Missouri Dental Association Promotes Its Agenda

February 18, 2010

Missouri Dental Association Promotes Its Agenda

Two op-eds, attributed to different members of the Missouri Dental Association (MDA), appeared in the Columbia Missourian and the Examiner in response to my op-ed about dental therapists (which appeared in both the Columbia Missourian and the Examiner). Although these responses were textually the same, they have different credited authors: In the Missourian, the op-ed is attributed to Dr. Rob Coyle, DDS, and in the Examiner, the authors are Matt Niewald, DDS, president of the MDA, and Scott Roberson, DDS, trustee of the MDA. One can only wonder why the same piece is attributed to different authors, but a reasonable conclusion may be that the MDA asked its members to submit a pre-written op-ed to these newspapers. The MDA’s purpose is not secret, given that the last line of both pieces reads:

We would encourage others, both inside and outside of the profession, to contact your legislators and ask them to support the MDA agenda. Working together, we are confident we can bring common sense solutions that will improve the oral and overall health of our state.

The MDA suggests other factors, like Medicaid reimbursements, that may be contributing to the problem of providing access to dental care for Missourians. These are valid points, but they do not provide an adequate reason for their offhand dismissal of the value of dental therapists. The MDA implies that dental therapists “would compromise the safety” of patients. I’ve addressed the issue of the quality of dental therapists in the comment section of previous posts, and within the op-ed itself. The studies of dental therapists, from New Zealand, Australia, the UK, and Alaska, have so far shown that they provide quality in patient outcomes that is comparable to that of professional dentists, and studies show that altering licensure rules to allow dental therapists to practice could improve access to care for children in the United States.

This opposition by the dental lobby despite the lack of evidence to support their position, evidenced in op-eds like these from the MDA, or in legislation to prevent teeth-whitening in kiosks, is an attempt to keep market share by using government power rather than by providing a better service at a better price. Artificially protecting a profession from competition — especially high-quality competition — does not help keep patients safer. Arbitrary rules that prevent qualified mid-level professionals from entering the market only hurt the people they are purporting to help: the patients.

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5 Comments »

Caitlin, while I applaud your efforts to help solve the access to care issues, I do not think that the studies you site on quality of care are ’studies’ only surveys. I suppose that ‘any care is better that no care’ could be your claim. The problem with this type of care is that safety and competence is compromised. Would you be willing to have surgery by a surgical assistant that has been trained for two years, with no with medical school degree or residency? The irreversible nature of dental care, let alone diagnosis by one not trained is very risky. This would be the start of a two tier system of care. I feel that everyone should have the best quality and competent care available. There are many other issues surrounding access to care and my concern with the DHAT type of para-professional. As a member of the ADA and MDA I have tried to encourage changes at the state and national level to allow for better access, but so far to no avail. I would be happy to talk with you about this further. Please call me. Scott Roberson, DDS
office: 816 350 0808
cell:816 516 3672

Comment by Scott Roberson, DDS — February 19, 2010 @ 4:20 p.m.
Thanks for the comment, Dr. Roberson.

Dental therapists only provide a limited range of services — which does not include surgical procedures. All of the published research shows that, for the limited range of services that dental therapists provide, patient outcomes are not significantly different from that of patients who have been treated by dentists instead.

With that clearcut body of evidence, it should be a matter for consumers to decide whether they want to pay a premium to have a full-fledged dentist treat them for basic services, or whether they’re willing to trust the lesser training of a dental therapist who will also charge less for that similar range of basic work.

If, as you suggest, an increase in the number of practicing dental therapists would reduce safety for that basic range of services, those therapists will soon find themselves without paying customers. Markets are very efficient tools at sorting out the optimal equilibrium between risk, cost, and benefit.

There’s no reason to continue to subsidize dentists through the regulatory capture of exclusive licensing when dental therapists have a comparative advantage at providing basic dental services.

Comment by Eric D. Dixon — February 19, 2010 @ 4:34 p.m.
Caitlin, the limited range of services include basic fillings, which are technically surgery on a tooth–a living part of the body. The services provided by the DHAT’s in Alaska include extractions of teeth, also surgery. That why I asked if you would submit to a two year trained para. for a biopsy, tonsils or cyst removal? The concept of excellence of care with proper education and continuing education is essential.
In my opinion the biggest barrier to access to dental care is financial. In talking to people at the Dental school where much indigent care is provided, the problem occurs when a patient has to pay $2-$5 for a simple filling or $25 for a root canal or extraction and doesn’t come back – simply unable to pay anything. A second barrier is distribution of dentists, not a shortage of dentists. This is primarily due to market forces where a dentist can not be supported in rural areas with enough patients.
My attempts have been to secure tax credits, state and federal to encourage all practices, general and specialty, to see a signficant number of medicaid patients. Unfortunately, I have not been able to get past the politics. I as well as dozens of dentists see patients for free care every week. The programs I help with are both state wide and local. Many of these patients are not on medicaid but can not afford dental care. The local program is screened through the school nurses and then refered to one of 18 dentists for definitive and ongoing care. Scott Roberson, DDS

