There was an article in the Washington Post yesterday(7/2) that was critical of dentists. I wrote a reply to the author, Mary Jordan. Here is the link to the article and my reply below.

https://www.washingtonpost.com/amphtml/politics/the-unexpected-political-power-of-dentists/2017/07/01/ee946d56-54f3-11e7-a204-ad706461fa4f_story.html

 

Dear Ms. Jordan,

As a practicing dentist I could not let the article you wrote on organized dentistry pass. I have been very upset since reading it and feel that you did a poor job of explaining the issue. First of all, dentists do not overwhelmingly support the ADA. Many dentists have refused to join because the ADA is considered ineffective or does not adequately represent dentists’ interests. 64% membership in the ADA is an embarrassment. When I started practicing it was closer to 90%. There were many issues brought up in the article about dentists attempts to stifle competition but I will focus on mid-level providers.

Mid-level provider is the latest attempt by the ADHA, the American Dental Hygiene Association, the hygiene equivalent of the ADA, to expand functions for their members by skirting state dental practice acts. Twenty years ago, they lobbied states to allow independent practice for hygienists again using access to care as an argument. A law was passed in Colorado. Instead of setting up practices in inner cities and treating Medicaid patients, some hygienists set up practices in Vail, a ski area with well to do residents and tourists. Once hygienists realized how expensive it was to set up and run a dental office, most of these practices failed. You cannot make money in a dental office by doing hygiene alone. The fees do not support the costs to run a practice. So now the ADHA has changed its focus to allowing hygienists to perform irreversible operative procedures where reimbursement is much higher.

Thus the push for mid-level providers. They claim that these providers will be less expensive to train. Of course they will. Dentists work hard for 4 years to get an undergraduate degree. We studied very hard to put ourselves in a position to make us qualified candidates for dental school. During our Senior year we applied to dental school and those of us lucky enough to be accepted, spent the next 4 years training to become dentists.  Currently, it costs a student up to $400,000 to get through college and dental school. Dentists spend the first 2 years of dental school taking physiology, anatomy, and biochemistry classes with medical students in addition to our dental curriculum. Mid-level providers are dental hygienists who first must become dental hygienists by going to an accredited dental hygiene program right out of high school. These programs are the equivalent of an associates degree at a community college and is a 2 year program. The ADHA proposal for a mid-level provider would establish an additional 2 year program with the curriculum established, not by dentists, but by the ADHA. Their cost would be approximately 1/4 the cost of going to dental school. The problem is that they do not have the breadth of knowledge required to handle all aspects of the job, in particular, emergencies. Once they complete a program they will be permitted to work anywhere. In my state the proposal did not require them to work in an underserved area or to treat Medicaid patients. The requirement that they affiliate with a licensed dentist is a joke. A licensed dentist does not have to be present onsite and is liable for the work done by mid-level providers. Most dentists who I talked to would never accept that liability.

It is an insult to dentists to be told that we are greedy and just trying to stifle competition when our true concern is public safety. Hairdressers doing tooth whitening? What happens when someone who has open tooth decay has this done and their tooth abscesses? Mid-level providers doing fillings and extractions? What happens when a procedure goes bad and there is not a licensed dentist anywhere near the office to do the next phase of treatment?

I would like to ask attorneys, who should determine the parameters of your profession, you or paralegals? Or accountants, should your bookkeeper determine what it takes to become a CPA or be allowed to do what you do by taking an abbreviated course? Or surgeons, should an APRN perform surgery without going through the rigorous training you had?

Doing fillings is more than picking up a drill and drilling a hole in a tooth. That has been our main concern, not competition and not a loss of revenue. Dental fees have traditionally gone up at a much slower rate than the rest of medical costs and I would maintain that the affordability is less a factor of dentists doing dentistry but the fact that middle class income has essentially dropped 30% over the past 30 years. Dentists buy the latest equipment, use the best materials and labs and take many hours of continuing education every year. I am proud to be a dentist and will always fight to uphold the highest standards in my profession. My final question to legislators when I have educated them about this issue is, “who would you allow to treat you and your family?” That has been the final determinant of whether this is a good idea, not arm twisting. Thank you for your time.

Henry M. Rosenberg D.M.D.

Manchester, Connecticut

 

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With all of the talk about repealing and replacing the Affordable Care Act one overlooked aspect is that nobody has been talking about dental care.  Specifically, whether dental insurance should be part of medical insurance instead of a separate plan. Does anybody doubt that the mouth and good dental health are important to overall health? If your teeth hurt, you can’t chew and cannot get the nutrition you need. That’s obvious but dental disease can also be a window into the overall health of a patient.

 

When I perform an exam, the first thing I do is an oral cancer screening. Cancer is only one thing we may see but other lesions can be an indication of health concerns. Candida is a yeast infection that when seen in the mouth can indicate the presence of a weakened immune system. It can also indicate long term antibiotic usage particularly in women who have had urinary tract infections. It is also quite common in asthmatics who rely on inhalers. Candida is easily treated but not if it is undiagnosed.

