Sesquicentennial review: the making of a profession.

I shook my head on many occasions as I contemplated the changes in dentistry that have occurred over the past 150 years that I would discuss in this article, often thinking to myself, "How could the early dentists have possibly practiced dentistry every day under those circumstances and with those tools?" It made my own clinical career seem pretty easy but engendered in me great admiration for my predecessors and our profession.

Increasing productivity in dental practice: the role of ancillary personnel.

Dentistry has achieved substantial improvements in productivity which have the effect of making more care available at reasonable cost. Data are presented documenting trends in productivity. These are analyzed with respect to number of dentists, hours worked by dentists, and the use of ancillary personal in dental offices. There is strong evidence linking increased productivity to the use of ancillary personnel. The history of creation, recognition, and integration of ancillary personnel into dental practice is also presented.

The effects of insurance carrier market power on dentists and patients.

BACKGROUND: Market power among dental insurance carriers is a carrier's ability to reimburse dentists at rates below what would exist in more competitive areas. Competition among carriers for dentists' participation in their networks protects dentists from highly discounted fees. The authors examined the extent to which dental insurance carriers facing less competition increase fee discounts. METHODS: The authors selected a sample of dentists from listings of general practitioners. They identified 219 metropolitan areas and contacted 11,542 dentists in those areas by mail, telephone or both. A total of 8,017 dentists completed surveys (a response rate of 69.46 percent). The authors' key focus was the possible relationship between carrier market power and the size of the fee discount. The authors compared discounts across metropolitan areas with their differing levels of insurance coverage and carrier market shares. RESULTS: Carrier market power was directly related to the sizes of fee discounts. The larger discounts were found where there was significant dental insurance coverage and few carriers providing this coverage. Dentists' net incomes were significantly less in areas with larger fee discounts. CONCLUSIONS AND PRACTICE IMPLICATIONS: Dental insurance carrier market power leads to increased fee discounts. These higher discounts reduce dentists' earnings. Although the larger discounts may result in lower overall patient costs, this patient benefit is temporary. Ultimately, the number of practicing dentists in these communities will decrease as dentists seek improved practicing conditions elsewhere. This reduction will lead to overall fee increases until the earning potential of dentists is restored.

The effect of the Great Recession on the demand for general oral health care and orthodontic care.

BACKGROUND: This study was undertaken to quantify how the Great Recession impacted the demand for general oral health care and orthodontic care in the United States. The authors conducted an analysis to help dentists anticipate changes in demand for care during future economic downturns. METHODS: The authors analyzed Medical Expenditure Panel Survey data for the period 2003 through 2015. Data plotting for the various factors considered showed patient demand before, during, and after the Great Recession, including an indication of postrecession recovery. Statistical significance across time was determined using a χ2 test. The point estimates and statistical inferences took into account the complex survey design of the Medical Expenditure Panel Survey. RESULTS: General dentist visits declined slowly and steadily during the Great Recession, reaching a low of 38.4% in 2010, and have not shown significant signs of recovery. Orthodontic visits also declined to an all-time low of 2.5% in 2010, although they have somewhat recovered. Out-of-pocket expenditures were lower in 2015 than in 2003 for general dental and orthodontic care. CONCLUSION: The effects of the Great Recession resulted in a decrease in the demand for oral health care, differing for general oral health care and orthodontic care. PRACTICAL IMPLICATIONS: These findings, especially in combination with leading indicators for economic downturns, will allow dentists to better plan and use strategies for maintaining practice stability during periods of reduced demand for care.

Orthodontic dental patients and expenditures--2004.

INTRODUCTION: In this article, we describe recent trends in the age of patients receiving orthodontic services and look at how expenditures for these services are related to patient age and income level. METHODS: These findings are based on 3 national health expenditure surveys sponsored by the Agency for Healthcare Policy and Research conducted in 1987, 1996, and 2004. RESULTS: Recent increases in the number of patients receiving orthodontic services were largely due to an increase in the overall population. There has been a shift in the age distribution of patients receiving such services. Children 8 to 18 made up a greater percentage of all patients receiving orthodontic services, but there were fewer adult patients aged 19 years and older. CONCLUSIONS: Children 8 to 18 years old made up a larger percentage of patients who received orthodontic services in 2004 compared with 1996 and 1987. The percentage of total dental expenditures of children 8 to 18 for orthodontic services might increase in the future because of less need for restorative services among this segment of the population.

