Are dentists risking losing their relevance?

Two things occurred in the last few days that helped coalesce for me a gaggle of troubling thoughts I've been contemplating over the past couple of years. The first was a report on network television about a new program at Duke University that has dramatically changed their delivery of primary medical care. The change was stimulated by Duke listening to troubling issues voiced by patients about their care at Duke. The concerns related to both patient access to care and their worries about the quality of that care they received. Prior to the change, Duke physicians provided care in the typical manner. Patients waited to see the doctor. While waiting, someone might take their vital signs, but for the most part they just waited. In addition, patients were given little or no information about how long it might be before the doctor arrived. Once the physician did come, she or he took down the chief complaint and a rushed history of the present problems. They would only ask the key questions needed to make a decision and then order tests. Finally, they'd write prescriptions or make other therapeutic recommendations. The doctor then flew on to the next room. No time was typically spent getting more in-depth information or learning about other, perhaps less acute or severe, aspects of the patient's overall health. Patients and doctors felt hurried, the number of patients the doctor could see was limited, and important features of the patient's overall health often went unaddressed. No one felt satisfied at the end of the day that excellent medical care had been provided.

Duke's answer was to change how care was delivered. Instead of the physician being the only true provider of expert services and the only decision-maker, a team was established to deliver care. The care delivery team was led by the physician and included a physician's-assistant (PA), a clinical pharmacologist (CP), nurses, and a social worker (SW). The PA met with the patient first to gather important information and ask relevant questions; the PA also ordered needed tests. The nurse gathered information including vital signs. The physician took information from other team members and met with the patient to integrate the data and ask any more questions needed to reach a diagnosis and/or treatment plan. The PA, nurse, and CP then carried out the next needed steps, including the CP determining the best pharmaceutical regimen and writing prescriptions. The SW helped to arrange financial assistance, visits to specialists or transportation, or manage psychosocial matters. Why was this approach better? Well, the physicians found they could see more patients and, as importantly, they were able to spend more time with each patient. They used the extra time to learn more about the patient's overall health, including psychological issues. The doctors also felt less rushed and less regimented. Why? Well, it was because the team approach allowed them to use less of their precious time doing routine (and to them less stimulating) aspects of patient interaction that could be done by other members of the team. Instead, they could focus on those aspects of medical care delivery that truly require 4 years of medical school and several years of residency to master.

In the business world, this is known as the division of labor. That is, taking a task and dividing it up into subunits. The subunits are then assigned to different individuals, each of whom bring the skills needed for that particular step in accomplishing the overall task, whether it be building a car or delivering a meal at Burger King. Because an individual focuses on just one aspect of the task, they become very skilled and thereby efficient at that subtask. Some steps in the task may require a much higher degree of expertise than others, such as a physician. By freeing that individual from portions of the overall task that require less expertise, or expertise physicians find challenging to keep current (like clinical pharmacology), the special expert can focus on what they, and only they, can do among the team members. This not only improves the overall productivity of the team, it also gives the special expert even greater experience and expertise, driving efficiency and quality ever higher.

I do not believe Duke is necessarily the first place to have found the team approach to health care a better strategy; they just happened to get publicized at a time I was grappling for examples to use in my own quest for ideas. More on that later.

The second occurrence in the past week that caught my attention occurred at a meeting of my state's dental society. We were working on a strategic plan for our organization and our facilitator threw a quote up on the screen. I cannot recall whom he attributed it to, so I Googled it and found it was from Jim Collins, the well-known writer of books on good business strategies. The quote, “… and for those of you who dislike change, you are going to really hate being irrelevant.” is to me one of the best statements for why individuals should always be ready to consider changing how things are done or our beliefs about something. This obviously comes at a time of great stress on the world due to the global economic crisis, with regular calls to make significant changes in how we conduct ourselves as individuals, groups, and nations.

So how do the television story on changes at Duke and the Collins quote come together for me? Well, it relates to an American Dental Association (ADA) task force to which I was appointed last year. This task force was created, I believe, in response to both the growing problem of inadequate access to dental (oral health) care by a sizable percentage of the American population, as well as to recent governmental considerations to allow the creation of new types of dental care providers.

