Is General Dentistry Dead?

[winnie bear]

A couple of years ago, one of the dentists whom I shadowed showed me an article on AGD Impact entitled, "Is General Dentistry Dead?" It talked about the possible fate of general dentists, stating that "Many fear that dentistry, the first specialty of medicine but also its historical outcast, is finally going the way of primary care medicine, poised to sink with a sigh into a mire of competing providers."

With hygienist and physician's assistant advocating groups actively lobbying for the right to perform more procedures, there seems to be concerns about increasing competition further saturating metropolitan areas and not necessarily resolving the issue of access to care as we would hope for with greater # of providers. This thought took a back seat for awhile until a professor/dentist at a school I interviewed at recently talked about something that made me start thinking about this again.

I learned that Dental therapists (DT) are trained to perform a number of procedures that historically a GP would do, and DTs could become the way of primary care in the near future. It was mentioned that one of the goals is to increase the # of DT's to provide care at rural areas to address the issue of access and affordability of dental care. Whether or not future DT's would follow through with providing care in rural areas is uncertain. If there isn't a formal way of enforcing this (like a contractual agreement), I would imagine, candidates will have to be assessed very carefully: Where do they currently live? Where do they want to live? What about the candidate suggest that they prefer a life in rural areas?

Between the opinions of the article, the dentist, the dental professor and among other sources, there appears to be a common query: with various groups of dental professionals (hygienists & dental therapists) on the rise to performing much of what GP's can do, with a decline in baby boomer population over time (and those who tend to need greater dental care), with improved education and prevention options, and with future generations becoming more knowledgeable and responsible in taking care of their oral health, are these professionals I've spoken with over the years predicting what is to come for the future of general dentists in the next several decades?

Will private practice for dentistry become the thing of the past as seen in medicine? Will the shift in the roles of hygienists, DTs, PAs, and nurses make generalists and family practice a rarity and having specialists a thing of the future? Is this necessarily a bad thing?

This may be controversial but I'm very interested in hearing what current and future dentists and all of SDN community have to say on this topic. I welcome all opinions biased or not. I would appreciate that we all be courteous and respect one another's opinions. Thank you for your time!

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[mike3kgt]

If there isn't formal a way of enforcing this (like a contractual agreement), I would imagine, candidates will have to be assessed very carefully. Where do they currently live? Where do they want to live? What about the candidate suggest that they prefer a life in rural areas?

I found it funny that when I was applying to dental schools that I saw on some document I had to submit to the school that Miami-Dade county (where the city of Miami is) is considered an underserved dental community.

So in theory, even if this regulation were enforced, these providers would still set up in metropolitan areas, probably in shopping malls next to Nordstroms... wait wait wait, underserved... let's be reasonable... Kohl's or TJ Maxx.

 

[Tooth Pulp]

ADA will regulate this, don't worry. Even if DT's do emerge, most will be supervised by Dentists. Dentistry isn't only about "drilling and filling" and the ADA recognizes this.

 

[thewobblytooth]

from what I understand, we've never really had an "equivalent" counterpart, so Dentistry is still probably one of the better protected fields out there. (in respect to medicine and others)

 

[dentalWorks]

Well, time to quit dental school I guess

 

[winnie bear]

Well, time to quit dental school I guess

Aw . My intentions weren't to dissuade anyone or shed any negativity. It's a topic that's come up over the years and I wanted to get folks' viewpoint, particularly those who have been in the profession who might've felt the changes (but really, anyone who wants to chime in). I didn't post it on the predents but I do have it as a link...I'll remove it in case it stresses ppl out especially during app time.

Occupations evolve and it is what it is. This may not necessarily be good or bad. I just wanted to start a dialogue to get more perspectives because people I respect seem to differ in their views quite a bit.

 

[7 Iron]

I'm only a D1, but I am not worried about the future of GP dentistry. About 90% of dental school grads become GPs and only the small remainder pursue a specialty. Obviously then the supply of dentists is not going down. We can definitely make it if we work hard enough. It's true that you have to stay up on recent advances and take continuing ed in order to stay competitive in the market, but remember as a GP you're able to perform any dentistry procedure that you feel comfortable doing.

You also mention a decline in the baby boomers. I beg to disagree. That encompasses 18 years of births, and there are millions and millions of boomers. They will need lots of care for their oral health, especially as they get older.

Future generations taking much better care of their oral health? You should see some of the mouths in clinic!