Foreign-trained dentists licensed in the United States: exploring their origins.

BACKGROUND: The authors explored the origins of foreign-trained dentists seeking licensure in the United States. METHODS: The authors analyzed data received from the American Dental Association Department of Testing Services for candidates who took the National Board Dental Examinations (NBDE) Part II from 2002 through 2005. They also established proxies for the information they sought in lieu of existing direct data. RESULTS: A total of 4,136 candidates took NBDE Part II from 2002 through 2005. The greatest number of foreign-trained dentists originated from India, the Philippines and Colombia. CONCLUSION: The greatest number of potential U.S. dental licensees are primarily from Asia, the Middle East and South America. However, precise studies need to be conducted to generate more exact data about foreign-trained dentists who practice in the United States. CLINICAL IMPLICATIONS: The source of international dental graduates seeking licensure in the United States has implications for the licensure process and for the potential accreditation of foreign dental schools.

The dental care of U.S. children: access, use and referrals by nondentist providers, 2003.

BACKGROUND: Improvements in oral health care services have not reached evenly across every segment of American society. The authors examine the role of nondentist practitioners in referring child patients for dental care by analyzing data from the 2003 Medical Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality and the National Center for Health Statistics. METHODS: The authors provide national estimates of the percentage of the civilian noninstitutionalized population of the United States aged 2 through 17 years who had a dental visit, who had a dental checkup and who received advice from a nondentist health care provider to have a dental checkup. RESULTS: Overall, 38 percent of all poor, near-poor or low-income children and 60 percent of all middle- or high-income children aged 2 through 17 years reported having had a dental checkup during 2003. The authors observed no significant differences between poor, near-poor and low-income children and higher-income children in terms of having been advised by a nondentist health care provider to have a dental checkup. CONCLUSION: Although income may not predict the likelihood of patients' receiving advice from a nondentist health care provider to have a dental checkup, children from families with higher levels of income were more likely to seek dental care than were children from families with lower levels of income. Practice Implications. Efforts to increase access to dental care should aim to maximize the benefit of advice provided by nondentist health care practitioners to receive a dental checkup, so that children from families with limited income are as likely to receive a dental checkup as are children from families with higher levels of income.

The role dentists can play in mass casualty and disaster events.

Dentistry has valuable assets, both in personnel and facilities, to bring to the initial response to a mass casualty event when the local traditional medical system is overwhelmed. This article describes the services dentists can provide to allow physicians to provide the services only they can provide. The education and training of dentists that is required for preparation and the need to develop an integrated emergency response plan are discussed.

The differences between dental and medical care: implications for dental benefit plan design.

BACKGROUND: Dental benefit plans have grown since they were introduced in the 1960s. More than one-half of the American population is covered by a private dental benefit plan today. In general, these plans have been designed to mirror medical insurance plans, despite the fact that dental care is significantly different from medical care. The author discusses the differences and how they should influence dental benefit plan design. CONCLUSIONS: The differences between dental care and medical care, how oral diseases are treated, the diseases' natural histories without treatment and the organization of the dental profession compared with that of the medical profession require that dental benefit plans be designed differently than medical insurance plans if they are to be effective. The operation of dental and medical plans requires different mind-sets. IMPLICATIONS: If they are to be effective, dental benefit plans and attempts to control the costs of those plans must be designed with the specific nature of oral diseases and the organization of the dental profession in mind.

Dental practice: prices, production and profits.

BACKGROUND: This article explores the relationship of dental fee increases, physicians' fee increases and overall price increases. The author uses the applicable consumer price indexes (CPIs) for the past 30 years to determine whether any similarities in behaviors exist. The relationship between office operating costs, production and net income also are explored. CONCLUSIONS: Although there are quantitative differences, the CPIs move in parallel fashion. An abrupt change in the overall trend of all CPIs to a decrease in the degree of increases occurred in the 1980s and has continued. Increased production by dental offices is the key strategy being used to maintain office net income. PRACTICE IMPLICATIONS: Dentists would be wise to track the CPIs for trend information that could be useful to them as they manage their practices and devise strategies to maintain net income.

