A joint investigation with

Dr. Bill Calnon: Why Dentistry Needs More Prevention, Not More Treaters

As president of the American Dental Association, Bill Calnon, D.D.S., advocates for more than 156,000 dentists across the U.S. Calnon tells FRONTLINE that the major challenge facing the nation’s oral health system is not that there are too few dentists, but rather too little emphasis on prevention. “If this is truly a preventable entity, dental disease, which it is, then the true answer, the bedrock of any answer has to be how do you stop the disease, not how do you put more treaters out there,” he says. This is the edited transcript of an interview conducted on Jan. 13, 2012.

Is there a strict line between teeth and the rest of the body?

There is distinct correlation between oral health and systemic or full-body health, especially in terms of poor oral conditions being very interrelated with diabetes, with cardiovascular disease and many other diseases.

… Would it be better if dentistry and the rest of medicine were more integrated?

They’re becoming much more so. … I think that both professions are much more collaborative in both scientific endeavors.

Also, we’re finding that when you have a patient, a patient should have a dental home and a medical home, and those homes really more properly are probably termed a “health home.” So when you are trying to promote wellness in a patient, you can’t divorce dentistry from the rest of the body. …

Do you think people, perhaps maybe less so now, but historically have not appreciated the health impact that a toothache can have?

That’s very true. And I think now, thankfully with more health literacy being promoted, people are finally catching onto the true interaction between oral health and systemic health. …

There’s one study we’ve seen says there is a dental shortage in this country. Is that true?

No, I would totally disagree with that. In fact, surveys done by the American Dental Education Association and the American Dental Association actually show that over the next few years, the number of dentists will actually increase, and the ratio of dentists per population will actually increase.

It’s actually a federal study. … What did they get wrong?

… It’s not a lack of dentists. It’s more referred to as a maldistribution of dentists. There are too many dentists in some areas, not enough in the others. …

Probably the easiest thing to talk about is the debt burden of especially new dentists. Because of that, dentists want to stay in populated areas. So if you could have incentives whereby some of that debt is removed, I think you would have a much easier time attracting dentists to underserved areas.

They’ve got to pay some bills. … And if you go to some of these places, it’s a lot harder to make a buck?

The economic model is very different. … So what we’re looking for is the ability to incentivize the movement of enough dentists into areas, whether it be in private settings or whether it be in what we refer to as the safety net — which really is very tattered at this point and that needs some assistance — whether it be through federally qualified health programs, whether it be through the Indian Health Service [IHS], whether it be other programs that already exist that need proper funding. And I guarantee you will get dentists in those.

Tell me about this tattered safety net you described. What do you mean by that?

There is a safety net out there that involves various governmental agencies, that employs the Medicaid aspect of things, that employs the Federally Qualified Health Centers [FQHC], the Indian Health Service that is already in existence, and takes to some degree the private model and turns it into a public health care model with the idea of serving underserved populations.

But unless policymakers, unless lawmakers sufficiently fund those programs, then there is always a lack of dentists in there, not so much because people don’t want to work in those settings, but because the funding isn’t there to attract new people into it.

So we’re talking about Medicaid and the fact that it doesn’t reimburse enough to make it worthwhile for a dentist to see a lot of poor people?

Medicaid is horribly underfunded in most places, and Medicaid in most states in this country will only cover children. There are very few states in this country now that cover adult dental treatment other than some emergency care.

So if you’re poor in this country, what would you do if you have a toothache?

… The model we currently have is predicated on a surgical treatment model, and we’re very good at that. We know how to fix decay.

But what we have to talk about — and we have to shift the paradigm — is to not be a surgical model but be a disease-management model where we’re stopping the decay; we’re preventing. The whole premise of disease management is prevention, and the vast majority of dental disease is preventable.

So let’s go back to that poor person who would like to prevent the toothache in the first place. Where do they go? They can’t afford it, and … there’s all kinds of gaps in the safety net. … It seems like a big hole in the safety net, isn’t it?

There are holes in the safety net, and there are [no] two ways about it. … You asked, how does somebody enter into that preventive model? American Dental Association at this point has what we think is a terrific new member of the dental team called the CDHC, the Community Dental Health Coordinator, because we realize that there are many barriers to oral care in this country, several risk factors that have to be addressed.

One of them is the system itself. The average person out there in some of these areas takes a look at the system and doesn’t know how to maneuver the system, how to find the places that they can get treatment. And sometimes they don’t even know they need treatment unless there is dire disease.

The CDHC model is predicated on individuals coming from these underserved populations and being trained as community health workers — which the model already exists in the medical world — but these have special dental skills.

“Sometimes they don’t even know they need treatment unless there is dire disease.”

