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HUMBUG !!
The dental profession is clings to its basic assumption that all patients can be treated in a more or less similar fashion. There has been no organizational approach to dental fears and anxieties, despite the fact that less than half of the population avails themselves regularly of dentistry's necessary health maintenance services.
Now, I hear lots of "yes-buts" already, like, "In my office, we practice gentle dentistry", and "in my office, we take that 'we cater to cowards' phrase to heart", or "we always offer nitrous oxide, and we have an electronic anesthesia device and air abrasion". I hope, with this editorial, to redirect the thinking of those of you with excellent patient management skills, and to light a fire beneath those of you who haven't given much thought to it in the past.
Let's look at the essence of the patient experience in dentistry. What is it that we really do?
It is possible to have an appendectomy performed with local anesthesia. I've seen it done. A little xylocaine, a skin incision, some retraction (with associated discomfort), "run" the small bowel, remove the vestigial appendage, close in layers, and lots of ice cream (sorry- thinking of another invasive surgery that can be done under local). If you poll your friends and acquaintances, however, you probably can't find one who has had this done or would submit to it.
The arrogance, then, of dentistry, is that we perform surgery of hard and soft tissues in the mouth, under the nose, in front of the eyes, and central to the ears of all of our patients, and we expect them all to be able to sit there and "take it" in an agreeable and adult manner. Then they are asked to go to the front desk to pay for this intrusion into their person. We are kidding ourselves.
Thought of in this light, no wonder more than 50% of the population doesn't avail themselves of our services. Many organizations and institutions in dentistry are willing to write off more than half of our potential market as "bottom of the barrel", "lower echelon", "uneducable", "clinic patients", or in some other term suggesting undesirability. Don't sell these patients short.
Most other industries that see themselves as providing necessary services, would be aghast to see >50% non-utilization of their services. For example, consider the oil change industry for cars. For the public to ignore this necessary service is to spell disaster for their cars. Changing oil is a universally agreed upon necessity that the public understands better than their need for dental health maintenance. Several companies have created market positions for themselves by making the oil change experience quicker, easier, less expensive, and a better choice than do-it-yourself (an option our potential patients don't have). If Jiffy Lube felt that 50% of the population was not getting its oil changed on a regular basis, it would launch an educational advertising avalanche, or an "awareness campaign".
The fact is that the American public continues to maintain its cars better than its health. We need to have an organizational understanding as to why that is. What then are the barriers to acceptance of basic dental care?
Access
As you shall see, the relative weight of each of these items is debatable in studying dental avoidance. Access and Finances are nearly the same issue in the US, although this may not be the case in some third world countries. Shared History, a la Johnny Carson's frequent root canal jokes and family "tribal" storytelling, is mostly the same issue as Fears and Anxieties. (If you are an adherent to Jungian Theory, a Collective Subconscious aversion to dentistry is probably best quelled by providing several generations of patients with excellent dental experiences.)
So, the three basic barriers to acceptance of dental care are money, poor dental values, and apprehension. AIDA hopes to affect each of these issues in its tide of change, but let's concentrate on Fears. Let's get specific about what has prevented Dentistry as an institution from better serving its constituents.
THIS, GENTLEMEN, IS A HUMBUG........
AAMOS, the American Association of Oral and Maxillofacial Surgeons, has achieved a great disservice to the public and the profession. In 1997, a proposal for ADA recognized specialty status for dental anesthesiology was strongly opposed and defeated by this specialty association.
To achieve specialty status, a group must prove public need and demand for the services. AAMOS counter argued this need with a survey that stated that only five percent of the population avoids dental care because of apprehension or anxiety. Apparently , the members of the ADA House of Delegates must not communicate with their patient base, because they accepted this argument and defeated the resolution.
A few quick thoughts on this issue:
Do you trust surveys enough to overrule common sense? Ten percent of the population is said to have measurable mental illness. How many would admit to it on a survey? Most dentists’ report their experiences with apprehensive patients to reveal high levels of denial on the part of the patients. Who among us have not seen patients in our own chairs "white knuckle" their way through a procedure, exuding stress and psychic trauma, despite our own laudable efforts? Who among us has not had patients say, "Doc, I wish I could just go to sleep and get it all done at once"? Who among us has not had patients who were had so much emotional overlay attached to their treatment that we wished they would go somewhere else, for everyone’s benefit?
Dental anesthesiologists provide or allow for the provision of restorative or rehabilitative care of individuals who are unable or unwilling to receive dental care in more conventional formats.
Oral surgeons do not, may not, and should not provide restorative and preventive care for their patients. Therefore they cannot serve all patient needs despite their ability to provide anesthesia services.
Dental anesthesiologists also receive advanced training in caring for medically compromised patients. Aside from the apprehensive population, this is another grossly under served population, unless your opinion is that every patient with systemic complications should see an AAMOS member for full mouth extractions.
Thousands of children are emotionally mistreated every year by dentists who are not trained in handling the special emotional needs of the very young. Nursing bottle caries is still a very real entity in every socioeconomic bracket in this country. There are too few pediatric dentists to serve this need, and not all pediatric dentists choose to include anesthesiology in their armamentarium.
The oral surgery specialty itself has proven and brags proudly that the style of "operator anesthesia" utilized by most practitioners is among the safest anesthesia techniques available. Dental anesthesiology has a safety record that is at best equaled, but not exceeded by medical anesthesiology. Operator anesthesia is obviously cost-effective, and the argument that medical anesthesiologists could meet the present need for such services would precipitously increase the cost of said services, nor has it happened in the past, under the same parameters and constraints.
Importantly, it should be obvious that AAMOS has a huge potential financial interest in the issue, and thus a conflict of interest exists. First, AAMOS fears that adding the tool of anesthesiology to "common" dentistry will open the door for increasing numbers of general dentists to place implants and provide third molar extractions. Well, take a general look at the marketplace. Managed care provides disincentives for specialty referral, and greater motivation to provide high copayment and uncovered procedures. Dental anesthesia will not be a leader in this move toward generalist care--- the die is already cast. Secondly, AAMOS is scrambling to redefine its territory on all borders. Reimbursement for orthognathic surgery is almost impossible today. TMJ remains an untouchable to third parties. Plastic surgeons and ENT surgeons are treating jaw trauma. Some oral surgeons are trying to market nose jobs, liposuction, and facial plastic surgery of all types. The attempt to make dental anesthesiology a specialty was interpreted and fought as another encroachment into their self-defined realm, and was self-serving in its victory. We hope that future incarnations of the ADA House of Delegates will show the maturity to judge this proposal on its own merits and not on a basis of organizational fear on the part of one special interest group.
Isn't one role of Organized Dentistry to promote the wellness of Society??
Let's really tackle this issue. Providing board certified, well trained pain and anxiety control specialists to our menu would be a wonderful first step. Extend an open hand to the marketplace.
K. Randall Groh, DDS
Acting Chair
The American Independent Dentist’s Association
336 Alhambra Circle
Coral Gables, FL 33134
E-Mail feeforserv@aol.com
January 13, 1998© K. Randall Groh, 1998
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8American Independent Dentist's Association
Last update 01/29/98