The impact of concentration in dental insurance markets on dental reimbursement in Minnesota.

The following article has been prepared by the American Dental Association (ADA) at the request of the Minnesota Dental Association (MDA). The article is the culmination of a rigorous national study by the ADA to measure the concentration of dental insurance in major dental marketplaces around the country. Five Metropolitan Statistical Areas (MSA's)from Minnesota were compared to other MSA's around the country. The results of this study are very significant for dentists and dental patients in Minnesota. Minnesota' practicing dental community may find the results of the study to be somewhat disturbing. Nevertheless, the MDA believes that it is important to share the results of this study with MDA members and others in the Minnesota dental community. It is important to consider both the study's short-term ramifications, as well as its long-term implications, as we attempt to better understand Minnesota's dental marketplace. It is also important for MDA members to know that the ADA brought the results of this study as they relate to the Minnesota Dental Marketplace to the appropriate federal agencies. The ADA believed that these agencies might choose to develop it into an anti-trust case. After reviewing the matter and working with the ADA over a long period of time, these agencies decided that they would not proceed with a Minnesota-based anti-trust case; additional information beyond what the ADA was legally able to provide was needed by the federal agencies in order for them to proceed. The MDA will continue to analyze and respond to these dental marketplace developments.

Simple indicators for projecting short-term dental market fluctuations.

BACKGROUND: There have been fluctuations over time in dental care expenditures in the United States. This project aims to develop simple indicators that are easily available to people and that can be useful to predict short-term market fluctuations. METHODS: The authors analyzed data concerning 30 variables for the period of 1980 through 2012 for correlations with dental care expenditures during that period, looking for factors that historically moved in a highly correlated manner, either positively or negatively, with dental care expenditures. The authors lagged the factors to determine their potential predictive value for dental care expenditures. RESULTS: Personal consumption expenditures and gross domestic product emerged as valid leading indicators for predicting short-term dental market fluctuations. CONCLUSION: Two simple measures that are easily available to dentists and others can serve as indicators of short-term fluctuations in the dental marketplace. Their validity as indicators can, and should, be monitored regularly. PRACTICAL IMPLICATIONS: These indicators can be of significant value for practitioners in being alerted to potential market changes and planning to accommodate these changes. Combined, these factors can tell what changes are coming and when they have arrived.

Practice settings and dentists' job satisfaction.

BACKGROUND: The nature and organization of dental practice is changing. The aim of this study was to explore how job satisfaction among dentists is associated with dental practice setting. METHODS: A survey measured satisfaction with income, benefits, hours worked, clinical autonomy, work-life balance, emotional exhaustion, and overall satisfaction among dentists working in large group, small group, and solo practice settings; 2,171 dentists responded. The authors used logistic regression to measure differences in reported levels of satisfaction across practice settings. RESULTS: Dentists working in small group settings reported the most satisfaction overall. Dentists working in large group settings reported more satisfaction with income and benefits than dentists in solo practice, as well as having the least stress. CONCLUSIONS: Findings suggest possible advantages and disadvantages of working in different types of practice settings. PRACTICAL IMPLICATIONS: Dentists working in different practice settings reported differences in satisfaction. These results may help dentists decide which practice setting is best for them.

Access to dental care: solving the problem for underserved populations.

BACKGROUND: Americans are enjoying an increasing level of oral health. However, oral health improvements are not being experienced evenly across the population. The poor, some minorities, institutionalized elderly people and other groups do not have adequate access to dental care. OVERVIEW: The author discusses the need to understand clearly the barriers to care affecting underserved populations and presents a framework for designing access-to-care programs. CONCLUSIONS: The author concludes that access-to-care problems are complex and will not be solved easily or quickly. A complete understanding of the barriers to care being experienced by any group under consideration must be achieved, and an improvement plan must be designed to address those specific barriers considering the demand for care, the dental work force and the economic environment. PRACTICE IMPLICATIONS: Failure to understand the barriers to care and address them adequately will result in limited success in enhancing access to dental care for underserved populations.

Access to dental care: the triad of essential factors in access-to-care programs.