Comment by Scott Roberson, DDS — February 19, 2010 @ 6:15 p.m.
In an effort to understand your thought processes on this issue, I would appreciate your comments on the “studies” you have referenced. Of the eight articles you have sighted, four, or one half are written by Dr David Nash of the University of Kentucky; a career academic, public policy ultra liberal and someone who generally holds himself out to be an expert on ethics. I was struck in your original article by the use of the term “professional dentists”—a term coined by Dr Nash in a letter to the editor of the Journal of the ADA (V135,No1,21-22) in which he questions the ethics of the business of dentistry, and I quote:
“I do think the members of our profession deserve to understand what sociologists and bioethicists have for many years argued are the distinctions between professions and businesses. Professions are distinguished from businesses in that the professional relationship is one in which the professional (dentist) holds considerable power, as a result of knowledge, over the individual (patient), placing the patient in a vulnerable position. Thus, the need exists for the dentist to place the patient’s interest at a level equivalent to or above that of his or her own. The professional dentist’s primary motivation and responsibility is, or should be, “caring” for patients.”

And although I agree with Dr. Nash’s treaty on protecting the profession of dentistry from unscrupulous business practices and the very serious need to keep patient care at the highest level possible, the fact is we are still blessed with a free market system of providing dental care and thus must operate our offices by sound business principles. Dr Nash’s works are really no more than an academic trying to “publish or perish” and “push or pull” his liberal agenda onto the practice dentistry.

The article from New Zealand in its conclusion actually questions if the dental therapists has been used effectively or if it even has fulfilled its original objectives in “forestalling disease” and “prevention”. The article from Australia is thin support of your position at best. It evaluated only seven therapists working under the supervision of dentists in the Royal Hospital of Melbourne and merely studied if a therapist could place a filling on someone over the age of 25 instead of under the age of 25. The study you have sighted from the UK was a review of patient charts to determine the amount of time therapists spend doing various procedures and does not draw any conclusion on quality of care.

Finally the article by Dr Bolin on Alaska. This pilot study of the new therapist set up by the Alaska Tribal Council in cooperation with the ADA again simply reviewed patient charts to determine if the types of procedures performed by a therapist were consistent with the type of procedure which was performed by a dentist for a similar diagnosis. The article sites a 95% consistency between a therapist and dentist; however the study reviewed the chart entries of the therapists while they were in training and under the direct or indirect supervision of the control group dentists. Dr Bolin does not comment nor was his study designed to evaluate quality of any treatment but was rather the accumulation of data and the treatment planning process of the therapist in a very controlled teaching environment.

If one carefully and objectively evaluates the sources you have used to support your position, or really understands the methodology in scientific literature or even has a passing familiarity with research—your conclusions or perhaps more accurately your “editorial spin” on this issue is completely without merit. None of these sources look at anything approaching an evaluation of the safety of a dental therapist or even remotley speeks of your proposal, which seems to be an independent dental healthcare provider performing diagnostic and surgical care outside the traditional dental setting and for a population which many times is more complicated than average.

Your statement:
Dental therapists only provide a limited range of services — which does not include surgical procedures. All of the published research shows that, for the limited range of services that dental therapists provide, patient outcomes are not significantly different from that of patients who have been treated by dentists instead.With that clearcut body of evidence, it should be a matter for consumers to decide whether they want to pay a premium to have a full-fledged dentist treat them for basic services, or whether they’re willing to trust the lesser training of a dental therapist who will also charge less for that similar range of basic work.

This statement is either simple fabrication or a sloppy interpretation of your own sources. I do not necessarily believe you have intentionally been dishonest with the readership in your previous posts and op ed pieces but I would hope just rather inexperienced in your research and understanding of such a complex issue. Which is it? Do you stand behind these “studies” or are you willing to do some real research into ALL sides of this idea?

Oh and by the way—the MDA did not initiate the bleaching legislation—it was forwarded to the capital by two very bright and concerned dental students—the legislation was filed and first read before the dental association ever knew anything about it!!!!!!!!!!!!!!!