Although there are still some debates about the severity of and reasons for problems in access to good dental care, it seems clear that in many states the citizens and their elected representatives believe there is a serious access problem. This is typically portrayed as primarily a problem in rural parts of the country that have no dentists. Yet there is evidence of concern even in areas that do have dentists. The worry is that access is compromised by the cost of dental care. Also, some patients feel they must wait longer than desired to see dentists. Sure, new dental schools are coming online, and many existing schools are increasing class sizes. But these changes are unlikely to change what I feel is a major root cause of the problem. That is, that the current way most dentists practice is poorly designed to deliver high-quality care to the large numbers of patients who are currently underserved. Every dentist knows there are practice styles that deliver care to sizable numbers of patients. They are usually called “dental mills.” These practices commonly (but not always) focus on procedures covered by public assistance programs while ignoring other aspects of a patient's oral health needs. In this way, they commonly see larger volumes of patients, but also are commonly thought to deliver suboptimal care.

In any event, due to the access to dental care problem, several states are now exploring the idea of allowing non-dentists to provide many of the services usually reserved, by license, to dentists. I understand this includes irreversible procedures such as administering local anesthesia, preparing teeth for restorations, placing and sculpting restorative materials, and extractions. Not surprisingly, this fills many dentists with discomfort and even anger. At first blush, it sounds as if legislators want to give privileges to non-dentists to do most of what we dentists provide for patients. However, is that really the case? What aspects of dentistry truly require one to have a college degree and then 4 years of professional school? Put in another way, what dental procedures really require a college degree and dental school? This is a critical question, and the answers may be tough for us to swallow. But if we chew on it awhile maybe the answer might go down more easily.

As an oral-maxillofacial surgeon and an educator, the idea of a non-dentist giving local anesthesia and extracting an erupted tooth seems fraught with danger. I have worked with literally thousands of dental students, and I have seen my share of hematomas, inadvertent facial nerves temporarily paralyzed, and many, many missed blocks. I have also seen teeth broken leaving the roots, extractions taking far longer than necessary, prolonged postoperative bleeding and pain, and occasional infections. Thankfully for the student and the patient, faculty members were there to help remedy the problems. However, it would be wrong to say that the students always needed to rely on us. The truth is that in most cases things went well once the student was taught the mechanics of tooth removal and gave more and more injections. As the students gained more experience with local anesthesia and extractions, they needed us less and less. And, once the faculty signed off on their competence, they graduated and were licensed; they and their patients had no one to rely on in their office other than the dentist we trained. Did they learn how to do local anesthesia and extractions in the classroom? Yes, in part. But, for the most part, they learned how to do these procedures by performing them.

Does this argue that dental school is therefore necessary for one to learn how to give local anesthesia and remove an erupted tooth? Well, to answer that one needs to dissect the care being provided here even further. The actual mechanics of giving an injection and removing an erupted tooth are only one aspect of care in this situation, and I feel are relatively straightforward to master. What requires more complex training and experience is what I'll call the “intellectual aspects” of the care.1 These include:

The intellectual aspects of the case are the ones I believe have more to do with patient safety and clinical success than only being able to provide local anesthesia and get a tooth out. And I feel these knowledge-based aspects of the case are the ones that do require the understanding of human anatomy, physiology, biochemistry, microbiology, pathology, immunology, molecular biology, disease pathophysiology, pharmacology, and the other aspects of a complete dental education, including how to be a critical, science-based thinker; and also requires college level preparation and the intellectual maturity college helps create.

Many dentists participate in dental missions to provide needed health care in financially poor parts of our country and the world. They commonly bring along dental students, some of which know how to extract teeth before they go, but many of whom have never taken out a tooth or ever given local anesthesia. Most haven't yet taken all their basic science courses or gained competence in exodontia. I know that in many cases those students are quickly taught the basic mechanics of local anesthetic administration and tooth removal while at the mission site, and proceed to do so, under the watchful eye of the “chaperone” dentists. And, with respect to local anesthesia, there are many states where dental hygienists are licensed to give local anesthesia without being dentists or having graduated from college.