As for dental therapists, I think unfortunately those may start to become more widespread but it will take years. I do hope as other people have said, that the ADA works hard to limit them if they do become legal in more states. Most legislators have their eyes, for the time being, set squarely on medicine. Dentistry is an aspect of medicine but luckily for us we fly under the radar So be confident in your decision to pursue dentistry if it's what you want to do!

 

[drhobie7]

Wow, the way I see it there's never been a better time to be a GP. Restorative materials have never been better. Lab capabilities improve each year. You have the ability to make crowns in your office with CAD/CAM machines. Cosmetic dentistry was a shadow of what it is today 20 years ago. GPs are doing more specialty procedures than ever before. Look at what's happening to dental implants. I wouldn't be surprised if GPs did the overwhelming majority of dental implants in 5 years. I know of plenty of dentists who do a 1 year GPR or AEGD and come out doing their own sinus lifts and dental implants. I see more GPs doing molar endo now due to rotary and vertical filling (although I only learned lateral condensation in dental school). Then of course there's orthodontics, which is becoming more accessible to GPs each year with companies that will plan the case for you and use either bracket placement guides and prebent wires or snap on devices like invisalign. Just about the only specialty which doesn't appear to be done more by GPs is pediatric dentistry. Gonna need a huge technological advancement to help a GP deal with a screaming kid. The trend in medicine is for NPs and PAs to do the more mundane, simple tasks, and MDs to do more complicated patient care. I really don't see any evidence of this yet in dentistry. Even if it were to happen, I dont think it would be much of a problem. I don't think many GPs out there are excited about holding onto amalgam restorations. Disclaimer: I'm not a GP. Perhaps my perspective is unrealistic. (But I don't think so!)

 

[DrJeff]

Okay, lets talk about DT's (or whatever other of the acronyms they're referenced as ADHP's, DHAT's, etc ) Currently in the United States, there's about a quarter million dentists give or take. Currently in the United States, in training or under limited, study guided practice, there's less that 50 DT's. There are currently less than 10 states where from a legisaltive standpoint, either DT's legislation has been passed or is considered to be receiving ACTIVE legislative attention. DT programs (from development, to implementing, to regulatory control determination) cost $$. The overwhelming majority of states currently have a budget deficit. The overwhelming majority of states have been cutting their medicare dental programs to save money (especially for adults). Most DT's models ultimately rely on gov't funding to work, since the overhead for a DT "office" won't be that much different than for a private practice (a dental chair will still cost the same for a DT as for a private practice doc, same with a handpiece, a curing light, bonding agent, electricty, staff, etc, etc, etc). Gov't IS starting to realize that it's supply of $$ isn't limitless and the number of plans that they're funding to operate at a loss IS becoming a factor.

Now take a CRITICAL, not EMOTIONAL look at the data (just as we're supposed to do as clinicians)

The GP will be around and thriving for a LONG time to come!

 

[charlestweed]

ADA will regulate this, don't worry. Even if DT's do emerge, most will be supervised by Dentists. Dentistry isn't only about "drilling and filling" and the ADA recognizes this.

ADA allows more new dental schools to open and existing schools to expand their class size. In my opinion, this is much worse than allowing the DT’s to perform some dental procedures.

In order to survive, new grad dentists need to learn how keep the overhead as low as possible. There is no point of having the high tech equipments/instruments and have no patients to work on. I know plenty of GP’s who own small 2-3 chair offices in Southern California and do really well. With low overhead, they can charge their patients low fees and this helps increase the treatment acceptance from the patients.

 

[jay47]

ADA will regulate this, don't worry. Even if DT's do emerge, most will be supervised by Dentists. Dentistry isn't only about "drilling and filling" and the ADA recognizes this.

That is key- DT will be supervised by dentists. You won't be out of a job, but you may have more hassle. I don't understand how the ADA thinks that people going into a 2 year program can learn to effectively drill and fill teeth. It take us 1 year practicing on fake teeth to begin starting on patients, and still some people had a very difficult time with prepping teeth. Sure, 2 years later, they may be alright, but that is with a year of practice almost daily prepping fake teeth. Let's face it, if people go into a 2 year program, they are going to have to learn to work on people very quickly, and the quality of work they will perform will not be up to par (although there are some pretty crappy dentists out there too- I've seen some stuff that should make people lose their licenses.

