The President Responds
Featured in AGD Impact, May 2008
Pg. 48

Posted on Thursday, May 08, 2008

The March 2008 issue of the Journal of the American Dental Association (JADA) includes an editorial written by JADA Editor Michael Glick, DMD, and O.T. Wendel, PhD. Academy of General Dentistry (AGD) President Vincent Mayher, Jr., DMD, MAGD, responded. The following letter is the original letter that was sent to the JADA editor in response to that editorial. A second, shorter version of the letter—a length that was necessary to meet JADA publishing guidelines—was forwarded to the editor several days later.

Michael Glick, DMD

Editor, JADA

211 E. Chicago Avenue

Chicago, IL 60611

Dear Dr. Glick:

Upon reading the title of the Commentary/Editorial “Lessons Learned: Implications for Workforce Change” (Journal of the American Dental Association, March 2008), the reader must assume that that “lesson” that was learned was from the Alaska DHAT situation. Since there was no disclaimer that this opinion is that of the authors, and not that of the American Dental Association (ADA), this editorial could be construed as the authors (Drs. Wendel and Glick) offering an official “mea culpa” on behalf of the ADA. 

The opening sentence states, “We should not be threatened by emerging groups of oral health providers but invite them into our midst....” I would respectfully ask, who are the authors referring to when they use the word “we”? Is it the dental education community? Is it the specialist community? Or, is it the general dentist-private practitioner community—those of us “in the trenches”?

As a general dentist who has spent the past 27 years in those hallowed trenches, I would also ask the question: Will these mid-level providers be performing specialty services, such as endodontic therapy, periodontal surgery, fixed orthodontics, or surgical extractions? Or will they be performing restorative dentistry, the mainstay of those of us in general practice?

The authors repeat the warning that “demand for oral health care is forecasted to increase dramatically over the next decade....” While this may or may not be the case, those of us in the trenches still have holes in our schedules. If you call my office today, chances are that you will be able to get an appointment tomorrow.

With respect to disparities in service delivery, this is definitely a problem that needs to be addressed. But, essential to this is the need to educate the public, especially those in the vulnerable segments of society who not only need to be made aware of the importance of good oral health but of the importance of good general health in an environment that is conducive to such learning. 

We were all saddened to read of the totally avoidable and tragic loss of two children a year ago, due to complications of dental disease. Questions continue to be asked: Were these situations in which the patients went from dental office to dental office and were repeatedly turned away? Or, were these situations where dental treatment was not prioritized because the patients and their families were not educated to understand the importance of optimal dental health?  

The issue is not whether the provider of dental services is a dentist or a so-called “mid level provider.” Creating and enhancing social services that will ensure that those in need of treatment will understand the value of dental care is the much-needed first step. And if you disagree, ask any general practitioner who treats Medicaid patients about how much higher the “no-show” rate is among this patient population. 

Clearly, many of these individuals are dealing with severe economic, cultural, and social problems that hamper their ability to address their dental needs. This is where applicable social services could augment access to care. Private dental offices simply are not equipped to deal with the social circumstances surrounding Medicaid patients’ lack of prioritization for dental treatment. To offer up as “the solution” to this disparity, the CDHC and the ADHP is a “band-aid” approach, at best.

Toward this effort, the authors argue that academic institutions need to immediately assume a leadership role in reshaping a new system of oral health care education and delivery modeled after the medical model where “physician assistants and nurse practitioners assume greater responsibility for primary medical care” and where opportunities would be created for “practicing dentists to learn how to incorporate and coordinate oral health care services for their patients together with other allied health professionals who will be given the opportunity to carry out many of the procedures that today can be performed only by dentists.” Again, I respectfully ask, will these include those procedures that are many times referred to as “specialty” procedures?

The dental community has long been subjected to the warning that we need to take proactive steps to address health care disparities before “we are told what to do.” The ADA delegates heard this in 2006 in the much remembered “freight train coming your way” speech that was presented to them.

If this federal “freight train” is to gain momentum, it will need money to fuel it. Additional funding for dental care is something the federal government has been reluctant to ante up for many years. In fact, the trend is quite the opposite. We have seen decreased Medicaid funding and have been fighting a continued battle to increase funding for Title VII, General Practice Residencies (GPR) back to their 2005 levels, before they were mercilessly slashed to prehistoric levels. These are the same GPRs that brought dental care to the underserved communities with a proven record of retaining graduates of these programs in those communities. With less and less fuel to sustain it, I wouldn’t be looking for that freight train to be arriving any time soon.

Remember, while the authors write that “the academic institutions are in the driver’s seat,” the problem we face is much bigger than the DHAT issue, and it presents a more complex set of economic, cultural, and social hurdles than can be solved with the wave of a magic wand and the creation of mid-level providers, while, at the same time, meddling with state dental practice acts. 

All of the communities of interest need to be at the table to address the future of dental care. And, the predominant force needs to be that of the general practitioner in the trenches who historically has been on the outside looking in when it comes to having a say in changing trends in the delivery of dental care.

And, while open discussion is essential, it should not move quickly to planning—not until the barriers to equitable delivery of oral health care are painstakingly identified. Then, and only then, can objective, apolitical, and realistic remedies be presented to the dental community and to the patients, who so very much are in need of our services.

Vincent C. Mayher, Jr., DMD, MAGD

President

Academy of General Dentistry