So, am I saying you do not need to be a dental graduate to safely remove a tooth? Not really. What I am saying is that as long as there is a dentist working with a patient needing an extraction, the actual delivery of the local anesthetic and removal of a tooth might be done safely by a non-dentist. Legislators and others might then ask, well why is the dentist needed at all or why can't the dentist be across town, able to come if problems arise or available via telephone? I believe the reason the dentist should be readily available is because of those intellectual aspects of the care being provided. The making of the proper diagnosis and treatment decisions, the ability to foresee problems, and the ability to manage the unusual during or after surgery are what makes the dentist essential to safe care.

I use the removal of a tooth my primary analogy because I believe I have the most credibility as an oral-maxillofacial surgeon and an educator. However, a similar argument could be made for preparing a tooth for a restoration and then placing the restoration. Taking a dental handpiece and bur to take away tooth structure and ready it for a restoration, and then placing a restoration, is in the real sense an irreversible procedure. Most dental school programs begin preparing students to do this aspect of dental care before much of their basic science education has occurred. Is this because college prepared them to manage dental disease in some special way? Unlikely. The actual preparation of teeth is learned in a process more akin to an apprenticeship than the building of scientific knowledge via didactic education. Sure one must learn things such as surface tension and friction, and how various materials function. But to go ahead and learn how to properly prepare a tooth, one mainly needs acceptable hand-eye coordination and the ability to follow directions. There is little judgment needed in knowing the basics of preparing a tooth. The faculty member teaching tooth preparation will typically describe how to do it, then show you how they do it, and then watch you while you attempt to mimic them. Eventually most students can do so and thus learn how to do various tooth preparations. Learning how to fill the prepared tooth is taught in a similar manner. So again I ask, what, if anything, do dental students learn in college to prepare them to prep and fill teeth that makes someone without a college education unable to do so?

Remember, I believe the actual preparing and filling a tooth is not the totality of proper care delivery. Rather it is the intellectual aspects of the case, like deciding if a restoration is needed, what kind of restoration, should the patient be told their situation has a higher chance of failure, what to do if problems occur with the tooth or the patient during the procedure, and other aspects of restoring a diseased tooth that go far beyond the actual mechanical preparation of a tooth. I also don't believe it is far-fetched to predict that in the not-so-distant future tooth preparation will be a robotic procedure and most restorations will be milled or otherwise custom manufactured in the dentist's office. Will that eliminate the need for dentists? No way, because the intellectual aspects of patient dental care will be too hard to duplicate by machines for a very long time, if ever.

Do I believe dentists then don't need to learn how to prepare and fill teeth or do extractions? No way! These skills are necessary to both be able to learn more complex procedures and be ready to assist or take over for a dentist-extender unable to use straightforward means they've been taught to do these procedures.

Some may say that only fully trained dentists can acquire the special touch that lets one know when you are approaching the dental pulp and need to more carefully continue any additionally needed tooth preparation, or consider indirect pulp capping strategies. Or in the case of exodontia, be able to feel when one is applying so much pressure that one risks fracturing a jaw. But the way one develops that judgment (that touch), which sounds the alarm that other techniques are needed, comes not from reading books or articles, or from clinical simulations; it comes from repeatedly doing procedures on patients. Hopefully one is overcautious while learning and spares the patient problems by backing off long before problems occur. But as one gains more experience one learns how much one can safely do. This experience based on repetition doesn't necessarily occur in dental school. It often arises months or even years after dental school, particularly if one trains in a school unable to provide students enough repetitions to master a procedure. I submit that we should consider that non-dentists can master straightforward procedures (the mechanical aspects) in the same way. And because such individuals can focus exclusively on those procedures, they can reach mastery more quickly, while the neophyte dentist must spend much of their energy and focus delivering the intellectual aspects of dental care, as well as mastering more complex procedures that no one is questioning requires complete dental training.

