American Association of Dental Consultants Articles tag:aadc.org,2008:/site/articles//1 2008-09-10T21:25:41Z AADC Presents articles and opinions of interest to the Dental Benefits Industry. Many of the topics presented may be found in our Associations Publication The Beacon. We make every effort to reference all content to the submitting author. Movable Type 3.31 The Beacon: Spring 2008 tag:aadc.org,2008:/site/articles//1.80 2008-09-10T21:23:52Z 2008-09-10T21:25:41Z The Spring Issue of the Beacon is now available for download here.... admin here.]]> Defining and Differentiating Inlays and Onlays tag:aadc.org,2008:/site/articles//1.78 2008-02-06T23:14:59Z 2008-09-04T23:19:13Z AADC Positions Committee Position Statement: Defining and Differentiating Inlays and Onlays The availability of new technology continues to advance the practice of dentistry and provides dentists with opportunities to practice more efficiently with improved treatment outcomes. However, as more dentists... admin download this file to continue reading... ]]> The documents above are in PDF format. You will need Adobe Acrobat® Reader® to view and print it.
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]]> Laser Fluorescence in Caries Diagnosis tag:aadc.org,2007:/site/articles//1.79 2007-05-28T23:19:39Z 2008-09-04T23:22:14Z

AADC Positions Committee Position Statement Laser Fluorescence in Caries Diagnosis Throughout the history of dentistry, technology has played a crucial role. From early developments such as anesthesia, vulcanite for dentures, x-rays, and amalgam to more recent developments in the twentieth... admin download this file to continue reading... ]]> The documents above are in PDF format. You will need Adobe Acrobat® Reader® to view and print it.
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]]> Ethics Summit Initiative Report to American Association of Dental Consultants tag:aadc.org,2007:/site/articles//1.16 2007-04-06T22:11:54Z 2007-04-06T22:21:36Z

Prepared by Richard M. Celko, DMD, MBAThe Ethics Summit Initiative began with an opening session on Tuesday January 20, 2004.Introduction of the keynote speaker, Dr. Charles Dwyer, Academic Director of the Aresty Institute's Managing People Program in the Wharton School and Associate Professor in the Graduate School of Education at the University of Pennsylvania was made by Program Facilitator and Subject Matter Expert, David W. Chambers, EdM, Ph.D,MBA, editor of the Journal of the American College of Dentists and Professor and Associate Dean for Academic Affairs, University of Pacific, School of Dentistry. admin Prepared by Richard M. Celko, DMD, MBA February 2, 2004 Ethics Summit Initiative Truth Claims in Dentistry Westin Grand Bohemian Orlando,FL January 20-21, 2004 The Ethics Summit Initiative began with an opening session on Tuesday January 20, 2004.]]> Introduction of the keynote speaker, Dr. Charles Dwyer, Academic Director of the Aresty Institute's Managing People Program in the Wharton School and Associate Professor in the Graduate School of Education at the University of Pennsylvania was made by Program Facilitator and Subject Matter Expert, David W. Chambers, EdM, Ph.D,MBA, editor of the Journal of the American College of Dentists and Professor and Associate Dean for Academic Affairs, University of Pacific, School of Dentistry. Dr. Dwyer's opening remarks focused on "Values, Perceptions and Truth". He mentioned that "Ethics provides a better solution than an alternative and when Ethics fail, there are laws and when laws fail, there is war". Additional comments were made regarding truth in advertising and what leads people to be untruthful. Dr. Chambers made remarks and outlined the expectations and sessions to be held. There were plenary sessions with the general assembly, led by Dr. Chambers which outlined broad topics and specific questions to be discussed in the smaller subgroups which followed the plenary. Subgroups were identified and assembled and led by a Subject Matter Expert (SME). Group Three's SME was Dr. Thomas Hasegawa, Professor and Associate Dean of Clinical Services, Baylor College of Dentistry, and Chairperson of the American College of Dentists Ethics Committee. Members of Group Three were P.D. Miller, Phil Bonner, Tammy Byrd, Esther Scherb, Larry Farrell, Richard Jones, Ken Follmar, Evelyn Ireland , Robert Klaus and G. Siminovsky. Richard Celko Dr. Hasegawa made a few comments regarding the format and then the discussion focused on truth in dentistry. Topics included truth in advertising of certain products and how claims are made. The need for standards and program guidelines was discussed. Truth in submission of claims was also mentioned. It was defined that the reason claims are submitted with improper codes tend to be so that additional benefits are obtained. Mentioned in addition, was that approximately 60% of physicians have made statements (untrue) to insurance carriers in an effort to obtain coverage for the patient. Motivating factors contributing to untruthful or partially truthful behavior were also discussed. 