And with those dental skills these people will be helpful in having people, number one, understand the need for dental care early on. They will be out there talking about prevention; they will be out there helping people, literally taking them by their hand if they need treatment and helping them maneuver the system and finding places for them to get care.

Where is this idea right now?

We have three pilots at this point. Two of them are rural, and one is urban. The urban one at this point is in Philadelphia, and the rural one at this point is in Oklahoma. And we have three cohorts of individuals that are out there in the field working, and it’s proving to be very effective.

We’re in the evaluation phase at this point, and hopefully in the very near future this will be something that becomes much more prevalent in the United States.

How will this be funded?

The first three cohorts are being fund[ed by] the American Dental Association.

So the ADA recognizes there’s a problem here?

Very much so, and we’re very active[ly] trying to come up with distinct solutions to it. …

You’re a dentist; you have a small practice. … Why can’t a dentist just take care of this poor person who comes in with a mouth full of decayed and broken crowns that are off? Wouldn’t that be the kind and compassionate thing to do? But it’s not as simple as that, is it?

Well, that’s what dentists do. Dentists do take care of patients, and anytime a patient comes in and becomes a patient of record of a practice, there is a bond that forms between that practitioner and that patient.

Right, but if somebody coming in off the street who doesn’t have money to pay is presented with this kind of situation, if somebody comes into your office, do you do pro bono work at all?

You’d be surprised how many dentists do a tremendous amount of pro bono work. …

But we’re just relying on their generosity, frankly, to fill what is a rather large gap in the safety net, right?

Dentists are a very charitable group, but unfortunately charity does not create an answer in the sense that it’s not a health care system. …

“Dentists are a very charitable group, but unfortunately charity does not create an answer in the sense that it’s not a health care system.”

I assume you’re pretty familiar with what has happened in Alabama. … A quarter of the population lives in areas where there is a shortage of dentists, and it’s very difficult for them to obtain access, and this nonprofit entity has filled a gap there. Yet they set up shop there over strenuous objections by the dentists of Alabama. Help us understand why they would be against that idea.

I wouldn’t say that anybody is against an idea, but we have to always go back and know, is the doctor-patient relationship absolutely sacrosanct; that no patient should ever be in a position of seeking care where they don’t have that ability to have discussion with a dentist and have the ability to make choices on their own. …

So this nonprofit model that has worked out for some poor people in Alabama, you’d say that’s not the way to go?

I’d say that it is a potential in some areas, but we still have to always maintain that same doctor-patient relationship where the patient really is the person going in achieving care but getting it in the best way. …

But we just talked about how hard it is.

It is hard, but that’s again why we’re trying to counteract this by programs much like our CDHC program that I was talking about before, because there are places for people to go in the system that exists.

A lot of times the system itself, however, is part of the problem as far as having people find those right practitioners, find their clinics that do exist out there. And that’s what the whole model of CDHC is, to help people maneuver the system and navigate the system that already exists and has potential for them to go to places. …

It’s not just the idea that the navigation of the practices; it’s a navigation of the system that’s out there, too. For instance, the Medicaid system: A lot of people don’t know how to navigate through with the current Medicaid system in many, many states. It’s very onerous.

Can it be fixed?

I think it can be fixed, yes, but … one of the concerns that a lot of practitioners have is the administrative aspect of it. Many states are trying to fix the Medicaid systems by doing what’s called the “carve-out,” where they actually are carving dental Medicaid out of the entire Medicaid system and trying to … get more dentistry for the dollars that are placed in there and less administrative costs.

They’ve done a lot of work on this in Maryland as well. And do you think that’s moving in the right direction, what they’re doing there?

Very much so. I think anytime you can take a system and try to repair the system and try to make that system much more effective with the bottom line being more dentistry being done for the people that really truly need it, I would call that a success.

… Dentists have their nose to the grindstone, so to speak, trying to keep a business going and seeing patients. To what extent [are they] kind of in this little bubble where they’re doing their work and not really fully appreciating this need out there?

I think that’s why they rely on the American Dental Association as their parent organization. We represent about 70 percent of all dentists in this country. …

There are local societies, and there are component societies, and there are state societies certainly [that] keep them well involved in state advancements, whether it be Medicaid, state issues. And that’s how most people become very well educated as far as not being in their bubble.

The ADA — obviously a very successful, powerful organization. We’re here in this 20-story building that you have, and staff and so forth. Is the ADA here to protect the status quo?

No, not by any means. The ADA is a very proactive association. … We’re here equally for the public as well as we are for our members.

… Is the ADA in any specific way encouraging dentists to treat people who don’t have the money to get dental care?

