorations.

The new U.S. healthcare reform bill passed into law March 22 provides funds to set up 15 pilot programs for midlevel providers in other states. The law also allows the DHATs now operating in Alaska to work in other states if authorized by state law and requested by an American Indian organization.

Debate over these provisions has split organized dentistry. The ADA, the Academy of General Dentistry, and five dental specialty organizations are opposed to licensing DHATs outside Alaska, while the American Association of Public Health Dentistry, the Association of State and Territorial Dental Directors, and several nonprofit advocacy groups have spoken out in its favor.

So how could a new group influence these trends? In his speech, Dr. Roberts said the Austin Group developed three policy statements asking for action from the ADA. He did not disclose any details of the statements, however, other than emphasizing that the ADA should maintain its current position on midlevel providers. He also told DrBicuspid.com he is not ready to release any details of the strategy his group is considering.

A spokesperson for the American Dental Hygienists’ Association said her organization had no comment on the Austin Group.

ADA meeting planned

In an interview with DrBicuspid.com, ADA President Ronald Tankersley, D.D.S., said he didn’t anticipate any change in the ADA’s position on midlevel providers. “Our position basically is that doctors should do treatment planning, oversight, and surgical procedures,” he said.

The Austin Group is not the only group of dentists pushing the ADA to take a hard line, he added. “I’m aware of these groups meeting outside the ADA umbrella,” he said. “That’s their right. Depending on the different states, we do have members who want to approach this in different ways. We would like to get them all under one roof to talk about their problems.”

To that end, the ADA is inviting dentists from around the country to its Chicago headquarters July 18 for a Conference on Workforce Issues. The invitation-only meeting will not set policy, however. An ADA House of Delegates resolution adopted last year specifically leaves workforce needs to the jurisdiction of the states.

“All dentists really want the same thing,” said Dr. Tankersley. “Almost all of us understand that the real tragedy is that 35% of the population is underserved, and we want to serve that population. But that doesn’t mean we have to violate the policies of the ADA to get there.”

The ADA lobbied unsuccessfully in the healthcare reform process to expand Medicaid dental benefits to adults and increase its reimbursements for dentists. Now, Dr. Tankersley said, the association is trying to build coalitions with other organizations to strengthen its future campaigns for similar goals.

“Depending on your particular strategy, you can set your sails differently, but we’re all heading for the same goal.”

Copyright © 2010 DrBicuspid.com

Related Reading
ADHA honors Minnesota senator for midlevel provider work

Midlevel providers: Is Washington next?

ADA questions Kellogg report on midlevel providers

Midlevel provider debate roils North Carolina

Wis. study calls for midlevel providers

THE MAKING OF THE AMERICAN MOUTH: DENTISTS AND PUBLIC HEALTH IN THE TWENTIETH CENTURYBy Alyssa Picard Piscataway (NJ): Rutgers University Press; 2008. 312 pp., $45.95

On 17 June 2007, Clark Hoyt, ombudsman for the public at the New York Times, wrote an entire column about a single image that had accompanied a story on immigration reform.1 At issue: An opponent of an immigration bill, William Murphy, who had been photographed sitting and smiling on his front steps, was clearly missing a tooth.
More than 1,200 readers had written to complain. They accused the Times of purposefully selecting the photo to demonize Murphy and, by implication, the entire anti-immigration reform movement. Others had written to say that they agreed with Murphy’s views, although they personally distanced themselves from him because of the photo.

Hoyt described the difficult decision editors faced in featuring that side of Murphy’s face. He was missing an eye on the other side and had asked the paper to photograph his “good side.” Murphy acknowledged that his appearance made people uncomfortable, regretting that readers focused on his appearance rather than the merits of his arguments.

But so it is in America. Good teeth signal social class and intellectual achievement here, as Alyssa Picard knows well. In The Making of the American Mouth, she provides an engaging history of the evolution of American dentistry, including the profession’s influence over our social norms and health policy. It’s a book that anyone keen to understand and improve our current national state of oral health ought to read.

Picard describes how dentists’ major goals—improving oral health and advancing professional status—first aligned in the early part of the twentieth century. But she also convincingly asserts that now dentistry as a profession largely has abandoned public health goals in favor of protecting its economic self-interest.

The book initially describes how dentists’ professional evolution of establishing education standards, adhering to science, and creating licensing closely tracked physicians’ evolution, although the dentists lagged their MD colleagues by more than a decade. Physicians did not consider oral maladies to be infectious diseases. They relegated the human mouth to dentists—a clinical separation that continues to the present day.

In the early 1900s, oral hygiene programs based in public schools established the foundation for modern dentistry with routine preventive tasks, female assistants, and regular visit schedules. Parents who could afford follow-up treatments took their children to private dental practices. Dentists actively promoted the connections between good oral health and American aspirations, particularly with poor immigrant children. From very early on, Americans learned to value dentists’ clinical authority and aesthetic prescriptions.