So what am I leading to in this essay? It is that rather than stick to the position that dentists, and only dentists, can safely do dental restorations and extractions, might we consider supporting an approach more like the Duke example. That is, propose a dental care strategy that has the dentist as the leader of a team and the team include individuals that can do some of the very routine mechanical aspects of dental care. This strategy would expect the presence of the dentist, but would allow non-dentist special assistants (dentist-extenders) who, under the dentist's orders and guidance, do routine yet irreversible aspects of patient care. These dentist-extenders would be trained and licensed to do the mechanical aspects of routine cases, like local anesthesia, class II restorations, and extractions. Then, when the dentist decided a patient needed those services, could have the dentist-extender perform the actual procedure. If the extender experienced anything unusual they would be trained to have the dentist intervene and use the dentist's education and training to help determine what the extender should do or even complete the procedure themselves.

How would this be of any benefit? Well, by freeing up the dentist from some routine procedures they could be like the Duke physicians. The dentist could see more patients and perhaps spend more quality time in the diagnostic and treatment planning of patients. They could also focus on the delivery of more complex procedures that only they could provide. This division of labor to those on the team according to who can do each aspect more efficiently or safely will give the dentist a more solid basis upon which to maintain the status of the quarterback of dental care, increase the office's productivity, increase patient flow, and, I maintain, is very likely to make a positive change in the financial health of a practice. This is particularly likely if dentists are able to spend more time doing the complex procedures that have better financial margins.

Of course, improved productivity and financial success could lead some dentists to just take more time off. But I feel most would use their improved productivity to see more patients and perhaps even be able to maintain their fees or even lower them, with greater volume more than making up the difference. I believe general dental practice would be more fun, since the more routine, less stimulating types of procedures would be delegated to other team members. This already occurs in practices where dentists work with dental hygienist. These specialty trained individuals, once experienced, typically provide hygiene care at least as good as that delivered by a dentist, and this frees the dentist up to do less routine services. Many orthodontists I visit seem to make great use of the team strategy, having specially trained and experienced assistants do many of the routine mechanical aspects of orthodontic care, while the orthodontist focuses on diagnosis, treatment planning, and handling the less-routine, more intellectually demanding aspects of orthodontic treatment.

I was educated in the 1970s and our dental school was part of the TEAM program. We had specially trained expanded-duty assistants. These assistants had been trained to place rubber dams, carve amalgams, and make temporary crowns. This allowed us as students to see two patients at a time (revolutionary) and be 100% more productive. It was a real letdown to go back to having to do all these things myself and slow back down when I rotated off my time in the TEAM program. I believe some states now permit this kind of assistant, but certainly not most. But why not? Are we so convinced that no one other than ourselves can do dental procedures that we won't consider other care models? If so, I fear the Jim Collins quote will come true. There are those who do feel people with less training than dentists can do several of the routine irreversible things we perform. They are convincing government officials and the public that this is true. Thus, we're seeing state after state strongly considering the training and licensing of non-dentist providers. What worries me the most is that they are doing this in spite of protests from dentists. Plus, and most distressful, these midlevel providers are not mandated to work under the auspices and supervision of a dentist. Why I'm worried is hopefully clear from my earlier statements. It is because I do not feel these midlevel providers can or will be given enough training to be able to provide the intellectual aspects of patient care that truly protect patient safety and excellent outcomes.

Don't think this will happen? Well let me paint you a picture of the future that has a strong possibility of coming true based on current trends. Mrs. Diaz, whose husband heads up the local government-run bank and makes a reasonable income, hasn't had regular dental care for several years. They have good dental coverage so she goes to the website and finds the list of allowed providers. Mrs. Diaz chooses one that practices in a nearby shopping center since her pharmacist changed her antihypertensive drug regiment and she needs to pick up the prescriptions. While waiting for her dental appointment, Mrs. Diaz notices a diploma on the wall. At first she assumes it is a dental degree, but upon a closer look sees that it is from a community college. It is a degree in dental therapy. She assumes this is the hygienist's diploma. Once in an operatory, a person comes in, introduces herself and looks over the forms Mrs. Diaz filled out in the reception area. The person asks a few simple questions, examines Mrs. Diaz' mouth and makes some digital images of Mrs. Diaz' teeth. She looks at the images and tells Mrs. Diaz that unfortunately she has several carious teeth, needs routine hygiene care, a few extractions, and may benefit from some implants. Mrs. Diaz is surprised at this point since the provider was the person whose name was on the diploma and she assumed the dentist would be in to go over her record and determine the treatment plan. Mrs. Diaz is further surprised when the dental therapist lays out the treatment plan schedule. It will begin with restoring the carious teeth while tending to Mrs. Diaz' periodontal needs, and end with some needed but not urgent extractions and once a year check-ups. Mrs. Diaz asks about the possibility of implants to replace the teeth she'll be losing. The therapist says, “Oh I don't do those. I'll refer you to a dentist for that work.” I could go on with the picture at this point, describing how dental therapists are now the preferred provider of routine dental care and work independently of dentists, but my diatribe is already lengthy.