 

Another dental disease that can indicate general health issues is gum disease. Younger adults with gum disease frequently have underlying health concerns. Some have drug problems accompanied by poor nutrition and poor oral hygiene. Others may be diabetic. Diabetes is known to interfere with healing and people with diabetes are prone to gum disease and tooth loss.

 

Dentists for years have been pushing to have dental care added to medical insurance plans because there are many limitations to current dental insurance plans. Most dental insurance plans have yearly maximums while medical insurance does not. This means that after a set amount of money is paid by the insurance company, it will no longer pay anything for that year.  This has led people to stop work midstream only to start again once insurance kicks in again, usually at the beginning of the following year. What an inefficient way to complete treatment. If included with medical insurance, all work could be completed at the discretion of the patient and in a timely manner. No matter what happens to the Affordable Care Act, it is time to include dental care. After all, it is vital to peoples’ health.

I was asked an interesting question by a patient this morning. He asked whether diet has any effect on gum disease. I had to think about the question because most people I talk to about diet are usually concerned about cavities.

When I talk to patients about gum disease, the primary concern is getting them to clean their teeth better at home by flossing, brushing and using some type of interdental device like a proxabrush:

butler-gum-proxabrush-handle

  or Airfloss:

airFloss

Plaque is a film composed of bacteria and the remnants of food particles that the bacteria has digested. These bacterial waste products cause inflammation in the gums and can eventually lead to gum disease. If the food is high in sugar, it creates more acid and can cause cavities. Any food that allows bacteria to thrive and multiply can contribute to gum disease.

The simple answer to the initial question is what you eat has less to do with developing gum disease than how meticulous you are about cleaning your teeth at home. Changing your diet may contribute to you being healthier and enable your body to fight off gum disease but oral hygiene is still more important.

So, eat a healthy diet and exercise but also be sure to do all you can to keep your teeth clean.

On Friday April 7th I again volunteered for the Mission of Mercy which is a dental clinic sponsored by Connecticut Foundation for Dental Outreach. This was the tenth year of the Mission and my 6th. Free dental care is provided for anyone who wants it with no questions asked. This year we treated over 1500 patients.

On the top left is me with a good friend of mine, Dr. Bruce Tandy. I am on the right. To the right is my dental assistant, Krystal who volunteered to work in the area that sterilizes instruments. Below Krystal is a photo of me with Congresswoman Rosa DiLauro. The photo at the bottom is of my favorite patient of the day, Anthony, with 2 second year dental students from the University of Connecticut. Anthony came through the line 3 times so we got to catch up throughout the day. I worked in the area that did local anesthesia. We numbed people all day.  I worked with other dentists as well as students from the UCONN dental school. It was an exhausting but wonderful experience.

The American Dental Association recently asked Congress to pass legislation calling for the repeal of the “use-it-or-lose-it” rule for flexible spending accounts, allowing consumers to build balances over several years. Up until now, if you put money in a flexible spending account and did not use the money by the end of the specified time, the money was lost. That seems unfair since even though the money was pre-tax money because it was still your money. The proposal by the ADA would allow people to carry over the money from year to year and allow them to build balances to cover medical or dental expenses. It seems like a good idea. I hope Congress takes it seriously.

http://www.ada.org/en/publications/ada-news/2017-archive/february/organized-dentistry-coalition-supports-eliminating-use-it-or-lose-it-rule?nav=news

Many times when I present a treatment plan, I imagine that this is what my patient is thinking. At those times I wish they would ask that question but even if they don’t, I present as if that is exactly what they are asking. How do you know if you need the dental work presented if you don’t ask? Patients are not trained in dentistry but are smart enough to understand need if properly presented.

I will list a few situations where you need to be sure. Two procedures in particular tend to be overdiagnosed and sometimes abused. They are scaling and root planing and replacement of existing fillings.

Scaling and root planing is a valuable treatment performed on people who show evidence of gum disease. Normally the patient will have a periodontal exam where the dentist or hygienist measure the depth of the gum around each tooth. These areas are called pockets.

measureperiodontal1

When a patient has healthy gums, the pockets measure 3mm or less. In that case all that is needed is a normal cleaning or prophylaxis. Once pockets start to measure 4-5mm, then there may be a need for scaling and root planing. Also, there should be evidence of calculus(the stuff the hygienist scrapes off) below the gumline and possibly bone loss on Xray.

subgingival-calculus

If these criteria are met, scaling and root planing is a very effective treatment.

When should a filling be replaced? Normally, a filling should be replaced when a new cavity has formed near an old filling or if an old filling has fractured, loosened or fallen out. Slight imperfections in fillings can most times be repaired without removing the whole filling. This preserves tooth structure and can lead to a longer life for the existing filling.  Needless drilling can weaken teeth and should be avoided. This also applies to people who want to replace their fillings for cosmetic reasons. An old, silver filling can last many,many years with no harm to the patient. 

It is important for you to get treatment when needed but it is as important for you to know when to ask more questions and when to move ahead with the treatment. If in doubt, seek a second opinion.

Please visit my website at http://www.rosenbergfamilydental.com

 

 

 

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