The effects of insurance carrier market power on dentists and patients

BackgroundMarket 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.MethodsThe 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.ResultsCarrier 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 ImplicationsDental 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.     

Dental Care for Pregnant Women

BackgroundThe authors conducted a study to examine factors associated with general dentists' provision of care for pregnant women and the extent to which they provide comprehensive dental care.MethodsThe authors mailed an 86-item questionnaire to 1,000 practicing general dentists in North Carolina. Survey domains included provider knowledge about pregnancy and dental health, dental treatment practices, barriers to providing care, outcome expectancy, and personal and practice demographics. The primary dependent variables the authors analyzed were whether dentists provided any treatment to pregnant women and, among those who did, the extent to which they provided comprehensive services. The authors performed multivariate regression analyses to determine factors associated with dentists' provision of care to pregnant women (P < .05).ResultsA total of 513 surveys were returned (a response rate of 51.3 percent), of which 495 surveys had complete responses. The authors included the completed surveys in their analyses. The mean age of the respondents was 46 years. The results of multivariate analysis showed that respondents who perceived a lack of demand for services among pregnant women and provided preconception counseling were less likely to provide any treatment for pregnant patients than were those who perceived a demand for services and who did not provide preconception counseling, respectively. Dentists who were male, had a low knowledge score, provided preconception counseling and treated largely white populations of patients were less likely than female dentists, those who had moderate or high knowledge scores, and those who treated a population of minority patients to provide comprehensive care for pregnant women.ConclusionsMost general dentists in private practice provide care for pregnant women, but the authors found notable gaps in dental provider knowledge and comprehensive dental services available for pregnant women.Clinical ImplicationsAlthough many general dentists provide some dental care to pregnant women, more should be done to ensure that this care is comprehensive.     

Variations in self-reported provision of services by general dentists in private practice

BackgroundVariations in dentists&;apos; provision of services have been documented, but information about contributing factors is limited.MethodsThe authors used responses to a 2003 survey of general dentists in private practice in California (46 percent response rate; 3,098 dentists included in the final sample) to assess variations in service provision and its correlates. They used logistic regressions to assess the correlation of various characteristics with the self-reported percentage of time spent providing services.ResultsThe results show variations in services provided by general dentists in private practice. Multiple factors, including the dentist&;apos;s sex, region of practice, employment of hygienists, patients&;apos; race and population income in the area of practice were significantly and independently associated with provision of services.ConclusionsThe survey results reflect practice variations that existed before the latest economic downturn, which resulted in a loss of jobs and medical and dental insurance. The data serve as the baseline for future studies of changes in dental practice and for assessing the impact of the 2010 health care reform legislation on dental practice.Practice ImplicationsImprovements in oral health care, the recent economic decline and health care reform may lead to changes in dental practice and in the dental workforce.     

Dentist Workforce Trends in a Primarily Rural State: Iowa: 1997–2007

BackgroundState dental boards maintain minimal demographic and practice characteristics about licensed dentists. The authors describe the creation and monitoring of an enhanced surveillance system concerning Iowa's dentists.MethodsThe Iowa Dentist Tracking System (IDTS) was used to collect demographic, educational, practice arrangement, office location and work hour data for all active Iowa dentists beginning in 1997. IDTS staff members add newly licensed dentists to the system as practice locations become available. They also contact each dental office semiannually by telephone to update this information. The IDTS Advisory Committee meets annually to review these data and monitor trends.ResultsThe Iowa dentist workforce was relatively stable from 1997 through 2007; however, a large number of dentists are expected to retire during the next decade, which could create a shortage of providers, especially in rural areas. Although the percentage of male and female dentists who practice part time (< 32 hours per week) decreased between 1997 and 2007, young female dentists are more likely than young male dentists to practice part time.ConclusionsIDTS is a workforce tracking model that can be used to understand trends at the community, regional and state levels. An aging dentist workforce in Iowa could put a strain on the public's ability to access dental care, especially in rural counties.Practice ImplicationsIn the development of workforce policy, workforce tracking systems such as IDTS provide additional information in considering the number of dentists, location, accessibility and potential productivity of a workforce.     