We always encourage our members to help out in any way we can. In fact, last year our House of Delegates passed resolutions that urged our members to not only be involved but be involved in community action. …

So we’ve encouraged our members to be very involved in any community health organizations, be very involved in any community health outreach so that dentistry’s voice is heard when those decisions are being made.

Is there a sense among dentists that change is coming and that if you don’t get ahead of it, things will change in ways you won’t like?

It’s not so much that [things will change in] ways we won’t like, but when we advocate through either this office or our Washington office for changes that we would like to see in health care, we would like to see the inclusion of dentistry in health care and especially — as we got back to one of your questions before — having people understand the interaction between oral care and systemic full body care that we’re very proactive in that way.

You oppose the Affordable Care Act. Why is that?

No, we did not oppose the Affordable Care Act. … Actually what we tried to do is we lobbied very heavily to get adult care included in the Affordable Care Act.

As part of Medicaid?

In any form.

In any form? And in general dentists have resisted being part of Medicare in the past, right?

Medicare has never reached out to include dentistry.

Is there a sense among dentists that they’d rather not participate in these programs because you go back to all the paperwork and the onerous aspects of being a part of these systems?

If you look historically, the administrative aspect of these programs has been extremely onerous. … And yes, if you can take away the administrative burden, I think you would find dentists much more willing to participate in these programs. …

We spent some time gathering some footage of Dr. Terry Dickinson, the Mission of Mercy. Have you participated in that ever?

Yes. I know Terry very well.

… Does it make you sad?

It makes everybody sad. We certainly recognize there’s a major problem. And again, whereas those Missions of Mercy and other like programs out there try to fill a little bit of void, charity in itself is not a health care system. But we applauded them for all they do. …

… When you pick up the paper or the Internet or whatever, and you read that somebody dies in this country of a toothache, what goes through your mind?

What goes through my mind is that it’s totally unnecessary. …

Completely preventable, and ultimately these poor people who this has happened to, the cost of the system is so much more than it would be if they had been given proper care from the beginning, right?

Much higher. There are studies that show that if a child is seen by a dentist in their first year of life that they spend about 40 percent less throughout their lifetime on dental care.

So most people who are poor and they get sick, they go to the emergency room. And if it’s a toothache, generally they give them some antibiotics and they send them away. That’s not good, right?

No, it’s palliative care, because what you have done is you haven’t answered the problem. You’ve given somebody the ability to relieve the pain, but you haven’t taken care of the problem. So chances are you’re going to see that same person probably back in a very short period of time with the same problem. …

… Can we just go into a little more detail about this, the interconnectedness between your teeth and the rest of your body? …

When you think about what oral disease is, it is a true bacterial entity. It’s a bacterial disease, and the mouth is part of the entire body. So that disease process, if left unchecked and allowed to progress, can certainly set up issues with other organs in your body. …

So you have to neglect it for a while, but can it kill you?

Untreated oral disease can lead to many different outcomes. It can lead to other diseases within your body. Ultimately, in a rare instance, oral disease can be the focal point of a disease process leading to death.

I’m talking about the entire medical community here, not just dentists. Has it taken a little bit of time for there to be a full appreciation of all this? …

I think it’s been understood, it’s been suspected, but as science has evolved and more scientific endeavor has been undertaken, we know now that there are distinct links. And I think both communities, whether it be medical or dental, are certainly embracing that whole concept of the interaction between the two entities. …

… It’s kind of odd to me, even if you’re in the private insurance game, dental insurance is separate from your medical policy. Should that be the case?

Dental insurance actually is not dental insurance where medical insurance is. Dental insurance probably more properly should be called dental assistance. …

… Let’s talk a little bit about dental therapists. We have been to Minnesota, and we’ve seen it firsthand. It seems like a good idea. It fills a gap, doesn’t it?

I think we should have to step back and think of, again, the overall picture. The addition of new treaters into the current system, the American Dental Association feels, is a pathway that this country should not go down, because again, what it does is it approaches the problem from maintaining it as the surgical model. …

If this is truly a preventable entity, dental disease, which it is, then the true answer, the bedrock of any answer has to be how do you stop the disease, not how do you put more treaters out there to treat the same thing. We are very up front about the fact that we are never going to drill and fill and extract our way out of this problem.

“We are never going to drill and fill and extract our way out of this problem.”

Just because you embrace dental therapists, does that somehow lead you to more surgery? Dental therapists could be just as much advocates for prevention as a dentist, right?

The model that we have seen are more treaters, and we don’t feel we need that. If we can decrease the demand for dentistry, we feel the current system can be applied into these other settings.

A little while ago you were saying how important it is to have that personal relationship between the treater and the patient. … If a person can’t get to a dentist and can only afford to or reach or whatever the case may be, it happens to be a therapist. But if they have this relationship which you advocate, isn’t that better?

