Health: Boom Times for Dentists, but Not for Teeth

[Guest guest]

Dentists appear to be satisfied with their numbers .. they want no more

dentists .. no more care .. they just want more money. Butch

 

 

October 11, 2007

 

Boom Times for Dentists, But Not For Teeth

 

By ALEX

BERENSON<http://topics.nytimes.com/top/reference/timestopics/people/b/alex_beren\

son/index.html?inline=nyt-per>

 

For American dentists, times have never been better.

 

The same cannot be said for Americans' teeth.

 

With dentists' fees rising far faster than inflation and more than 100

million people lacking dental insurance, the percentage of Americans with

untreated cavities began rising this decade, reversing a half-century trend

of improvement in dental health.

 

Previously unreleased figures from the Centers for Disease Control and

Prevention<http://topics.nytimes.com/top/reference/timestopics/organizations/c/c\

enters_for_disease_control_and_prevention/index.html?inline=nyt-org>show

that in 2003 and 2004, the most recent years with data available, 27

percent of children and 29 percent of adults had cavities going untreated.

The level of untreated decay was the highest since the late 1980s and

significantly higher than that found in a survey from 1999 to 2002.

 

Despite the rise in dental problems, state boards of dentists and the

American Dental Association, the main lobbying group for dentists, have

fought efforts to use dental hygienists and other non-dentists to provide

basic care to people who do not have access to dentists.

 

For middle-class and wealthy Americans, straight white teeth are still a

virtual birthright. And dentists say that a majority of people in this

country receive high-quality care.

 

But many poor and lower-middle-class families do not receive adequate care,

in part because most dentists want customers who can pay cash or have

private insurance, and they do not accept

Medicaid<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthto\

pics/medicaid/index.html?inline=nyt-classifier>patients.

As a result, publicly supported dental clinics have months-long

waiting lists even for people who need major surgery for decayed teeth. At

the pediatric clinic managed by the state-supported University of

Florida<http://topics.nytimes.com/top/reference/timestopics/organizations/u/univ\

ersity_of_florida/index.html?inline=nyt-org>dental

school, for example, low-income children must wait six months for

surgery.

 

In some cases, the results of poor dental

care<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics\

/teeth_and_dentistry/index.html?inline=nyt-classifier>have

been deadly. A child in Mississippi and another in Maryland died this

year from infections caused by decayed teeth.

 

The dental profession's critics — who include public health experts, some

physicians and even some dental school professors — say that too many

dentists are focused more on money than medicine.

 

" Most dentists consider themselves to be in the business of dentistry rather

than the practice of dentistry, " said Dr. David A. Nash, a professor of

pediatric dentistry at the University of

Kentucky<http://topics.nytimes.com/top/reference/timestopics/organizations/u/uni\

versity_of_kentucky/index.html?inline=nyt-org>.

" I'm a cynic about my profession, but the data are there. It's

embarrassing. "

 

A defender of the profession is Dr. Terry D. Dickinson, a practicing dentist

who is also the executive director of the Virginia Dental Association. He

says he believes that dentists are charitable and want to provide care to

poor patients. But dentists are also in business; they must pay rent and

employee salaries, and they deserve fair fees, he said.

 

" Charity is not a health care system, " Dr. Dickinson said.

 

Dentists, of course, are no more obligated to serve the poor than are

lawyers or accountants. But the issue from a public health standpoint, the

critics say, is that even as so many patients go untreated, business is

booming for most dentists. They are making more money while working shorter

hours, on average, even as the nation's number of dentists, per person, has

declined.

 

The lack of dental care is not restricted to the poor and their children,

the data shows. Experts on oral health say about 100 million Americans —

including many adults who work and have incomes well above the poverty line

— are without access to care.

 

A federal survey shows that 27 percent of adults without insurance saw a

dentist in 2004, down from 29 percent in 1996, when dental fees were

significantly lower, even after adjusting for inflation. For adults with

private insurance, the rate was virtually unchanged, at 57 percent, up from

56 percent. Since 1990, the number of dentists in the United States has been

roughly flat, about 150,000 to 160,000, while the population has risen about

22 percent. In addition, more dentists are working part time.

 

Partly as a result, dental fees have risen much faster than inflation. In

real dollars, the cost of the average dental procedure rose 25 percent from

1996 to 2004. The average American adult patient now spends roughly $600

annually on dental care, with insurance picking up about half the tab.

 

Dentists' incomes have grown faster than that of the typical American and

the incomes of medical doctors. Formerly poor relations to physicians,

American dentists in general practice made an average salary of $185,000 in

2004, the most recent data available. That figure is similar to what

non-specialist doctors make, but dentists work far fewer hours. Dental

surgeons and orthodontists average more than $300,000 annually.

 

" Dentists make more than doctors, " said Morris M. Kleiner, a University of

Minnesota<http://topics.nytimes.com/top/reference/timestopics/organizations/u/un\

iversity_of_minnesota/index.html?inline=nyt-org>economist.