 

[dentalWorks]

That is key- DT will be supervised by dentists. You won't be out of a job, but you may have more hassle. I don't understand how the ADA thinks that people going into a 2 year program can learn to effectively drill and fill teeth. It take us 1 year practicing on fake teeth to begin starting on patients, and still some people had a very difficult time with prepping teeth. Sure, 2 years later, they may be alright, but that is with a year of practice almost daily prepping fake teeth. Let's face it, if people go into a 2 year program, they are going to have to learn to work on people very quickly, and the quality of work they will perform will not be up to par (although there are some pretty crappy dentists out there too- I've seen some stuff that should make people lose their licenses.

ADA.....doesn't think that, and from what I remember, ADA has always been not-so favorable of this whole mid-level provider business

 

[DrJeff]

ADA.....doesn't think that, and from what I remember, ADA has always been not-so favorable of this whole mid-level provider business

Correct. The ADA has been, and still is against a mid-level provider. Feeling that the patient deserves treatment by a dentist.

The push for a mid-level has come from a combination of legislators being pushed by "patient advocacy groups" (then again one can ask them the question if they've ever actually asked the folks their apparently advocating for if THEY want to be treated by a "second tier" provider or a dentist - answer - they haven't). Groups such a Kellog and Pew who tend to fund many of these studies when looked at closely, aren't exactly the most impartial of groups (remember who with a research paper one of the 1st things yu should do is not look at the results, but look at who is funding the research in the 1st place to see if from the start the potential for bias exists).

Additionally on the legislative front, if you ever have the chance to talk with one of your elected officials about this (and I would encourage you to, since they like to listen) is that what dentistry needs to do is not get into the whole "access to care" issue, but the UTILIZATION of care discussion. Access to care in theory would provide access to 100% of people. However, the reality is that even with *cough*free*cough* care the UTILIZATION rate is at best about 60%. The reality is that unless your talking a military style system where going to the dentist is mandatory, there is a very significant portion of the populaton that will not seek out dental care (unless its an EXTREME emergency situation) no matter what. There is plenty of dentists available to handle to demands of the populatin with its current utilizaton rates. Trying to develop a system for 100% access will just end up wasting dollars on that significant population that won't seek care. If those dollars are directed at existing providers to make the reimbursement rates FAIR, that will have a much greater impact on access. The bottomline is that the overhead for a mid level won't be any less than that for a dentist, and if a midlevel is getting the same rates for a procedure as a dentist is (and one would sumise that would be the case since in the medical world a nurse practitioner gets the same reimbursement for suturing up a laceration as an MD/DO does) then they'll have te same problems meeting overhead as a dentist would. The key is that dentistry, when talking about this issue needs to stick to the objective data, which can be tough when the opposing side tends to have mor emtoional "data" than objective data

 

[yappy]

DrJeff, you speak the truth. At a free dental clinic I volunteer at we ran stats for last quarter and had ~35% no show. Many of these patients are also recurrent: they receive care and good home instructions + materials, yet still let their mouths go and come back with more severe problems when they have pain.

I like your idea of utilization. If patients had as much pride for their oral health as they did their I-phones much less people would go years without seeing a dentist and as a result be healthier and in the end have to pay out less.

I guess what I'm saying is it's poor judgement to execute an aggressive access to care action when the population you're trying to serve doesnt care enough to come and get it for free. A poster on here showed an article that stated 50% of the population doesnt see the dentist. I wonder what percent of this 50% can afford care yet doesnt value dental care enough to pay. If they dont care why should anyone else?

EDIT: OP: I'm not a dentist but I have shadowed some newer grads who have recently opened up general practices. They seem to be doing good. In fact one got on the "fastest growing business" section of our cities paper. My home town is not NY or CA. It also isn't fly over country. So it seems that some are making it work.

Dental Works: Dont quit. Hang tough!

 

[DrJeff]

DrJeff, you speak the truth. At a free dental clinic I volunteer at we ran stats for last quarter and had ~35% no show. Many of these patients are also recurrent: they receive care and good home instructions + materials, yet still let their mouths go and come back with more severe problems when they have pain.

I like your idea of utilization. If patients had as much pride for their oral health as they did their I-phones much less people would go years without seeing a dentist and as a result be healthier and in the end have to pay out less.

I guess what I'm saying is it's poor judgement to execute an aggressive access to care action when the population you're trying to serve doesnt care enough to come and get it for free. A poster on here showed an article that stated 50% of the population doesnt see the dentist. I wonder what percent of this 50% can afford care yet doesnt value dental care enough to pay. If they dont care why should anyone else?

