by Michael Silverman, DMD
Synergy is often explained as "one plus one equals three." The concept: Two or more independent forces brought together equal more than the sum of its parts.
At the moment, my thoughts are focused on the inverse of synergy - where one plus one equals less than one; perhaps even zero. I don’t know that a specific antonym of synergy exists, but I’d like to propose one: overregulation.
It is happening right now in dentistry and it’s a serious threat to all of us. Dentists, as we all know, face a myriad of regulations aimed primarily at ensuring public and employee safety. There are HIPAA, OSHA, and FDA, and DEA, EPA and FTC rules to monitor and adhere to. Regulations include state-by-state licensing and educational requirements, the use of pharmaceuticals, and the disposal of dental materials.
In 2002, according to a report from Duke University, overall health services regulations cost the average U.S. household $1,546. With dental services comprising 4.7 percent of the nation’s health expenditures, it is reasonable to estimate that dental health regulations cost each American household roughly $70 to $75 a year. Keep in mind that the 70 bucks or so in regulatory costs are before a patient even opens his or her mouth.
While that may not seem like much of a burden to some, for the 108 million Americans who go without dental insurance, any superfluous spending may very well be the tipping point between affording dental care and doing without.
Is all $70 to $75 superfluous? Of course not.
But regulators, like lawmakers, tend to regulate, in part, because that is what they are hired to do. It doesn’t look productive to constituents to say, “Everything is operating just fine as it is.” So every year or two, regulators and regulative bodies conjure up new proposals to “improve” upon existing regulations.
The public and the profession pay a high price for such “fix-it-even-if-it’s-not-broken” thinking. It is one of the main reasons the costs of dental visits across the country are far outpacing inflation, yet most dentists struggle to grow their incomes at anywhere near the rate fees are rising.
A current example of this - and one that is dear to my heart - is the American Dental Association and its effort to revise ADA guidelines covering the administration of oral conscious sedation, or OCS. The ADA, although lacking regulatory authority, carries enormous weight with state dental board members who do mandate the rules of our profession. Indeed, 18 states largely regulate directly off of ADA guidelines.
In October 2005, the ADA’s House of Delegates, the broad governing body that ratifies the association’s professional practices guidelines, affirmed the safety and efficacy of OCS and other forms of anesthesia and lauded its “remarkable record of safety” under existing guidelines.
But, remember - regulators regulate.
Less than two years later, with no reported incidences of adult morbidity or mortality stemming from OCS, a committee of the ADA is pushing a dramatic revision of its guidelines, including a requirement to more than triple the number of continuing education hours necessary to administer the exact same safe and effective protocols that the House of Delegates praised in late 2005. Somewhere in my imagination, I hear the clatter of calculator keys adding up the additional hundreds of millions of dollars Americans stand to pay for such folly.
“If the ADA’s proposals are adopted and implemented by state dental boards, we estimate patients will be forced to pay at least $250 and as much as $750 more for the exact same OCS procedures and protocols they are already receiving,” says Dean Rotbart, a former columnist and investigative reporter for The Wall Street Journal, who serves as TEAM 1500’s director.
Editor’s Note: The Trust for Equal Access Medicine, or TEAM, is a non-profit coalition of more than 1,500 independent health-care providers who are dedicated to making quality medical and dental care available to all Americans. Visit on the Web at www.team1500.org.)
Rotbart argues that rather than serving patient safety first and foremost, the ADA’s efforts are directed more at protecting the economic interests of oral surgeons, dental anesthesiologists, and other specially trained practitioners who feel threatened by the growing popularity and use of oral sedation by general dentists and nonspecialists.
I don’t know if I agree with Rotbart’s attribution of motive; I believe the vast majority of those serving on the ADA’s committees and board are praiseworthy and operate in what they sincerely believe to be the public interest. That said, I have no doubt whatsoever that the ADA’s proposals are wrong for patients, wrong for dentists, and wrong for the many millions of Americans who already avoid the dentist.
Why? Because anything that unnecessarily inserts barriers between dental care and dental patients is a giant leap backward. Unnecessary regulations not only impose additional costs on dentists, which are then passed on to consumers, but in this instance harsher regulations are likely to drive patients away from oral health care altogether.
OCS dates back many decades. While not in wide use before 2000, dentists have long known that the best way to relieve the fear and anxiety of dental-phobic patients is to administer a mild oral sedative before and/or during their treatments. I have had a great deal to do with the increasing popularity of OCS since 2000, having helped train more than 7,500 dentists on proper OCS protocols and, in turn, proudly looking on as they have treated - safely and effectively - more than one million patients who previously avoided dental care due to their anxieties.
To me and my fellow cofounders of the Dental Organization for Conscious Sedation, or DOCS, the idea of refining oral sedation techniques and teaching them in an affordable, three-day course was a no-brainer. I, myself, treated more than 2,750 patients using OCS and found it amazingly effective and safe without exception.
DOCS courses thoroughly cover patient assessment (including which patients should not be treated with OCS), the pertinent pharmacology, techniques, and safety monitoring, and the psychology of fearful patients.
Our launch of DOCS came against the backdrop of the landmark report by Dr. David Satcher, then the U.S. Surgeon General, called “Oral Health in America.” Dr. Satcher detailed at length the calamity of adults and children in America who, despite advancements in dental technology, were left outside the system and suffered - emphasis on the word “suffered” - the consequences.
The Surgeon General challenged our profession to do better; to use innovation and inspiration to find ways to make oral health care more widely available. Of all the problems he mentioned in his report of more than 200 pages, Dr. Satcher never even hinted that our profession needed yet more regulation to solve the problem.
Those of us who were inspired by Dr. Satcher’s call for inclusion didn’t realize it at first, but using innovation to serve the unserved also revitalized our own practices. The true elegance of OCS is that it has greatly enriched the lives of the dentists who use it, along with the oral health and self-esteem of their patients. Generally, OCS patients have neglected their oral health for many years and require significant remediation. Because OCS removes the barrier of anxiety and fear, they are now actually thrilled to see the dentist, keep their appointments, and are wellsprings of referrals. Moreover, once safely and properly sedated, they are ideal patients: serene, responsive, and abundantly grateful.
Those dentists who’ve completed our three-day courses frequently report that they enjoy their work more than ever and, because of the nature of OCS patients, are actually earning significantly more than they were before they began offering oral sedation. Further, the higher the volume of patients these OCS dentists serve, the greater their flexibility to keep their fees in check.
But don’t think that oral sedation hasn’t gone a long way toward meeting Dr. Satcher’s challenge of expanding care to the neediest. It has. From inner-city neighborhoods to rural towns to nursing homes, OCS dentists provide anxiety-free treatment to those who most need it. One great example is Dr. Matthew Winkle, who works in a public health clinic that caters to the Siletz Indian tribe on the Oregon coast. “In this rural community, dental caries and periodontal disease are higher than the typical Unites States population. Many are also dental phobic to a paralyzing degree,” wrote Dr. Winkle to the ADA, asking it to forestall its passage of tougher OCS guidelines.
Those who establish guidelines at the ADA and the state dental board members who set regulations must be mindful that sometimes, more really is less. In the spirit of innovation that Dr. Satcher envisioned back in 2000, dentists have safely and effectively reached more than one million Americans who otherwise would not have been seen by any dentist - or not been seen until the only remaining choice was edentulism.
There are still roughly 89 million Americans who OCS has not yet rescued. But given the trend, OCS will ripple in larger and larger circles until it is one day available to all Americans. That is, unless its natural growth is stunted by unnecessary regulations.