1. money, greed 2. ego, pride, acceptance 3. easy way to avoid conflict,/confrontation/ 4. sense of security 5. covers for incompetence Discussion then focused on whether this translated into just the dental professions, all professions or society as a whole. It was decided that this was prevalent within the society and that it would be of future initiatives would be necessary to identify all components. There was discussion about the need for standards within all of the organizations represented. It was mentioned that some organizations have strict measures and educational requirements before allowing participation or membership, as well as passing certain examinations (ex. Board examination for specialty) whereas other may only have a financial requirement which would be limited to paying dues. Consensus was reached that the need for establishing guidelines and criteria for all associations to be measured was necessary. The purpose would be to gain consistency within the respective profession. An example that was mentioned was the need for standards in advertising with substantial evidence as basis rather than presentations based on testimonials. The need for reliable data and the ability to reproduce results with certainty and validity would lend credibility. Additional plenary discussion took place with the general assembly and Dr. Chambers asked the SME to provide brief synopsis of each of the subgroup discussions. Dr. Chambers quantified some results and these will be part of a paper for publication for the JACD. Also discussed was the need to identify and prioritize barriers to truthful behavior. The five most important behaviors as identified by group three included: 1. Debt burden 2. Lifestyle expectations 3. Incompetence, overtreatment 4. Peer pressure 5. Financial repercussions Conclusion was reached that some people are untruthful and provide services or due to the need to satisfy financial obligations. Others may not be truthful as a means to cover lack of experience or competence with certain procedures. Some people would choose to state that they may be familiar with how to do something when in reality they may have very limited knowledge or exposure. The discussion focus then changed and concentrated on the need to identify opportunities for truthful behavior and these included: 1. Full disclosure (example manufacturer and a paid consultant) 2. Peer review (Literature basis), Evidence Based Dentistry 3. Increased communications, raise awareness 4. Establishing and enforcement of credential and standards specific to industry. 5. Education of providers and consumers. In conclusion, the purpose of this summit was to recap the progress made in the prior summits as well as identify the opportunities and barriers to truth and truthful behavior. 1. There was discussion regarding the need to establish and provide consistency in content of Ethics courses taught within Dental Schools. 2. The establishment on a voluntary basis of credentialing bodies and certification programs for all allied healthcare professions. A follow up article regarding the data will be published in the JACD (unknown date). I would be available for discussion if more details or further information is necessary. Respectfully submitted, Richard M. Celko, DMD, MBA National Dental Director of Utilization Management, Aetna AADC Representative for the 2004 American College of Dentists Ethic Summit Initiative Is collegiality between dentists and benefit consultants possible? tag:aadc.org,2007:/site/articles//1.14 2007-03-14T19:53:52Z 2007-03-14T21:47:38Z admin By: Dr. Robert Laurenzano Let's be honest. There are many dentists who view third party payers with suspicion and regard those who work with them—such as dental benefit consultants—as the enemy. But it's also important to understand who the consultants are: in many cases, the parties on both sides are dentists, professionals who share much in terms of common education, hands-on practical knowledge, experience with the realities and hardships of clinical practice and a desire to be part of a profession that upholds high ethical standards.]]> Source: ADA NEWS, Vol. 38 No. 5 March 5, 2007 Dr. Robert Laurenzano, a certified dental consultant, is AADC president-elect and is in general practice in North Potomac, Md. ]]> Does Anyone Understand EBD? tag:aadc.org,2006:/site/articles//1.2 2006-08-18T23:22:44Z 2006-08-19T20:23:37Z By: David W. Chamers, EdM, MBA, PhD Evidence-based dentistry (EBD) is the profession's Rorschach test. The way dentists feel when they hear EBD probably says more about how researchers think dentists should practice than how practitioners actually use evidence to improve oral health care. From the outset it is necessary to observe that dentistry has always been grounded in research, and good research and good grounding have been practiced for three-quarters of a century. EBD may be "the same old lady in a new dress," but the dress is so dazzling and so scanty that something really has to be said about it. admin By: David W. Chamers, EdM, MBA, PhD Evidence-based dentistry (EBD) is the profession's Rorschach test. The way dentists feel when they hear EBD probably says more about how researchers think dentists should practice than how practitioners actually use evidence to improve oral health care. From the outset it is necessary to observe that dentistry has always been grounded in research, and good research and good grounding have been practiced for three-quarters of a century. EBD may be "the same old lady in a new dress," but the dress is so dazzling and so scanty that something really has to be said about it. ]]> here.) In this essay, I will focus on issues in EBD that arise from the concept of "best evidence" and the notion of combining sources of evidence. I will also comment on the fear that EBD can be used to limit the freedom of practitioners. This is a hard argument to dispel because there is some truth in it. The Meaning of "Best Evidence" There are three problems with the concept of "best evidence." First, the term is ambiguous. Let me try to make the point by mentioning that I only eat in the "best" restaurants. I too seldom dine at the French Laundry in Napa or the Inn at Little Washington, acknowledged exemplars of unique food impeccably prepared from the best ingredients; big wine lists; and attentive, knowledgeable service and plenty of it. Researchers at the University of Oxford in England have developed a list like this of the characteristics of "best evidence" in health care research, which is available at www.eboncall.co.uk/content/levels.html. This is the sense of best evidence that advocates of EBD have in mind- the best imaginable. Most of the EBD research has focused on establishing such standards and sorting the literature in search of a few good examples.
"Practitioners are concerned with predictability of results as well as with average performance. They want products and procedures that are unlikely to fail."
But there is a humbler and more frequently used definition of best. It means that none of the other available alternatives is better. I have had some excellent meals in Chapel Hill, Omaha and Portland. I pick the finest eateries in those towns, and, when necessary, at the best dives on the Interstate when I am tired and hungry. The best evidence available may not meet the Oxford standards, but it is still the best in a very real sense. When a practitioner bases his or her choice of therapy on a single randomized control trial report in JADA, years of successful personal experience, or the advice of some knowledgeable colleagues, the dentist may be using the best evidence available. The advocate for EBD make a useful point when they urge practitioners to review the literature generally and investigate specific issues as part of their practices. They also make a useful point in insisting that we should give heavy weight to research results that are grounded in good science. William Gies said so eighty years ago when he founded the International Association for Dental Research, and it is still true. My second concern is that the "best evidence" in the EBD sense may not actually exist in sufficient quantities to be a useful guide to practice. Although individual randomized controlled trials are not the best evidence, they are near the top of the list. Between 1990 and 2000 there were 106 RCTs published in peer review papers regarding endodontic therapies, 438 in oral surgery, and 198 in orthodontics. The current supply of "nearly best evidence" is simply too thin to provide the kind of scientific base to practice that animates EBD enthusiasts. (See Richard Niederman's June 2003 paper in the Journal of Dental Research.) The third problem with best evidence is subtle. Evidence should be valid, meaning that conclusions from the samples observed would not differ much from the conclusions drawn from observing every possible meaningful case. Thanks to EBD and many other researchers, the standards for internal validity (methodological rigor) have been elevated in oral health research. What remains largely unaddressed is the problem of external validity. This concerns itself with the representativeness of the sampling. EBD researchers seem focused on sophisticated conversations among themselves over extracting defensible findings instead of finding out how practitioners use information or what information they find valuable. Are carefully controlled RCTs representative of the typical practices to which their conclusions are meant to generalize? Best evidence cannot be defined without reference to the context in which it is to be applied. This issue has yet to be tackled by EBD. The Meaning of Combining Evidence There are also issues with the part of the definition of EBD having to do with combining evidence. The methodological advances that systematic reviews has made possible for combining multiple RCTs into a single estimate of the measure of effect for an intervention are impressive. The methodological advances in EBD have come in learning how researchers combine scientific data rather than in how practitioners combine research with their own experience and presenting patients. Beyond the obvious unresolved issue of utility, there is a logical problem here. Researchers do not "combine" data in the same sense that practitioners do. Research combining cannot take the place of the combining done in dental offices. Researches describe and practitioners act. When describing, various evidence is averaged, weighting for the credibility of the source. This is what EBD researchers do when they publish. But taking an action precludes taking alternative actions; it is a different logic and an "average" approach is not possible. Under such circumstances the appropriate decision rule is to commit all resources to the action favored by the most credible evidence and ignore the other data. The combining problem (or more properly the problem of selecting the best strategy) is apt to be even more complex than just suggested. Averages are reported in the literature because theoretical summaries are meaningful in theoretical contexts. We are moving away from p-values as tests of differences between averages (toward confidence intervals). But we haven't moved far enough to be meaningful when introducing research results into practice settings. Practitioners are concerned with predictability of results as well as with average performance. They want products and procedures that are unlikely to fail. Thus robustness - satisfactory outcomes over a range of realistic situations in individual offices - becomes a desirable criterion for practice-ready evidence. Robustness has yet to enter the thinking of proponents of EBD.
"The challenging case, especially for the insurance industry is the middle ground. Isn't it reasonable for government, brokers and payers, and even professional associations to convert trends supported by evidence into guidelines and to make those guidelines mean something in practice?"
As practiced today, EBD is predominantly an academic discipline trying to sell itself to dentists. In order for it to be successful, at a minimum, it must solve the problems associated with a useful definition of "best evidence" and what it means to "combine evidence" in the context of dental practice. EBD has been useful as a reminder that science has always been, and must continue to be, the foundation upon which progress in practice is grounded and as a development in the way data from multiple studies of good methodological rigor can be summarized and reported. These are useful, perhaps even necessary improvements, but they are insufficient. More science needs to be done before EBD can be considered useful to the practitioner. Policy-Based Dentistry A good understanding of EBD has been made difficult by two red herrings. Evidence-basers have characterized practitioners who disagree with them as empirics; practitioners who fear the development have cried "third-party interference and control." Neither of these is a useful way to promote the profession. When a practitioner reports that "X works well in my hands" he or she may be reporting a scientific fact. Noting that "Y works better in some other people's hands" is not a satisfactory argument to the contrary. What must be compared is the outcome in context not the approach in the abstract. The argument about outside control is as difficult to address because it is as ill defined as EBD is. Researchers and academics that support EBD have generally said that they are not advancing uniform standards for how care is to be provided. They are, however, sometimes caught talking about practice guidelines, parameters of care, clinical protocols, or critical paths. At issue here is who decides that care is appropriate for a particular patient in a particular office. The definition of EBD certainly implies that individual dentists do. But sometimes the EBD literature spills over from "best evidence" to "best practices." The challenging case, especially for the insurance industry, is the middle ground. Isn't it reasonable for government, brokers and payers, and even professional associations to convert trends supported by evidence into guidelines and to make those guidelines mean something in practice? There are benefits to be gained from this approach, and standards of care and consensus conferences existed for years before the three-letter-buss-word. Precisely because the opportunity for individual practitioners to combine best evidence in their offices is reduced by this practice, it cannot be called EBD. I prefer to think of it as policy-based dentistry - somebody decided what is best generally and attempts to move, by various incentives, all practitioners in that direction. EBD can contribute to creating good policy. But in its current incomplete state of evolution, it can also mislead. As just one example, evidence-based dentistry (and dental research generally) has failed to develop a complete method for managing sampling variance and its impact on generalizability of research results. Valid policy must be robust enough so it does not preclude acceptable variation in practice that is appropriate or even best given prevailing practice circumstances. Research methods designed to find the "best" are blunt instruments for finding the generally best. We need to know which variation matters. One can get in over his or her head trying to cross a river that is only three feet deep - on average. Good science should be one of the foundations for PBD (policy-based dentistry), just as it is for EBD. Because PBD has not been identified as a respectable entity to be explored seriously, it is even less likely to be understood than EBD. There is a field of health policy research with a rich tradition but few practitioners. Bringing these experts into the discussion would be a useful protection against the view that research will provide sufficient answers to oral healthcare strategy. Here is my summation. EBD has stimulated some valuable innovations in clinical dental research. Organized databases and meta-analyses are sound new tools, with more productive years of development in front of them. Discussions about "best evidence" have been useful for researchers, although they have not gone far enough in considering external validity or in identifying sources of variance and promoting technologies that are context and practitioner robust. Practitioners need to be shown how to verify and improve the outcomes in their offices, not told that they should practice in a certain fashion because others have found it effective. Dr. David W. Chambers is Professor and Associate Dean for Academic Affairs and Scholarship at the School of Dentistry, University of the Pacific and Editor of the American College of Dentists. ]]> Emerging Opportunities for Oral Health tag:aadc.org,2006:/site/articles//1.3 2006-08-12T18:14:08Z 2006-08-19T19:59:29Z By: Harold C. Slavkin, DDS The human characteristics of curiosity, wonder and ingenuity are as old as mankind. For tens of thousands of years people around the world have been harnessing their curiosity into inquiry and the process of scientific methodology. The international fruits of these endeavors have resulted in agriculture, transportation, global networks of communications, energy resources, housing, environmental considerations, enhanced computational powers, entertainment, and biomedical research that has improved the quality of life as well as the human lifespan during the 20th century in many nations around the world. admin By: Harold C. Slavkin, DDS The human characteristics of curiosity, wonder and ingenuity are as old as mankind. For tens of thousands of years people around the world have been harnessing their curiosity into inquiry and the process of scientific methodology. The international fruits of these endeavors have resulted in agriculture, transportation, global networks of communications, energy resources, housing, environmental considerations, enhanced computational powers, entertainment, and biomedical research that has improved the quality of life as well as the human lifespan during the 20th century in many nations around the world.]]>
These and hundreds of other "scientific and technological highlights" reflect a "tipping point" or that time in human history when scientific discoveries are rapidly translated into improved oral health care for people around the world
Oral fluids have become "informative fluids" that can be used for diagnostics, the management of drug therapy, and a number of forensic applications. The science and technology of miniaturization (nanotechnology) now enables a full clinical laboratory to be compressed upon a miniature chip and this "lab-on-a-chip" technology is being applied to rapid and sensitive analyses using saliva as a diagnostic fluid for oral as well as systemic diseases and disorders. These and hundreds of other "scientific and technological highlights" reflect a "tipping point": or that time in human history when scientific discoveries are rapidly translated into improved oral health care for people around the world. Oral health care is nested within a much larger context that blends social, economic and political processes but it takes much more than scientific discovery and translation to application. In the United States, we have fragmented or segmented health care with profound correlations to SES (social and economic status). For example, the Surgeon's General Report Oral Health in America, released by Surgeon General David Satcher in May 2000, indicated that 110 million Americans do not have dental insurance and that almost one-third of the population does not have access to oral health care. Oral health disparities are very significant in America with particular impact upon children born into poverty, the poor and working poor adult populations, and the poor elderly. Further, we have tensions between dental and medical "enhancements" versus disease- and disorder- directed diagnostics, treatments and therapeutics. We have confusion between conditions versus diseases as recently indicated with respect to obesity versus diabetes or hypertension. Globally, the World Health Organization (WHO) proposed a shift in definition form health being equal to the absence of disease, to health being part of quality of life and a sense of wellness. These major forces of change must be acknowledged. Oral health care is related to education and social values, culture, health values, economics and macro- as well as micro- trends that impact the individual, family, community and population. The emerging opportunities for oral health are enormous! Suggested Readings U.S. Department of Health and Human Services. Surgeon General's Report Oral Health in America. U.S. Department of Health and Human Services 2000; Washington D.C. 2. Cohen DW, Slavkin HC. Periodontal disease and systemic disease. In: Periodontal Medicine, Eds. Rose LF, Genco RJ, Cohen DW, Mealey BL, B.C. Decker Inc., Hamiltion, Canada 2000; 1-10 3. International Human Genome Sequencing Consortium. Initial sequencing and analysis of the human genome. Nature 2001; 409:860-921. 4. Venter JC et al. The sequence of the human genome. Science 2001; 291:1304-1351. 5. Evans WE, Relling MV. Pharmacogenomics: translating functional genomics into rational therapeutics. Science 1999; 286: 487-491. 6. Peltonen L, McKusic VA. Dissecting human diseases in the postgenomic era. Science 2001; 291: 1224-1229. 7. Syvanen AC. Accessing genetic variation: genotyping single nucleotide polymorphisms. Nature Reviews: Genetics 2001; 2:930-942. 8. Slavkin HC. Toward molecular based diagnostics for the oral cavity. J. Am Dent Assoc 1998; 129:1138-1143. 9. Slavkin HC. The Surgeon General's Report and special needs patients: a framework for action for children and their caregivers. Special Care Dentist 2001; 21(3):88-94. 10. Slavkin HC. Expanding the Boundaries: Enhancing Dentistry's Contribution to Overall Health and Wellbeing. J. Dental Education 2001; 65:1323-1334 11. Slavkin HC. The Human Genome, Implications for Oral Health and Diseases, and Dental Education. J. Dental Education. 2001; 65:463-479. 12. Genco RJ, Scannapieco FA, and Slavkin HC. Oral Reports. The Sciences 2000; 25-30. 13. Slavkin HC, Baum BJ. Relationship of Dental and Oral Pathology to Systemic Illness. J of Amer. Med. Assoc. 2000; 84: 1215-1217. 14. Eichelbaum M, Evert B. Influence of pharmacogenetics on drug disposition and response. Clin Exp Pharm Physiol 1996; 23: 983-985. 15. Slavkin HC. Applications of pharmacogenomics in general dental practice. Pharmacogenomics. 2003; 4:163-170. 16. Chai Y, Slavkin HC. Prospects for tooth regeneration in the 21st century. Microscopy Research & Technique. 2003; 60-469-479. Dr. Harold C. Slavkin is Dean of the University of Southern California School of Dentistry and past director of the National Institute of Dental and Crainofacial Research. He will also be presenting the Keynote Address at the 2004 AADC Spring Workshop in Fort Myers, FL. ]]> Data Warehouses and the Dental Consultant tag:aadc.org,2006:/site/articles//1.4 2006-08-10T18:23:49Z 2006-08-19T20:00:15Z By: Michael del Aguila, MS, PhD Data warehouses in the dental insurance industry are a well-recognized reality. However, the misperceptions surrounding them both exaggerate their misuse and underestimate their potential. Understanding the composition and requirements for appropriate use of these tools can dispel some of the mistrust, and open dialogue on the best uses of these tools. Without question, the appropriate use of a data warehouse can contribute substantively to the construction, deployment and evaluation of the next generation of dental benefits products. Getting to that point is not easy because it requires constant reexamination and refinement of basic assumptions and analyses. admin By: Michael del Aguila, MS, PhD Data warehouses in the dental insurance industry are a well-recognized reality. However, the misperceptions surrounding them both exaggerate their misuse and underestimate their potential. Understanding the composition and requirements for appropriate use of these tools can dispel some of the mistrust, and open dialogue on the best uses of these tools. Without question, the appropriate use of a data warehouse can contribute substantively to the construction, deployment and evaluation of the next generation of dental benefits products. Getting to that point is not easy because it requires constant reexamination and refinement of basic assumptions and analyses.]]> Dr. Michael del Aguila is a member of the AADC and president and CEO of Delta Dental Data and Analysis Center. ]]> The Role of Dental Insurance In The Future-State of Medicaid tag:aadc.org,2006:/site/articles//1.5 2006-08-08T18:28:04Z 2006-08-19T20:01:05Z By: Gary A. Colangelo, DDS The American Dental Association's Medicaid dental initiative should hasten the evolution of this federal/state partnership toward a more accountable program that demonstrably improves the oral health of Medicaid eligible citizens. Success of the ADA's initiative can lead to a Medicaid dental program that will: admin By: Gary A. Colangelo, DDS Assumptions The American Dental Association's Medicaid dental initiative should hasten the evolution of this federal/state partnership toward a more accountable program that demonstrably improves the oral health of Medicaid eligible citizens. Success of the ADA's initiative can lead to a Medicaid dental program that will:]]> Assumptions The American Dental Association's Medicaid dental initiative should hasten the evolution of this federal/state partnership toward a more accountable program that demonstrably improves the oral health of Medicaid eligible citizens. Success of the ADA's initiative can lead to a Medicaid dental program that will:
  • Emphasize outcome measures that reflect improvement in the oral health of eligible Medicaid recipients.
  • Require actuarially sound and market-based reimbursements to dentists and health care facilities.
  • Allow community-based care delivery innovation.
  • Promote the development of symbiotic collaborations in the community to improve access and effectiveness of oral health care delivery.
  • Maintain state level dentist peer review oversight to assure appropriate, cost effective Medicaid oral health care delivery.
  • Promote state financial risk retention as well as eligibility determination and provide incentives to expand dental coverage for under served populations.
  • Require state program management and cost control through partnerships with organized dentistry, dental plans and consumer representatives.
The Role of Dental Plans Dental plans should play a central administrative role in the future state of the Medicaid dental program. Dental plan core competencies are claim management, utilization management, cost control, network development and maintenance, and outcome reporting. Dental plan personnel also have experience in quality assurance and oral health care delivery models. Dental Medicaid Program Administration With market-based dentist reimbursements, Medicaid eligible recipients can be provided coverage that is no different form commercial dental plan products. Rather than create a separate Medicaid dental program, existing dental plan products can be modified to comply with EPSDT or other state and federal requirements. In addition to being a more efficient administrative process, Medicaid recipient will no longer be stigmatized by having present a Medicaid identification card when seeking dental care. A core function of dental plans, is the management of reimbursement arrangements using sophisticated claim processing platforms. Coupled with trained and motivated customer service representatives, existing claim processing efficiencies and dentist acceptance can be integrated into the Medicaid dental program. Medicaid financial risk retention by states will remove the dental plan disincentive related to improving access to care. Dental plans should contract with states through administrative service agreements while states collaborate with dentists and financial consultants to develop Medicaid resource allocation and control procedures compatible with the availability of public funds and state legislative agendas. Network Development Dental plans have heavily invested in the development and maintenance of dental networks and have established standards to assure assess to general dentists and specialists. The creation of an adequate Medicaid dental network has been a failure in most of the United States. The use of existing networks will not only reduce Medicaid costs but also better assure adequate assess. Program Innovation Community based collaborations Dental plans often include community service as part of strategic business development. These initiatives may include collaboration with health care and social service agencies that have missions related to oral health care delivery. Many community-based collaborative models with documented positive outcomes are available for study and replication. Care delivery models Dental plans operate staff model oral health care delivery systems where there is inadequate dental manpower in the private practice sector or where there are positive strategic business relationships with other health care entities such as hospitals. Many of these models have long term financial and clinical success and could be suitable for Medicaid care delivery replication. Outcome Reporting Most dental plans use claim-processing systems that allow data formatting or downloading for a variety of outcome reports. Outcome measures need not be costly direct patient oral assessment. Indirect, NCQA-like indicators such as preventive procedure frequencies, self-care knowledge assessments and mix of restorative procedures can be used to indicate program effectiveness. Greater accountability of the dental Medicaid program can be attained through the use of dental claim history data:
  • Utilization reports that demonstrate frequency and cost by dental treatment codes
  • Retrospective studies to determine the appropriateness of rendered dental care
  • Retrospective reviews must include peer review panels of dentists who can render opinions on practice patterns and care appropriateness
  • Comparative studies using claim history and epidemiological data such as caries assessment studies
Quality Assurance Credentialing of dentists most often includes these components:
  • Primary source accredited dental school graduation and state licensure certification
  • Disclosure of past or pending malpractice litigation, license restrictions or health care facility sanctions
  • Office inspections to assure OSHA compliance, adequate record keeping and patient access standards compliance
In addition to credentialing, dental plans also maintain a patient complaint resolution service, pre-payment review procedures, denied claims appeal systems and utilization management programs. Communication Dental plans have regular patient and doctor communication vehicles for administrative and clinical information. Newsletters, check stuffers and single-issue announcements are commonly used. Many health care plans are investing in health promotion education on Web sites and in written media. All of these sources are available for Medicaid program communication. Gary A. Colangelo, DDS Gary.colangelo@carefirst.com 410 528 7908 ]]> I Have Had Enough! tag:aadc.org,2006:/site/articles//1.6 2006-08-05T18:37:38Z 2006-08-19T20:20:20Z By: Gordon J. Christensen, DDS, MSD, PhD World-renowned dental lecturer and educator, Gordon Christensen, DDS, MSD, PhD sounds off about the dental professions' ethics admin By: Gordon J. Christensen, DDS, MSD, PhD Where has the professionalism of my "profession" gone? I have seen a major degeneration in the ethics of the dental profession over the past several years.]]>
"In my opinion, the ethics of the dental profession have taken a real 'dive.'" - Gordon J. Christensen, DDS, MSD, PhD
This editorial discusses the relatively recent and obvious degeneration of ethics in the dental profession and calls for a change of direction by all parties involved. The following actual documented examples do not name specific individuals or companies to avoid confrontations. I present the following information as examples of the problems I see in the ethics of our profession. If the shoe fits-wear it! Let's examine some of the negative situations that are contributing to this degeneration. OVERTREATMENT I was one of the original instigators of the recognition of esthetic dentistry, over 25 years ago. However, my pet subject has turned into a monster with unbelievable overtreatment of unsuspecting patients. This problem of overtreatment is not limited to esthetic dentistry. It is spread throughout the profession. I will list a few current examples. Convincing patients that removal of amalgam restorations is mandatory for systemic health reasons is not a legitimate or logical practice in most situations. Yet, many patients go through that elective procedure with the hope that some miraculous cure of a systemic condition will be accomplished. Of course, there are a few situations in which amalgam removal may actually be indicated for reasons other than esthetics. Recently, a patient was examined by me and my staff for a second opinion on an "esthetic upgrade". She had traveled several hundred miles to have the exam, and she did not inform me of her reasons for requiring a "second opinion" until later. We suggested a treatment plan that included scaling, polishing, at-home bleaching, minor esthetic tooth recontouring, a few anterior and posterior tooth-colored resin-based composite restorations, and two elective veneers. When the plan was presented, she sighed in disgust. Just a few hundred miles from Utah, she had received a treatment plan for twenty-eight veneers and a total occlusal rehabilitation, equal to the cost of a very good new automobile. If this were a singular occurrence from one less-thanreputable dentist, I could understand it, but this has happened to me several times in the recent past from various practitioners. Dentists are actually being taught by popular speakers on how to do the same overtreatment to their own patients. I have had the unfortunate challenge to redo several of these over-treated cases after the fracture failure of the ceramic restorations, debonding of veneers placed over grossly overprepared dentin surfaces, or degeneration of the occlusion that appeared to have little occlusal adjustment after seating the restorations. If treatment plans containing all of the treatment alternatives are presented to patients, including the advantages, disadvantages, risks, and costs of each alternative, and if the consenting patient accepts and demands a radical plan, the treatment becomes more understandable. It is well known that patient's elect to have radical esthetic plastic surgery on various parts of their bodies, knowing that the procedures are elective. But, oral overtreatment in the name of esthetic dentistry without total informed consent of patients, primarily for dentist financial gain, is nothing less than overt dishonesty in its worst form. You cannot put tooth structure back after it has been removed. Solution: Dentists should evaluate their diagnosis and treatment planning procedures to ensure that all of the various treatment options are presented to patients. If patients choose a radical, elective treatment plan, primarily for appearance purposes, they should be told all of the negatives before they choose to initiate the treatment plan, including potential premature failure, occlusal problems, and need for re-treatment in just a few years. Informed consent should be thorough and complete. Treatment plans should be separated into mandatory treatment and elective treatment, and patients should have a complete understanding of the difference. Financial income to the practitioner should be related to the needs and decisions of the informed patient, not the needs of the practice. ADVERTISMENTS IN DENTAL JOURNALS AND MAGAZINES As I thumbed through a current "cosmetic" magazine, I noted the presence of ads for several light enhanced in-office bleaching devices, touting their superiority to other bleaching techniques. It must not matter to some manufacturers that it has been proven and published that the tested bleaching lights do not effect a greater tooth color change than the bleach solution alone. I find it amusing that one manufacturer actually advertised that his product could be used with or without the light. Dentists are not without guilt in this situation. Recently, I talked to a practitioner in a course who blatantly told me that he knew the lights did not improve the bleaching, but he thought that patients accepted bleaching fees better if bleaching lights were used. At some time in the future, bleach-light combinations may be found that will allow faster and better tooth lightening than the bleach alone. We are still waiting.
Overtreatment in the name of esthetic dentistry without total informed consent of patients, primarily for dentist financial gain, is nothing less than overt dishonesty in its worst form." - Gordon J. Christensen, DDS, MSD, PhD
Solution: I suggest that editors of journals and magazines recruit thoroughly informed, honest consultants, who have had actual clinical experience with the concept being studied, to screen the advertisements, weeding out the misleading or overtly dishonest ads. Additionally, dentists need to be wary of advertising from companies known to exaggerate product characteristics or to misrepresent the advantages of their products in ads. Companies should realize that honest advertising is clearly evident to inform readers, and similarly dishonest ads are soon disproved by clinical results. When clinical research and experience do not confirm the claims in the ads, dentists lose confidence in believing any future ads from the company involved. ARTICLES IN JOURNALS A recent research paper published on the most commonly used esthetic dentistry procedure in a prestigious "peer reviewed" journal, and showing positive characteristics for the product evaluated, was funded by the company selling the system. In some situations, this may be legitimate, but in this case, studies from other researchers published in the same issue with the commercially supported paper would certainly have made the results more credible. Most companies are doing their best to be honest and sincere, but the few who flagrantly try to promote their products by "bought research" soon become identified by practitioners. A popular, well accepted technique was denounced in another research paper in a "peer reviewed" journal. Immediately, dentist participants in continuing education courses asked why the clinically successful technique, which most of them were using, didn't do better in the research. After reviewing the paper, it was found that a third-party payment company, with obvious vested interests to reduce the use of the popular concept, had funded the research. You have read many scientific projects that test a group of commercially available products, and find one product to be the best. It should not be a surprise to find that the product from the company funding the study had the most positive results. Unfortunately, dental education and dental educators have always been under funded. Dental manufacturers provide much of the funding for university-based dental research. Although not impossible, it is difficult for a dental faculty member to remain totally unbiased, when accomplishing a research project, if all or a major portion of his/her salary comes from the research grant. Additionally, when a company-funded project can be delayed or stopped by the funding company. The recent tobacco research fiasco is manifestation of this problem on a larger scale. Such information is lost to the public of practitioners until someone else happens to study the same question. Peer review of research in dentistry, with a few exceptions, is not a guarantee that a published paper has legitimate conclusions. In my opinion, peer review in dentistry is in need of major revision, bringing in many more practicing clinicians along with their academic counterparts, and using more than a few persons as reviewers on controversial topics. Solution: Dentists - wake up! How many companies can produce an unbiased research project? I know a few, but there are many that are questionable. Editors - publish more than one paper on the same subject when a company-funded project is published in your journals, recruit peer reviewers who have expertise in the specific subjects of the papers, and expand your review teams to include more "real world" practitioners who know clinical dentistry. Companies - just be honest. We practitioners soon discover dishonest research by simply observing our clinical results, and you and the patients will be the losers. EVALUATION OF PRODUCTS Most dental journals and magazines have product endorsements in them from companies or individuals that have been paid to evaluate the products they are endorsing. If independent companies want to evaluate dental products and report on them, honesty in the results would be increased if these evaluations were accomplished without fees paid to the evaluating company by the manufacturer that produced the product. The evaluating companies should obtain their income from publication of their data, or other means. The lay group, Consumer Reports, is a prototype for such evaluations. This company does not allow publication of their data for commercial purposes, but it is readily available from the company. Some dental companies use information from published papers in their product advertisements. With the permission of the author/researcher, and if the information is used in fairness to other similar products in the study, such inclusions in ads appear to be appropriate. Reference to the published paper should be included. Solution: Again, dentists beware! Analyze the source of endorsements carefully. When the endorsement in an advertisement looks questionable, money has probably changed hands. Companies, be honest! Your good products sell by word of mouth about clinical success. Honest, conservative ads are appreciated, and you are respected when practitioners read them. SPEAKERS ON THE LECTURE CIRCUIT After spending roughly 40,000 hours on the circuit, I can probably comment on this one with some experience. Can you smell a paid-off speaker? If you can't, you are pretty naive. Although for most of the larger meetings, speakers have to sign a statement that they are not being paid by companies producing products contained in their lectures, there are many devious ways to get around that challenge. How about paying spouses or other relatives, funding children in college donating to favorite charities in the speaker's name (this is okay if the money is donated in the company name and the speaker does not get a tax deduction), using company condos, cabins, or planes, paid vacations, and many other manufacturer perks? It is relatively easy to observe when a speaker favors one company or another in lectures. It is obvious when the speaker is selling his or her own dental product to the exclusion of other products in the course. Solution: Do not attend lectures of speakers who appear to be on the "take". These speakers soon expose their financial commitments by their overt favor of products, companies, or commercial techniques. I have seen hundreds of speakers come on the circuit and burn out within a couple of years. Suggest reliable speakers to your colleagues, especially younger dentists. SUMMARY I apologize for making some of you nervous, and perhaps even resentful, but I HAVE HAD ENOUGH! I do not like the new unethical face of my profession, where incessant seeking of more money has replaced service to the public, honesty, and self-respect. Numerous areas of major ethical concern in dentistry are identified in this article. The ongoing, if not accelerating, degeneration of professional ethics in dentistry is clearly evident to even casual observers. Improvements in professional ethics are necessary to regain our self-respect and the respect of the people we serve. All of us need to improve, including practitioners, speakers, dental schools accomplishing research, manufacturers, editors, and evaluation groups. It is time to return to honesty and to dealing with our fellow men and women in the way we would want to be treated ourselves. I do not think it is too late. Dr. Gordon Christensen, a prosthodontist in Provo, UT, is Co-founder and Senior Research Consultant of Clinical Research Associates (CRA). Dr. Christensen is also the Director of Practical Clinical Courses, a continuing education career development program for the dental profession at Brigham Young University and the University of Utah. You can contact Dr. Christensen at: Practical Clinical Courses, 3707 North Canyon Rd., Suite 3D, UT, 84604-4587. Fax (801) 266-8637. Visit his website at gordonchristensen-pcc.com. ]]>