Comment by Dr S — February 23, 2010 @ 12:18 a.m.
Thank you for your comments. I am curious what evidence to the contrary you are referring to. I performed a pubmed literature review of dental aides, therapists and assistants and I did not find any evidence of “the other side” that you accuse me of ignoring. I would appreciate it if you would enlighten me, though, because I do not wish to be deceptive.

I will definitely agree that the evidence is not conclusive, but there is evidence that they are successful in some ways, and there is a lack of evidence to the contrary. A freer market in dental care (note, I am not advocating a completely deregulated or unlicensed market) would help bring down the cost of care and raise oral health standards.

Unfortunately, there is not a whole lot of research on the subject, because it is a burgeoning field. More research needs to be done though, because there is definite potential. If, as you believe, dental therapists cannot provide proper surgical care, then that shall be quickly evident. (The early research though seems to indicate the opposite.) Evidence-based dentistry only comes about though with an accumulation of studies and research. I definitely agree that there needs to be more research, but I also maintain that the early body of research is quite hopeful as a manner to improve the oral health of the population by expanding affordable access.

Comment by Caitlin Hartsell — February 23, 2010 @ 10:02 a.m.

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Caitlin, while I applaud your efforts to help solve the access to care issues, I do not think that the studies you site on quality of care are ’studies’ only surveys. I suppose that ‘any care is better that no care’ could be your claim. The problem with this type of care is that safety and competence is compromised. Would you be willing to have surgery by a surgical assistant that has been trained for two years, with no with medical school degree or residency? The irreversible nature of dental care, let alone diagnosis by one not trained is very risky. This would be the start of a two tier system of care. I feel that everyone should have the best quality and competent care available. There are many other issues surrounding access to care and my concern with the DHAT type of para-professional. As a member of the ADA and MDA I have tried to encourage changes at the state and national level to allow for better access, but so far to no avail. I would be happy to talk with you about this further. Please call me. Scott Roberson, DDS
office: 816 350 0808
cell:816 516 3672

Comment by Scott Roberson, DDS — February 19, 2010 @ 4:20 p.m.

Thanks for the comment, Dr. Roberson.

Dental therapists only provide a limited range of services — which does not include surgical procedures. All of the published research shows that, for the limited range of services that dental therapists provide, patient outcomes are not significantly different from that of patients who have been treated by dentists instead.

With that clearcut body of evidence, it should be a matter for consumers to decide whether they want to pay a premium to have a full-fledged dentist treat them for basic services, or whether they’re willing to trust the lesser training of a dental therapist who will also charge less for that similar range of basic work.

If, as you suggest, an increase in the number of practicing dental therapists would reduce safety for that basic range of services, those therapists will soon find themselves without paying customers. Markets are very efficient tools at sorting out the optimal equilibrium between risk, cost, and benefit.

There’s no reason to continue to subsidize dentists through the regulatory capture of exclusive licensing when dental therapists have a comparative advantage at providing basic dental services.

Comment by Eric D. Dixon — February 19, 2010 @ 4:34 p.m.

Caitlin, the limited range of services include basic fillings, which are technically surgery on a tooth–a living part of the body. The services provided by the DHAT’s in Alaska include extractions of teeth, also surgery. That why I asked if you would submit to a two year trained para. for a biopsy, tonsils or cyst removal? The concept of excellence of care with proper education and continuing education is essential.
In my opinion the biggest barrier to access to dental care is financial. In talking to people at the Dental school where much indigent care is provided, the problem occurs when a patient has to pay $2-$5 for a simple filling or $25 for a root canal or extraction and doesn’t come back – simply unable to pay anything. A second barrier is distribution of dentists, not a shortage of dentists. This is primarily due to market forces where a dentist can not be supported in rural areas with enough patients.
My attempts have been to secure tax credits, state and federal to encourage all practices, general and specialty, to see a signficant number of medicaid patients. Unfortunately, I have not been able to get past the politics. I as well as dozens of dentists see patients for free care every week. The programs I help with are both state wide and local. Many of these patients are not on medicaid but can not afford dental care. The local program is screened through the school nurses and then refered to one of 18 dentists for definitive and ongoing care. Scott Roberson, DDS

Comment by Scott Roberson, DDS — February 19, 2010 @ 6:15 p.m.

In an effort to understand your thought processes on this issue, I would appreciate your comments on the “studies” you have referenced. Of the eight articles you have sighted, four, or one half are written by Dr David Nash of the University of Kentucky; a career academic, public policy ultra liberal and someone who generally holds himself out to be an expert on ethics. I was struck in your original article by the use of the term “professional dentists”—a term coined by Dr Nash in a letter to the editor of the Journal of the ADA (V135,No1,21-22) in which he questions the ethics of the business of dentistry, and I quote:
“I do think the members of our profession deserve to understand what sociologists and bioethicists have for many years argued are the distinctions between professions and businesses. Professions are distinguished from businesses in that the professional relationship is one in which the professional (dentist) holds considerable power, as a result of knowledge, over the individual (patient), placing the patient in a vulnerable position. Thus, the need exists for the dentist to place the patient’s interest at a level equivalent to or above that of his or her own. The professional dentist’s primary motivation and responsibility is, or should be, “caring” for patients.”