Trend analysis of dental practice rent and mortgage expenses: 1989-1995

BACKGROUND: The authors analyzed trends for rent and mortgage, as reported by independent active private practitioners, for the period of 1989-1995. Rent and mortgage were analyzed overall and by different characteristics. METHODS: In the ADA's annual "Survey of Dental Practice," dentists reported gross billings and net incomes, as well as itemized practice expenses. The authors tabulated survey responses over time to develop trends and compare rent and mortgage expenses for each year. If trends over time were not exhibited, the authors combined multiple years of data to develop more reliable statistics. RESULTS: Approximately three-fourths of independent active private practitioners reported rent but no mortgage expenses. The percentages of practitioners who reported rent or mortgage was stable over time. The percentage reporting rent only as an expense increased with the number of dentists in the practice, the age of the reporting dentist and the number of office locations. In contrast, the opposite was true for dentists reporting mortgage only as an expense. CONCLUSIONS: The authors found that office rental is more common than is office ownership and that mortgages as a percentage of gross billings and in dollar amounts were similar to rents. They also found that because the cost of office space as a percentage of gross billings decreased as the number of dentists in the practice increased, limited economies of scale may be present in the cost of dental office space. PRACTICE IMPLICATIONS: There is not a large financial advantage to ownership, so renting is likely to remain an important way to acquire office space. As only limited economies of scale exist in office space expenses, many group practices may choose to rent office space.     

Rural dentists: Does growing up in a small community matter?

BackgroundThe aging of the dental work-force has implications for both patients and dentists, especially those in rural and underserved areas. Anecdotal information regarding dental workforce trends indicates that students from rural communities are more likely to practice in rural communities than are students from urban areas. Although the medical literature supports this premise relative to physicians, there are no data to verify this statement relative to dentistry. Therefore, the authors decided to study whether this premise applies to dentistry.MethodsThe authors conducted a retrospective analysis of dental student records from a Midwestern dental school for the years 1980 through 2010 to determine if there was a statistical correlation between the size of a dental student's town of origin and the size of the community where he or she practiced after graduation. They also examined what role, if any, the student's sex played.ResultsDentists from rural areas were approximately six times more likely to practice in a rural area than were dentists from urban areas. Female dentists were only slightly less likely to practice in a rural community than were male dentists.ConclusionDentists from rural communities were more likely to practice in rural communities than were dental students from urban areas.Practice ImplicationsTo ensure future access to care in rural communities, rural dentists may want to recruit actively or work closely with dental students from rural areas when hiring associates or seeking purchasers for their dental practices.     

Dentists' variability in restorative decisions, microscopic and radiographic caries depth

Abstract Restorative and dental caries depth decisions were recorded for 5168 unrestored approximal tooth surfaces by 17 dentists who worked in the school dental clinics of the North York (Ontario) Public Health Department. Each dentist examined 15 pairs of experimental bitewing radiographs for which true caries depth had previously been determined by microscopy of the sectioned teeth following production of the radiographs. The dentists independently recorded their restorative decisions and radiographic caries depth perceptions. The relationship between the variation in the dentists' restorative decisions and their perceptions of caries depth based on a re-reading of the bitewings on the one hand, and true caries depth on the other was also examined. The percentages of total variability in each dentist's restorative decisions attributable to radiographic and to microscopic caries depth were estimated using regression analyses. Large variations were found among the 17 dentists' distributions of overall restorative and depth decisions. The relationship between microscopic caries depth and the dentists' restorative decisions was, understandably, less strong than that of the dentists' radiographic perceptions of caries depth and restorative decisions. Relative to true caries depth, high numbers of false positive and false negative restorative decisions were made. Overall, 50% of the variability in the dentists' restorative decisions was explained by their perceptions of radiographic caries depth; however, among individual dentists, the range was from 29% for one dentist to 69% for another. A much lower percentage of the overall restorative variation was explained by microscopic depth, 18%. Like the findings of the only two previous European studies that quantified the role of radiographs on clinical decisions, this study demonstrated that dentists' perceptions of dental caries depth using bitewing radiographs play a major but variable role in their restorative decisions for approximal tooth surfaces.     

Counseling on Early Childhood Caries transmission by dentists

Objective: High levels of Streptococcus mutans on teeth of young children are predictive of Early Childhood Caries (ECC). Transmission from mother‐to‐child is common and studies have demonstrated treatment of the mother results in less ECC. The objective of this study was to determine how dentists have adopted the practice of counseling about ECC. Methods: In 2006 as part of a larger study on dental care for pregnant women, we surveyed 829 general dentists in Oregon. The questionnaire contained questions to capture the extent to which general dentists have adopted counseling pregnant women about ECC transmission, to describe personal and practice characteristics, and examine how dentists' views on the ease of adopting of new procedures related to ECC counseling. Multivariate logistic regression was used to identify separate and additive effects of demographic and practice characteristics, attitudes, and beliefs. Results: The adjusted odds of a dentist who strongly believed in the link between mothers and babies and provided ECC counseling were 1.60 (95% CI 1.3‐2.0, P < 0.01). The odds of a dentist who reported discussing ECC with staff members and provided counseling were 2.7 (95% CI 1.7‐4.3, P < 0.01). Male dentists were less likely to counsel patients than female dentists (Adjusted OR = 0.5, 95% CI 0.3‐1.0, p < 0.05). Conclusions: The strongest predictors of counseling patients about ECC were dentists' belief in the evidence of caries transmission and dentists' discussion of ECC during staff meetings.     