" If I had a kid going into the sciences, I'd tell them to become

a dentist. "

 

But despite the allure of rising salaries, the shortage of dentists will

almost certainly worsen, because the nation has fewer dental schools and

fewer dentists in training than a generation ago. After peaking at 5,750 in

1982, the number of dental school graduates fell to 4,440 in 2003, as

several big dental schools closed their doors. The average dentist is now 49

years old, according to the American Dental Association, and for at least

the next decade retiring dentists will probably outnumber new ones.

 

Even if more students wanted to enter the profession, states are not moving

aggressively to expand dental schools or open new ones. Training dentists is

expensive, because dental schools must provide hands-on training —

unlike medical

schools<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtop\

ics/medical_schools/index.html?inline=nyt-classifier>,

which send doctors to

hospitals<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealtht\

opics/hospitals/index.html?inline=nyt-classifier>for

training after they graduate. Hospitals receive federal subsidies for

the training they provide to medical interns and residents, but the

equivalent system does not really exist in dentistry.

 

Meanwhile, the A.D.A. does not support opening new dental schools or

otherwise increasing the number of dentists. The association says it sees no

nationwide shortage of dentists, though it acknowledges a shortage in rural

areas. Dentists note that in the early 1980s, when dental schools were

graduating nearly twice as many dentists relative to the overall size of the

population as they are now, some dentists struggled to keep their practices

afloat.

 

Dr. Kathleen Roth, president of the A.D.A., said that the association is

working to increase Medicaid's reimbursement rates to make it more

cost-effective for dentists to treat low-income patients. While Medicaid is

supposed to cover both basic care and emergency procedures for children, the

program will pay only for emergency procedures — not basic care — for adults

in most states.

 

" Access to dental care, especially for children, has been a growing problem

for 10 years, " Dr. Roth said. " State and federal programs have decreased the

amount of dollars available. "

 

Besides calling for higher Medicaid reimbursement, Dr. Roth said, the

association supports putting health aides with basic dental training into

public schools. The aides would help get appointments for children who need

them and teach children basic habits like brushing teeth.

 

But critics say the association's plans would do little to solve the basic

problem of access to care. Moreover, even in states that have raised

Medicaid payments, most dentists still do not accept Medicaid patients.

Virginia, for example, overhauled its Medicaid program in 2005, raising

rates 30 percent. But only about 25 percent of all Virginia dentists now

accept Medicaid patients, compared with 15 percent before the changes.

 

Some dentists do not accept Medicaid patients because they frequently miss

appointments, which means lost revenue, said Dr. L. Jackson Brown, the

former managing vice president for health policy at the A.D.A.

 

With little dental care available for poor children, pediatricians are

teaching themselves how to apply fluoride varnish on baby teeth, a simple

procedure that can prevent cavities, said Dr. Amos S. Deinard, a

pediatrician and associate professor at the University of Minnesota.

 

" The dentists don't want to see these kids, " Dr. Deinard said.

 

Outside the United States, more than 50 countries, including some western

European nations, now allow technicians called dental therapists to drill

and fill cavities, usually in children.

 

Proponents of the therapists say their training is comparable to the

practical training that dentists receive, but without the general medical

training dentists get. Studies of the work performed by the therapists have

concluded that it is comparable to, and in some cases better than, that of

fully trained dentists.

 

Dr. Frank Catalanotto, a professor of community dentistry at the University

of Florida, said dental therapists would be a cost-effective way to provide

basic care to children and some adults who could not otherwise afford

treatment.

 

But state boards of dentistry have blocked dental therapists from working,

arguing that only dentists should be allowed to drill teeth, because it is

an " irreversible surgical procedure " and can lead to serious complications

like infections or nerve damage. Children of Alaska Natives in remote areas

have high rates of cavities and essentially no access to dentists, so a

coalition of tribes began a program in 2003 to use therapists to treat

native children.

 

" There's never been a dentist in these rural areas, " said Dr. Ron Nagel, a

dentist who helped create the Alaska program and is a consultant for the

tribal coalition.

 

But the American Dental Association fought the program almost as soon as it

began, dropping its effort only in July, after a state judge ruled in favor

of the program. Still, the group continues to oppose letting dental

therapists practice anywhere in the continental United States.

 

" What we're extremely uncomfortable with is that they need to drill teeth

and sometimes extract teeth, " said Dr. Roth, the association's president.

Use of therapists would create a two-tier system where some people have

access to dentists, while others must settle for less-qualified

practitioners, she said.

 

Dr. Caswell A. Evans, a dentist and associate dean at the University of

Illinois-Chicago, said dentists must stop fighting efforts to expand care to

patients they are not currently treating. The system is failing many

patients, he said.

 

" Right now we have a double standard of care, " Dr. Evans said. " Some people

can get it and some people can't. "

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