Friday, January 27, 2012

Who Really Cares about Public's Dental Safety and Health?

Just out of curiosity, I wanted to see who this “children’s partnership” is who has asked Dr. Davidson, CDA’s president for rigorous study of the safety and efficacy of performing complex dental procedures by non-dentists and to my shock and surprise, I found insurance companies and commercial corporations in the list of partners and supporters of this organization!  I just don’t understand why Dr. Davidson would support a request made by a foundation mainly supported by insurance companies on behalf of an organization who claims to care and support public’s dental health and safety and dental professionals!  Especially when congress on January 12, 2012 voted against spending any funds on any research on efficacy of alternate providers (please see footnote for links to congress announcement)!  Dr. Davidson in a letter on January 20, 2012 addressed to some members has invited meaningful discussions and I really would like to discuss this with an open mind!

Link to the page showing partners and supporters of the Children’s Partnership:

Here are just a few partners and supporters the Children’s Foundation:

Blue Cross of California Foundation
Blue Shield of California Foundation
California Association of Health Plans
California HealthCare Foundation
California Primary Care Association
The California Wellness Foundation
Center for Oral Health (formerly Dental Health Foundation)
The Henry J. Kaiser Family Foundation
Kaiser Permanente
W.K. Kellogg Foundation
L.A. Care Health Plan
Pew Center on the States, a division of The Pew Charitable Trusts
The Pew Charitable Trusts
Santa Clara Family Health Plan
Sierra Health Foundation
United Ways of California
Wellpoint Foundation

Why waste time and resources on any type of study to determine the safety and applicability of allowing irreversible procedures to be done by non-dentists?  The answer is so obvious at least to us dentist! Let’s take a fully trained and licensed dentist fresh out of school for example; would any experienced dentist consider someone who is fresh out of dental school “competent”?  Don’t we all look back now after practicing dentistry for many years, and think to ourselves how little we knew when we had just graduated from dental school?  I graduated 17 years from UCLA School of dentistry, cum laude with highest “RVU’s” (relative value unit) for performing most clinical work in my class and I even had passed an AEGD mini-residency in my senior year.  Yet everyday is a new experience for me, one where I learn from a procedure as simple as a three surface filling.  We all know that dentistry is a life long practice of learning and the learning part never stops.  How could anyone even agree to a study to test the safety of half trained providers when we all know, as fully trained and credentialed dentists with many years of experience that any training less than what is being provided today is dangerously inadequate!

Would any of us dentists agree for such half trained provider to treat our children or loved ones or ourselves for an irreversible procedure?  If anyone says yes, I would love to see that individual actually live up to it.

Children are such impressionable patients.  How many times a week we hear horror stories related to “childhood dental” experiences from our adult patients?  How many adult patients do we know who are permanently scarred due to an adverse experience related to a dentist visit in their childhood?  How many adult patients do we have who fear seeing the dentist only because of that adverse experience?  How many of us general dentists have the skills and patience necessary to deal with children’s complex yet sensitive personality, even after so many years of practice?  Now how in the world does anyone think that any study may prove it safe and effective to introduce this midlevel provider class to perform dentistry on children? 

On one hand newly graduates from dental school are encouraged to take a one year post residency to become more competent as most dentists think the clinical experience in dental school is not enough to prepare the general dentist for the ever complex need of the general public…on the other hand CDA is agreeing to “study” the safety of a half trained class of provider!

On one hand the formally trained and experienced registered dental assistant is refrained from grabbing the ultrasonic scaler to clean up the remnants of cement from a prepared tooth after removing the temporary and in some states hygienists are not authorized to give local anesthetic injections and on the other hand CDA is agreeing to a study which puts those less trained and experienced than RDAs and much less trained and experienced than RDHs in the front seat!

This simply doesn’t make any sense!

If we are talking about under served, rural areas where no dentist practices near by, I am sure no physician practices nearby either.  Somehow those people make it to the physician’s office and if they do, I am sure they can make it to the dentist’s office too.  If they live in a place that they simply can’t make it to any healthcare provider’s office then it is not safe to have kids in that area and government should introduce legislation to provide means of transportation for those people because anyone with kids knows that emergency strikes any moment and access to healthcare provider’s office is a necessity.  Do we see the medical profession training half hearted physicians and orthopedic surgeons in an effort to deal with broken bones and concussions of these kids in these rural areas?

Now in addressing the cost, we all know that the golden era of dentistry is long gone, so what we charge today doesn’t go towards lavish life styles anymore; it barely meets the demand of the ever increasing costs of a dental practice.  Now how in the world this mid-level provider is going to provide dental services at a reduced cost?  Which part of the cost is going to be eliminated in their practice?  Are they going to use a stool to treat patients?  Are they going to cut down on the cost of a digital sensor for taking x-rays? Or maybe they don’t need to take x-rays at all!  Are they going to buy and use expired dental material or would they purchase high quality dental material like dentists do?  Are they going to sterilize instruments or simply rinse it under water in between patients?  Are they going to work single handedly or would they need to hire assistants?  Are patients seen in the streets or in a dental practice set up which is compliant with all government regulations such as OSHA, HIPAA and ADA?  (Oh, let’s not forget the amalgam separator).  I really want to know how in the world anyone can provide cheaper dental services to general public these days without cutting corners and lowering quality of services and being non-compliant with regulations that our profession is held up to.