And although I agree with Dr. Nash’s treaty on protecting the profession of dentistry from unscrupulous business practices and the very serious need to keep patient care at the highest level possible, the fact is we are still blessed with a free market system of providing dental care and thus must operate our offices by sound business principles. Dr Nash’s works are really no more than an academic trying to “publish or perish” and “push or pull” his liberal agenda onto the practice dentistry.

The article from New Zealand in its conclusion actually questions if the dental therapists has been used effectively or if it even has fulfilled its original objectives in “forestalling disease” and “prevention”. The article from Australia is thin support of your position at best. It evaluated only seven therapists working under the supervision of dentists in the Royal Hospital of Melbourne and merely studied if a therapist could place a filling on someone over the age of 25 instead of under the age of 25. The study you have sighted from the UK was a review of patient charts to determine the amount of time therapists spend doing various procedures and does not draw any conclusion on quality of care.

Finally the article by Dr Bolin on Alaska. This pilot study of the new therapist set up by the Alaska Tribal Council in cooperation with the ADA again simply reviewed patient charts to determine if the types of procedures performed by a therapist were consistent with the type of procedure which was performed by a dentist for a similar diagnosis. The article sites a 95% consistency between a therapist and dentist; however the study reviewed the chart entries of the therapists while they were in training and under the direct or indirect supervision of the control group dentists. Dr Bolin does not comment nor was his study designed to evaluate quality of any treatment but was rather the accumulation of data and the treatment planning process of the therapist in a very controlled teaching environment.

If one carefully and objectively evaluates the sources you have used to support your position, or really understands the methodology in scientific literature or even has a passing familiarity with research—your conclusions or perhaps more accurately your “editorial spin” on this issue is completely without merit. None of these sources look at anything approaching an evaluation of the safety of a dental therapist or even remotley speeks of your proposal, which seems to be an independent dental healthcare provider performing diagnostic and surgical care outside the traditional dental setting and for a population which many times is more complicated than average.

Your statement:
Dental therapists only provide a limited range of services — which does not include surgical procedures. All of the published research shows that, for the limited range of services that dental therapists provide, patient outcomes are not significantly different from that of patients who have been treated by dentists instead.With that clearcut body of evidence, it should be a matter for consumers to decide whether they want to pay a premium to have a full-fledged dentist treat them for basic services, or whether they’re willing to trust the lesser training of a dental therapist who will also charge less for that similar range of basic work.

This statement is either simple fabrication or a sloppy interpretation of your own sources. I do not necessarily believe you have intentionally been dishonest with the readership in your previous posts and op ed pieces but I would hope just rather inexperienced in your research and understanding of such a complex issue. Which is it? Do you stand behind these “studies” or are you willing to do some real research into ALL sides of this idea?

Oh and by the way—the MDA did not initiate the bleaching legislation—it was forwarded to the capital by two very bright and concerned dental students—the legislation was filed and first read before the dental association ever knew anything about it!!!!!!!!!!!!!!!

Comment by Dr S — February 23, 2010 @ 12:18 a.m.

Thank you for your comments. I am curious what evidence to the contrary you are referring to. I performed a pubmed literature review of dental aides, therapists and assistants and I did not find any evidence of “the other side” that you accuse me of ignoring. I would appreciate it if you would enlighten me, though, because I do not wish to be deceptive.

I will definitely agree that the evidence is not conclusive, but there is evidence that they are successful in some ways, and there is a lack of evidence to the contrary. A freer market in dental care (note, I am not advocating a completely deregulated or unlicensed market) would help bring down the cost of care and raise oral health standards.

Unfortunately, there is not a whole lot of research on the subject, because it is a burgeoning field. More research needs to be done though, because there is definite potential. If, as you believe, dental therapists cannot provide proper surgical care, then that shall be quickly evident. (The early research though seems to indicate the opposite.) Evidence-based dentistry only comes about though with an accumulation of studies and research. I definitely agree that there needs to be more research, but I also maintain that the early body of research is quite hopeful as a manner to improve the oral health of the population by expanding affordable access.

Comment by Caitlin Hartsell — February 23, 2010 @ 10:02 a.m.

February 18, 2010