A comparison of expectations and impressions of ethical characteristics of dentists: Results of a community primary care survey

BackgroundTo better define potential challenges in dental professional ethics, the authors gathered data regarding patients’ characterizations of an ideal dentist and compared them with their impressions of dentists in general.MethodsThe authors invited 500 consecutively seen primary care patients at an academic medical center to participate in the study. Participants completed a 32-item survey assessing key domains of ethical characteristics of health care professionals: trustworthiness, honesty, beneficence, nonmaleficence, respect for autonomy, empathy, compassion, patience, courage, humility and dedication. The authors used the McNemar paired t test to compare respondents’ ratings of ideal dentists with their ratings of dentists in general.ResultsTwo hundred eight-five patients returned completed surveys, for a response rate of 57 percent. The authors found statistically significant differences between ideal and perceived characteristics in all but one domain. The area of greatest difference related to the domain of trustworthiness (that is, dentists should not “propose unnecessary treatments just so they can make money”). For this survey item, 98 percent of patients reported that it was very or extremely important, but only 57 percent of respondents moderately or strongly agreed that dentists in general were engaging in this practice (P < .0001).Conclusions and Practical ImplicationsThese data reveal gaps between patients’ expectations of the dental profession and their actual impressions of dentists in general. Addressing these discrepancies may be crucial if dentistry is to continue to enjoy the public's trust.     

The dental safety net in Connecticut

BACKGROUND: Many poor, medically disabled and geographically isolated populations have difficulty accessing private-sector dental care and are considered underserved. To address this problem, public- and voluntary-sector organizations have established clinics and provide care to the underserved. Collectively, these clinics are known as "the dental safety net." The authors describe the dental safety net in Connecticut and examine the capacity and efficiency of this system to provide care to the noninstitutionalized underserved population of the state. METHODS: The authors describe Connecticut's dental safety net in terms of dentists, allied health staff members, operatories, patient visits and patients treated per dentist per year. The authors compare the productivity of safety-net dentists with that of private practitioners. They also estimate the capacity of the safety net to treat people enrolled in Medicaid and the State Children's Health Insurance Program. RESULTS: The safety net is made up of dental clinics in community health centers, hospitals, the dental school and public schools. One hundred eleven dentists, 38 hygienists and 95 dental assistants staff the clinics. Safety-net dentists have fewer patient visits and patients than do private practitioners. The Connecticut safety-net system has the capacity to treat about 28.2 percent of publicly insured patients. CONCLUSIONS: The dental safety net is an important community resource, and greater use of allied dental personnel could substantially improve the capacity of the system to care for the poor and other underserved populations.     

The role of Pakistani dentists in tobacco cessation

Objective : To assess Pakistani dentists' ability, willingness and perceived barriers to carry out tobacco cessation activities for their patients in the dental office. The study is limited to the smoking form of tobacco use. Method : Using a structured questionnaire for a cross sectional study, 239 full time or part time practising licensed dentists based in Islamabad and Rawalpindi were recruited by two sampling techniques; convenience and cluster sampling. Participation rate was 66.2%. Result : Based on the characteristics, the study population is assumed representative of the average Pakistani dentist. Prevalence of smoking amongst dentists was 20.3%. Only one‐third rated their knowledge and ability regarding tobacco cessation messages as good/excellent. The majority of the dentists considered tobacco cessation activity as peripheral to their profession. The main barrier to performing tobacco cessation interventions was cited as gender. Conclusion : Dentists exhibit a superficial approach to delivery of smoking cessation care. It is recommended that dentists be trained in delivering effective tobacco dependence intervention, using the WHO/FDI advocacy guide for oral health professionals, modified to incorporate gender oriented culturally sensitive doctor‐patient interaction. Tobacco cessation clinics should also be set up in private and public sectors to augment the dentists' participation.     

Preventing dentists' involvement in torture: The developmental history of a new international declaration

BackgroundFor more than half a century, the risk of physicians participating in torture has received thoughtful attention in the field of medicine, and a number of international organizations have issued declarations decrying such involvement. Despite publications that provide evidence of dentists' having participated in torture as well, until recently the dental profession was quiescent on the subject.MethodsThe authors describe the historical background for a new declaration against dentists' participation in torture developed by the International Dental Ethics and Law Society and the Fédération Dentaire Internationale (FDI) World Dental Federation. They review various levels of involvement by dentists in torture and related activities in reference to existing World Medical Association declarations. Finally, they outline the process of drafting the new dental declaration, which was adopted by the FDI in October 2007.Clinical ImplicationsThe authors provide insight and guidance to clinicians who diligently serve their patients, unaware that they may face military or other pressures to participate in torture.     