BACKGROUND: Solutions to the problem of limited access to dental care for some segments of the population are being sought. Certain factors in access-to-dental-care program design are critical to the success of these programs. OVERVIEW: The author discusses the triad of factors that are essential in the successful design and operation of programs aimed at improving access to dental care for underserved populations. CONCLUSIONS: The author found that attention must be paid to creating an effective demand for dental care, an adequate dental work force to respond to that demand and an economic environment that enables patients and dentists to participate in any programs that are aimed at improving access to care. PRACTICE IMPLICATIONS: Failure to adequately address demand, work force and economic factors will condemn any program designed to increase access to dental care to failure at worst, or to limited success at best.

Dentistry's response to bioterrorism: a report of a consensus workshop.

BACKGROUND AND OVERVIEW: The possibility of a significant bioterrorist attack on the civilian population of the United States has become a focus of local, state and national attention since the fall of 2001. An appropriate role for dentistry in the response to a massive bioterrorist attack has not yet been established, even though dentistry's role in other disasters has been developed and proven to be effective. To develop a consensus on a potential role for dentistry in dealing with bioterrorism, experts in bioterrorism issues and representatives of key organizations that could play a role in dentistry's response met at the American Dental Association's Workshop on the Role of Dentistry in Bioterrorism in June. CONCLUSIONS: In the event of a bioterrorist attack, dentists may be called on to fulfill several functions: education, risk communication, diagnosis, surveillance and notification, treatment, distribution of medications, decontamination, sample collection and forensic dentistry. Local dental societies should develop a plan for the dental response to potential bioterrorist attacks that can be integrated into each community's mass disaster response plan. Educational programs for dentists should be developed to prepare them for providing services they may be recruited to perform in an emergency. PRACTICE IMPLICATIONS: Dentistry has assets in personnel and facilities that can be of great value in responding to a major bioterrorist attack on the United States.

Self-reported satisfaction of enrollees in capitated and fee-for-service dental benefit plans.

BACKGROUND: This article examines the impact of capitated, or CAP, and fee-for-service, or FFS, dental benefit plans on the enrollees' satisfaction with their plans and their satisfaction with their dentists. METHODS: The authors selected four dental markets: California, New Jersey, Michigan and North Carolina. Eight Fortune 500 companies participated. Enrollees were selected randomly and interviewed about their experiences with their dental plans. The sample consisted of 2,340 respondents, of whom 42.3 percent were enrolled in CAP plans and 57.7 percent in FFS plans. RESULTS: The major findings were that those enrolled in FFS plans were four times more likely to be very satisfied than dissatisfied with their dental plans than were those in CAP plans. The FFS plan enrollees were 16 times more likely to be very satisfied than dissatisfied with their dentists than were those in CAP plans. CONCLUSION: Enrollees generally were satisfied with their plans and their dentists but those in FFS plans were the most satisfied. The higher the premium paid, the higher the level of satisfaction. PRACTICE IMPLICATIONS: Enrollees with perceived unmet needs were less satisfied with their dental benefit plans and dentists. Taking care of needs is the most significant thing dentists can do to affect patients' satisfaction.

Incorporating bioterrorism training into dental education: report of ADA-ADEA terrorism and mass casualty curriculum development workshop.

Numerous areas have been identified in which the dental profession may be called upon to assist in the event of a major terrorism attack. In order to successfully fulfill these roles, dentists and dental students must be adequately prepared. Dental schools play a vital role in this preparation. Participants in an ADA-ADEA workshop reached consensus that all dental students should be trained in a core set of competencies enabling them to respond to a significant bioterrorism attack, help contain the spread of the attack, and participate in surveillance activities as appropriate upon direction of proper authorities. Further emergency response training should be available to individuals interested in gaining additional knowledge and skills to assist in response to an attack. Participants also concluded that, where possible, training should be seamlessly implemented into the current curriculum without the addition of new courses; however, the group also recognized the possible need for alternative models at some dental schools. Challenges to implementing bioterrorism training into the dental school curriculum include regional variation, management of the basic science curriculum, and financial considerations. The development of an exportable training package will be considered and funding sources explored in moving forward with the development of a curriculum.