In my office, my base hourly fixed overhead is over $150.00!  I never cut down on quality of service and I am strictly compliant with all regulations….I provide personal attention to every patient and never double book, I am very ethical (as we all should be) and never over diagnose or over treat….I barely make enough money to pay my staff’s salary, and pay my lease and take home enough to pay my rent and my bare cost of living….This is what practicing dentistry in an ethical way and providing high quality dental care generates in this day and age.  How in the world is anyone even suggesting that mid-level providers would provide safe dental care at a lower cost?  Where exactly is the saving coming from?  Please enlighten me so I implement it in my practice and pass the savings down to my patients right away….Why should only midlevel providers provide lower cost dental care….maybe dentists would be willing to do that as well so please share the wisdom so those of us who are interested pass the savings along to our patients.

Let’s be realistic, we can’t be such hypocrites.  On one hand, during the CDA convention we have leaders of our profession telling us how having a laser and even a microscope for general dentist is becoming “standard of care” and on the other hand our association is willing to conduct a study to access the safety of introducing a mid-level provider to perform irreversible dental procedures on kids!  On one hand our courts rule in favor of a parent who challenges the safety of amalgam and Nitrous oxide use in treating kids and our professional association takes no position on the issue and on the other hand the very same association  agrees to studies to determine safety of non-dentists treating kids.  This is really an extreme example of a profession with double standards.

In our country government has no direct role healthcare administration.  President Obama introduced “Obama Care” and some people claimed it to be unconstitutional because it requires everyone to have health insurance.  In those states where mid-level provider concept has already become law without organized dentistry having any role either organized dentistry is “non-existent” or it simply is representing the best interest  of another group other than dental providers and patients!  any entity claiming to represent the best interest of public (patients) and/or dentists (dental professionals) cannot in the right mind, even think it would be safe to have a non-dentist provide dental care at a lower cost to anyone, especially children.  If as dental professionals we claim to care for the safety of general population and claim to have any standards for dental care, we cannot possibly agree to any studies to access the safety and efficacy of educating non-dentists to perform dental procedures.  No study will ever prove this to be safe because ever such misconception is claimed safe, every hygienist and every registered dental assistant in this country should claim rights that are being denied at the moment.   We won’t need general dentists anymore and it would only make sense to train mid-level providers and specialists.  No one needs dentist and hygienists anymore.  If our specialists now are worried about too many dentists specializing, they would really have something to worry about when 100% of the dentists go to specialty school… but then again, with mid-level providers treating the general public, I am sure there would be enough work for specialists because every filling would turn into a root canal and saving a tooth would be meaningless so we would either need root canals or implants.

If legislature ever passes a law in California in support of introducing mid-level providers to perform irreversible procedures on people, I would expect organized dentistry to file a lawsuit on behalf of all members it represents against government for ignoring public’s safety and exposing everyone to irreversible damages with no regard to facts.  In those states that it has already become law, organized dentistry is either dead or representing maybe insurance companies’ best interest instead of general public and dental professionals. 

Why waste time and resources evaluating something that we already know is NOT SAFE?  Why even agree to such study?  I can only think of one group benefiting from this and that is “insurance companies”.  Surely they would contract with these mid-level providers at lower fees than the dentists and surely patients would opt for lower co-pays and surely that means more profit for insurance companies and major harm for general public because “cheap” is not always “safe” and while I am all for reasonable spending strategies, I wouldn’t compromise safety of my loved one in the hands of a non-dentist where it ultimately could lead to much higher expenses dealing with failures and irreparable harm.

As a general dentist, with 17 years of experience providing dental care for patients almost everyday, I don’t need a study to determine safety of having irreversible dental procedures performed by non-dentists…I already know the answer, NOT ONLY IT IS NOT SAFE, IT IS DANGEROUS!

As a general dentist who is ethical, and committed to providing quality dental care with passion to patients who doesn’t cut corners I don’t need a study to see if anyone can provide quality dental care at a lower cost to patients!  I already know the answer, IT IS IMPOSSIBLE!

As a general dentist, and a professional taking the oath to do no harm, if my government one day passes a law, authorizing dental practices which would clearly harm everyone, I would see it a duty to file a lawsuit against legislature and let the court and jury decide if that is legal or government clearly overstepping its authority by authorizing harm on public’s health and safety.

As a general dentist and proud member of organized dentistry (at least until now!) who claims to overlook public’s safety and best interest with respect to dental practices of dental professionals, and best interest of its members; I certainly hope nothing but firm opposition to such legislation and in case it becomes law, immediate actions by filing lawsuits before both public’s safety and best interest of dental professionals both are irreversibly harmed

Who ever has introduced this thought and idea, certainly doesn’t have anyone’s best interest in mind other than his/her own.  It may be a glamorous political campaign or an eye catching agenda while climbing the ladder to higher posts and positions… who knows….but one thing is for sure, no dentist should ever even entertain this idea as no dentist would ever allow a mid-level provider to treat his or her child or loved one and that should say something to general public who blindly may support this idea because it sounds like a more affordable alternative to being seen by a fully trained dentist.   If this ever becomes law, I would strongly advise everyone to go to the other side of the border for dental treatment as a dentist in another country is by far more qualified and safer than a non-dentist in the homeland when it comes to irreversible dental procedures.

Related Links:

-          Congress Prohibits Funding for Alternative Providers:
-          AGD paper on Access to Oral Care:
-          AGD Position on mid-level provider issue:
-          Breaking Down Barriers to Oral Health for All Americans:  the Role of Workforce:
-          CDA Support Letter on SB 694:
-          CDA Access Report:
-          Which Organizations support “Children’s Partnership”:
-          The Children’s Partnership: