Journal of the IDA

INDIANA DENTISTRY

CONTINUINGEDUCATION

ACCESS TOCARE

ETHICS

HEALTH CARE REFORM

THIRD-PARTYINSURANCE ISSUES

RELEVANCEOF ORGANIZEDDENTISTRYCHANGING PRACTICE

MODELS

RISING COST OFDENTAL EDUCATION

THE BUSINESS SIDEOF DENTISTRY

THE “UNRETIRED”DENTIST

10 TRENDSSHIFTING THE FOUNDATIONS OF INDIANA DENTISTRY

FALL 2012VOL. 91, NO. 3

INDENTAL.ORG

JOURNAL INDIANA DENTAL ASSOCIATION

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FALL 2012 VOL. 91, NO. 3

CONTENTS

MAKING SURE OUR PATIENTS ARE COVEREDJohn R. Roberts, DDS, IDA President-------------------------------------3

REPAIRING DENTISTRY’S TATTERED SAFETY NETDouglas M. Bush, IDA Executive Director -------------------------------4

SPECIAL SECTION:10 TRENDS SHIFTING THEFOUNDATIONS OF INDIANA DENTISTRY

HEALTHCARE REFORMSeema Verma, MPH, and Kaitlyn Shaw ---------------------------------6

THE RISE OF LARGE GROUP PRACTICESCharles L. Steffel, DDS, MSD -----------------------------------------------8

THE RISING COST OF DENTAL EDUCATIONJohn Williams, DMD, MBADean, Indiana University School of Dentistry -------------------------11

WHO WILL WIN THE BATTLE TODEFEAT BARRIERS TO CARE?David R. Holwager, DDS----------------------------------------------------15

DENTAL ETHICS: AN OBITUARYRichard E. Jones, DDS, MSD ----------------------------------------------18

INSURANCE: THREE’S A CROWDTerry G. Schechner, DDS---------------------------------------------------22

CONTINUING EDUCATIONKaren E. Ellis, DDS, and Jeffrey A. Stolarz, DDS ---------------------24

A NEW COURSE FOR IDA LEADERSHIPSteven P. Ellinwood, DDS--------------------------------------------------26

THE BUSINESS SIDE OF DENTISTRYThomas R. Blake, DDS -----------------------------------------------------28

THE UNRETIRED DENTISTMichael D. Rader, DDS ------------------------------------------------------31

$

$

THE RACE FOR RELEVANCEMary M. Byers, CAE ---------------------------------------------------------32

Classified Advertising ------------------------------------------------------36

In Memoriam------------------------------------------------------------------38

New Members----------------------------------------------------------------38

Index to Advertisers --------------------------------------------------------39

FUNNY THING: SOCIAL SKILLS IN DENTISTRYRandy J. Carroll, DDS-------------------------------------------------------40

SOMETHING ELSE IS ABOUT TO CHANGEJack Drone, DDS, Editor, JIDA--------------------------------------------44

EDITORIAL BOARD

Dr. Jack Drone, EditorDr. Steven P. Ellinwood, Assistant EditorDr. Michael D. RaderDr. William B. Risk, Peer Review EditorMr. Will Sears, Managing Editor, IDA Director of CommunicationsMs. Kari Alting, Advertising Manager

COUNCIL ON COMMUNICATIONS

OFFICERS OF THE INDIANA DENTAL ASSOCIATION

Dr. John R. Roberts, PresidentDr. Desiree S. Dimond, President-ElectDr. Steven J. Holm, Vice PresidentDr. Daniel W. Fridh, TreasurerDr. Jack Drone, EditorDr. Jeffrey A. Platt, Speaker, House of DelegatesDr. Jill M. Burns, Vice Speaker, House of DelegatesDr. Terry G. Schechner, Immediate Past PresidentMr. Douglas M. Bush, Executive Director, Secretary

SUBMISSIONS REVIEW BOARD

Dr. Jeffrey A. Dean, Indianapolis, IndianaDr. Roger L. Isaacs, Indianapolis, IndianaDr. Joseph H. Lovasko, Hammond, IndianaDr. Jeffrey A. Platt, Indianapolis, IndianaDr. Christopher R. Miller, Indianapolis, Indiana

A publication of the Indiana Dental Association. Custom design by Lane Design.

Mission: Produce and distribute, at a profit, credible, high-quality publications that inform Indianadental practitioners about the latest scientific, socioeconomic and political developments affectingdental practice and oral healthcare.

The Journal is owned and published by the Indiana Dental Association, a constituent of theAmerican Dental Association, 401 West Michigan Street, Suite 1000, Indianapolis, IN 46202-3233.Subscription rate of $8 per year to IDA members is included in the annual association dues. IndianaAlliance Association members may subscribe at the same rate as IDA members. The subscriptionrate for retired members is $25 per year; non-members may subscribe at $100 per year. Individualissues may be purchased for $25 each.

The editor and publisher are not responsible for the views, opinions, theories, and criticismsexpressed in these pages, except when otherwise decided by resolution of the Indiana DentalAssociation. The Journal is published four times a year and is mailed quarterly. Periodicals postagepending at Indianapolis, Indiana, and additional mailing offices.

Manuscripts—Scientific and research articles, editorials, communications, and news should beaddressed to the Editor, 401 West Michigan Street, Suite 1000, Indianapolis, IN 46202-3233.

Advertising—All business matters, including requests for rates and classifieds, should beaddressed to the Managing Editor, P.O. Box 2467, IN 46206-2467. Deadline for all copy is 15 daysprior to the first month of publication, unless otherwise stated by the editor.

Copyright 2012, the Indiana Dental Association.

Dr. Lorraine J. Celis, ChairDr. Thomas R. BlakeDr. Ted BrauerDr. Eric S. BrowningDr. Jack DroneDr. Dawn R. Durbin

Dr. P. Bruce EasterDr. Steven P. EllinwoodDr. Bruce E. HolderDr. Chad R. LeightyDr. Thomas M. MurrayDr. Marc S. Smith

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JIDAFALL 2012 VOL. 91, NO. 3

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overhead? This raises another question: Why do some patientshold the dental office accountable for their benefit plan infor-mation? They have the agreement with their employer, not thedentist. What started as a nice gesture to help patients withtheir coverage has become a heavy, tedious burden of assumedresponsibility for dental offices.

Another factor interfering with the delivery of optimal care isagreeing to discounted fees for the sake of being busy. Not onlydoes the insurance promise that you’ll get more patients, but bysigning the agreement the dentist “guarantees” that more carewill have to be provided at the discounted rate, in order tomaintain the current income that would be produced without adiscount. In other words, if your profit margin is cut $15 to $20,and your overhead is somewhere between 60-70%, you’d haveto do twice the dentistry to net the same income. I guess theimportant thing is to believe “busy hands are happy hands,”whether you can pay your bills or not.

What can be done to change the conundrum in which wefind ourselves? Dentistry can’t outspend the insurance indus-try’s marketing program, nor should it engage in propaganda.The advantage that dentistry does enjoy is one-on-one contactand building an earned trust with the patient. We as individualdentists need to take the time to educate our patients about thevalue of needed treatment as it pertains to their personal needs.Treatment dictated and pre-scripted by a benefit plan that isfocused on profitability for the third-party administrator is notoptimal care by any measure.

In addition to educating our patients, we must first be true tothe dental profession and not fall into the habit of only discussingcovered procedures for our insured patients. The comprehensivetreatment plan should be guided only by what is needed, notwhat a particular plan allows. Ultimately it is still the patients’decision as to what care they receive, but it is our duty to informthem, educate them, and preserve patient choice in health care.

Reference

1. Murphy, Mark, DDS, FAGD. “Insurance-odontitis: Our Greatest Handicap.”Dentaltown. July 2012.

MAKING SURE OURPATIENTS ARE COVEREDAnd I’m not just talking about insurance

John R. Roberts, DDS

IDA President

riginally intended to be an improvement to access tocare, insurance coverage can ironically become a handicap tooptimal care. You might ask, How in the world could financialbenefits become an impediment? There are actually severalreasons I have observed over the last three decades in my prac-tice, many of them shared by our colleagues.

One type of coverage that does not interfere with the doctor-patient relationship and is truly a help to patients seeking care isdirect reimbursement from employers, without restrictions as towhat services or procedures are covered. The patient is informedof their treatment choices and receives reimbursement to pay forany treatment rendered within a set limit of total costs for aperiod of time.

The other limitations that adversely affect providing careinclude maximum benefits that have not changed in 30 to 40years, despite all other costs increasing exponentially. Fourdecades ago, $1,000 to $1,500 could allow considerable care tobe rendered. Today, that means choosing between one molarendodontic treatment or one crown, and probably exhaustingall of the yearly coverage. If dental benefits kept up with infla-tion, $7,000 of allowable yearly care would be the norm for atypical employer provided plan.1 I haven’t heard a good expla-nation of how dental “insurance” premiums have more thankept up with inflation (as have insurance company profits), butthe coverage limit is still around $1,000 each year. More irony:Some dental insurance companies are enjoying the status of“not-for-profit,” while paying their CEOs millions of dollars.

An associated problem has evolved over time as patients wantto stay within the yearly maximum benefit, despite what theymight truly need in a given year. I believe this is why six-monthrecall is typical—it’s what benefits will allow. For non-insuredpatients, the recall appointment is set according to the individualneeds of the patient, perhaps three months for periodontal care,or once a year for a long-time patient of record who rarely, if ever,needs any treatment.

Wouldn’t it be great if not missing the exact six-month recallby one day didn’t cause the insurance company to rule the pro-cedure to be “non-covered?” When this happens, do you ask thepatient to pay 100%, or do you make it a freebie and add to your

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“Twelve hundred children a year in Florida get their dentalcare under general anesthesia in the hospital,” said Dr.Catalanotto. The hospital expense could have been avoided for“pennies on a dollar” had preventive care been provided in aprivate practitioner’s office. “At Medicaid rates, the cost wouldbe $50-60 a visit.”

Corporate dental chains, backed by profit-driven privateequity firms, also found themselves in Frontline’s line of fire.Frontline described them as a new system of care, “flourishingin states that have raised Medicaid rates in hopes of gettingmore care to kids.”

Reporter Miles O’Brien asked, “Are corporate dental chainsfilling the gap, or taking advantage of people in pain?” He inter-viewed corporate executives who defended their model, andformer corporate practice employees who alleged treatmentplans were driven by production quotas and bonus incentives.“It became more about numbers; more about meeting dailygoals,” said one former officer manger. “The computer systemtracked production in minute detail.”

Dentistry was portrayed in an even less favorable light whenSen. Bernie Sanders (I—Vermont) issued his February 29, 2012,report, “Dental Crisis in America—The Need to Expand Access.”A Senate hearing held the following day highlighted disparitiesin access to dental care and proposed the dental therapist mid-level provider model as a strategy for getting dental care to thecitizens who need it the most. The report also emphasized dol-lars wasted on hospital ER visits for dental-related problems.

“Because no real dental safety net exists in the United States,many people turn to the emergency room for care,” the reportstated. It cited a Pew Center study that estimated that, nation-wide, in 2009 there were 830,000 ER visits for preventabledental conditions. It included specific data from two states:Iowa, where the average cost to Medicaid for dental relatedER visits was $500; and Florida where the dental ER visitsaveraged $765.

The report made only cursory reference to the role of govern-ment in funding preventive care safety net programs. “Accordingto a 2011 study published in the Journal of the American MedicalAssociation, when Medicaid payment to dentists increased,children were more like to see a provider.” It quickly added,“However, while increases in reimbursement rates lead to someincreases in access, increasing payment levels alone will notsolve the access problem.”

The American Dental Association asserted its own solutionsto the access to care problem in an August 2011 position paper,“Breaking Down Barriers to Oral Health for All Americans:Repairing the Tattered Safety Net.”

The ADA’s position agrees with some positions taken in Sen.Sanders’ report, but is in sharp contrast to others. It disputes theclaim that there is a shortage of dentists or that mid-levelproviders are a solution.

REPAIRINGDENTISTRY’STATTEREDSAFETY NETDouglas M. Bush

IDA Executive Director

rinity, a brown-eyed five-year-old clad in a hospital gown,looked into the camera as her grandmother lamented, “No den-tists want to see children on Medicaid…her teeth are infected.She’s had a lot of pain with them.”

Thirty-one-year-old Vanessa traveled eight hours to a chari-table event in Virginia to have all of her teeth extracted. “I’vebeen to the ER three times within the last six months. I can’ttake the pain. It’s too excruciating.”

Thus began Frontline’s special report entitled, “Dollars andDentists: The Dental Care Crisis in America.” As I sat to watchthe two-part report broadcast on PBS television outlets on June 26,I braced myself for the anticipated assault on dentistry. Surely‘heartless’ dentists would be blamed for the shortcomings ofour dental delivery system. While there was some of that, I waspleased to see a thoughtful, fairly balanced documentary.

Hit hard were the states’ Medicaid systems—Florida in partic-ular. The program reported that only ten percent of dentists par-ticipate in Florida Medicaid, and only 25 percent of Medicaid-eligible children see a dentist in any given year. Dr. Cesar Sebates,President of the Florida Dental Association, explained, “I lookedinto becoming a Medicaid provider because I do believe in givingback. I noticed that the reimbursement schedule was abysmal…it was maybe 20 percent of what we would normally charge. Ithought to myself, this doesn’t make any sense. This is not thedentist’s fault.”

Dr. Frank Catalanotto, Chair of the Department of CommunityDentistry at the University of Florida College of Dentistry,explained the absurdity of the State’s underfunded Medicaidprogram. Trinity, the five-year-old girl profiled in the Frontlineinvestigation, required hospital-based dental surgery that costthe Florida Medicaid program $18,000.

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“The ADA believes that the available population of dentists isnot a primary issue, and that precious resources should not besquandered on unnecessary efforts to augment the workforcewith midlevel providers…The problem is not how many den-tists there are; but rather where they are, and whether they areable to serve disadvantage patients, either in private practicesor in connection with clinics, health centers or other facilities.”

The ADA concluded with seven “fundamental principles”that it feels are crucial to successfully addressing the access tocare problem:

Prevention is essential—“The nation will never drill, filland extract its way to victory over untreated dental disease.But simple low-cost measures…will pay for themselves manytimes over.”

Everyone deserves a dentist—“The existing team system ofdelivering oral health in America works well for patients in alleconomic brackets. It does not need to be reinvented. Rather,it needs to be extended to more people.”

Availability of care alone will not maximize utilization—“In too many cases, people are unable or unwilling to takeadvantage of free or discounted care… missed appointmentsrepresent erosion of available treatment time that the systemcannot afford to waste.”

Coordination is critical—“Too many government and gov-ernment-administered programs suffer from a failure tomanage and exchange information about best practices forsafety net operation.”

Treating the existing disease without educating the patientis a wasted opportunity, making it likely that the disease willrecur—“Anyone who enters the dental operatory for restorativecare should leave the operatory with an understanding of howto stay healthy and prevent future disease.”

Public-private collaboration works—“Private practice den-tists will continue to deliver the hands on care to most of thepopulation, regardless of the payment mechanism…. Make iteasier for the dentists to deliver care and the safety net willaddress the oral health needs of more patients.”

Silence is the enemy—“Let’s take the ‘silent’ out of the‘silent epidemic.’”

We are taking steps at the Indiana Dental Association toaddress these issues head-on. Both in advocacy efforts andthrough our various charitable care programs, there are real wayswe can help effect positive change for those who need it most.

In June 2012, IDA President John Roberts appointed aCharitable Care Workforce to investigate how the IndianaDental Association can adopt a strategic approach to charitabledental care in the state. Watch for updates at www.indental.org.

Editor’s Note: To view Frontline’s story, Sen. Sanders’ report,or the ADA’s access to care position paper, visitwww.INDental.org/JIDA

“Anyone who enters thedental operatory for

restorative care shouldleave the operatory with

an understanding ofhow to stay healthy andprevent future disease.”

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dental benefits. The selection is further complicated by the factthat the definition and age cut-off for pediatric dental servicesremain unclear. Indiana has not yet selected an EHB benchmarkpackage or an associated dental benchmark package. Once theselections are made, they will define the benefit package thatwill be considered the EHB benchmark in Indiana.

While the PPACA does not require products in the individualand small group markets to cover adult dental services, presum-ably these services will be available to consumers on riders asthey are today. Individuals earning between 100% and 400% ofthe Federal Poverty Line (FPL) are eligible for tax credits to pur-chase coverage in an Exchange; however, these tax credits areindexed to plans covering the EHB and can only be applied tocoverage considered to be EHB. Thus, the tax credits cannot beapplied to adult dental coverage, and the cost of this coveragemust be borne by the consumer. This is likely to result in manyadults with subsidized health coverage who lack dental coverage.

Stand-Alone Dental Plans on the Exchange

The PPACA-created Exchanges also have a potential impacton dental coverage. Exchanges are a place that individuals canshop, purchase, and compare cost and quality of health plans.Individuals eligible for a tax credit must purchase their planthrough an Exchange. The PPACA requires that an operationalExchange exist in each state by October 2013. This Exchangemay be a state-based, federal-partnership, or federally operat-ed Exchange. Regardless of who operates the Exchange, it mustoffer stand-alone dental plans. Outside of comprehensivehealth coverage, stand-alone dental is the only coverage that isexplicitly authorized and required for all Exchanges. Stand-alone dental plans on the Exchange will be subject to all appli-cable qualified health plan (QHP) certification requirements(requirements for plans that offer on the Exchange) and will berequired to obtain this certification prior to offering their planon the Exchange.

Exchanges have several options in how to offer dental bene-fits to consumers. In addition to the stand-alone dental plans,pediatric dental benefits could be bundled with health benefits.The QHP plans could either provide the benefit themselves orpartner with a dental plan. The bundling option will allow fora single price, which may reduce confusion for consumers.Another option would be to have stand-alone pediatric plansand/or adult plans. In this case both pediatric and adult dental

SHIFTING THE FOUNDATIONS OF INDIANA DENTISTRY

HOW NEW FEDERAL LAW AFFECTSYOUR PATIENTS AND PRACTICE

HEALTHCAREREFORMSeema Verma, MPH

Kaitlyn Shaw

The Patient Protection and Affordable Care Act(PPACA) of 2010 and the recent Supreme Courtruling have a key impact on the coverage of dentalservices. New minimum standards for benefitpackages, the potential Medicaid expansion,

and dental coverage through an Exchange have the potential toimpact access to dental care. Low-income individuals are partic-ularly vulnerable to a lack of dental coverage, and it is unclearwhat the impact of the law will be on traditional employercoverage of dental services and the commercial market.

The Essential Health Benefits

Starting in 2014, the PPACA requires every plan sold in theindividual and small group markets to provide a core group ofservices called the essential health benefits (EHB). In each state,the EHB will be indexed to an EHB benchmark plan. As such,the EHB in each state will be based on the covered benefitsoffered through the State’s largest existing commercial products.States can choose their EHB benchmark; however, they mustensure that the benchmark covers all PPACA-required EHB.The PPACA lists pediatric dental services as EHB, and all stateswill be required to include them in their EHB benchmark plan.None of Indiana’s EHB benchmark options provide pediatricdental benefits, as dental services are frequently offered in theform of a rider. Per federal guidance, benefits offered on a riderare not considered covered in the EHB benchmark options.In the case of the pediatric dental benefit, states have beeninstructed that if the benchmark plan does not offer pediatricdental then it must be supplemented with either the pediatricdental benefits from the Federal Employees Vision and Dental(FEDVIP) benefit plan or the State Children’s Health Insurance(SCHIP) dental benefits to create a benchmark for pediatric

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plans could be offered and priced outside of the general healthbenefit. Due to the PPACA EHB requirements, every individualwould be required to select and pay for at least a pediatric den-tal plan, regardless of whether they wanted the plan or had eli-gible children. These options are not mutually exclusive, andan Exchange could require the pediatric benefit to be bundledwith the health benefit (but allow for stand-alone dental plansfor adults).

Offering stand-alone dental plans on the Exchange may spurmore consumers to purchase dental coverage; however, it alsohas the potential to create confusion, as only the pediatric portionof the dental plan will be covered by federal subsidies. Explain-ing this situation to consumers and developing stand-alone dentalplans that do not overlap with pediatric coverage (possiblyalready included in an individual’s health plan) will be key con-siderations as Exchanges are implemented. An Exchange willhave to consider which policy makes it easiest for the consumerand how the dental insurance market operates today.

Medicaid

The State's Healthy Indiana Plan (HIP) is a non-entitlementMedicaid waiver program established in 2008 that servesroughly 40,000 adults. HIP provides health coverage to adultsbut does not offer full dental benefits. Although the originalauthorizing HIP language required dental services to be offeredas a rider, the Centers for Medicare and Medicaid Services didnot allow the dental rider to be offered. HIP does offer dentalbenefits limited to the Early and Periodic Screening, Diagnosis,and Treatment (EPSDT) program for individuals aged 19 and20. Eligible individuals 18 and under receive dental benefitsthrough SCHIP. In 2011, the Indiana Legislature passed a lawthat would make the Healthy Indiana Plan (HIP) the coverage

“The Patient Protectionand Affordable Care Act,

and recent SupremeCourt ruling, have a keyimpact on the coverage

of dental services.”

vehicle for the Medicaid expansion. This occurred before theSupreme Court decision, and it is currently unclear if Indianawill commit to a Medicaid expansion, or if CMS will extendIndiana's waiver. Early estimates indicate an expansion cost ofapproximately $2 billion over the next eight years. The futureof the HIP program is also unclear, as it expires in December2012 and requires federal approval to continue. Additionaluncertainty surrounds whether adult dental services will beadded to the HIP program or to a Medicaid expansion productin the future.

Conclusion

The PPACA strengthens pediatric dental care and should resultin an improvement and expansion in dental care for children;however, given the EHB requirements and the uncertainty of theMedicaid expansion, access to dental care for low- and moderate-income adults is likely to continue to be a key issue.

About the Authors

Seema Verma, MPH, is the founder and owner of Seema VermaConsulting, Inc., in Carmel, Indiana. Verma served as the archi-tect of the Healthy Indiana Plan and is currently helping tooversee Indiana's implementation of the Patient Protection andAffordable Care Act.

Kaitlyn Shaw graduated from Randolph College with degrees inEconomics, French, and Mathematics. Shaw is currently pursu-ing a Master’s in Public Health from the Indiana UniversitySchool of Medicine.

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CHANGING PRACTICE MODELS:

THE RISE OFLARGE GROUPPRACTICESCharles L. Steffel, DDS, MSD

Dentistry has long been delivered by a systemthat is very much a cottage industry. Thousandsof small offices with one or two doctors provideoral health care to their patients. The term “cot-tage industry” originated hundreds of years ago

when most people lived in rural settings. During the wintermonths, there was little work to be done. In order to supple-ment incomes, individuals or families would work at home(cottage) with their own equipment producing products suchas clothing, pottery, and furniture. When the IndustrialRevolution came, these small, local sources of goods andservices gave way to large, centralized factories.

Many of you may remember a time when every town and cityhad only local stores and restaurants. Nowadays it is hard to findsuch businesses that are not national chains. Walmart, BananaRepublic, and Macy’s are the norm, and McDonald’s, Applebee’s,and Ruth’s Chris Steakhouse are virtually everywhere.

In health care, just one generation ago, we filled our pre-scriptions at the local drug store and got our eyeglasses froman independent optometrist. These businesses were ownedand operated by neighbors and friends. Today, CVS andWalgreen’s are on almost every corner. According to the visioncare trade magazine Vision Monday, Luxottica Retail (operatingunder the brands LensCrafters, Pearl Vision, Sears Optical, andTarget Optical) was the top retailer of eyeglasses in 2009, withsales of over $2.5 billion. Walmart ranked second, and Costcowas fifth!

Can dentistry be far behind? It seems that every day wesee a national dental chain opening a new office just downthe street. Is this the future of our profession?

The Health Policy Resource Center (HPRC) of the AmericanDental Association conducts extensive economic and marketresearch on the dental profession. The most recent surveys,performed between 2009 and 2011, give us a snapshot of dentalpractice today. The 2009 Survey of Dental Practice showed thatover 80% of all dentists in private practice who responded workin solo or two-doctor offices. Ninety-two percent of private prac-tice dentists are in offices of four or fewer doctors. Only 8% ofdentists work in practices of five or more doctors. The survey

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considered dentists to be working in “Large Group Practices”if multiple locations were owned or managed by a single busi-ness unit, even if there were only one or two doctors perlocation. Though large group practices are the fastest-growingsegment of the dental profession, these statistics suggest theirpresence in the overall market may be smaller than perceived.

For the purposes of analysis and data collection, the HPRChas classified dental practices into four size groups: Practiceswith 1 to 4 dentists are called Solo/Cooperative; 5 to 9 dentistsare called Large Group Practices; 10 to 19 are Larger Groups;and practices with 20 or more are called Very Large GroupPractices. For this article, any practice with 5 or more dentistswill be referred to as a large group practice (LGP).

Large group practices come in many shapes and sizes. Thereare group practices that are wholly owned by dentists in thegroup, with or without employed associated dentists. In thesepractices, the owner dentists handle most management respon-sibilities. When these groups reach a critical size, they mayemploy non-doctor practice administrators. There may be a sin-gle, large office location, or multiple locations that encompass aparticular geographic area. These practices are more commonin larger cities and specialty groups. There are many largegroup practices of this type throughout Indiana.

Another doctor-owned model utilizes a Dental ServiceOrganization (DSO). This business structure is sometimes calledthe franchise model. There will be numerous offices, typicallywith one dentist per location. The dentist owns the individualpractice, but outsources business, marketing, and managementduties to the DSO. While the doctor is not an employee of theDSO, there are long-term contractual payments to the DSO forits services. Heartland Dental Care, based out of Effingham,Illinois, is organized similarly to this type of LGP. Heartlandhas over 300 offices in 18 states, with 51 offices in Indiana.

In some large group practices, nearly all dentists areemployees. Although ownership shares may be available topractice doctors, majority ownership by private-equity firmsis a growing trend. Aspen Dental and Kool Smiles are two ofthe largest group dental practices in the country and are ownedby private-equity firms. Aspen Dental has about 350 offices in22 states, and Kool Smiles, the country’s largest Medicaid dentalprovider, has 129 offices in 15 states. Both have a significantpresence in Indiana.

That has raised concerns about their marketing and practicemanagement. Production-driven practice policies have raisedconcerns about overtreatment. On June 26, 2012, PBS aired areport titled “Dollars and Dentists” on its Frontline program.The feature took a long, hard look at claims that the private-equity owners of these two Large Group Practices werepressuring their employee dentists to increase profits viaquestionable means.

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Fontana, CEO of Aspen Dental Management (owned by LeonardGreen & Partners, a Los Angeles private-equity firm), statingthat “dentistry is a fragmented, ‘cottage’ industry ripe for man-agement services.”

Another reason for the growth of corporate owned LGPs maybe the struggling economy and high student debt. It is becom-ing increasingly difficult for new dental graduates to start a newpractice or purchase an existing one. The cost to equip a newdental office with state-of-the-art equipment and technologycan exceed a half-million dollars. In the American DentalEducation Association’s Survey of Dental School Seniors, 2011Graduating Class, 88.8% of graduating seniors reported havingeducational debt. Of those students with educational debt, theaverage debt when entering dental school was $35,670, plus anadditional $180,557 acquired during dental school. That’s over$200,000 of educational debt before the new doctor sees his orher first patient! Educational debt is increasing rapidly and isapproaching the average net income of all dentists. New dentalgraduates have few options that will give them the income nec-essary to service this debt. Practice ownership, the dentist’sAmerican dental dream, is quickly moving out of reach for thenext generation of practitioners.

There are some positive aspects of large group practice thatare attractive to many new graduates. Employed dentists are freeof the management and administration headaches of practiceownership. Business and staffing affairs are the responsibility ofthe management company. Expensive technology that would beout of reach for a beginning practice owner is common in manyLGPs. Geographic mobility is especially attractive to employeddentists whose spouses may have to relocate for their careers.

There are some economic advantages to LGPs. In August,2009 Rick Workman, DMD, the founder and CEO of HeartlandDental Care, told the ADA Board of Trustees that they “obtainsubstantially better pricing for supplies, equipment, and labservices compared to independent dentists.” When askedabout Heartland’s fees, Workman stated they “are able tonegotiate from a strength position for favorable fees andpricing with various entities, including insurance companies.”

So what does the future of dentistry hold for the newgraduate? Will our cottage industry undergo the same corporatetakeover that overran pharmacy and optometry not so longago? Is practice ownership no longer an attainable goal forcurrent students in our dental schools? Certainly, some changeis inevitable. I have seen so much change, changes that no onecould have foreseen, in the 34 years since I graduated from theIndiana University School of Dentistry.

Here is what we do know: In the 2010 Survey of DentalPractice, 86% of private practice dentists were practice owners,either sole proprietors or partners. Only 10.5% were employeddentists and 3.5% were independent contractors. Private prac-tice is still dominated by dentist-owners.

In the case of Kool Smiles, a chain that specializes in treatingchildren on Medicaid, Frontline reported that several stateshave investigated claims of unnecessary care, inflated billing,and Medicaid fraud. Charges of high-pressure sales tactics andovertreatment being billed to health care credit cards forpatients of the Aspen Dental chain were investigated. In bothstories, concerns over non-dentist managers influencing treat-ment planning and clinical decisions were raised.

Senator Charles Grassley (R-IA), ranking member of theUnited States Senate Finance Committee, has been investigat-ing several private-equity owned dental chains. Sen. Grassleyquestioned whether dentists at these chains are able to makeclinical decisions for their patients, free from corporate pres-sure to increase production and profits. While managementcompanies perform valuable office support services for dentaloffices, many believe that they should not be allowed to dictatepatient care decisions. American Dental Association policystates that dentists should be “free to exercise individual clinicaljudgment and render appropriate treatment to their patientswithout undue influence by any third-party business entity”(Dentist’s Freedom to Exercise Individual Clinical Judgment[1997:705]).

So why are these LGPs and chains becoming so popularnow? The ADA Health Policy Resource Center estimates thatfrom 2009 to 2011, the number of large group practices hasgrown 25%. What factors have influenced and enabled thisexplosive growth? In August 2010, the New York Post openedan article with the warning, “The private-equity barbarians maysoon be running a dental office near you.” The article reportedon private-equity firms bidding for ownership of Aspen Dentaland Kool Smiles, predicting the price for each LGP couldexceed more than $500 million. Why so much? The article saidthat most dentists “still work outside a management practice,”and that “healthcare reform that is cutting into reimbursementfor medical doctors is not affecting dentists.” Most important toprivate-equity firms, according to the Post, dentistry “is one ofhealthcare’s last bastions of fee-based services.” The articlepointed out that over 80% of dentists work solo or with only oneother dentist. In other words, dentistry is the last cottage indus-try remaining in healthcare. Bloomberg.com quoted Robert

“Large group practicescome in many types,including dentists asowners, shareholders

or employees.”

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In unpublished data collected in 2009, dentists in largegroup practices were surveyed about satisfaction with theircurrent practice situation. Results were grouped by the practicesize. As practice size grew, fewer dentists were happy with theircurrent situation. In LGPs with 5 to 9 dentists, 73% stated theypreferred their current practice setting. In practices with 10 to19 dentists, that number fell to 56%. And in the very large grouppractices, those with 20 or more dentists, only 42% were satis-fied with their current practice setting. Another finding of thissurvey was that in LGPs, net income per doctor fell as the sizeof the practice increased.

One final thought as I look to the future of our profession:I like to call it the “fear factor.” We all know that patients feargoing to the dentist. Fear is one of the top reasons people post-pone or neglect needed dental care. But this fear factor cansometimes be an advantage to the caring practitioner. As areferral-based specialist, everyday I hear patients say, “I hateall dentists, except my own.” I believe what they really mean is,“I fear all dentists, except my own!” I am an endodontist, andfear is something that must be overcome with every patient.What I have seen, and grown to appreciate after all these years,is that patients develop a strong, trusting relationship with theirown individual dentist. A discount coupon or slick advertisingdoes not easily break the bond of trust between a patient andhis or her dentist. Certainly, we have all lost some patientsdue to economic factors, like a change in their insurance plans.But what amazes me is that most patients stay, in spite of theseeconomic incentives to leave. I don’t believe a corporate chainbuilds the same trusting relationship, especially if the patientsees a different dentist at each visit. People don’t fear the phar-macist or optometrist. Perhaps that is one of the reasons theircottage industries disappeared.

I see change coming to our profession. That is certain.Change is inevitable. But I do not see the end of the solo andsmall-group practices we know today. Large group practice willcontinue to grow and thrive, but I do not believe that largegroup practice will be the end of our cottage industry, or theprofession of dentistry.

Editor’s note: This article represents the opinions solely of theauthor, which are not to be accepted as views of the ADA orIDA unless such statements have been expressly adopted bythat Association.

About the AuthorDr. Charles L. Steffel practices endodontics in Indianapolis,Indiana, and serves as Seventh District Trustee for the AmericanDental Association. Dr. Steffel also served as the 144th Presidentof the Indiana Dental Association.

A NATIONAL AND INDIANA PERSPECTIVE:

THE RISINGCOST OFDENTALEDUCATIONJohn N. Williams, DMD, MBA

The American public expects competent, well-educated healthcare professionals to providequality care. In turn, it costs money to build andsustain a quality dental education program tomeet the public’s expectations. This investment

is made, however, in order to graduate a competent generaldentist—one who possesses the scientific knowledge, technicalskills and the professional ethics to provide excellent oralhealthcare. Of late, higher education has been seen as anincreasingly costly enterprise, resulting in larger student debtat the time of graduation.1 The cost of a student receiving adental education is no exception to this trend. In order to betterunderstand the cost of dental education and explore optionsto address some moderation of the costs, it is important tounderstand the underlying issues, sources and uses of funds.

America has one of the most advanced healthcare systemsin the world. Indiana is a contributor to this system by being inthe business of educating new dentists from as far back as 1879,a date which marks the opening of the private Indiana Collegeof Dentistry in downtown Indianapolis. By the mid-1920s, thedental college had become public—a part of Indiana University—and was thus, in part, supported by the state as a public institu-tion of higher education. Presumably, this was a statement bythe legislature and people of the State of Indiana that the Statedesired to have a publicly supported school to assure an appro-priate number of competent dental graduates to meet the oralhealth needs of the people of Indiana. While the IU School ofDentistry remains part of the Indiana’s higher education systemtoday, the level of public financial support has decreased overtime. By comparison, in the early 1960s, tuition was $430 peryear, and the State provided a much larger share of the cost fora student attending IU. But in 2010-2011, in-state resident tuitionwas $26,278 per year, and the state provided a little over 21% ofthe annual operating funds.2

Nationally, the total reported expenditures (excludingresearch) to educate a DDS student averaged $91,402/full-timeequivalent (FTE) student/year (2008-2009). Individual dental

$

12


TABLE 5:Average 4 Year DDS Tuitions 2010-2011Rank Order by Resident Tuition

RESIDENT $

Nebraska 24,301

Indiana 26,278

Michigan 30,254

Minnesota 31,269

Iowa 31,658

Illinois 33,920

Ohio 36,233Source: American Dental Education Association Official Guide to Dental Schools 2011

TABLE 6:Average 4 Year DDS Tuitions 2010-2011Rank Order by Non-Resident Tuition

NON-RESIDENT $Michigan 47,364

Iowa 52,020

Minnesota 56,999

Indiana 57,570

Ohio 61,356

Nebraska 64,624

Illinois 72,852Source: American Dental Education Association Official Guide to Dental Schools 2011

TABLE 4:Percentage and Dollar Amount of Operating Revenue 2008-09for IU School of Dentistry

PERCENT DOLLARS

Tuition 32.6 19,065,849

Research 6.9 4,035,410

Patient Care 20.3 11,872,293

Financial Aid 0.4 233,937

State and Local 21.5 12,574,103

GraduateMedical Education 2.8 1,637,558

Endowment 2.7 1,579,073

Annual Gifts 0.5 292,421

UniversityIndirect Support 8.9 5,205,094

Other (CE, AuxiliaryEnterprises)* 3.4 1,988,463

TOTALS (%) 100.0 58,484,200Source: 2009-10 ADA Survey of Dental Education Finances Vol. 5 (September 2011)*Other—Includes IUPUI campus assessments

TABLE 1:Percentage Expenditures 2008-09 US Dental Education

PUBLIC PRIVATE ALL INDIANAEducation 28.8 26.4 28.1 28.2

Research 13.5 7.0 11.4 13.6

Patient Care 26.4 26.2 26.3 28.3

Financial Aid 3.2 2.5 3.0 1.8

Major Capital 2.9 4.1 3.3 3.5

Other* 25.0 33.3 27.9 24.6

TOTALS (%) 99.8 99.5 100.0 100.0Source: 2009-10 ADA Survey of Dental Education Finances Vol. 5 (September 2011)*Other—Includes IUPUI campus assessments. (Note: Columns <100% due to rounding)

TABLE 3:Percentage Revenue 2008-09 US Dental Education

PUBLIC PRIVATE ALL INDIANATuition 19.1 52.8 30.5 32.6

Research 11.8 7.5 10.4 6.9

Patient Care 21.7 23.3 22.3 20.3

Financial Aid 3.2 0.9 1.1 0.4

State and Local 23.0 1.6 15.8 21.5

GraduateMedical Education 1.9 0.5 1.5 2.8

Endowment 1.0 2.6 1.4 2.7

Annual Gifts 1.9 2.6 2.2 0.5

UniversityIndirect Support 14.4 4.5 11.7 8.9

Other (CE, AuxiliaryEnterprises)* 2.0 3.7 2.9 3.4

TOTALS (%) 100.0 100.0 99.8 100.0Source: 2009-10 ADA Survey of Dental Education Finances Vol. 5 (September 2011)*Other—Includes IUPUI campus assessments. (Note: Columns <100% due to rounding)

TABLE 2:Percentage and Dollar Expenditures 2008-2009for IU School of Dentistry

PERCENT DOLLARSEducation 28 16,492,544

Research 14 7,953,851

Patient Care 28 16,551,029

Financial Aid 2 1,052,716

Major Capital 4 2,046,947

Other* 25 14,387,113

TOTALS 100 58,484,200Source: 2009-10 ADA Survey of Dental Education Finances Vol. 5 (September 2011)*Other—Includes IUPUI campus assessments

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Expenditures

Looking at the dental education enterprise across the UnitedStates, two types of schools collectively expended slightly over$2.71 billion in 2008-2009 to provide education, research andservice in support of the profession. These costs were dividedbetween state schools ($1.77 billion) and private dental schools($940 million).7 Table 1 shows the percentage of dollarsexpended for the major areas of operating a dental school.The major cost is tied to personnel as represented in the educa-tion and patient care categories, which together make up overhalf of the dental school expense. Table 1 further shows the dif-ference in percentage expenditures between public and privatedental schools. While education and patient care expenses aresimilar for both types of schools, private institutions spend lesson research and more of their own monies on “other” expenses,since they must self-fund more activities.

A comparison of the IU School of Dentistry against thisnational expenditure profile shows that the major expenses paral-lel those nationally mainly in education and patient care, althoughcosts for patient care are slightly higher at IU when compared toeither public or private dental schools. A detailed breakdown bydollars is shown for IU School of Dentistry in Table 2.

Revenues

Looking at the revenue derived to support the United Statesdental education enterprise, the 2009-2010 ADA report showsthat the two types of schools collectively generated over $2.88billion in 2008-2009 to provide education, research, and servicein support of the profession. These costs were divided betweenstate schools ($1.89 billion) and private dental schools ($979 mil-lion). Table 3 shows the percentage of dollars generated bysource. The major source of revenue for private dental schoolsis tuition (52.8%) compared to public dental schools (19.1%) andprivate dental schools derive less from research. The “UniversityIndirect Support” category for private dental schools is less aswell, since they are expected to pay for more of their own operat-ing costs at the school level and not at the campus level. Indianahas a similar arrangement as a private dental school under theResponsibility Center Management (RCM) financial program inuse at the IUPUI campus. The IU dental school pays for morelocal services, but benefits from keeping more tuition and clini-cal revenue at the dental school.

Again, the comparison of the IU School of Dentistry againstthis national revenue profile shows that the major sources ofrevenue parallel those nationally mainly from tuition andpatient care. One note is the much larger proportion of revenuegenerated from tuition (32.6%) compared to the national aver-age for public dental schools of (19.2%). Indiana also has aslightly lower percentage of its revenue coming from state and

school expenditures range, however, from a high of $155,623/FTE student/year to a low of $46,392/FTE student/year.3 IUSchool of Dentistry spends about $86,000/FTE/year to educatea dental student, which is slightly below the national average.4

The major portion of this cost is in support of clinical education.

During the late 1960’s through the 1970’s, the federal govern-ment was active in funding health professions education. In a2005 publication by the federal Health Resources and ServicesAdministration (HRSA) entitled: Financing Dental Education—Public Policy Interest, Issues and Strategic Considerations, abrief history of federal financing policy is provided.5

Federal support for dental education was largely con-fined to short-term funding some 30-40 years ago andhas been reduced significantly over the past 2 decades,to the point where less than 1 percent of predoctoraldental education revenues in 2001 came from Federalfunds. State and local government support for dentaleducation in public dental schools declined by 25 per-cent in recent years, from 66 percent of total dentalschool revenues in 1991 to 49 percent in 2001, andcontinues to fall. State and local government supportfor dental education in private dental schools declinedfrom 10 percent in 1991 to less than 3 percent in 2001.Declines in public funding for dental education arewidely viewed as a significant factor in the closing anddownsizing of U.S. dental schools over the past twodecades and an impending crisis in dental education.5

In the decade since this HRSA report was written, state insti-tutions have continued to replace state support with primarilytuition and fee dollars to fund dental education. Total direct fed-eral educational revenue to dental education in 2008-2009excluding federal grants was only $11 million of $2.9 billionamounting to only 0.4% of total revenue.6 State and local fundingrepresented only 15.8% on average distributed as 23% for publicdental schools and only 1.6% for private ones in 2008-2009 insharp contrast to the situation since 1991 as cited above.6 IUSchool of Dentistry is slightly below the national figure at 21.5%.

“Although IUSD remainspart of Indiana’s highereducation system, itslevel of public financialsupport has decreased

over time.”

14


premiums, we probably won't see a roll back in tuition costs,but we can see a slowing of the annual dental tuition increase,which in recent years has exceed 8.0% per year.9 Figure 1 showsthe picture of tuition increases for both resident and non-resi-dent students from 2001 through 2011. Both groups havealmost doubled over this time period.

In considering what we can do, I offer two possibilities forconsideration of slowing or reducing the costs of dental educa-tion at IU. There are other ideas, and I welcome your thoughtsabout other ways to address the costs of dental education.A more exhaustive discussion of cost of dental education canbe found in an article for the Journal of the American DentalEducation Association entitled “Dental education economics:challenges and innovative strategies.”10

Clinical Efficiency

Personnel costs of clinical instruction need to be examinedto assure all dental schools are operating clinics efficiently.This analysis applies to both faculty and staff. At IU, the averageclinical experience, and hence revenue, derived from patient carebased on our reduced fees (approximately half of communityfees), for our D3 and D4 students amounted to about $16,500 peryear in 2009.11 Once in practice, however, a new graduate needsto generate two-times that amount per month in order to earn abasic entry level of compensation. The school could better pre-pare D4 students by structuring clinical operations and patientcare to expand the volume of care delivered to enhance the stu-dent’s educational experience and support a higher revenuestream.

Curriculum Modifications

Undergraduate education has enjoyed success in makingavailable advanced placement and college level courses at thehigh school level. One can argue that based on the competencyphilosophy of US dental education, dental students should rou-tinely be able to place out of various biomedical sciencescourses, based upon satisfactory completion and assessment,that they have mastered the curriculum. In turn, this wouldreduce their educational course load and reduce costs associatedwith taking biomedical sciences again once enrolled in dentalschool. A further “check” on student competence is successfulcompletion of Part 1 and 2 of the examination administered bythe Joint Commission on National Dental Boards, which arerequired for dental licensure in all 50 states.12

local support (21.5%) versus (23%) for other public dentalschools. A detailed breakdown by revenue dollars is shownfor IU school of Dentistry in Table 4.

Tuition

With Indiana having a larger proportion of its operatingrevenue coming from tuition, we are seeing the impact of agreater reliance on tuition to fund the dental school. Tuition isset by looking at benchmark institutions and approved by theIU Board of Trustees. One set of benchmarks is the seven Big 10schools, which now includes Nebraska. A review of both in-state resident and non-resident tuition shows that Indiana ismid-range when compared against these benchmark programsfor non-resident tuition and at the lower end for in-state dentalschool tuition.8 The strategy has been to keep in-state tuitionrelatively low to thwart a student perception of limiting educa-tional access based on tuition costs. Big 10 in-state residenttuition ranges from a low of $24,301 to a high of $36,533 (overa 4 year average). The impact of high tuitions on non-residentsis seen in the Big 10 as well. These four-year average annualamounts range from a low of $47,362 (Michigan) to a high of$72,852 (Illinois). Tables 5 and 6 outline the rank order for bothresident and non-resident tuition costs for seven of the Big 10universities that have dental schools.8

How to Control the Cost of Education

By understanding the underlying sources and uses of funds forboth public and private dental schools, one can better under-stand the challenges and changes that might be made to reducethe tuition cost for students. Like rising US health insurance

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

Non-Resident

Resident

2010-112009-102008-092007-082006-072005-062004-052003-042002-032001-02

$17,413

$27,386

$18,607

$29,345

$21,041

$32,716

$22,684

$34,274

$24,289

$36,989

$25,908

$38,638

$27,570

$41,290

$29,879

$43,969

$32,934

$46,859

$35,422

$50,053

Figure 1:Tuition Increases for Resident and for Non-Resident Students,2001-02 through 2010-11

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Summary

Indiana University School of Dentistry remains committedto graduate competent general dentists. In the face of the costof dental education, we are open to explore alternative educa-tional and clinical models to enhance the educationalexperience for all students, while reducing the cost to providethat education. As dean, I welcome your thoughts and ideas tofurther reduce educational costs.

References

1. USA Today Student loans outstanding will exceed $1 trillion this year.Oct 27, 2011. At: http://www.usatoday.com/money/perfi/college/story/2011-10-19/student-loan-debt/50818676/1Accessed: July 10, 2012.

2. Indiana University Academic Bulletin; School of Dentistry, 1961-62, page 18.

3. American Dental Association: 2009-10 ADA Survey of Dental EducationFinances Vol. 5 Chicago, (September 2011), p. 91.

4. Ibid. p.88.

5. HRSA Financing Dental Education: Public Policy Interests, Issues andStrategic Considerations 2005

6. American Dental Association: 2009-10 ADA Survey of Dental EducationFinances, Vol. 5 Chicago, (September 2011), p. 6.

7. Ibid. p.7.

8. American Dental Education Association: Official Guide to Dental Schools2011, for students entering in fall 2012. American Dental EducationAssociation publication, Washington, DC.

9. American Dental Association, Survey Center, Surveys of Dental Education,(Group II, Question 15a).

10. Walker MP, Duley SI, Beach MM, Deem L, Pileggi R, Samet N, Segura A,Williams JN. Dental education economics: challenges and innovativestrategies. Journal of Dental Education December 2008; 72(12); 1440-49.

11. American Dental Association: 2009-10 ADA Survey of Dental EducationFinances, Vol. 5 Chicago, (September 2011), p. 18.

12. Joint Commission on National Dental Examinations.At: http://www.ada.org/2289.aspxAccessed: July 20, 2012.

About the AuthorDr. John N. Williams is the Dean of the Indiana University Schoolof Dentistry.

DEMOLITION DERBY:

WHO WILL WINTHE BATTLETO DEFEATBARRIERSTO CARE?David R. Holwager, DDS

Access to care—how difficult can this be?The answer is more complicated than is thought.Answers could be found in the considerationof many facets to the primary access problems:barriers, cultures, demographics, oral health

literacy, physical distances, impairments and economics, toname a few. The issues of access are also political in natureand are being used to advance the cause of different groupsto advance their agendas.

The American Dental Association (ADA) convened in 2009of over fifty different groups who have been identified as stake-holders in oral health concerns. The groups includedrepresentatives from government agencies, foundations, den-tal-related industries, Native Americans, professional dentalgroups, and consumer groups. The summit was well attended,with tenuous discussion on the issue.

Finally the group came to the conclusion to put the differ-ences aside and work towards solutions in areas where thereis agreement. The summit on access then evolved into the U. S.National Oral Health Alliance. Since the 2009 summit the worknecessary to form the alliance, bylaws, administration, mem-bership, and economic concerns have been developed andadopted. Mr. Douglas Bush, Executive Director of the IndianaDental Association, was a member of the Alliance formationgroup. The ADA joined in the winter of 2011-2012.

The ADA defines mid-level dental provider as any oralhealth provider whose training and responsibilities arebetween those of ADA-recognized dental team members(community dental health coordinators, oral preventive assis-tants, dental assistants, expanded function dental assistants,and dental hygienists) and those of a licensed dentist.

16


stainless steel crowns, and recementation of crowns. Thismodel, like the DHAT, does not require the direct supervisionof a dentist and could practice independently.

Implications

DHATs (both forms) and ADHPs are mid-level models thatperform invasive procedures on patients. The pattern uponwhich these models are based is that of the nurse practitionersused in medicine, but with the significant difference being theability to perform invasive procedures.

The American Dental Association (ADA) and the IndianaDental Association (IDA) do not support any of the above mod-els of mid-level providers, but instead offer support to thedoctor who has graduated from a CODA-accredited school ofdentistry and gone through the licensing procedures requiredby the State Board of Dentistry.

Currently the ADA is conducting a pilot study for a new typeof dental team member, modeled after the Community HealthWorker (CHW). Called a “Community Dental Health Coordinator”(CDHC), the dental team member’s role is to help solve access tocare issues for the underserved who have difficulty in seekingdental care. The CDHC helps with the logistics of getting thepatient to and from the care provider, and educates the patientand community on the importance of good oral health and pre-vention. The ADA and volunteer members developed the pilotprogram such that it would meet CODA standards, if advanced.The CDHC is under the supervision of a dentist, who goes intothe community to aid individuals in getting the dental care theyneed. The CDHC will help in the raising of the oral health literacy,along with education in the causes and effects of oral diseases,especially relating to the decay process.

The functions the CDHC may perform besides education andlogistical support are to be authorized by a dentist, to includecoronal polishing, fluoride treatments, sealant placement, place-ment of temporized restorations, selective scaling for periodontaltype-one, and gather diagnostic data for the dentist. Note that theCDHC works under the supervision of the dentist and does notperform invasive procedures, nor does the team member diag-nose the oral condition. Neither is the CDHC a mid-levelprovider, but a member of the dental team who, like a CHW,helps the patient navigate their personal access to care issues.

The pilot study involves the development of an educationalmodel that can either be taught in a classroom setting or via theInternet through an online course. There is also a required 18-month internship during which students develop and demon-strate their clinical skills with the aid of their clinical instructors.The CDHC study involves individuals with various backgrounds,including dental hygiene and dental assisting. Some participantswill also come from an expanded functions dental assistant

There are indeed many models that focus on answers toaccess. Foundations, individuals in public health, governmentalagencies, and the American Dental Hygiene Association haveall proposed the mid-level provider.

The following is an outline of the major models of workforcemodels (mid-level providers) by different groups.

The Dental Health Aid Therapist (DHAT) model consistsof an individual who is a high school graduate with eighteenmonths to two years of training and education to perform thefollowing duties: diagnosis, extractions, pulpectomies, restora-tions, local anesthesia, prophylaxis, pulp capping, and theplacement and cementation of stainless steel crowns. DHATsbegan in New Zeeland but can now be found in Alaska, Canada,Great Britain, and forty-nine other countries.

Minnesota already has a model of the DHAT, which is taughtat the University of Minnesota and has graduated students whoare now practicing in that state. The educational requirementshave college pre-requisites and consist of a 40-month B.S. pro-gram followed by a 28 month M.S., as well as licensure by theirstate board of dentistry. The duties Minnesota’s model can per-form include the following: anterior primary crowns, diagnosis,restorations, prophylaxis, extractions, local anesthesia, pulp cap-ping, stainless steel crowns, prescriptions, space maintainers,recementation of crowns, and a traumatic restorative technique.They are not required to be under the supervision of a dentist.

The Advanced Dental Hygiene Practioners (ADHP) is a modelput forth by the American Dental Hygiene Association (ADHA).The individual would hold a dental hygiene degree, license, andwould complete the educational requirements for certificationas an advanced dental hygiene practioner. The duties an ADHPcould perform are as follows: diagnosis, extraction, periodontaltherapy, pulpectomies, pulp capping, local anesthesia, nitrousoxide administration, prescriptions for pain relief, orthodontics,

“If dentistry doesn’tsolve the issues of

access to care,someone else will.

Opposition withoutan alternative solutionis the wrong answer.”

17WWW.INDENTAL.ORG

caseworkers have been a contributing factor to the issues ofaccess. The basic economic model of any access solution mustwork, or it will surely fail.

Conclusions

Access to care issues pose real threats to dentistry as weknow it. If the adoption of any of the DHAT or ADHP workforcemodels is deemed acceptable to governmental agencies, howlong does it take for the sub-standard care they provide to bean acceptable level of care for the entire population? There is areason dentists and dental hygienists have a required level ofeducation and an emphasis on continuing education: It is toprovide the highest possible standard of care for every patient,not having multiple levels of care.

Dentistry has worked over the years to be a profession wherethe level of treatment success is predictable, the patient level ofconfidence in care is high, and the level of comfort in treatmentis acceptable. The hallmark of dentistry as well as medicine isto improve treatment modalities, reduce the discomfort of thepatient, reduce or eliminate the disease process, and educatethe patient in prevention of diseases and good overall health.A reduction in educational standards for dental healthproviders under DHAT or ADHP models will not achieve this.

Advocacy for the oral health of our patients is not just theresponsibility of the leadership of the Association, but theresponsibility of every doctor and dental team member. Thepatient must be our first concern, including the underserved.The IDA and the ADA are working for the profession to retaindentistry’s high standards. You need to not only be a doctorand educator in your profession, but also an advocate.

About the AuthorDr. David R. Holwager practices general dentistry in CambridgeCity, Indiana, and is the current Chair of the American DentalAssociation’s Council on Access Prevention and InterprofessionalRelations. He also served as the 148th President of the IndianaDental Association.

(EFDA) background or work for a dental clinic, while others willparticipate with a high school degree as the highest academicand/or training credential.

The program has been conducted through four dentalschools thus far: Arizona, Temple, Oklahoma, and UCLA, witha number of associated clinical sites in rural, urban, and NativeAmerican settings.

The study also involves a evaluation of the education moduleand the effectiveness of the CDHC, not only including the differ-ence it makes in patients’ access to care, but also the level towhich the provided care increases efficiency of the clinic and/ordentist. The sustainability of the CDHC must also be proven, forif the economic model does not work, the cost of the educationwill not be worthwhile.

The last cohort of students will finish in September 2012,with a partial evaluation by this year’s ADA House of Delegatesand a full report of the program and evaluation of the project forreview and approval of the 2013 ADA House of Delegates. TheADA, unlike others, will not put forth a model of a new dentalteam member unless that model has a positive evaluation.

The Challenge to Have the Right Answer

Dentistry’s challenge will be to solve the issues of access or,quite simply, someone else will do it for us. It has been proven,as the profession learned in Alaska, that opposition without analternative solution to improve the issue of access is the wronganswer. Governmental bodies will look for a solution, and weknow there are already many alternatives for them to con-sider—all claiming to have the answer. The issues of access tocare for the underserved also emerged in medicine, in whichphysicians also said “no,” but offered no other solution toaccess; they now have nurse practitioners.

The ADA’s solution, unlike the other workforce models, isnot a therapist, but an educator, who has cultural competenciesto explain the importance of good oral health, explain the valueof prevention, and arrange the logistics of care. The well-trainedmembers of the dental team render care. Under this model,there is no lowering of the educational requirements or a differ-ent standard of care for the underserved.

Economic Factors

Access also has an economic side. When reimbursementsrates are fair, there has been an increase in providers and anincrease in utilization of Medicaid services, not to mention alowering of complaints from the voters. Underfunding of theprograms, administrative issues with claims, and unresponsive

18


The diminishing professionalism was so gradual that themajority of ethical dentists did not notice. Even the guardianprofessional associations did not notice at first. Later theyfeared litigation, and did not want to lose members. Somecouncils on judicial affairs were disbanded for irrelevancy.It was too late.

As the possibility for profits grew, fake centers of higher learn-ing sprang up. The institutes charged high fees, the presentationswere glitzy, and the participants received certificates, master-ships, marketing packages, national television campaigns, andthe promise of large profit centers. The bastion of professional-ism had always been the peer standard. Ironically, as organizeddentistry did not notice that tens of thousands were being taughtto perform below the standard of care, those practitionersincreased in mass enough to redefine the peer standard.

Eventually, all areas of oral healthcare focused on profit overpatient. This included some dental manufacturers, some dentalsupply companies, some dental laboratories, and even someauxiliaries. It became increasingly difficult for honest practi-tioners to “compete” on an uneven playing field. They becamedisgruntled, retired early, and encouraged quality young peopleto study other fields.

Arrangements

There is talk of replacing the coveted American dental sys-tem with the British system. Society is beginning to feel thatsince they are getting “ripped off” with high fees and low serviceand the dental associations aren’t protecting them, then lowfee/low service might be okay. Alternative service providers areevolving and will eventually displace some dentists. The ADAwill become a small group of angry old men that commiserateabout the past. Membership will shrink to study club sizebecause there will be no compelling reason to belong. Dentists’income will shrink considerably as they compete with lesser-trained technicians and mid-level providers. A lower standardof dental care will become acceptable. The respect for dentistswill decline, as they are no longer considered an ethical andlearned profession.

Sound Grim?

Dentistry today is actually not dead—yet—but how manyof the aforementioned “causes of death” are already realitiestoday? Maybe it’s not too late for dentistry to address the issueof profession versus business.

Ethics: The rules of conduct recognized in respect to a partic-ular class of human actions or a particular group, or dealingwith values relating to human conduct, with respect to therightness and wrongness of certain actions and to the goodnessand badness of the motives and ends of such actions.

DENTAL ETHICS:

AN OBITUARYRichard E Jones, DDS, MSD

It was a tragic day for nearly 150,000 dentists,their families, and three-quarters of a billionAmerican dental patients whom they had treated.It was announced today that the profession ofdentistry is dead.

It was an unexpected shock. Dentistry had long been reveredas one of the most respected of all professions and was consid-ered by business analysts as a healthy and profitable industry.

Investigators determined a cancer-like disease to be thecause of death, which was likely undiagnosed for more than 20years. The century-old profession passed away after a long bat-tle with hucksterism, false advertisers, uncredentialed training,fake degrees, and a plethora of dental treatment gadgets.

It took many decades to establish accredited dental schoolsand ADA-endorsed specialties, and for practitioners to incorpo-rate evidence-based materials and techniques into theireveryday practice. American dentistry enjoyed the higheststandard in the world.

It took less than two decades to undermine those efforts andrevert to the roots of barber dentistry. The autopsy report pointsthe finger at the suit between the American Medical Associationand the Federal Trade Commission, and the subsequent agree-ment with the American Dental Association, which eventuallyredefined the profession as a business and emasculated thepowers of self-regulation. A small group of entrepreneurs dis-covered that by changing their mission from healthcare toprofit, they could increase their personal income from the top2% in America to the top 0.5%. This led to false advertising andviolations of clinical standards. Naturally, other dentists gradu-ally jumped on the profit bandwagon with the feeling thateveryone else was doing it.

The ADA missed the opportunity to proactively defend theprofession from national trends and influences. Professionalself-regulation declined to a state of inactivity. The public wasexposed to billboards advertising painless dentistry, infomer-cials decrying the use of amalgam (in opposition to thescientific evidence and the official position of the ADA), unrec-ognized specialties (cosmetics, sleep apnea, implants),non-credentialed certifications and fellowships, free exams,“two-for-one” product sales, kickback rewards to referrers,claims of superiority, prioritization of bright-white smiles andpartial treatment over dental health, and on and on. PainlessParker would be pleased with the dental retail industry of 2012.

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Society has changed from a loyal, trusting public that vieweddoctors with awe and respect to a suspicious and litigious groupthat expects “someone else” to be responsible for their problems.Society has become commercial and greedy. Some have come toaccept “baloney” advertising as credible. Society is subject tofads, such as cosmetics, and believes them to be more importantthan comprehensive care.

Society is susceptible to the direct marketing of products andtechniques. Society has begun to notice the change from a self-less profession to a production-based retail industry. Society’schange is understandable but it does make it difficult to providequality care in a reputable manner.

Government helped to redefine marketing in dentistry whendeciding the profession could not restrain (or self-regulate) trade.This new interpretation of dentistry as a business may be theseminal event that will result in the death of the profession as weknow it.

It is unfortunate that the government generally doesn’t under-stand dentistry or appreciate its importance to the health andproductivity of the American citizen. The learned professions aretoo complex and sophisticated for legislators and bureaucrats tomicromanage. When government considers that a profession is atrade and undermines self-regulation, the profession eventuallybecomes a trade.

Government and society have begun to notice the changesin dentistry. They see the emergence of the retail model andthey see the decrease in self-regulation. They never understoodthe profession of dentistry; they trusted us to understand andcontrol. Now they realize that they (government and society)must exert influence and increasing control over the businessof dentistry.

Generational changes in society and in dentistry are havinga significant and noticeable impact on the profession. Loyaltytoward institutions has been replaced with cynicism. Lifestyledesires and immediacy of gratification are different. Communi-cation styles are different enough to hinder cross-generationalcollegiality and mentorship. In the past, the dental associationprovided a formal bond between dentists, and collegialitywas a powerful informal bond that facilitated mentorshipand peer pressure. As dental “peers” become less similar andmore distant, conformity to our traditionally held professionalvalues declines.

Mentorship can be a powerful tool for learning clinicaldentistry, practice management, and dental professionalism.Mentorship has traditionally been a key component of theprofession of dentistry, hardly mentioned and often taken forgranted. Dental mentorship has suffered greatly for a complexarray of reasons. Most notably, perhaps, are growing genera-tional differences between older and younger practitioners.Both can learn immensely from one another, but both must firstabandon their preconceived notions about what the other canoffer. Also, new practitioners with huge debt, while feeling

Profession: A vocation founded upon specialized educa-tional training, the purpose of which is to supply disinterestedcounsel and service to others, for a definite compensation,wholly apart from expectation of excess profit, and is grantedautonomy (self-regulation) by government and society by virtueof ascribing to a code of ethics.

Business: A profit seeking enterprise.

When a customer buys a car, he may possess the sameknowledge as the salesman. The salesman is interested inprofit. The customer is interested in purchasing a knowncommodity for the best price, knowing that protection isoffered by courts and consumer groups. When a patient goesin for brain surgery (or dentistry), they cannot understand theprocess, but believe that they will receive a proper clinicalservice for a standard fee knowing that they are protected byprofessional standards.

There is a significant difference between a professionalreceiving a definite compensation and a business owner whosemission is excess profit. The dental professional has a missionto provide a sophisticated healthcare service to a patient witha specific dental problem, for a reasonable compensation,and with no interest other than to heal and cause no harm.

The “Professional” Environment HasChanged in the Past 20 Years

There are national forces that have caused dental practition-ers and all parts of the oral health system to change focus. Com-mercialism is displacing the Hippocratic Oath. Profit motive isdisplacing altruism.

“In the past, the dentalassociation provided

a formal bond betweendentists, and collegialitywas a powerful informal

bond that facilitatedmentorship and peer

pressure.”

20


Dental manufacturers and supply companies used to beon the oral healthcare team with a mission to advance dentalcare for the patient, but some have been seduced by commer-cialism. Your dental house rep used to provide evidence-basedsupport for technique; some now pressure you to borrowmoney for the purchase of the device du jour in order to makemore profit and keep up with the race for the million-dollar netpractice? The dental trades have a great opportunity to help theyoung dentist and establish a career-long partnership that bene-fits all, including the patient.

Corporate Dentistry

The development of an “assembly line” model makes senseto a non-dentist. The treating doctor may not plan treatment;a specific time may be allotted for a certain class of restorationthat is expected to produce a certain profit; and undue pressureincentives may be placed upon the dentist worker. Does thissystem make sense to a professional healthcare provider, alearned doctor, or a trusting patient? And does this dentalworker still fit the definition of a professional? Corporate den-tistry can be a good system for the patient and for the dentistbut the dental profession, the dental association, the ethicalconcepts, and the legal and regulatory paradigms are basedon concepts of solo practice. Guidelines have not kept pacewith evolutionary changes and must be restructured.

Debt for young dentists is unprecedented, as are theirincredible setup costs—not to mention unrealistic incomeexpectations. A $300,000 burden with a million-dollar “buy-in”may well discourage the traditional dream of private practice.Dentistry has been based upon the paradigm of the solo (orsmall group) practice. It is a privilege to personalize your prac-tice to fit your mission, vision, and personal values.

Is the dental corporation owned by a non-dentist or a pri-vate-equity group? Is the mission profit based? Is the dentistempowered to make treatment decisions based upon their ownprofessional values? It should be noted that dental corporationsplacing oral health over profit are a valuable part of the profes-sion of dentistry.

Academia has always been part of the learned professions,but it has now been tainted by commercialism. How much con-trol does the business side of the university now exert? Is pres-sure to demonstrate profit affecting curriculum and teachingmethods? Is tuition so high that it contributes to limited practiceopportunities? Have dental school curricula been “watereddown” to meet the demand of technology over technique? Isthere too much information for a four-year curriculum?

underprepared for the dental world of 2012, actually desirementorship. They are being “mentored” by self-proclaimed“institutes,” emporiums of continuing education, and dentalbusinesses that offer employment and systems. They are also“mentored” by manufacturers and dental supply companiesthat promise personal wealth, but actually seek corporatewealth. They are “mentored” by slightly older dentists whohave themselves been seduced into thinking that dentistryis a business and not a profession.

It seems that the classic mentoring pattern of young dentist/old dentist is changing to new dentist/financially successfulyoung dentist, new dentist/promises of wealth, and new den-tist/corporate management.

Mentorship may well hold the key to the future of dentistry.Young dentists might well question the origins and virtues ofthe profession of dentistry. They might go back to the roots of agreat profession to discover why they have a great opportunityand what they need to do to preserve that treasure for them-selves and the future.

Associations provide many valuable services, but thelarger they are, the slower they adjust to and embrace change.Associations do not want to lose members, and they chooselitigation issues very carefully. The ADA relies on state and localdental organizations to self-regulate. The local associationsseem to rely on the larger group to take the lead. There is morereaction than pro-action. Change is so gradual that by the timeit is recognized, the new status quo becomes acceptable andperhaps a new standard. Now is the time to make clear state-ments of standard of care.

Continuing education used to be a proud system of dissemi-nating valuable knowledge; it involved teaching and learning.CE has now become big business with orientation toward profit.The suppliers (formerly teachers) have discovered huge profitswith glitzy presentations that promise big profit for the practi-tioner. Too often, the expensive “products” that are sold at theemporiums of CE have the same level of value and integrity forthe practitioner as the “new procedure” has for the patient:overpriced, over-utilized, and under-needed.

But the practitioner now has a fake certificate, initials touse unethically after their name, a marketing package, andthe promise of a great profit center.

Technology and “gadgets” are displacing technique andprecision. There is no question that technological advanceshave made immeasurable contribution to dental healthcare.There is risk that the purchase of an expensive gadget obligesits use and might even drive the treatment plan. There is alsorisk of believing that if the technology is high-tech enough andexpensive enough, it will compensate for operator shortcomings.Technology is not better than proper diagnosis, treatment plan-ning, and accurate and appropriate implementation.

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A Better Prognosis

What is the big deal about being a profession, especially ifit interferes with business success? To begin with, the profes-sion of dentistry has, for a century, been compensated at the topof income levels. How much more wealth do you need or want,and what are you willing to give for it? Being a professionalenables you to serve and continue to serve the healthcareneeds of patients with evidence-based treatment. Undue focuson profit, production, and the temptation to market falsely dis-tracts from the goal of healthcare (treatment of the clinical needand being a doctor). Retail businesses are competitive and statis-tically don’t last. A true professional can practice for decades,continue to care for thousands of patients, and accumulategreat wealth for his or her family. A dental professional enjoysthe trust and respect of society, government, and his or her com-munity. That is invaluable and cannot be purchased or stolen.

It sometimes feels like no one cares, and nothing is beingdone to save the profession. Dentists are so busy, work so hard,and lead such complicated lives that “little details” like profes-sionalism and ethics generally warrant little attention. Theconcept of professionalism has been distorted to the point thatit is not recognizable, and few have noticed. But some thingsare being done to save the profession of dentistry. Hopefully,it is not too little, too late.

The Indiana Dental Association has taken steps to reactivatethe crucial Council on Judicial Affairs. Although the Council onPeer Review and the Wellness Committee are likely the onlyactive demonstrations of self-regulation, they are highly effectiveand have become national models. The IDA has taken inten-tional steps toward leadership training. Immediate-Past IDAPresident, Dr. Terry Schechner, appointed a Taskforce on Ethicsand Professionalism that has been very active in developingdiverse, innovative, proactive, and positive (as opposed to puni-tive) systems to enhance professionalism. The IDA has beenactive in their support of other group efforts in the ethics arena.

The Indiana University School of Dentistry, under DeanJohn Williams, is acutely aware of the problem and is makingsignificant efforts. IUSD has had a history of strong ethics cur-ricula and remarkable synergy with the IDA and other dentalgroups. Significant efforts are made to provide counsel andpreparation for practice. The white coat ceremony for thenew freshman is an effective orientation to professionalism.Two years ago, a student-driven program called the StudentProfessionalism and Ethics Association (SPEA) was formed.Indiana students are on the forefront with an active group andtwo national leadership positions. Dean Williams has alreadyprovided generous financial and enthusiastic support.

The new generation of dental students is enthusiastic aboutthe profession of dentistry. Their knowledge of ethics is aston-ishing. They yearn for guidance and mentorship, but they have

proven to be industrious on their own. They form student ethicsgroups and eagerly attend meetings, despite busy schedules.They will be fed one way or another.

The Indiana Section of the American College of Dentists,with the support of the national ACD, has embarked on aninnovative mentoring program with a generous grant fromthe national ACD organization. It will be structured and formalin nature from a student’s senior year until five years after grad-uation. A training program for mentors and mentees is beingdeveloped. The goal is to develop lifelong relationships thatenhance the professional and ethical practice of dentistry.

The Indiana Section of the International College ofDentistry has been actively implementing a national ICDprogram of student mentorship called Great Expectations.This professionalism program is designed to guide the begin-ning dental student toward a more professional attitude andbehavior through peer influence.

Small groups are making efforts to save the profession,but they lack the critical mass; too much has been allowed tochange over the past 20 years for only a small collective groupto address. Only a groundswell of professionals can save den-tistry from the fate of being a retail industry. I am reminded ofthe poem by Reverend Martin Niemoller:

In Germany they came first for the Communists, and Idid not speak up...Then they came for me, and by thattime no one was left to speak up.

You no longer have the luxury of dismissing the importanceof being a professional or delegating the responsibility foraction to others. Dentistry can only be saved from the fate ofthe retail industry by the collective action of a critical mass ofdental professionals.

What Can You Do?

First, begin with yourself. All IUSD students are familiarwith the six Expectations of the Professional from Rule/Bebeau,Quintessence, 2005:

1 Acquire the knowledge/skills of the profession to thestandard set by the profession.

2 Continue learning as new advances and technologiesemerge.

3 Put the oral health interests of patients before self.

4 Abide by the profession’s code of ethics.

5 Serve society (not just those who can afford your care).

6 Participate in personal self-regulation, the monitoring of theprofession, and participate in professional associations.

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Second, look to the future by nurturing professionalism inothers. The responsibility of mentorship should be number 7on the Expectations of the Professional. Let your associationsand study clubs know that you value professionalism. Educateyour patients about the ADA Code of Ethics and ProfessionalConduct, and encourage them to walk away from dentists whodo not measure up.

Third, there are good reasons to have legal and ethicalrequirements to report unethical behavior. It is part of self-regulation, and if you turn away and I turn away, that behaviorbecomes acceptable as the peer standard. No one knows betterthan you what is going on in your dental community, and noone is in a better position to see that something is done about it.Give the benefit of the doubt and call your colleague. If theresponse is not appropriate, consult your local dental societyor the IDA.

If you see little value in the profession and don’t care aboutits future, take your money and pretend that it is someone else’sproblem. Or if you never really thought that dentistry was a pro-fession, and you were always smug about falsely reaping other’srewards, then lie and cheat every chance you get. See howmuch that you can get away with before you get caught. Someindividuals are so smart that they can kill the Golden Goose andstill be proud.

Most have not realized the gravity of our situation and havenot appreciated the value of being part of a profession. Mosthave been so busy making an excellent living that they forgotthey never could have been successful, had they not been con-sidered a professional. I fear it’s too late, but I hope that I amwrong. The change can begin with you, and it can begin today.

About the AuthorDr. Richard E. Jones is a retired prosthodontist from Schererville,Indiana. He currently serves as Chair of the Indiana DentalAssociation’s Ethics and Professionalism Task Force, and Chairof the Council on Peer Review. In the past he served as Chair ofthe Indiana Section of the American College of Dentistry.

INSURANCE CONTINUES TO IMPACTTHE DOCTOR-PATIENT RELATIONSHIP.

THREE’SA CROWDTerry G. Schechner, DDS

Does my insurance cover this procedure?How many times have your patients asked youthis question? You recommend a treatment planbased on sound clinical judgment that best fitsthe needs of your patient, and the patient is

dependent on the disposition of an insurance company thatbases its treatment recommendations on factors other thanthe needs of the patient.

The patient will generally take the recommendations of theinsurance company over yours, because they are given infor-mation regarding your fees being too high, or perhaps the besttreatment method is simply too expensive for them at the time.The insurance companies have convinced the patients and,more importantly the lawmakers, that they have the patients’best interests at heart.

How did we evolve to a point where the well-educated,caring dentist has been essentially taken out of the loop indetermining the best treatment for our patients?

Dental insurance companies started providing benefits in the1960’s and 1970’s, which quickly became a popular part of bene-fit packages provided by employers. The benefit packages con-sisted of $1,000-$1,500 annual benefit cap with various levels ofdeductibles and co-pays, and some even provided orthodonticcoverage. In the beginning it appeared to be a good deal for bothpatients and dentists. The patient would not have to come upwith a large down payment out of pocket, and the dentist’s cashflow was improved by the influx of regular insurance money.

Some dentists tried to warn the profession about the dangersinsurance companies might pose in regard to diagnosis, treat-ment, and fees. All one had to do was look at what was happen-ing in medicine. The first sign that the insurance companieswere trying to be more influential in patient treatment deci-sions came when they started demanding pre-op diagnosticX-rays. The insurance company’s dental consultant had toexamine the X-rays before approving coverage for the suggest-ed treatment. In some, if not many, cases, they proposed theleast expensive alternative treatment, or LEAT, for the patient.

Isn’t it interesting that, with very few exceptions, antitrustlaws do not prevent the insurance companies from doing any-thing they want to do? They are partially protected from the FTCand antitrust lawsuits by the McCarran-Ferguson Act passed inthe 1940’s to protect insurance companies, big and small.

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Many dentists believe that some insurance companies alsouse X-rays as a tool to delay payment for services already ren-dered. Most states have laws mandating that insurance compa-nies settle claims within 30 days of receiving a claim. In someinstances the insurance company will issue a request for X-raysor other information on the 29th day, which immediately givesthem another 30 days to hold on to the dentist’s payment.

The next stage in gaining control over dental practices andmaximizing profits was the creation of managed care networks,where the dentist signed a contract agreeing to discount theirfees up to 20% in order to participate. The ADA has publisheddata from membership surveys that the average dental officeoverhead is around 70%. There is a concern that high overheadcan lead to shortcuts in treatment, use of inferior materials, oreven the rendering of little to no care to the patients enrolled inthese plans.

Starting in the early 2000’s, the dental insurance companiesdeveloped a new strategy for forcing dentists to enroll in theirPPO’s. The plan was simple: If the dentist was not in the plan,the insurance company would stop honoring the assignmentof benefit designation made by the patient. Almost all universalinsurance forms have a line where patients can sign and havethe payment sent directly to the dentist, or to themselves. Thevast majority of patients will direct that the payment be sent tothe dentist. Some insurance companies would ignore thepatient’s wish of where to send the money and send it directlyto the patient. This caused a considerable amount of confusionfor the patient who suddenly received a check from the insur-ance company, all while the dentist received no notification ofpayment made or the explanation of benefits (EOB). The dentaloffice would call the insurance company and find that paymenthad been made to the patient. When the patient was called,

they believed the payment was an insurance refund. Manytimes the patient had already cashed the check and still owedthe dentist their full fee.

The long-term effects were that the dentist’s cash flow wasdisrupted, and collection fees increased. Another side effect ofthe tactic was that the un-enrolled dentist did not receive theEOB and could not file for any secondary insurance. Many den-tists relented and signed up with the insurance company’s bestpaying plan. The net result was that the insurance companiesincreased their managed care networks and could point out tolawmakers that their network was popular with dentists, andthat they were saving consumers millions of dollars.

A new ploy for the insurance companies to maximize profitsfor their stockholders is non-covered services. The insurancecompany dictates to dentists enrolled in their plans what theycan charge for services not even covered by the insurance com-pany. Some dentists believe that the limitations on charges areformulated without regard to what a particular service actuallycosts to provide. In addition, there could be more and moreservices dropped out of coverage, but the fee is still set by theinsurance company.

Coordination of Benefits is yet another clever moneymakerfor dental insurance companies. For dentistry, if there are twodental insurance policies, the primary plan will pay, but thesecondary may have a clause that states that since one insur-ance plan has paid, there will be no duplication of benefit.The full premium is paid for both policies, but the benefit isonly truly paid by one. There is no refund of the portion of thepremium that can’t be used as a benefit; therefore, the insur-ance company keeps it as pure profit.

“Two is company, three is a crowd” has been an expressionused for years to describe intimate relationships. The companyshould be the dentist and the patient. Over the past 40 years,the insurance companies have slowly interjected themselvesfurther into that relationship and, in some cases, have materiallyimpaired it. Insurance companies don’t go to school for eightor more years to learn about dentistry or patient care. Patientcare is not their mission, profits are.

The benefit caps have not kept pace with inflation, but thepremium increases have. There have also been more restrictionsplaced on these meager benefits. The dentists have tried toremain true to the relationships with their patients. We havegone to the legislature to fight for our patients. The only arenawhere we are allowed to promote a united voice for dentistryis the Statehouse.

During the past six or seven years, we have made little head-way. The insurance companies have well financed lobbyistswho can outspend us at every level. Their message is that theyare fighting for the patients to keep costs down. The patientshave often sided with the insurance companies because wehave been portrayed in the media as rich, uncaring health prac-titioners. We need to become better advocates for ourselves at

“In the beginning,dental insurance

looked like a good dealfor patients and

dentists alike, sparingpatients from large

down payments whileimproving dentists’

cash flows.”

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Fortunately since those early beans and rice days of practice,we have been able to choose CE courses not based solely on theinvestment necessary to attend, but the investment we hope togain for our personal development, our dental team members,and most importantly our patients.

How we select CE courses depends on several different factors,including cost, location, the speaker, the topic, and time. The mostimportant common denominator usually is topic: We don’t knowvery much about something and would like to learn more about it.Dentistry is extremely dynamic, and new technologies and tech-niques are being introduced at a very rapid pace. When we werein dental school, the curriculum didn’t include probiotics, lasers,or cone beam radiography. Quite simply, if you want to learn aboutany new innovations, you have to seek them out.

Our education at Indiana University School of Dentistry wasexcellent; there is no denying that. But dental school shouldnever be the endpoint to our education—always the very begin-ning. Fortunately for us, and for any member of our profession,there is a plethora of CE styles from which to choose that meetany time or budgeting restrictions.

The Internet Factor

How has CE changed for us since we entered the professionin 1999? We almost sound like we are from the dark ages byadmitting this, but in all reality computers and the Internet didnot factor much in our dental education. The Internet and asso-ciated technologies have changed CE accessibility andparticipants engage the content. It is hard to imagine sittingin a CE class without at least one person’s smartphone ringing,or the “ding-ding” of an incoming text message. Social medianetworks keep us connected to each other and make informa-tion available almost instantaneously. With a smartphoneyou can take notes during a lecture, take photos of slides, logimportant dates, keep track of CE credits and, at the end ofthe day, send a Facebook request to a former classmate withwhom you were able to reconnect at the course—or connectwith a new colleague you were able to meet.

When registering for the Rocky Mountain DentalConvention, held in Denver Colorado this past January,everything was done electronically. There was even a mobileapplication to register for and log CE, get updates on roomchanges, find details about lectures and social events, andeven peruse vendors participating in the exhibition hall.

A new challenge to dentists seeking CE is to be aware ofpatients’ access to the innovations in dentistry. For the mostpart, information about new treatment options is also availableto our patients. The public seeks information on the Internet,so it is vitally important that we stay current on the latest infor-mation to adequately answer our patients’ questions and needs.Our patients might not know or understand applications of lasersin a dental practice, but most want to be reassured that their

both the state and national levels. We need to get the insurancecompanies’ antitrust exemption repealed. We need to convincelawmakers that the insurance companies put profit for thestockholders over patient care and safety. All of us must partici-pate and become engaged in the legislative process.

The uncertainty of how all of these issues will evolveunder the Affordable Care Act remains. The law encouragesthe expansion of state Medicaid programs, but the SupremeCourt decision on the law prevents the federal governmentfrom imposing expansions on states. Adult dental Medicaidmay continue to be optional, and the increases of visits to theemergency room for dental disease will continue to be an issue.

Dental insurance interference will continue, until we fighthard enough to take back control. Every one of us must recog-nize what the future will hold for those who follow after us indealing with third-party payers. Understand that your decisionwill be the legacy that is passed on to those who follow, evenyour own children who may choose to become dentists. Youmust get involved and help take back our profession from theinsurance companies.

About the AuthorDr. Terry G. Schechner practices pediatric dentistry in Valparaiso,Indiana, and serves on the Indiana Dental Association’s Councilon Governmental Affairs and Committee on Insurance,Retirement, and Relief. Dr. Schechner also served as the 153rdPresident of the IDA.

CONTINUINGEDUCATIONKaren E. Ellis, DDS

Jeffrey A. Stolarz, DDS

Immediately after graduating from dental school,a time when most new dentists shudder at theidea of sitting through yet another class, wealways enjoyed going to a dental lecture. We lovecontinuing education. As wide-eyed, eager,

novice dentists with concerns of how to pay student loans, mal-practice insurance, and basic living expenses, the goal wasalways to find the least expensive CE courses available to fulfillthe licensure requirement. Every reader knows that means freeand, admittedly, sometimes that was even too expensive!

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dentist is staying current with new technology. A young mothermay search online for information regarding oral health and howthat can affect her unborn child, but she will certainly come toyou, her dental provider, to help her understand the content shehas read. For all of the good information that is available, we knowall too well there can also be misinformation. It is our responsi-bility to assist our patients with sorting out fact from fiction.

The Internet also ties us to the medical community. As welearn more about the relationships of systemic and inflamma-tory diseases to the oral cavity, online resources are a valuabletool to educate ourselves and patients on those connections.Sometimes all it takes is a quick Google search to learn abouta new medication a patient is taking, or a disease with whichwe may not be familiar. It is much more convenient having thePhysicians’ Desk Reference (PDR) or pharmacology resourcesonline, as they are continually updated and current.

Also demonstrating a positive benefit of the Internet to ourability to learn is the ADA365. This is a fantastic way to partici-pate in the American Dental Association Annual Session if youare unable to travel to San Francisco for the live presentations.From your computer, you can stream recorded video content,and if you happen to be watching it live, there is the ability to usea chat application to ask the speakers questions in real time.

Evidence-Based Dentistry and Live Courses

Another change in the new landscape of dental CE is theconcept of evidence-based dentistry. Discussions in coursesaren’t founded in hearsay or opinions but in the idea thatresearch is used to guide clinical decision-making; therefore,the practitioner can provide the best care for patients. First,this approach makes sense, and certainly a class has morecredibility if the information given is based on research andnot on the sales need of a particular company.

During our sophomore year of dental school, Dr. CharlesTomich took our Oral Pathology class to the Indiana MedicalHistory Museum on Vermont Street on the near west side of Indi-anapolis. Yes, a field trip in dental school was pretty awesome,

and still is. (I am sure we all felt a collective relief to be sparedfrom the dreaded assault of Clinical Correlations!) We won’t forgetthe formaldehyde-filled jars holding preserved specimens fromyears ago in the pathology lab, but in touring the museum wewere also struck by the beauty of the teaching amphitheater. Onecan imagine a professor performing dissections on a cadaver orteaching on a variety of topics in this atmosphere.

This teaching method from years ago is resurfacing inan updated modality in the form of Dentistry in the Round,which is returning for the third year at the American DentalAssociation Annual Session this year in San Francisco. On thefloor of the exhibition hall, dentists can go to a modern versionof the Medical History Museum teaching amphitheater. There isa completely functional dental operatory where live patientdemonstrations are done by some of our industry’s top clini-cians. For example, this year you can see Dr. GordonChristensen demonstrate Class II Resin placement, or Dr. JonSuzuki perform soft tissue augmentation. Seeing new proce-dures performed live is a highly effective learning method.

Back for the third year at the ADA Annual Session is theOpen Clinical Science Forum. These are great opportunitiesif you want a short course (usually one hour in length, or oneCE credit) packed with a great deal of information. These areopen panel discussions on current dental topics with the latestresearch, hosted by members of the ADA Council on ScientificAffairs. The Council brings in authorities and lead researcherson topics like fluoride efficacy and osteoradionecrosis of thejaw. The discussions amongst the researchers are always livelyand include equally engaging question-and-answer sessions.It is a great way to stay current on hot topics in dentistry.

What Worked for Us

When we were asked to write this article, we were invited toshare which courses have had the most impact on us personallyand professionally. We certainly agree that the American DentalAssociation Council on the New Dentist Annual Conference wasnot only pivotal in our careers, but perhaps has been some ofthe most important CE in which we have participated. The NewDentist Conference is geared toward clinicians in practice tenyears or less. (At this point you have done the math and yes,it is true, we have exceeded the “cut off.” But don’t tell...as thisis a meeting we will both continue to attend!) As recent gradu-ates we found this was a perfect conference to attend, becausewe could get 10-12 hours of CE over a weekend, didn’t have totake much time off from work, and the registration fee was lowand included all of the CE, social events, and meals. The lec-tures have been different every year, but always with leadersin our profession with subject matter aimed toward issues ayoung dentist may encounter. The conference has always hada relaxed environment, providing ample opportunity to learnfrom each other and ask questions. As a result of these confer-ences we have a network of friends across the country.

“One of the benefits oforganized dentistry is

that it will always give usthe resources we need

to stay current.”

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We have also found that it is always best to participate ina variety of CE offerings. DVDs are great, but perhaps go to ahands-on workshop, too. CE courses on practice managementare valuable, but certainly try to take clinical courses as well.CE is all around us; you really don’t need to try that hard tofind an educational opportunity. There are online courses, liveCE and webinars, newsletters and journals, local study clubs,dental lab-sponsored CE, institutional learning centers (i.e.Kois, Pankey, LVI, etc.), and dental organization-sponsoredCE (i.e. ADA, IDA, AGD, AAWD, etc.) offered at local, state,national, and international levels—just to name a few.

Another great CE opportunity that we both participate isthe IUSD/IDA Academy of Continuing Education. The Academymeets twice a year and offers great speakers at a very afford-able tuition. Through this venue we have had the opportunityto hear Stanley Malamad, Peter Jacobsen, and Carl Misch.The speakers are always impressive.

We certainly don’t see anything wrong with getting CE fromonline courses, journals or DVDs (ask us about our VHS collec-tion of veneer preps, rotary endodontics, or mandibularanesthesia collecting dust!), but for us the benefit of going to CEis networking with colleagues. Getting out of the office is goodfor the spirit, and actually sharing stories and ideas is a veryimportant component of educational development. You beginto realize that everyone has the same challenges. We can learnso much from each other.

It is the networking with others, helping each other withpersonal and leadership development and, most importantly,the camaraderie with others that make actually attending CEspecial. Dentistry can be isolating at times, and it always helpsgoing to a class to be around others and share experiences.

Another benefit in getting out to a class is because oftentimes leaders in our profession are also in attendance, and youcan interact with them and give input to issues you feel areimportant. At the New Dentist Conference, the ADA President,President-Elect, and Regional Trustees are all in attendance.What better way to get involved than to have one-on-one con-versations or lunch with these leaders! And they listen. Going toCE is not only important for what you receive from a lecture,but for the exchange of ideas that takes place among col-leagues. The friendships we have made along the way havebeen as invaluable as the clinical knowledge we have gained.

What Does the Future Hold for Dental CE?

It is hard to know what CE will be like in the coming years,but with the expanse of research being done, development ofnew technologies, and the great leadership of our profession,it will be exciting. One of the benefits of organized dentistry isthat it will always give us the resources needed to stay current.We will probably continue to gravitate toward more hands-onworkshops and live presentations, but also look forward to the

possibilities of courses involving simulation models such as thenew simulation laboratory at IUSD. The important thing for allof us is to just get out there, recharge our learning batteries, andfind a course that inspires and recharges us for our patients.Keep learning. And hopefully, we will run into you at a coursein the future!

About the Authors

Dr. Karen E. Ellis practices general dentistry in Indianapolis,Indiana.

Dr. Jeffrey A. Stolarz practices general dentistry in Whiting,Indiana, and is a member of the Indiana Dental Association’sCouncil on the New Dentist and Council on Dental Benefits.

DIVERSITY:

A NEWCOURSEFOR IDALEADERSHIPSteven P. Ellinwood, DDS

Ask a group of people to define the term leader-ship, and you will discover that each personhas a unique, personal definition. A person’sview of leadership has deep roots in his or herexperiences related to generational differences,

gender, region, and even personality style, only to name a few.Without acknowledging, understanding, and engaging thesedifferences in a respectful way, we fail to unlock an individual’sability to effectively lead.

As we have watched the practice of dentistry evolveacross the years, so have we watched the faces among ourAssociation’s membership diversify. We must understand thestrengths this growing number of differences might bring toorganized dentistry, as well as how we can put these strengthsto work for the profession, if we are to survive the many chal-lenges we currently face.

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Perhaps the most significant change we must be willing tomake is to embrace the ever diversifying population of dentistsin our state, specifically ethnic and gender diversity. Whitemales have predominantly occupied the dental profession formany years; however, if you look at this year’s freshman class atIndiana University School of Dentistry, 52% are female, and11% identify themselves as an ethnic minority.

For too long, the assumption has been that there should beno change to the IDA association model, and that each year’snew crop of dentists will fill the existing leadership roles as inthe past. This thinking has actually worked for many years, butour world has changed. New dentists’ volunteer time may befilled with projects not related to our profession. Or, they mightnot view the ADA, IDA, or local dental society as their represen-tative in the dental community. To view these increasingly com-mon values negatively does not take into account the individuals’experiences. For example, certain individuals may have alwaysfelt they were on the outside of large organizations and seek outsmaller peer groups. They may feel their concerns are not asglobal as the ADA or IDA, and wish to focus on improving gen-der, ethnic, or general dental issues in their own communities.

The change is already here, but how that affects leadershipis yet to be identified. As there is little time to prepare andadapt, we must be nimble in embracing and engaging thepositive impact these trends can have for our Association,our profession, and ultimately our patients. It is in everyone’sbest interest to find out what we must do to ensure new dentistswill join our organization, and then feel compelled to carrythe torch for the profession as leaders.

About the AuthorDr. Steven P. Ellinwood practices general dentistry in Fort Wayne,Indiana, and serves as Assistant Editor of the Journal IndianaDental Association. Dr. Ellinwood serves on the Indiana DentalAssociation’s Council on Communications and is Chair of theLeadership Development Committee.

Generational Differences

There is a remarkable amount of literature defining the cur-rent categorization of generational groups in the United States,which sometimes confuses more than enlightens. We can allaccept that it is unfair to completely stereotype one generationfrom the next, but co-authors of Race for Relevance, HarrisonCoerver and Mary Byers, compiled studies that generally indi-cated “Baby Boomers expect to lead, while Generation X overallhas less desire to lead…Millennials value teamwork and are theultimate multi-taskers.” Yet we still cannot force all individualsinto their respective generational boxes. Having insight into thecore values of a generation can be very helpful. Yet, the followingstatement from Race for Relevance might be the organized den-tistry’s most important warning about generational differences:

“With each succeeding generation, there appears tobe a growing disconnect with trade associations andprofessional societies.”

What are we to do with such a statement—accept our demiseand run for the hills? Not quite. We can and must work harder toenergize the younger generation of practitioners to become activein our dental societies. These individuals are energetic, intelli-gent, and tech-savvy in ways most of us are not; we need them.

It is also pointed out in the book, and we all have experi-enced this, that there seems to be less and less time. In our fightfor efficiency in work, family life, and community involvement,we have only created a growing checklist of items that neverseem to all get accomplished. Any member, especially thosewho are involved at any level of organized dentistry, will tellyou that they love helping lead our profession—but it’s some-times impossible to find the time. No generation is exempt fromthis trend; none of the new technology has been able to slowdown our lives. Acknowledging this trend, we must not onlyseek to provide new opportunities that make effective use ofvolunteers’ time, but we must take a hard look at our existingactivities and be honest about where time is being wasted.

GENERATIONAL DIFFERENCESGENERATION YEARS OF BIRTHBaby Boomers 1946-1964

Generation X 1965-1981

Generation Y(Millennials) 1982-1999

“We must be willingto embrace Indiana’s

ever-diversifyingpopulation of dentists,specifically ethnic and

gender diversity.”

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Many students do not enter dental school having a solididea of what they want to do at the end of the four-year curricu-lum. Students wishing to specialize need to take the time tounderstand all of the criteria necessary to be admitted into thespecialty of their choosing. For example, creating a vision ofwhat it will be like to be a specialist is key in getting through therigors of a difficult program. This includes the investigation,observation, and extremely hard work necessary for success.Similarly those electing to practice general dentistry (whichaccounts for about 83% of the graduates) need to explore howto best begin in that field. There are many options, which willbe discussed later in this article, but investigation into the prosand cons of each choice is essential from an early time to beable to optimize success and satisfaction.

An ADA survey in 2003 showed that only 5% of dentists hadenough money saved from their practices to retire. For a myriadof reasons, this survey shows that even with time and experi-ence, there is no guarantee for success. The blessing for manydentists is that they are not forced to retire at age 65, yet I wouldimagine that most would like to at least have the option. I per-sonally know many dentists who have practiced well into theirseventies to maintain their desired income levels.

In a 2010 ADA survey of dentists 40 years and older, the aver-age age for dentists to retire is trending up and is now at about66.9 years of age. (Interestingly, when asked the same question ofproposed retirement to dentists under 40, most thought theywould retire around 60 years of age.) This is essential knowledgefor the student, as there may be fewer opportunities to start apractice than there were in previous eras of graduation. As a mat-ter of fact, a study of 2008 graduates showed that only 8.6% ofgraduates actually start out owning their own practices. If one ofthe major reasons that dentists are practicing later in life now isfrom a financial shortfall, then what was not learned along theway to enable these professionals to be able to retire when mostevery other occupation has members who are able to do so?

There are two glaring omissions in today’s dental schoolcurriculum: business education and “soft” skills. With all of thetechnical and science requirements, it is difficult to know howto more integrally insert these two needed topics in an alreadypacked program.

Whether we are willing to admit it or not, health care is abusiness. While we do not know what the future of the healthcare industry will be, it is certain that there will always be roomfor the entrepreneur. The dental student currently has limitedexperience in what it takes to run a business. Although there isan extramural requirement in order to graduate, most take thetime to look at materials and technique rather than determinehow things are ordered, how staff is managed, or how to read aprofit/loss statement. I would also suspect most mentor dentistswould not be forthcoming in sharing those items with a student.

THE BUSINESSSIDE OFDENTISTRYThomas R. Blake, DDS

None of the issues shifting the foundationsof Indiana dentistry will be more importantthan those affecting students currently studyingto become dentists. While the future of dentistryis in their hands, practicing dentists share in the

responsibility to maintain the respect that our time-honoredprofession has gained over the years. Whether a student, recentgraduate, or grizzled veteran, we all play a part in the scenarioscurrently occurring in dentistry.

One of students’ most critical barriers to enjoying the profes-sion as much as we have is the amount of educational debtacquired by the time they graduate. In an ADA survey of 2008graduates, it was found that almost 93% of graduates had edu-cational debt upon graduation and 64% had additional debt.The average debt for graduates had risen to $240,000 in totaldebt, with the educational debt accounting for 75% of this load.Over the four years preceding, the average debt had increasedby $55,000. Of course, this debt does not include purchasinga practice, home, or equipment, if that is the course the gradu-ate chooses. Due to this factor alone it is important that, earlyin a student’s career, he or she develops a plan for managingdebt and transitioning successfully into practice.

One of my favorite books, The Seven Habits of HighlyEffective People, written by the late Steven Covey, is certainlyapplicable to the young student in school. The two most impor-tant habits for students are to first be proactive, and secondto begin with the end in mind. Most students come into schoolfocused on all of the science and technical skills that will berequired to pass boards and gain licensure, but no matter howintelligent or what kind of “hands” the student has, there is nodirect connection to financial success.

Most first-year students do not even think about the fact thatthey will be running an actual business that will provide a livingfor themselves, their families, and their employees. Proactivitymeans a student is beginning to look at opportunities from dayone of dental school. It is the responsibility of the older dentistto help the younger dentists find these opportunities. We arefortunate at Indiana University to have Dean John Williams,who is fully aware of the fact that today’s students will be run-ning tomorrow’s practices and is doing everything he can toassure those students’ success.

$

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If the extramural experience and the dental school do notprovide the tools for the aspiring dentist to organize and buildhis or her business, how will a student learn? As evidenced bythe absurdly low percentage of dentists being able to retire andthe increasing age of retirement, perhaps the only way this islearned is in the “School of Hard Knocks” and, even then, it mustnot be being learned well. Students must be guided through vari-ous viable business models and learn how to ascertain metricsfrom the practice, such that financial independence can beachieved. Many practices are out of control when it comes tospending, because no one has ever taken the time to know whatprudent spending is. I feel that these ideas are coming to light,at least here in Indiana. Having as many dentists as possibleachieve financial success will be a step in the right direction inkeeping the dignity of our profession intact, and offices andequipment that run at full capacity for our patients.

Students must also begin the process of mastering thepsychology of dentistry, or “soft skills.” Most successful dentalpractices have taken the time to realize the importance ofcreating and nurturing the relationships that occur among thedoctor, staff and patients. Many science-oriented dentists donot have these traits naturally and have to develop them as theymature in their practices. Once again, it is more than techniquethat determines overall success.

The student gets practice at soft skills with a few patients,but the relationship developed with the dental school patientis not realistic in a real-time practice. No one is going to spendtwo hours doing a Class I composite in private practice.

How does one nurture these relationships along the way?As I always relate, how do you get good at free throws? Answer:Shoot a lot of them. This is the same with patients, yet eachpatient is an individual with a unique set of circumstances,a unique personality, and a unique health history. There is nosingular way to relate with patients, but the doctor must sur-mise what is best for the patient and be able to communicateit effectively, such that the patient can achieve optimumhealth—or at least understand what it takes to achieve it.

Reaching New Heights

There are many other considerations in optimizing chancesfor success in dentistry, but many of them have to deal withgaining experience and vowing to be a lifelong learner by seek-ing quality continuing education opportunities. There are nowendless opportunities to learn more about subjects not ade-quately addressed in four years of dental school. Once again,older dentists can help lead the way in assisting the novice inthe search for quality programs.

Mentors: The Informal Advantage

While it would be ideal if there were lists of dentists willingto help their younger colleagues in the profession, no solid pro-gram formally exists. There are dentists who are more thanwilling to share their knowledge to an eager novice. As HeinrichHeine once said, “Experience is a good school, but the fees arehigh.” An older mentor can help his or her mentee to avoid pit-falls that can cause financial and emotional heartache.