Some may say let some states go ahead with plans for mid-level providers; it cannot happen in my state. Nonsense. If legislators and citizens see reports that mid-level providers are delivering routine care at a lower cost and seeing patients dentists don't currently have the time or inclination to see, they will ignore the protests of dentists and change their dental practice acts. In addition, once a provider is out there doing mainly routine aspects of dental care and doing it successfully, at least in most cases, they will become the dental gatekeepers. Sure, fully trained dentists will still be needed, but we will only get cases the mid-level provider chooses to refer to us, namely those with complex medical problems and complex dental needs. And the mid-level provider will possibly take care of all the straightforward aspects of care, leaving only the most difficult and less commonly covered dental problems for the dentists.

I try to be optimistic for the most part, but in this situation it is hard to be optimistic for dentists. This is because I worry that it will be too late before enough dentists recognize the threat and bodies like the ADA House of Delegates take actions to head off the track we're on at present. And by head off, I do not mean just say “no” or propose halfway access to care measures like the “dental social worker” kind of plan. Rather, we need to put forth an audacious2 plan that keeps the dentist properly positioned in the leadership position of a team that includes dental extenders. These providers need training that should have to follow standards and be under the Commission on Dental Accreditation, and work under the authority of state dental boards. I feel such training should be provided by dental schools where dental-extenders and dental students could learn to work with each other, and the students learn how to best utilize these individuals. The dental team will also likely benefit, especially in areas with fewer dentists, from dental social workers who can help educate citizens about oral health, guide people to the dental practice, and help those in need to qualify for dental benefits, particularly if dental care comes to be under any national health plan. The training of dentist-extenders may also need to be done by organizations like the ADA for a while to help in the ramp-up time of such a new endeavor.

My goal in this essay is not to push the concept of dentist-extenders as the only viable path. My only agenda is a sincere attempt to say it's time to get real and starting discussing meaningful changes to how we deliver dental care. We must stop pretending or wishing things aren't in need of change, or waiting for day the government increases Medicaid coverage for dental care to appropriate levels. Dentists are at serious risk of losing a large part of our relevance. The truth is change has occurred. The cat is out of the bag, the popcorn has popped, the toothpaste is out of the tube. Dental therapists, or whatever other terms used for them, are out there practicing. And more are on the way, eventually coming to a state like yours. The debate is no longer should or will this happen; it has happened. Are we as dentists going to pout and tell everyone what a bad idea dental therapists will be, expecting that to somehow make them go away?

I submit a better strategy is to carefully examine what aspects of dentistry separate us from mere technicians. I believe those are the intellectual aspects of insuring safe and excellent dental care. These are the ones that cannot be easily replicated by attending a community college or 2-year training program. Patients are best served when cared for by a dental team led by a dentist. But dentistry must come to grips with the reality that dentists alone cannot efficiently deliver all the needed care. To that end, I believe the idea of dentist-extenders put forth in this essay is at least one idea worth considering.

In the end, I envision a day when oral health in America is available to all its citizens, and delivered by teams led by dentists. But for this vision to become reality the dental profession must become more of a proponent of a viable and bold solution to the access to care problem, whether the problem is due to the number of dentists or the cost of dental care. The time has ended for us to just be against the proposals of others who seek solutions to the dental access problem in America. Adding a dentist-extender to the dental team in a dentist's office offers a real chance to accomplish the goal of access to good oral health for all. I am certain that once we as a profession accept that real change is needed in how we deliver care, other even better ideas will emerge. The time to debate the existence of a problem has past.