No, we don’t feel it’s better, because we feel that undertrained individuals or lesser-trained individuals in this country are not the answer. That model is not an answer.

What we feel is that especially when you are dealing with underserved populations, you have to step back and think that these people are not only underserved probably from a dental perspective but also from a medical perspective. They are probably a population that is at extremely high risk from a medical perspective as well, so we don’t understand why anyone would want a lesser-trained individual dealing with that population. …

They deserve a dentist; they deserve a doctor.

So is there a sense among dentists that this somehow diminishes the profession by allowing this?

The United States of America and its citizens enjoy the highest level of oral care or dental care in the world, the vast majority, and we realize that there is a certain segment that doesn’t, and that’s the segment we have to deal with. But to lower the bar is not the answer. …

You said that they were undertrained. Really are they undertrained? I mean, it seems like they go through a fair amount of training and a couple of thousand hours of direct supervision by a dentist.

They go through training, but to compare that training to the training of a dentist, in my eyes you just cannot do that. … They are minimally trained.

In a perfect world you want to keep the bar as high as possible, but if there is this arbitrary bar setting which means that a lot of people are just left out of the game, that’s not good either.

It’s not good, but again, the answer is not putting more treaters out there. The answer is preventing the disease. It’s the most cost-effective solution to this.

… So explain how this prevention model would work without people having access to a dentist.

You can have access to a dentist, but you also have this Community Dental Health Coordinator that I mentioned before that’s a major component of this, because what we find is that the underserved populations, number one, need somebody that they can trust from their own entities, from their own population. And the model shows that these people will come from these populations, and they will be trained to help people coordinate the system.

But one of the biggest things we find is that if you put treaters into these situations, if people don’t realize that they need help, they’re not going to come. If they have pain, that’s a different story. But a lot of people are not symptomatic. A lot of people, before that actually occurs, before that frank caries lesion or cavity or before the swollen face ever occurs, that would have been the time to have had preventative intervention.

… That is an excellent, commendable, worthy goal, but we would have to take down Coca-Cola in the process or something.

You don’t have to take down Coca-Cola, but … that is part of the issue, OK? So, I mean, dietary control — there are so many things that have to be looked at here.

What you have to do is you have to change behavior. You have to go out, and part of the preventative model is more than what we think of as having somebody sit you down and say, “Brush more, floss more,” and that kind of thing. You have to take people, and you have to get at the early stages. So whether it be young mothers, whether it be caregivers of children, you have to convince them that it’s time to have a healthier lifestyle.

We talk about disease management instead of a surgical model. Wouldn’t it be interesting to have the promotion be health promotion — not just how do you get rid of disease, but how do you promote healthiness in people? How do you convince people that their lifestyle should be one that leads them to be healthy? How do you change behaviors?

These are huge issues which even the ADA with its 20-story building can’t go after, right? Let’s talk about the poor person with the toothache in the meantime. What is he or she going to do until we solve all these societal problems that make them have the toothache?

It’s a very good question, because those have to go hand in hand, and our idea is that you must do both at once. You have to, at some point, stop the bleed. You have to, at some point, stop the process of dental disease.

What do you do with the population out there in the meantime? You have to incentivize dentists to go to these areas, and you also have to convince policymakers and legislators that it is a wise investment to put proper funding into the safety net we spoke of before so that these people have a place to adequately be treated and properly be treated, because what we find is that dollars spent on that kind of process, along with the preventative model, is the cheapest way to get to the end of this.

The truth of the matter is this is a group of people that don’t have a lot of clout among politicians, and it’s difficult for them to have their voice heard, isn’t it?

That’s why the American Dental Association exists, and that is why dentists belong to this association. We advocate not only for our own members; we advocate for the American public. And that’s exactly what we try to advocate for, because our voice is loud.

We have a very high membership rate, and politicians are the ones that we try to influence and educate as far as where they should be changing laws. They should be directing dollars, even though they are precious, so that you get your best return for your dollar and the American public benefits from that in the highest way they can.

How do you reconcile that advocacy, though, with a program whose stated purpose is — and apparently is successful at — reaching more people and giving them the care they need? When you talk about the therapists or the nonprofit dental clinics and the opposition that dentists put up — in Minnesota there was a huge fight to stop the dental therapists from occurring. You say you advocate reaching these people. Here’s an effort to reach them, and yet the dentists oppose it. Why?

We feel that any surgical intervention done by anybody to a dental patient should be done by a dentist because of the level of education that that takes.

But even if it’s supervised by a dentist and they have good training and there is all kinds of rules that they have to abide by?

I don’t think you could compare the training from a surgical perspective that you’re asking somebody to do with what a dentist goes through.