EDIT: OP: I'm not a dentist but I have shadowed some newer grads who have recently opened up general practices. They seem to be doing good. In fact one got on the "fastest growing business" section of our cities paper. My home town is not NY or CA. It also isn't fly over country. So it seems that some are making it work.

Dental Works: Dont quit. Hang tough!

The other factor that really is starting to annoy me about advocacy groups for the "underserved" with respect to dentistry, is the notion that they need to aggressively go out of their way to try and find ways to get the "underserved" there for their *cough*free*cough* care. Please, give me a break! If you were to tell this exact same population that they needed to get somewhere at a specific time for say a free iphone, they'd all be at that place at that time, no matter what it took to get there!(and I think we all know that that's a true statement). Why then are we making extra efforts (at a cost which effects the amount of limited $$ available to those that are making the effort to get to the office for treatment) for those that don't want care?? This sector of the population might be econimically challenged, but generally speaking they're not physically disabled. So why are we in general almost looking at that sector as a whole like their physically disabled and have to provide everything for them to get their *cough*free*cough* care?? Isn't the offer of *cough*free*cough* care enough of a motivation??

 

[mike3kgt]

ADA will regulate this, don't worry. Even if DT's do emerge, most will be supervised by Dentists. Dentistry isn't only about "drilling and filling" and the ADA recognizes this.

The ADA is trying but the politicians have their heads up their re-election butts and look for easy solutions, which in this case, is to promote a second tier provider which doesn't cost much, is easy to "pen start" for politicians, and allows themselves to promote "helping access to care when the wealthy dentists only care about $$"

The problem will come when there are enough of these providers to form an organization to promote the "growth of the profession of dental therapy" and I guarantee you that one of these goals will be private, independent practice along with expanded functions beyond what the original legislation provides.

Take the ADHA's example as what I mean:
http://www.adha.org/news/10262011-clinic.htm
http://www.adha.org/media/releases/archives/2004/070804_adhp.htm

Then when they form their national organization, they'll form a PAC and use "access to care" as reason to promote their agendas.

Sounds great doesn't it?

 

[peg lateral]

The other factor that really is starting to annoy me about advocacy groups for the "underserved" with respect to dentistry, is the notion that they need to aggressively go out of their way to try and find ways to get the "underserved" there for their *cough*free*cough* care. Please, give me a break! If you were to tell this exact same population that they needed to get somewhere at a specific time for say a free iphone, they'd all be at that place at that time, no matter what it took to get there!(and I think we all know that that's a true statement). Why then are we making extra efforts (at a cost which effects the amount of limited $$ available to those that are making the effort to get to the office for treatment) for those that don't want care?? This sector of the population might be econimically challenged, but generally speaking they're not physically disabled. So why are we in general almost looking at that sector as a whole like their physically disabled and have to provide everything for them to get their *cough*free*cough* care?? Isn't the offer of *cough*free*cough* care enough of a motivation??

 

[beannaithe]

I think if DT do emerge they will be poorly received by the public. As a newer dentist with a GPR under my belt, I've found many patients are a little apprehensive about being worked on by a new person. Even as a doctor, there's a perception that I know nothing. Could you imagine how bad it would be for a DT with only 2 years of training straight out of high school? Most people would steer clear of DTs, thinking they are not trained enough to treat people.

Plus, the country runs into the problem of setting up DT clinics in under served areas. There could be a lot of questions about why under served populations don't get a qualified doctor, instead a partially trained person who does the work of a doctor without the degree. Talk about a PR nightmare.

 

[winnie bear]

Thanks everyone for your valuable comments! I wanted to share my own personal experience to add a little balance to those of yappy and DrJeff. Note that my experience isn't any more valid than anyone else's here; it's just another another experience.

I've serendipidously stumbled across different opporutnities to observe, volunteer, and assist at different clinics both private and nonprofit. I got to work with people who were recovering from substance abuse, people with disability, predominantly immigrant patient pool, children, low income and middle/upper class patient pools.