What's in a dental practice-based research network?: Characteristics of Northwest PRECEDENT dentists,their patients and office visits

ObjectivesThe authors conducted a study to describe the general dentists, practices, patients and patient care patterns of the dental practice-based research network (PBRN) Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry (PRECEDENT).MethodsNorthwest PRECEDENT is a dental PBRN of general and pediatric dentists and orthodontists from five U.S. states in the Northwest: Idaho, Montana, Oregon, Utah and Washington. The authors collected data from general dentists in Northwest PRECEDENT (n = 101) regarding the diagnosis and treatment of oral diseases in a survey with a systematic random sample of patients (N = 1,943) visiting their practices. They also obtained demographic data from the general dentists and their patients.ResultsThe authors found that 50 percent of the general dentists were 51 to 60 years of age, 14 percent were female and 76 percent were non-Hispanic white. More than one-half (55 percent) of the dentists had practiced dentistry for more than 20 years, 83 percent had private solo practices and 32 percent practiced in rural community settings. The majority (71 percent) of patients visiting the dental practices was in the age range of 18 to 64 years, 55 percent were female and 84 percent were non-Hispanic white. In terms of reasons for seeking dental care, 52 percent of patients overall visited the dentist for oral examinations, checkups, prophylaxis or caries-preventive treatment. In the preceding year, 85 percent of the patients had received prophylaxis, 49 percent restorative treatments, 34 percent caries-preventive treatments and 10 percent endodontic treatments.ConclusionsNorthwest PRECEDENT general dentists are dispersed geographically and are racially and ethnically diverse, owing in part to efforts by network administrators and coordinators to enroll minority dentists and those who practice in rural areas. Estimates of characteristics of dentists and patients in Northwest PRECEDENT will be valuable in planning future studies of oral diseases and treatments.     

Respect for Patients' Autonomy

BackgroundRespect for patients' autonomy is an ethical principle in health care highlighted in the ADA Principles of Ethics and Code of Professional Conduct. The author presents a case example to illustrate its importance in dentistry.MethodsUsing a clinical example of disrespect for patients' autonomy, the author underscores the importance of incorporating normative ethical principles in patient-dentist relationships.ConclusionsRespect for patients' autonomy sustains healthy boundaries between patients and the clinician. It underscores the importance of providing patient education and counsel without attempting to persuade or manipulate patients for dentists' benefit.Practice ImplicationsRespect for patients' autonomy is a fundamental principle of health care ethics that patients expect dentists to follow. The author encourages dentists to incorporate this principle into every patient encounter.     

Association between perception of dentist oversupply and expectations of dentistry: a survey of dental graduates in Japan

Background: The perception that there is a surplus of dentists may be an opportunity to explore attractive career options in dentistry in Japan. Methods: A self-administered questionnaire was mailed to 2,114 graduates of a private dental school in Japan. We asked about the perception of oversupply, rated by a visual analogue scale, work environment factors, potential areas of dentistry and necessary medical subjects for their dental practice. The association of a strong perception of dentist oversupply with work environment factors, dental areas and medical subjects was examined by multivariate logistic regression analyses. Results: The response rate was 66%, and data from 1,203 community dentists were analysed. Most respondents (76%) perceived either a strong or very strong surplus of dentists. A very strong perception was significantly associated with work environment factors, including practising in large cities and earning the second lowest of four levels of annual income, but no further associations were found with either the number of patients treated or with the other two ranges of income. This perception was negatively associated with the number of necessary medical subjects, specifically otorhinolaryngology, but no significant association was seen with the number of potential areas of dentistry. Conclusions: The negative correlation between the aspiration to acquire medical knowledge and the perception of dentist oversupply under the circumstance of the possibly excessive perception among community dentists invites further research on the benefits of teaching oral medicine to graduate entry students to build future working satisfaction.Key words: Perception of surplus, dental practice, dental education, oral medicine     

Conference Report

Abstract

The criteria that dentists use to judge the need for orthodontic treatment are not clear. This study investigates variation in dentists' perception of orthodontic treatment need. Seventy-four dentists were asked to assess 320 dental casts in relation to aesthetic and dental health need. The results of this investigation revealed that the panel was divided as what constituted a need for orthodontic treatment on dental health grounds. It is suggested that one method of achieving a more uniform evaluation of orthodontic treatment need is the use of an occlusal index. Until an occlusal index is accepted and used by the profession, the distortion of need and demand for orthodontic treatment by dentists' unequal perceptions will continue.