I’m not trying to minimize, but surely there is a dominion of work you can do on teeth that doesn’t require quite the expertise you have, right?

… In all my years of practice, I have never met a simple patient. And our concern — and my personal concern — is when people try to break down the certain aspects of dentistry performed on patients and say, well, they are only doing this simple procedure or they are only doing that, you can’t divorce any procedure from that person as a human being, as a patient.

I will give you an example. In my own practice eight months ago, nine months ago, I saw a patient that was there for a “simple restoration,” and it was minor. But as part of that, I don’t just look in that mouth and say, “You are here for this filling; let’s get this filling done, and you are done today.” I look around in that mouth, and I have skills because of my level of education that these other individuals simply don’t have. I do this with every patient. Most dentists, if not every dentist, does the same thing.

When you are in there, you are not looking just at a filling. You’re feeling; you are manipulating; you are looking around in the mouth. Something didn’t feel quite right in this lady. Found a malignant salivary tumor by virtue of just feeling around as I was just doing the simple filling. Two surgeries later, many months of treatment later, she is cancer-free.

And she is lucky she has a doctor like you?

Everybody deserves a doctor like that in this country.

But that’s not what happens?

It’s not to say it can’t happen. We have to be willing to put the funding into the existing situations where we can get dentists in these areas. People have to wake up and realize that that needs to be done. This is a crisis. We need to solve the issue. We need to solve the crisis. We can no longer say, “It would be nice, but we are not willing to put dollars there.” The dollars need to be there. It needs to be properly funded and needs to be efficient, and it needs to be undertaken.

… I don’t want to keep beating up on these therapists, and excuse me, I’m not trying to disrespect what you do for a living, but to some degree, if I’m poor and I have a toothache, you know, half a dentist or 70 percent of a dentist is better than zero.

There are already models that exist that are used within the system that we have in this country where we have trained auxiliaries that assist dentists in performing a lot of those duties. Those we are very much in support of.

Expanded function dental auxiliaries, for example, can work with a dentist, can work alongside a dentist, where the dentist does the surgical procedure, and then these individuals are there and are very well trained as far as placing the restorations. That we have no problem with. Our concern is the idea of a lesser-trained individual doing surgical procedures.

So is it just a matter of the jurisdiction of these lesser-trained people? Maybe they should be doing less than they are currently allowed to do. Is that what you are suggesting?

Our perspective is that their scope of practice is way too wide for the training.

Is it second-class care?

… That’s not for me to decide, but some people may consider that. But my answer is that every American deserves a dentist. …

How attainable is this?

I think what we first have to do is admit what the problem is. We have to stop and take a step back and say, how involved is this problem? And when I say “we,” I mean the American public. The profession does accept this already as far as being a major problem.

I think that lawmakers and policymakers have to step up to the plate and are willing to be educated in this. I will give you an example. A friend of mine who was at a Mission of Mercy in Connecticut two years ago had a lawmaker that was a fairly vocal proponent of I won’t say a therapist model, but an alternative model in the state of Connecticut. My friend had invited this individual to come to a Mission of Mercy. He accepted the offer. He stayed for three hours.

Halfway through that, he looks at my friend and says: “I had absolutely no idea what the problems were with these people. The complexity of the problems that these people come in with, and what I was being told and asked to do by supporting an alternative model, I had no idea.”

So my point of saying that is that one of the things that we really have to do is not just advocate but educate policymakers and decision makers. They have to understand what the problem truly is, not just the magnitude but the complexity of that problem.

Is this a problem that can be solved with money?

Proper funding certainly will allow a resolution to the problem, but by simply putting money in, no. OK, properly placed funding in programs that truly do approach the problem from an overarching concern and viewpoint that this is a preventable disease, yes, if proper funding is there.

But in this day and age we also realize that those dollars are very precious. So what our role is as American Dental Association is again to educate lawmakers and policymakers that this is a wise investment. Anybody that’s willing to put money, anybody that’s being asked to put money toward anything in this day and age should logically say, “What am I getting on my return?” In this case, you’re getting a tremendous amount on return. …

So at the bottom of the ledger, we end up saving.

Most definitely. … Aside from the misery factor, which is enormous, but it’s proven that if you can eradicate this disease at an early age that you have saved billions of dollars in this country. So that’s my point. …

It’s a tough sell these days.

It’s a sell that we take on as one of our primary objectives as an association is to educate and convince not only lawmakers, but also one of the biggest barriers that we find is oral health literacy in this country. …

Three years ago, the American Dental Association convened a meeting called the National Roundtable on Dental Collaboration in which we invited many different organizations that we would consider stakeholders in our profession. They are various specialty groups, but not just dentists — other groups outside of the profession itself that deal an impact with dentistry.