Students would benefit by seeking out such a mentor earlyin the educational process—not the day after they graduate.My own dentist and I had a mentoring relationship along theway, and I give him full credit for helping me establish my prac-tice. Those who care about our profession and the greater goodare there for the asking. It would be ideal if mentors wouldjump out to offer their services, but it is to the benefit of the stu-dent to actually seek the sage, even if it is out of the student’scomfort zone. These relationships generally continue to flour-ish over time, as both mentor and mentee advance inknowledge and experience.

Payback Time

Dental students realize that most of them will graduate withsignificant debt, that most will go into general dentistry with lit-tle to no business experience, and that the skill sets developedin dental school will not be sufficient alone to guarantee long-term success.

Regarding loans, today’s students are faced with suchmonumental debt that they feel the pressure to start makingsignificant money almost immediately.

Statistics from the 2009 ADA survey showed that 18.1% ofgraduates owned their own practice, while 73.6% worked asnon-owner dentists. Over 8% of graduates actually work in asecond career and 33.1% of graduates work only part-time asprivate practitioners. This part-time work figure is up dramati-cally (14%) over the four years prior and over 22% (which is alsoan increase over the prior four years) of that year’s graduateswent on to either graduate school or undertook a general prac-tice residency (GPR). When combining the statistics above, one

“Many students enterdental school with

no solid idea of whatthey want to doat the end of the

four-year curriculum.”

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can infer that a greater number of graduates are at least post-poning owning a private practice, if not electing somealternative business model.

The opportunity that seems to be the most advantageousfor graduates is to associate with an older dentist to gain experi-ence. This too is the reason that many students are electing totake a year in a GPR to learn more about different proceduresand practice. The associateship may present challenges, how-ever, if the new and senior dentists are not clear aboutexpectations at the outset. Beginning with the end in mind iscertainly the most important thing to take into considerationhere, and there are professional transition experts who canhelp to make the most advantageous work situation for bothparties involved.

Another avenue for the new graduate that has grown inscope is the corporate model, where the new dentist isemployed by a larger dental company and has a financial stakein the production that occurs in the office. While there is cer-tainly a financial benefit to the new graduate under this model,there is an expectation from the company that the new dentistwill be a profit center. Failure to live up to production standardscan lead to dismissal. New students looking into these opportu-nities have increased in number, as has the presence ofcorporate practices. One study has shown that at its current rate

of expansion, corporate dentistry will have a 17% share of themarket by 2018. The corporate model will be a force in thedental market for the foreseeable future.

Educational debt and the myriad of ways to practice aftergraduation require that the student look ahead to determine thebest path for individual success. Taking time to understandbusiness, as well as how to manage relationships with patientsand staff, are two skills not currently taught. These will need tobe learned in order to establish the successful practices of thefuture. Knowledge of these transitions will enable us as a pro-fession to be prepared for the next generation of dentistry.

About the AuthorDr. Thomas R. Blake practices general dentistry in Fort Wayne,Indiana, and serves on the Indiana Dental Association’s Councilon Communications and Finance Committee.

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“I have a large amount of practices where the dentist is inhis or her 60’s and 70’s practicing an average of three days aweek due to the economic downturn,” Dawn said. “It has defi-nitely been my experience that dentists are returning to workand delaying their retirement due to the economy and stockportfolios.”

The problem of not being able to find an associate or buyeris also frequently seen in the practices Midway serves. Dawnadded, “Ten years ago you saw dentists retiring at 60-65, but todayit is quite common to see a doctor working much past that age.”

Dr. Crisis’ solution of remodeling and upgrading his office isalso becoming a more common practice. Dawn said she hasseen an upturn in doctors building or upgrading their offices ata later age, occurring for two main reasons: First, they need abetter product to attract a smaller group of graduates and/oryounger dentists to buy their practice, and secondly they areworking longer, so the upgrades to newer, more technologicaloffices will attract more patients. The assumption of the doctorsis that by working for an additional 5-10 years, their investmentwill reap the benefits.

Dr. Planner’s dilemma came up at the IDA House ofDelegates meeting in June 2012. A retired dentist who had lethis dental license lapse petitioned the state board to allow himto sit for the hygiene licensure exam. He had been away fromdentistry too long to pass the dental exam, but he felt confidenthe could work as a hygienist. Dentists are “un-retiring” to sup-plement a retirement rocked by economic uncertainty.

In my first year in practice I hired a dental consultantbecause of my total lack of business experience. Tom O’Brien,a salty old dog if there ever was one, had spent his entire careerin the dental industry. He had worked for dental supply compa-nies for many years and was using his vast experience to helpyoung dentists get on a firm business foundation in their prac-tice. For me, Tom was a lifesaver.

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THE UNRETIREDDENTISTThe economic downturn has caused some dentiststo have to work beyond retirement age. This newtrend has an unexpected fruit: joy.

Michael D. Rader, DDS

Dr. Planner thought he had done everything right.He had very carefully and faithfully invested inhis dental corporation pension plan. His Indianahouse and condo in Naples, Florida, were mort-gage-free. Yet retirement was not turning out like

he had planned. First, the stock market downturn had shrunkhis retirement by 50%, and his home and vacation condo hadlost a lot of value—if he could sell them. Both he and his wifeare looking for jobs. Dr. Planner says, “I’m afraid that I will out-live my retirement funds.”

Dr. Crisis is 67 years-old and practices four days a week.He works because he doesn’t have enough money for his retire-ment. Dr. Crisis said, “First it was 9-11, then the Dot.com crash.Next the housing bubble burst. My retirement account doesn’tseem to be growing anymore.”

Dr. Disappointed would like to retire. In the past few years,he remodeled his office, replacing the equipment with newA-Dec chairs and dental units. He has been looking for an asso-ciate to work in his office with the plan to sell his practice andbuilding. But, Dr. Disappointed cannot find a qualified buyer.“There didn’t seem to be many who are risk-takers at that pointin their careers. These folks thought opportunity included aguaranteed salary usually beginning at $100,000 a year plusvacation and benefits,” Dr. Disappointed stated.

Drs. Planner, Crisis, and Disappointed represent the“unretired” dentist.

The 1970’s saw a remarkable increase in the number ofdental graduates produced annually. Federal government pro-grams addressing a perceived shortage of providers propelledthis increase. That group of “baby-boomer” graduates is nowreaching retirement age, and many factors—including someunintended consequences of governmental policies, as wellas economic, societal, and cultural shifts—will strongly influ-ence their retirement rate.

Dawn Metcalf, Sales and Marketing Manager at MidwayDental Supply, has seen the newly emerging difficulties indentists’ retirement planning.

“I would be boredwithout dentistry.

The thought of playinggolf more than once a

year, let alone every day,is frightening.”

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The future dentist may extend his or her working careerlonger than in the past. Whether forced by economic necessity,or simply by the enjoyment of a fulfilling and rewarding career,the working life of today’s dentist will look very different thenhis or her predecessors.

I’ve come to learn that you spend some really wonderfulyears gripping a dental handpiece and, in the end, you findout it was the other way around all the time.

About the AuthorDr. Michael D. Rader practices general dentistry in South Bend,Indiana, and serves as Associate Editor of the Journal IndianaDental Association. Dr. Rader also serves on the Indiana DentalPolitical Action Committee.

WHAT DOESIT ALL MEAN?THE RACE FOR RELEVANCEMary M. Byers, CAE

Much has changed in the profession of dentistry since theIndiana Dental Association’s creation in 1858. When the IDAwas founded, who could have predicted the dominant issuesin the year 2012 would include universal healthcare reform,ballooning dental education costs, third-party insurance battles,and large group practice models?

The one thing that hasn’t changed much over the years is theway the Indiana Dental Association does business. Like manyprofessional associations, the organization is heavily dependenton volunteers, dues revenue, and member engagement. Yet allare declining—forcing the association to take a close look atwhat the future holds for dentists in Indiana.

Here’s what’s challenging the Indiana Dental Associationand other organizations today:

Time PressuresThe lives of association members are increasingly complex,

affecting their ability to volunteer and/or access association serv-ices. Symptoms include poor attendance at council and commit-tee meetings, decreasing utilization of continuing education pro-grams, and an increasing number of members who don’t renewmembership.

It seemed that Tom knew practically every dentist in thestate and was a notorious namedropper. Tom eagerly men-tioned that he had consulted with a classmate.

“Steve is now so busy that with his spare cash he has pur-chased a roller rink as an investment,” Tom said. He clearlyimplied that if I followed his advice I, too, could be a captainof commerce.

While hopeful that Tom’s wisdom would magically growmy practice, all while feeling a bit envious of my classmate’squick success at the same time, it struck me as being a bit oddthat, time and time again, Tom cited Steve’s business triumphsoutside of dentistry and how soon he would be able to retire.I could not understand why dentists, who had worked so hardto be a success in dentistry, would gauge their success by howsoon they could retire.

I can’t think of any profession where someone walks awayat the pinnacle of success. You certainly don’t see professionalathletics do that; in fact, it’s usually the opposite. There exists agrowing group of dentists who want to continue to practice dueto the joy and fulfillment they find in their work.

Past IDA President Marty Szakaly said, “I have found that Ilove my profession more. I like getting up every day and goingto work. I’d be bored out of my mind if I didn’t have dentistry.”

It was a while ago that I had a discussion along similar lineswith classmate Dan White. At the time, Dan and I had been inpractice for 18 years. I remember looking at Dan and asking,“Well, do you think we are half done with our dental careers?”Dan, giving me a weak smile, replied, “I hope so. I think 36years is enough.” At the time I agreed, but not today. Dan, Steveand I have practiced for 33 years, and frankly I’m more both-ered by the idea that I might have to quit some day. Like Marty,I would be bored without dentistry. I don’t have a hobby thatcould possibly fill the time my job occupies. The thought ofplaying golf more than once a year, let alone every day, is fright-ening to me.

When my dad retired, within a year he had a part-time jobmowing greens at the local golf course. He liked the job becauseit kept him busy, and he enjoyed working with the other greenskeepers (who were either kids on college break or retirees likehimself). He didn’t like getting up at 4:30 a.m. and getting paid$8.00 an hour. His experience of returning to work part-time sosoon after retirement will make me think long and hard aboutmy retirement plans. The thought of finding a job, any job, tofill a void in my day makes the idea of reducing my practice tomaybe two days a week an appealing option.

If I want a part-time job why not be a part-time dentist?After all, one of the great benefits of our profession is theflexibility to work the hours you choose.

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Value ExpectationsWith economic pressures mounting, members are looking

for a clear return on investment for their dues dollar. Associationsmust be able to articulate and communicate a succinct valueproposition. Those that do will survive in the future.

Member Market StructureMany associations are serving member markets that are

vastly different from those they were initially designed to serve.For dentistry, this includes the increasing number of large grouppractices and the move from private pay to third-party payers.

Generational DifferencesWhile stereotyping is dangerous, it’s clear that each genera-

tion has its own values when it comes to volunteer service andexpectations regarding return on investment for dues dollars.Differing experiences also challenge associations as they attemptto be relevant to both those who grew up without computersand those who have been using computers since childhood.

CompetitionThe number of associations serving industries and profes-

sions has grown dramatically, resulting in increased associationvs. association competition. A quick online search shows over 60dental associations (not including state or local dental societies).

In addition, competition from the for-profit sector has increasedfor virtually every association offering, from publications to tradeshows, to educational programs and products such as insurance.

Associations’ ability to compete with a wide range of productand service providers is a new and considerable challenge.

TechnologyAssociations have been slow to adopt technology, and their rel-

evance is increasingly at risk if they don’t bridge the resulting gap.A tsunami of technologies has evolved to offer virtually every asso-ciation deliverable and function: education, information, network-ing, fundraising, grassroots mobilization, etc. There’s no ignoringthe fact that Facebook has 800 million members, YouTube viewsnow number over a billion daily, and more than a million mobileapps now exist.

Five Radical Changes for AssociationsIn light of the above challenges, what’s the secret to remaining

relevant? Today’s associations are addressing the above challengesin five ways:

qOVERHAUL THE GOVERNANCE MODEL

The typical association’s governance structure and processesare obsolete in today’s environment. They are too big, too slow,time-consuming, reactive, they underutilize the organization’shuman capital, and they are expensive to run. Sound familiar?

Associations need boards composed for performance that cangovern nimbly and effectively, not boards composed by geogra-phy, special interests, who one knows, or how long one has beenaround. A house of delegates that meets once a year makes it dif-ficult to move an organization forward quickly. And a large houseof delegates makes it costly and time-consuming to govern.

wEMPOWER THE CEO AND ENHANCE STAFF EXPERTISE

With volunteer time pressures increasing, associations mustincreasingly rely on staff expertise—and hire accordingly, bothin terms of the number of staff and the skillsets required. Overall,associations have been reluctant to transfer responsibility tostaff, sometimes resulting in stalled or slowed projects, missedopportunities, and responses that are “too little, too late.”

eRIGOROUSLY DEFINE THE MEMBER MARKET

What does the member of tomorrow look like? How are theirneeds different than the member of yesterday? These are keyquestions for associations to answer.

For dentistry, this means asking how the needs of a self-employed solo-practitioner differ from the needs of a corporatelyemployed dentist in a large group practice. Different model; dif-ferent needs. What, if any, difference does this make in the

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“Although muchhas changed in the

profession of dentistrysince the IDA’s creation

in 1858, the way theIDA does businessremains the same.Now the IDA must

take a close look atwhat the future holdsfor Indiana’s dentists.”

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$250,000. Today, 800 firms pay $1,995 each to subscribe toIBuild, producing annual revenue of $1.6 million. The projecthas been so successful that the association was able to pay offits loan for the project in just three years (despite a predictionIBuild wouldn’t be profitable for five or six years).

In 2003, Master Builders of Iowa made a bold decision:The association would focus on what it identified as its corecapabilities, in combination with what members prioritized,and let some products and services lapse—a strategy that’s oftenoverlooked in the association world. By narrowing its focus, theassociation has been able to develop deeper, more meaningfulservices for members, including project information and laborrelations services. Retention is up by 5% as a result.

Seeing a bleak future with fewer players in the market due tomergers, acquisitions, consolidations, and company closures, theNational Association for Printing Leadership decided to concen-trate less on overall market share and more on “share of member.”The philosophical change internally moved the organization fromone with a questionable future to an entirely new associationmodel. The group now operates as a consultancy, hiring industryspecialists to partner with members. The organization’s bleakfuture is now much brighter. In 2010 the association predicted itwould generate $2.4 million in consulting revenue. More impor-tantly, members are experiencing stellar returns as a result of theassociation’s consulting services, even in a challenging market.

A new environment requires a new way of doing business.To move into a future of prosperity, the Indiana Dental Associa-tion must ask, “How can we help members work less stressfully,more productively, and more profitability?” A solid answer tothat question will pave the way for Indiana’s dentists—and ensurethe association remains relevant in the future.

About the AuthorMary M. Byers, CAE, is a former state dental society executive anda strategy and planning facilitator. She’s the author of Race forRelevance: 5 Radical Changes for Associations and will again befacilitating the American Dental Association’s Mega Topic discus-sion at this year’s House of Delegates meeting in San Francisco.

product and service line-up, advocacy, and continuing educationoffered by the association? The answer(s) may change what theIDA looks like in the future.

rRATIONALIZE PROGRAMS AND SERVICES

The typical association tries to do too much. For most, theunderlying thinking is that the more programs, services, prod-ucts and activities offered, the more valuable membership is.Yet volume does not equal value. Associations succeeding todayactually offer fewer products and services—and only those theycan provide competitively.

tBRIDGE THE TECHNOLOGY GAP ANDBUILD A FRAMEWORK FOR THE FUTURE

For many associations, investments in technology have beenmade slowly and begrudgingly. The average $4 million/yearassociation spends more on printing and food than it does ontechnology (4.1% of total revenue; 1.6% if human resourcesexpenses are subtracted). New philosophy must acknowledgethe promise of technology and how it will be critical in position-ing associations in the future. Fortunately, the Indiana DentalAssociation appears to be well on its way to advancing this areaof its operation.

The New EnvironmentAssociations thriving today are adapting tools traditionally

employed by for-profit companies, such as market research,product testing, professional marketing, market segmentation,and value pricing. Take a look at what this new mindset hasdone for these associations:

The race for relevance at the Texas Trial Lawyers Associationrequired revamping membership categories. In doing so, theassociation accurately predicted losing 35% of its membershipin the short run. Can you imagine recommending such a radicalchange? Ultimately, the new member dues structure resulted indoubling revenues and a retention rate that increased 8% threeyears after the change occurred.

The New Jersey Veterinary Medical Association did what fewbefore it have: moved from geographically-based board repre-sentation to competency-based representation, and theorganization decreased the size of its board to five members.Both changes are the result of a close look at the reality of asso-ciation management and governance today: Volunteers arepressed for time, and associations are more complex than ever.Many are moving from operations-focused to setting strategicdirection and evaluating overall performance, mirroring for-profit boards more than a traditional association board.