Publicly funded hygiene programs managed by dentists furthered their civic, professional, and entrepreneurial goals. Providing preventive services to children created a public good and advanced the profession’s stature. At the same time, dentists established a norm that instead of relying on government-funded programs, restorative care took place in private practices and was paid for by patients.

Picard details how dentists struggled with the nascent science of tooth decay. Some theorized that decay was an evolutionary process similar to humans’ losing our sagittal crest, the elevated bony ridge on the skull whose necessity withered as jaws reduced in size. Others hypothesized that decay was due to genetic degeneracy. In hindsight, the theory that processed food deleteriously affected teeth and health—first put forward in the 1910s—proved prescient.

America’s expansionist ambitions in the Philippines and elsewhere in these early years of the twentieth century took U.S. dentists overseas, and adopting American clinical standards and aesthetic norms became an index of successful cultural assimilation. At the same time, some U.S. expatriate dentists noted the excellent oral health of indigenous populations and challenged the need for “American” teeth.

As the book continues, Picard describes how dentists, like physicians, fought against government involvement and public insurance, insisting that private practices, supplemented by charity care, were sufficient. Schemes for “socialized” insurance promoted but never realized during the Depression would, they argued, cripple innovation, curtail liberty, and restrict profits.

Dentists achieved a major goal when they championed the addition of fluoride to drinking water in the 1950s, although battles with opponents, discomfort with government involvement, and the resulting loss of clinical work soured their appetite for other public health interventions. Although fluoridation is heralded as a major public health achievement, dentists ultimately perceived it as a threat to their practices.2

Medicare, Medicaid, the Civil Rights movement, and the women’s rights movement further threatened the profession with government encroachment and demands by black dentists and female hygienists for more respect. Picard maintains that dentists’ promoting individualism and the private marketplace, in lieu of government initiatives, masked a desire to maintain race, sex, and economic prerogatives of the mostly white, mostly male profession.

In response to these perceived threats, in the 1960s and 1970s dentists retreated from public health, redoubling their focus on revenues for and aesthetics in their practices, particularly orthodontia. Picard shines especially in Chapter 7 with her description of the phenomenon among hip-hop devotees of adorning teeth with gold “grills.” The practice serves to demonstrate wealth, while mocking the norm established by whites. Ironically, Picard notes, the only widely accepted practice of garish teeth adornment is orthodontia.

Picard’s book falls short in presenting the consequences of our nation’s aesthetic preoccupations and dentists’ abdication of the community good. In 2000 the U.S. surgeon general declared a “silent epidemic” of oral diseases affecting our most vulnerable citizens.3 The 30 percent of Americans not well served by the private-practice system are the poor, the institutionalized, those living in rural areas, and those burdened with several medical conditions.4 Despite growing evidence of the connection between oral health and overall health, the inventory of untreated diseases and inequities is long.

The sociologist Eliot Freidson challenged professions not to use their practice monopolies for selfish advantage.5 Picard’s book leaves the reader feeling that dentistry has failed this challenge during the past half-century. Picard presents a rather monolithic assessment of the profession, given the numerous subgroups within dentistry that continue to advance policies and initiatives to improve the public’s health.

Dentists wield enormous power to make, or break, the American mouth. In the past few years, however, leadership for improved oral health has come increasingly from outside mainstream dentistry. Pediatricians have enhanced patient education and their clinical practices to address children’s oral health. Philanthropies have dedicated considerable resources to addressing dental access inequities. State legislatures have slowly expanded the scope of practice for midlevel dental professionals. And with federal funding, the Institute of Medicine has initiated two committees to recommend solutions for the silent epidemic of untreated cavities and diseases around teeth and in gums.

William Murphy, whose photograph outraged many New York Times readers, told the newspaper that he couldn’t wear his prosthetic tooth the day of the photo because of swelling from a medical condition. Imagine readers’ responses to him had he beamed an American smile.

Len Finocchio1

1 Len Finocchio (lfinocchio@chcf.org) is a senior program officer at the California HealthCare Foundation in Oakland. He leads the foundation’s program work in oral health.

NOTES

1. Hoyt C. The ugly part wasn’t his face. New York Times [serial on the Internet]. 2007 Jun 17. Available from: http://www.nytimes.com/2007/06/17/opinion/17pubed.html?_r=1&scp=1&sq=Ugly%20Part%20Wasn’t%20His%20Face&st=cse
2. Centers for Disease Control and Prevention. Ten great public health achievements—United States, 1900–1999. MMWR. 1999;48(12):241–3.[Medline]
3. U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general. Rockville (MD): Public Health Service; 2000.
4. Brown LJ. Adequacy of current and future dental workforce: theory and analysis. Chicago (IL): American Dental Association; 2005.
5. Freidson E. Professionalism: the third logic. On the practice of knowledge. Chicago (IL): University of Chicago Press; 2001.