One of the items that this group in our first meeting really wanted to tackle was oral health literacy and how can we improve messaging and how can we improve getting that message out to especially underserved populations.

What this group has come up with is another coalition called Healthy Mouths, Healthy Lives, and that group approached the Ad Council. … We made a pitch to them, … and they accepted the idea of doing an oral health literacy campaign, which will be the first one that they have ever done. This is going to be well over a $100 million campaign that will kick off next July or somewhere next summer.

Its messaging will be to parents and caregivers of very young children. This will be aimed particularly at underserved populations. This will be done both in Spanish and English, and our hope is that the outcome of this will not be just getting a message out there, … [but] messaging in such a way that we actually are going to try to hopefully change behaviors of the caregivers. …

… What is the ADA doing specifically on this front? How much is it spending? Is it putting its money where its mouth is, if you will?

Very much so. … The Dental Health Coordinator project that I talked about before, that’s just shy of $9 million that we over the last couple of years have taken our dues dollars and put toward it. So that is funded at this point by the American Dental Association.

Four million dollars of our members’ dues dollars are actually at this point being spent in various states trying to promote health literacy, trying to promote increased Medicaid fees, trying to be out there promoting fluoridation. All of these we know are proven entities that would decrease dental disease. …

The ADA can’t solve this problem on its own, though.

Not by itself, we cannot.

Has anybody tried to figure out what is the dollar figure? What would it take to fix this?

I have no idea as far as giving you a distinct dollar figure, but it’s the commitment at this point more than anything. …

Do you [sense the] crisis is actually building right now? It’s getting worse?

I think that what brings it to the forefront at this point is the economic downturn this country and this world has gone through over the last couple of years.

… Let’s talk a little bit about corporate dentistry. Do dentistry and Wall Street go hand in hand very well?

No, there are many different kinds of models as far as how you set up a dental practice. The ADA does not promote one model over another. That’s really part of the marketplace out there. …

Any place, no matter what kind of treatment facility that one goes to, a patient should always have the ability to know that his or her questions are being listened to and that the answer is being given by the dentists with no interference whatsoever from any other outside source.

Is it a good idea for private equity firms to have a stake in how things go in a dental chair?

I think where it will go back to as well as my answer is basically the same: The doctor-patient relationship has to be protected. That’s the bottom line.

So take us a little bit inside the ADA’s efforts to advocate for more, being embraced more as part of the federal system which is designed to provide that safety net. When you go around and ask to stitch up this hole in the safety net, what do you hear in response?

Actually, it’s beyond just federal. It’s state and federal. The way in which the American Dental Association works is, we’re the national umbrella for state societies as well, … so we work hand in hand with those societies, advocating for changes in funding at the national level, federal level, and also within state systems as well.

We find that our objectives oftentimes are more easily met at state levels, because a lot of times our members are more acquainted with individual lawmakers in those states. They may know them as neighbors; they may know them as patients. …

From a national level, we meet resistance. We’re always going to meet resistance. We know that. We met with that many times on a federal level. Doesn’t mean we can stop trying. … We have to go get more and more lawmakers firsthand knowledge as far as what’s going on. …

They can see firsthand what the problems truly are, and it’s usually very eye-opening to them, which is amazing to me. But it shows that need for education is definitely there, and the more educated they are, the idea is that when we do ask for proper funding, they’ll have a much better understanding as far as what the dollars need to go for. …

It really is an invisible crisis?

It is to some people.

So if every lawmaker could see a Mission of Mercy, maybe that would change that?

It would make a big impact I think. … There is an awareness problem.

So it’s up to you to change that, I guess.

That’s one of our major reasons for existence, is advocate for change. But also realize that we can do that largely by educating people. …

Back to this whole idea of corporate dentistry. We’ve talked to some people who have been inside these offices, and really, the simple way to describe it is it seems like Medicaid fraud, frankly. It seems like patients are overtreated; they’re given more expensive treatments than would be necessarily clinically mandated in your office, all in the name of meeting a bonus. Should there be systems like that in any sort of health care that reward overtreatment?

I think the way to answer that question is a fact that when a patient becomes a patient of record of any type of treatment facility, there are certain rights, there are certain expectations, and there are certain options that that patient should expect.

Some of those would be easy access to the treatment facility. It would be proper treatment that follows a prescribed treatment plan that is not considered overtreatment. It would be access at any point to their health care information. Any entity that provides that is doing an adequate job in providing good dental care.

There have been instances where corporate models, if you wish to call it that, have closed in the last couple of years. One in particular was called All Care. When All Care closed, that raised a tremendous number of questions about those rights and responsibilities and options of patients that I just spoke of. …

Do you hear from dentists that operate in these corporate entities that they feel pressured to do things they wouldn’t normally do?