Carolinas Associated General Contractors earmarked $1.2million to create an Internet-based platform designed to pro-vide a portal for members to bid on projects—in spite of apreviously failed effort that lasted 18 months and cost nearly

36


CLASSIFIEDSClassified ads for JIDA are $50 for the first 25 words and

$0.25 per additional word. The use of an association box num-ber is optional for an additional $20. The Managing Editorreserves the right to edit classified advertising copy for clarity.

Submit ads on the IDA website at INDental.org/Advertising.

POSITIONS AVAILABLE

Midwest Dental is seeking candidates for the greaterIndianapolis market. Since 1968, our philosophy of supportingdoctors and staff has led to unmatched consistency and pavedthe way for future growth. We pride ourselves on providingdoctors the ability to practice in a traditional, non-HMO prac-tice environment coupled with the flexibility and rewards agroup can offer. We are currently working on new opportunitiesin the greater Indianapolis market. We’d enjoy the opportunityto learn about your practice philosophy, career goals, andexpectations. To learn more, please contact Andrew Lockieat 715.579.4076 or email [email protected] online at www.midwest-dental.com.

Established private dental practice in heart of Broad Ripple (Indi-anapolis) seeking motivated dentist. 3+ years experience pre-ferred. Digital X-rays used. Email CV to [email protected].

Dental Dreams desires motivated, quality-oriented associatedentists for offices in IL (Chicago and suburbs), DC, LA, MI, MD,MA, NM, PA, SC, TX, and VA. We provide quality general familydentistry in a technologically advanced setting. Our valueddentists earn on average $230K/yr. plus benefits. Call312.274.4524 or email [email protected]. Newgraduates encouraged!

Part-time dental assistant needed for thriving private practice inShelbyville, IN. Please email resume to [email protected].

Busy, state-of-the-art dental office in northwest Indianais looking for a smart, progressive, hard-working dentistto join our team. We average 80+ new patients a month.Immediate availability. If interested please email resumeto [email protected] or fax to 219.322.9986.

Looking for a career change? Do you seek autonomy and clini-cal latitude? Join our group of practices and do the dentistrythat you want to do. Email your CV/resume to [email protected] or call Mike at 317.847.0099.

37WWW.INDENTAL.ORG

PRACTICES AVAILABLE

Exciting opportunity for dentists, hygienists, and assistantsto provide children with dental care in Indiana schools.No evenings or weekends. Email your resume or questionsto [email protected] or call Judy at 888.833.8441 x102.Pediatric or General Dentists wanted.

For more than forty years, Midwest Dental has served as atrusted transition partner for practice owners seeking discreet,efficient, transition alternatives. We offer vast experience insupporting practice owners through the transition process. Weseek like-minded care providers with a vested interest in thelong-term health of their patients and the careers of their staff.All discussions are strictly confidential. Importantly, we are adental practice so there are never any fees involved when work-ing with us. To learn more, please contact Justin Wolfe at312.720.1089 or email [email protected]. Visit usonline at www.midwest-dental.com.

Large practice in 3,500 sq. ft. office space with 5 operatories(expandable to 7). Very nice office with over 50 years of com-bined goodwill. Over 2,000 patients seen the past three years

with average collections of $950K/yr. Owner dentist is movingout of state. Buyer’s net of $284K after debt service. [email protected] for more information.

Practice in northwest suburb of Indianapolis with 5 operatories.Grossing $550K, net $225k in 3.5 days/week. Equipment anddecor new in last 5 years. Paperless/digital with Eaglesoft.Equipment in excellent condition. Efficient hygiene recall sys-tem, high treatment plan acceptance rate, awesome staff. A lotof potential due to no marketing and referring out molar endo,most ortho, 3rds extractions, and implants. Great opportunityfor continued growth and success. Over 2,000 active patients,average 37 new patients/month. Owner is flexible with turnkeyor becoming an associate. Email [email protected].

IUSD graduate seeks like-minded general dentist to purchaserural dental practice in Hawaii. Profitable office with assuredpatient base, excellent staff, doing all phases of dental careincluding pedo, oral surgery, endo and prosthetics. Full-timepractice (4 days) and full-time hygienist. Have time to enjoy golf-ing, outdoor, and ocean sports and no snow! Must have Hawaiilicense. Serious Inquiries may [email protected].

A picture may be worth a thousandwords, but just 25 words will sell yourpractice, get rid of that old equipment,locate volunteers, find an associate...

Share a word or two with your colleagues when

you place a classified ad in Journal Indiana Dental

Association. You’ll reach 2,900 dentists—young

and old, new and experienced—looking and ready

to respond.

IDA Classifieds

First 25 words $50.00

Each additional word $0.25

For your convenience, classifieds that appear in our publi-

cation and online may be purchased exclusively on the

IDA website at INDental.org/Classifieds.

38


IN MEMORIAMDr. Donald W. Johnson (Carmel, member of the IndianapolisDistrict Dental Society) died July 1, 2012. Dr. Johnson graduatedfrom the Indiana University School of Dentistry in 1956.

Dr. Mark D. Lemons (Martinsville, member of the IndianapolisDistrict Dental Society) died June 16, 2012. Dr. Lemons gradu-ated from the Indiana University School of Dentistry in 1985.

NEW MEMBERSEAST CENTRALDr. Lee B. Davis (IUSD 1981)Dr. T. Jason Zigler (IUSD 2012)

INDIANAPOLIS DISTRICTDr. Craig A. Arive (IUSD 2012)Dr. John W. Bailey, Jr. (IUSD 1998)Dr. Alyssa Balsbaugh (IUSD 2012)Dr. Jason A. Bayless (IUSD 2012)Dr. Brian E. Brown (IUSD 2012)Dr. Megan Byrne (IUSD 2012)Dr. Devanshu Chowdhary (IUSD 2012)Dr. Dennis S. Frazee (IUSD 2012)

PRACTICES AVAILABLE

MUNCIE, IN—Open 4 days per week. Collections have consis-tently been $725K/year. Contact Andrea Welch, broker at317.373.6178 or email [email protected] online at www.mid-ampracticesales.com

PORTLAND, IN - Open 4 days per week. Collections $1 mil-lion/year. Contact Andrea Welch, broker at 317.373.6178 oremail [email protected]. Visit online atwww.mid-ampracticesales.com

SPACE AVAILABLE

Ideal office space sharing opportunity in Fishers, IN. Greatlocation. 10 equipped operatories, 5,000 sq ft. Current doctorwill continue treating patients, but wants to fill more operato-ries! Please contact Dr. Green [email protected] for more information.

EQUIPMENT

Pro-Tech Vinyl Repair & Upholstery, onsite upholsters ofdental chairs, furniture or equipment. We clean stools,chairs, lobby seats, etc. Call 317.757.8304 or visit us onlineat www.pro-techupholstery.com.

39WWW.INDENTAL.ORG

Dr. Chris S. Ha (IUSD 2012)Dr. Olga Isyutina (IUSD 2012)Dr. John P. Jansen (IUSD 2012)Dr. Amanda F. Kot (IUSD 2012)Dr. Christopher J. Kumfer (IUSD 2012)Dr. Brian LaBlonde (IUSD 2012)Dr. Katie R. McNutt (Arizona University 2010)Dr. Jeffrey M. McQuinn (IUSD 2012)Dr. Patrick Murray (IUSD 2012)Dr. Mikel Newman (IUSD 2012)Dr. Chad E. Sloan (IUSD 2012)Dr. Katherine E. So (IUSD 2012)Dr. Shellie A. Steffen (IUSD 2012)Dr. Kira L. Stockton (IUSD 2010)Dr. Marc Stojkovich (IUSD 2012)Dr. Jiyun Thompson (IUSD 2012)Dr. Jenna E. Voegele (University of Minnesota 2011)Dr. Nathan Webster (IUSD 2012)

ISAAC KNAPP DISTRICTDr. Jonathan P. Coudron(Virginia Commonwealth University 2009)Dr. Paul Fisher (Ohio State University 2012)Dr. Keith J. Harrison (IUSD 2012)Dr. Joel Micah Johnson (Case Western University 2009)Dr. Matthew S. Kolkman (IUSD 2012)Dr. Connie S. Shim (IUSD 2012)

NORTH CENTRALDr. Jennifer C. Sitjar (IUSD 2012)

NORTHWEST INDIANADr. Kara E. Clark (IUSD 2012)Dr. Mark Dankowski (University of Louisville 2006

INDEX TO ADVERTISERSBowman Insurance & Benefit Service IBC

Data-Safe IT Services 30

Dental Care Alliance 36

IDA Insurance OBC

Paragon Dental Practice Transitions 37

PNC Financial 41

ProAssurance 39

ProSites 35

Sikich 38

Travelers Insurance (IDAIS) IFC

40


Dental students will talk about how difficult a certain profes-sor is. The degree of vulgarity used to describe the professordenotes the degree of difficulty. Newer students will also won-der if it is possible to be a dentist who specializes in buccal pitrestorations.

Young dentists banter about the complexities of running apractice. Their patient load is more arduous, cases moredemanding, staff more obscure, suppliers more testing, hoursmore strenuous, and equipment more problematic than yours.And whatever should be done about Pat who won’t wear thecolor coordinated dental team uniform?

Established dentists talk about extremely (in their eyes, any-way) unusual patient cases (real and imaginary) and try to workinto the chatter seemingly unscripted comments about exoticvacation getaways. “And when we got back from our hang-glid-ing trip over active artic volcanoes, the first patient scheduledwas a triple-impacted fourth molar endo!”

Dentists at or near retirement age will talk about days gone by.If younger dentists talk about the same thing, it is branded asdaydreaming but with age it is dignified as reminiscing. There’sthe chair-side assistant who could always put the correct instru-ment in your hand before you knew you needed it. And Wanda,who could clean and set up a room faster than anyone but rarelyhad matching socks. And a crown was only $65 (and no suchthing as dental insurance). And old Dr. Frank, who had a one-room office with no running water over the liquor store and car-ried a bucket of coal up the stairs each morning to heat the place.And these new dentists, they are so young and so talented.

Long-time, retired dentists chitchat about two things:When do they serve the pudding? and Are there any restroomsin this place?

And senile dentists will actually put a blindfold on at a dentalgathering and listen to see if these things are true. And it took mea half hour to get the stupid thing off after I tried walking downthe up escalator.

Editor’s Note: Upon this, Dr. Carroll’s last “Funny Thing” column,the IDA Editorial Board extends its gratitude to the author forhelping members not take ourselves too seriously. We salute Dr.Carroll’s continuing contributions to the betterment of organizeddentistry.

FUNNY THING

SOCIAL SKILLSIN DENTISTRYRandy J. Carroll, DDS

Some things may never change.

Practice management gurus of many types and ilk oftenharp on listening skills as a way to improve patient relations.We are advised to position ourselves at conversational distance(whatever that is), maintain eye contact (which eye, right orleft?), nod occasionally (with our eyes open and no snoring), andintersperse the dialogue with, “yes,” “I understand,” and, “that’strue” (or similar meaningless utterances). While this has theappearance of listening, actual hearing is not required.Admittedly there are some instances where listening but nothearing is a good thing. A recent patient, Mrs. McDonald (noknown relation to Ronald, but I wonder…), was seated in theexam room and was asked when her toothache started.

“Well,” she began, “it was when my sister, the one who goesto Florida for the winter, they have a real nice place there that isjust a few miles from the coast, she and her husband usuallyhead south when it gets cool, I think they drive down but theydo it in three days instead of two, because Edwin can’t drive atnight ever since he started taking the medicine for his musclecramps or something, I forget exactly. They have a new car thatEdwin got from his nephew when they were shipped overseasthat’s blue, no gray, and it has plenty of room in the back fortheir four dogs that are just like family, because if they ever…”

And ten minutes later you still don’t know when the toothachestarted. The whole exam takes twice as long as it should becauseMrs. McDonald talks at over 275 words per minute with gusts of310. Your receptionist confirms that it took even longer just tomake the appointment due to excess verbiage. It’s not that youdidn’t use your listening skills; Mrs. McDonald obviously didn’thave anything to say.

On the other hand, some patients have more to say than theyin fact do say. Norton made repeated appointments to discuss aproposed treatment. We listened. After the procedure he madeadditional appointments to confer on follow up care. We patientlywelcomed his inquiries. Norton had recently lost his wife andmerely wanted to talk things over with someone who cared.

With time, one can sharpen one’s listening skills to situationsbeyond the operatory. If you would take me and put a blindfoldover my eyes and place me in a group of dentists, I would be ableto tell you how old they are just by listening to the conversation.

155th IDA Annual Session | May 16-18, 2013 | Hyatt Regency Indianapolis

This year, the IDA Council on Annual Session has planned

new and exciting activities to compliment our growing

sessions. Aside from our first-class breakout presenters,

we’re offering mini sessions with our new CE Express that includes

one-hour hot topic sessions.

New Exhibit Hall hours and events will be featured as well.

We’re also pleased to welcome the Indiana University School

of Dentistry’s Alumni Association to our Annual Session.

Image copyright 2012, Indianapolis Convention & Visitors Association; visitIndy.com

YOU WON’T WANTTO MISS OUTON THIS LINEUP!

DR. GORDON CHRISTENSENThe Christensen Bottom Line 2013

DR. MARK HYMANPractice Management and Communications

DR. ROBERT EDWABOral Surgery and Medical Emergencies Workshops

LACI PHILLIPSCommunications and Dental Insurance Strategies

/

The Indiana Dental Association is an ADA CERP recognized provider. ADACERP is a service of the American Dental Association to assist dental profes-sionals in identifying quality providers of continuing dental education. ADACERP does not approve or endorse individual courses or instructors, nordoes it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the provideror to ADA CERP at ADA.org/goto/cerp.

DR. MITCHELL GARDINERDental Team and Malpractice Protection

DR. STEVE CARSTENSENSleep Medicine, Bruxism, and Appliance Workshop

KAREN DAVISTreatment Planning and Oral Cancer Workshop

TIM CARUSOFitness, Back, and Neck Pain

DR. DON LEWISEmbezzlement and Fraud

DR. TED PARKSOral Medicine Potpourri

…and much more!

More than enough live CE credits to meet your licensurerequirements! For more information about our 2013Annual Session, go online to www.INDental.org/Register.Registration will open in October 2012!

Want to experience much more in Indy?Visit www.visitindy.com to take a virtual tour of the city.

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in both print and on the website. Watch your mailboxes formore information in the coming weeks. Please consider sup-porting the IDA, while earning valuable continuing education.

As we carefully reshape the content, design, and distributionmethods for all IDA communications, we invite your honestfeedback. The hours and careful thought we devote to providingvaluable resources to members are not taken lightly, and we areproud of what we deliver; however, we will only be effectivewith your help, your insight, and your voice. Whatever yourage, whatever your communication preference, or whateveryour stance on any issue, this is your Association. Please reachout to any of the Editorial Board members below to share howyou want IDA communications to be an asset to your practiceand career.

Jack Drone, DDS—[email protected] || 219.866.7117

Steven P. Ellinwood, DDS—Assistant [email protected] || 260.492.2640

Michael D. Rader, DDS—Associate [email protected] || 574.233.0014

William B. Risk, DDS—Peer Review [email protected] || 765.742.0202

The Indiana Dental Association, since 1858, hasimplemented a variety of communication tools toreach and educate members about the develop-ments in dentistry and the Association. Those atthe helm of informing members have faced their

own challenges in finding the most effective, creative ways toboth distribute and archive these communications and, as yourcurrent Editor, I can say no different for this stage of our organi-zation’s history.

Last spring the Editorial Board concluded that we mustbe proactive in providing more valuable, useful content thatreaches the maximum number of members, while also shiftingour paradigm from one that accepts publications as a signifi-cant financial loss to the IDA. How can we add to memberbenefit, while helping the Association financially? We adoptedthe following Mission Statement for publications, which willnow appear at the front of every issue of the Journal:

Produce and distribute, at a profit, credible, high-qualitypublications that inform Indiana dental practitioners aboutthe latest scientific, socioeconomic and political develop-ments affecting dental practice and oral healthcare.

Our first major step in a new direction was the issue you areholding in your hands (or reading on your iPad or computerscreen). Some of our most passionate, expert members andfriends of the Association discussed the topics and trends thatwe must face as a profession—and every outcome of eachemerging trend will impact every dentist. This is the type ofresource we want to put in your hands.

Your next issue, Sea of CE, will guide you through the prosand cons of the various continuing education options bombard-ing your mailbox on a daily basis. This spring, you’ll find thelatest tips for running the your practice, an ongoing strugglefor most practices. To round out this volume of the Journal, thesummer issue will be a crash course on revolutionary practicemanagement tools your entire dental team can use. These issuesare all still in the works, so let us know what you’d like to see!

Perhaps most exciting for the Editorial Board is the additionof continuing education to every issue, starting with the nextissue. You’ll find a 1-credit self-study quiz—free for members.We are also developing Foundations, a 10-credit continuingeducation resource featuring some of the biggest names andhottest topics in dentistry. The new resource will be available

Something else is about to changeA New JIDA for the 21st Century Indiana Dentist

Jack Drone, DDS

Editor

Journal of the IDA

Documents

Transcript of Journal of the IDA