One doctor a while back told me that the reason why many private clinics don't accept DSHS (state dental coverage when it was available before the policy change) because of a number of reason that posed more of a hassle than anyone was willing to deal with. One of the reasons was the turnout ratio because patients under DSHS versus private insurance. This doctor still made sure at least 30% of the patients he saw at his clinic were DSHS. He also volunteers at the recovery center regularly. At this clinic, most everyone was so happy to be alive that they are often very grateful and appreciative towards all the volunteers. I remember when one of the patients who was so happy to be alive thanked one of the volunteers, the doctor responded, "I'm just God's humble servant". This has very little relevance to what we're talking about here but it was the kind of atmosphere that differed from my experience at the private clinics (which had their own unique great qualities but just different).

Then, when I began working at the center for people with disabilities, I realized that most are at the mercy of their caretaker to provide basic care that when they come with a less than ideal oral condition, reminding their caretakers the importance of preventative care is all we can do. But the caretakers would often have a number of patients under their supervision so I can see how this can be hard for them as well.

At one nonprofit clinic in which over 70% were DSHS. Here, I got to answer phones to schedule and reschedule appointments. And you're right, there were some cancellations. I also talked to parents of patients and heard their stories. One lady from Russia who moved here with her autistic son (just the two of them) talked to me about how difficult it is to pull her son out of school to visit the dentist (he has to come in regularly for his treatment). She takes 2 buses and it takes roughly about 2 hours each way that the days she has to bring her son to the clinic, he has to miss the entire day of school. The teachers were concerned about the number of days missed so she expressed her concern through her limited English to me.

I learn from talking to patients in person and over the phone, a lot of the times, the reasons for missed appointments are probably the same reason why I would miss an appointment (and I rarely miss appts). Luckily, those with experience working with the underserved understand and empathized with the patients and continue to provide their time and patience in dealing with the different surrounding circumstances of each person's lives.

I'm sure like DrJeff and yappy said, there are many who have different priorities. It hard to say what the general attitude is life for the majority who fall in the underserved category because each person's life is so very different. But as long as there are those people I met who work hard, live hard, appreciative (or even if they're not), I think it's necessary to have people continuously think of ways to help somehow.

Don't get me wrong, I've rarely volunteered before deciding to pursue dentistry. And I don't claim to be either all that altruistic or philanthropic. I'm no different than the gal next door. It wasn't until I started meet these people did I start thinking about how cool people really are and how different people's lives are.

 

[mike3kgt]

I'm sure like DrJeff and yappy said, there are many who have different priorities. It hard to say what the general attitude is life for the majority who fall in the underserved category because each person's life is so very different. But as long as there are those people I met who work hard, live hard, appreciative (or even if they're not), I think it's necessary to have people continuously think of ways to help somehow.

Don't get me wrong, I've rarely volunteered before deciding to pursue dentistry. And I don't claim to be either all that altruistic or philanthropic. I'm no different than the gal next door. It wasn't until I started meet these people did I start thinking about how cool people really are and how different people's lives are.

What you will also find is that those who pay nothing are the worst patients by far. They act spoiled, entitled, and will delay everything until it's a serious problem (including showing up late and no-showing).

Those that pay a % of their treatment, albeit a small %, tend to appreciate what they are having done, they take ownership, show up on time, and are incredibly nice people.

I practiced in a CHC for about 15 years, sliding fee scale, 1/3 state/federal funding, 1/3 grants, 1/3 patient payment. I treated line-cooks, fishermen (I was coastal), and workers and they were sweet, kind, and appreciative. One of the best experiences of my short career...

I also practiced in a medicaid office for about 8 months, they paid nothing, occasionally they paid $3.00 in co-pay. I treated very poor people but I also treated those who were well-off and on medicaid because they had a baby, or had a spouse that was disabled. Many drove up in beat up cars, some drove up in Land Rovers. Some were appreciative, most were entitled, curt, and rude. One of the worst experiences of my short career...

 

[winnie bear]

What you will also find is that those who pay nothing are the worst patients by far. They act spoiled, entitled, and will delay everything until it's a serious problem (including showing up late and no-showing).

Those that pay a % of their treatment, albeit a small %, tend to appreciate what they are having done, they take ownership, show up on time, and are incredibly nice people.

I agree that when services are given out for free, there will be those who take it for granted. As much as I despise hearing people act like the world owes them something, we probably have been guilty of self-entitlement at one point in our lives to some degree. I really think people don't know any better when they neglect to take care of themselves. But there are those who are lucky to have been educated about it and do their best to not take it for granted. I just hope that the flat out self-entitled, ungrateful individuals don't ruin it for the rest who are doing the best they can.