Both dentists that choose to work in situations, no matter what the entity, and the patients that choose to go to whichever entity they choose to go to have to make up their own minds on many things.

From a dentist’s perspective, it comes down to ethics. And I’m not saying yes or no about any type of treatment facility. But any professional has to always step back and say: “Am I doing the right thing? Am I feeling pressured? Am I treating a patient in a way that is not ethically and morally the standards that I want to work to?”

If the answer is no, then I think they know what they have to do: They have to move on; they have to do something else. Nobody should ever take a look at the standards that they have sworn their allegiance to, in essence, and ever take a look in the mirror and say, “I’m not upholding those standards.”

From a patient’s perspective, patients should never be pressured. Patients should always have the ability to have distinct interaction with the treating facility and the treating dentist. They should always have the option of being given a treatment plan and alternative treatment plans. And they should always, always be informed consumers, because a dental patient is a consumer of dentistry.

The decision whether or not to go ahead with treatment, the decision to choose whatever treatment from various treatment plans, is always the patient’s. The treating dentist should inform the patient and educate the patient. The patient is always a decision maker. If a patient does not feel that is how they are being treated, then my answer to that would be then they should be elsewhere.

There may not be an elsewhere. This might be their only alternative. It might be that or no care.

In many instances there are alternatives.

To back up just a little bit, you would point the finger at the individual dentist working for that company, not the private equity firm that owns the corporation?

I think any dentist is obligated to work in an ethical manner, and if they felt that whatever or whoever is their employer is telling them whatever mode of treatment is necessary or telling them to raise their quota, then they would have to step back and say, “Is that what’s best for the patient?” If the answer is no, and if the answer is, “I am going against my ethical standards,” then I think that dentist has some issues with how they are treating the patient. …

So you would not say that this is a problem of a corporate structure. It’s a problem of dentists that are not abiding by their oath as a dentist and as a caregiver?

It always comes down to the person physically treating the patient. If they feel that they are about to do something, or if they are being put into a position that they question whether their treatment is the best for that patient, then that dentist should remove themselves from that situation.

We’ve heard all these stories about, you know, sometimes a child receiving upward of eight crowns in all four quadrants of the mouth. I assume you’ve heard some of these reports. What goes through your mind when you hear this at the ADA? Does the ADA take a stand on that?

I’ve actually seen that firsthand, because in my former life, before I’m president of the American Dental Association, I was on the New York State Board for Dentistry back home in New York, and we would be the groups that would see those entities come in, as far as people being challenged, as far as was that proper work or not.

So does it take place? Unfortunately, yes, in this country it occasionally does. And is it good? Of course not. Does the ADA say anything about that? We certainly espouse that the ethics of proper treatment is what every dentist should always fall back to.

Are these corporate entities, these dental mills, if you will, are they yet another symptom of a broken system?

… There are many models out there that involve corporate America that we’re finding large group practices that become more mainstream and that we work very well with. Anytime you classify something as a “mill,” that is particular to a particular entity, and nobody is going to step back and say that those entities are probably doing the best thing.

So there are good corporate customers and citizens –

We feel there are. …

Health care, dental care and profits are often at odds, aren’t they?

Properly placed profits are fine. If the profit is dictating treatment from the standpoint of not doing what you think is best for the patient, then it’s not proper.

And that happens?

It happens in any field, but we would love to think that is minimally impacting our profession. …

If nothing else, you could say these corporate entities, Kool Smiles and the like, are really good at communicating. They’re good marketers.

They’re very good marketers.

… The fact is, they are actively going out and seeking these people and bringing them in. That’s why people think that’s their only alternative, right?

They’re very good at marketing.

Is that appropriate?

That’s a corporate model. That is what they do. That’s what some of them do. The bottom line still is the efficacy of the care that’s received and the ethical manner in which supposedly it is done. That’s the actual answer to that.

Does this give your profession a bad name, though?

Anytime that treatment is rendered in a way that could be considered unethical, it certainly reflects on the profession as in general.

I want to shift into these credit cards. … You really have to read the fine print to see what you’re getting into. Again, this is probably a manifestation of our system that has some holes in the safety net, and people are desperate, need help, and this is how they get it. Is this an unfair way for people to be forced to fund their dental care?

No, I don’t think it’s an issue of being forced. I think that there are multiple ways patients can finance their dental care. Credit cards are one of them, especially some newer ones. The best example is one called CareCredit, which is a very popular financing model.

Endorsed by the ADA, right?

Endorsed by the ADA. And what we find is that if properly used, it’s an excellent vehicle that allows people to finance dental care that otherwise might be left undone.

That being said, it becomes very, very important that the treating office, whether the dentist and/or office staff, fully educate and fully inform patients as to what this means as far as financing costs.

Brochures certainly can be given, but we have to make sure that people aren’t just handed a brochure. We have to have a conversation. We have to make sure that that patient is an informed consumer of credit at that point, before they become a consumer of dental care.

On the other hand, it also falls back on the patient to be somebody that understands the risk that they’re undertaking and not being too willing to take that risk unless they know they have the proceeds to pay for them.

Of course this is a person who probably has a terrible toothache and they’re desperate for help. They see the brochure, and they’re happy, and it says zero interest, and down there in the fine print: If you go one second past the due moment, you owe 29.9 percent retroactive to the beginning. It sounds predatory to me.

It actually falls back into the idea of properly educating the patient as a consumer. We use this in my own office. We have found absolutely no problems with it whatsoever, but we also take the time to properly educate our patients, and that’s what every professional in a professional office, I feel, should be doing. …

The truth is, though, GE Money is not making any money on this unless people do in fact go past the due date.

Not every person out there is given an interest-free time frame. That is an option. If a patient chooses to go beyond that time frame when they sign up for it, they know up front what that interest rate is.

Does it feel predatory to you, though, 29.9 percent?

It’s not one that I would like, but it is also one that if patients are informed properly and can set up payment plans in that 12-month period that they’re given interest-free and stick with that and understand that’s what they have to do, then I think that’s where the education piece really comes in. …

This notion of dentists graduating and being saddled with debt — take us into the world of somebody who is trying to set up a business as a dentist. I suppose a lot of people would think once you’ve got your diploma, this is a ticket to a nice lifestyle. Is that true?

Certainly it’s a major investment to become a dentist. There’s no two ways about it. The cost of dental education is extremely high, and it continues to escalate. A lot of young practitioners are coming out of school with hundreds of thousands of dollars of debt.

For them to go into private practice or any practice that requires a monetary involvement from there certainly increases that debt load. So just to get into practice certainly is an expensive proposition once you get out of dental school.

A lot of it has to do with debt management. More and more people are coming out of school with a much better understanding as far as how to utilize their debt and how to manage that debt as they try to go into various aspects of the profession.

But the bottom line is that it makes it harder for dentists to offer up care to those who are poor because they’re under so much pressure financially.

It certainly does from an economic model. But in actuality, I’ve had the distinct pleasure and opportunity to deal with a tremendous [number] of dental students over the last couple of years, and I have to tell you that I have never seen a generation of dentists that are more willing to be involved in serving underserved populations than the current group that is in dental school these days. …

… You talk a lot about prevention, and prevention is all well and good. Nobody is going to say prevention is a bad idea, but it’s a long-term idea. … There is a clear and present need right now for poor people who literally have toothaches, and toothaches that can kill them. What about that?

You have to take a look at the reason for those individuals not being able to access care. It is not always the fact that there is not a treater that’s somewhat nearby. …

There are numerous barriers out there, some financial, some geographic, some very cultural. And there is a multitude of ideas. Oral health literacy, or a lack thereof, is a major hurdle out there. …

We have to do our best job as far as how to eradicate those barriers and how to show people how to maneuver the system, how to get treatment and properly fund the safety net that does exist in this country. It’s imperative that that safety net be properly funded so that people can get treatment until the prevention model really does come into play.

We met this poor woman who’s just had a train wreck at her mouth. I’m sure she would be like, “That doesn’t help me very much.” What do we say to them? They deserve, it seems to me, a more immediate and concrete answer.

… A number of years ago in Maryland a 12-year-old boy [Deamonte Driver] unfortunately did die because of dental disease. In reality, what we find out much later is that if this young man, this boy, had had the ability to have someone help that family navigate the system, the outcome most probably would have been very different.

This is used as an example of how dire the problem is in this county, but it’s also used as an example of how proper negotiation skills in a system that is onerous to many people can be overcome and the necessity for exactly that. There are places for people to get treatment. They have to know to navigate the system to be properly placed into a treatment facility.

… There are people out there who are doing their homework, who are actively engaged in trying to find this care, and yet still cannot. That’s not good.

… One of the things they can do is call the various arms of our association, American Dental Association, and call the local component chapters and say: “I have a problem. Do you have individuals that will see someone in my situation right now or in the very near future to get me out of troubles?” … There are places.

If somebody is in that much pain and that much discomfort, the first thing is to eradicate the initial problem, maybe not treat their whole mouth but at least get them out of pain and get them out of any infection at that point. That certainly should be the primary goal. At that point, refer those patients to places where they can get proper treatment.

But it shouldn’t be this elaborate, should it?

We would certainly like it to be a much more simplified fashion. …

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