Pediatricians "trained in oral health"??

[S Files]

curious to hear what pediatric dentists / residents think about this push for pediatricians "trained in oral health" to perform oral exams, apply fluoride varnishes, etc....


Call for Applications: Oral Health
From: Wendy Nelson, Manager, Oral Health Initiatives ([email protected])

In its efforts to encourage an understanding of the role pediatricians can play in providing oral health assessments for young children, the AAP Oral Health Initiative is once again offering the Oral Health Risk Assessment Preceptorship program. This year eighteen awards will be given; ten for American Indian/Alaska Native (AI/AN) populations, 3 for migrant populations, and 5 for other underserved populations.



The program provides mentorship support to pediatricians (or sites linked to a pediatrician) interested in implementing oral health assessments and varnish application in their practice. These awards are designed to provide the recipient with individualized one-on-one training in performing oral health risk assessments, maternal/caretaker oral assessment interviews, and the application of fluoride varnishes by a pediatric dentist or pediatrician with oral health training.



Because of the increased number of awards, they will be awarded in two phases. Phase I: AI/AN sites with applications due date of March 9th and Phase II: Migrant and other underserved populations with application due later in the spring (the RFP and application for these awards will be sent out late March).



This Request for Proposal and Application is specifically for American Indian/Alaska Native sites.



If you have any questions, feel free to contact Wendy Nelson at 800/433-9016 ext. 7789 or by e-mail at [email protected].



Holly Noteboom
CATCH Program Coordinator
American Academy of Pediatrics
Department of Community, Chapter & State Affairs

141 Northwest Point Blvd
Elk Grove Village, IL 60007
847/434-4916 (p)
847/434-8000 (f)
[email protected]
www.aap.org/catch

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[Jaybe]

curious to hear what pediatric dentists / residents think about this push for pediatricians "trained in oral health" to perform oral exams, apply fluoride varnishes, etc....


Call for Applications: Oral Health
From: Wendy Nelson, Manager, Oral Health Initiatives ([email protected])

In its efforts to encourage an understanding of the role pediatricians can play in providing oral health assessments for young children, the AAP Oral Health Initiative is once again offering the Oral Health Risk Assessment Preceptorship program. This year eighteen awards will be given; ten for American Indian/Alaska Native (AI/AN) populations, 3 for migrant populations, and 5 for other underserved populations.



The program provides mentorship support to pediatricians (or sites linked to a pediatrician) interested in implementing oral health assessments and varnish application in their practice. These awards are designed to provide the recipient with individualized one-on-one training in performing oral health risk assessments, maternal/caretaker oral assessment interviews, and the application of fluoride varnishes by a pediatric dentist or pediatrician with oral health training.



Because of the increased number of awards, they will be awarded in two phases. Phase I: AI/AN sites with applications due date of March 9th and Phase II: Migrant and other underserved populations with application due later in the spring (the RFP and application for these awards will be sent out late March).



This Request for Proposal and Application is specifically for American Indian/Alaska Native sites.



If you have any questions, feel free to contact Wendy Nelson at 800/433-9016 ext. 7789 or by e-mail at [email protected].



Holly Noteboom
CATCH Program Coordinator
American Academy of Pediatrics
Department of Community, Chapter & State Affairs

141 Northwest Point Blvd
Elk Grove Village, IL 60007
847/434-4916 (p)
847/434-8000 (f)
[email protected]
www.aap.org/catch

They should have every right to include these dental procedures in their scope of practice as Pediatricians . . . As long as they have a Dental degree from an ADA accredited dental school, pass Part 1 and 2 of the NDBE, pass the necessary regional/national licensure exam, and obtain a valid dental license from their state board of dentistry.

Ohhhh, turf wars can be a B*tch!!!

 

[capisce?]

They should have every right to include these dental procedures in their scope of practice as Pediatricians . . . As long as they have a Dental degree from an ADA accredited dental school, pass Part 1 and 2 of the NDBE, pass the necessary regional/national licensure exam, and obtain a valid dental license from their state board of dentistry.

Ohhhh, turf wars can be a B*tch!!!

Wrong. Painting on a little fluoride varnish is hardly a 'dental procedure'.

I think it's great. It's a known fact that while many parents do not regularly see their dentists, they will see a pediatrician for immunizations and well-checks. The problem is that many people are ignorant regarding oral health, both patients and pediatricians. Educating parents from the start is a very important step towards improving the oral healhcare of a large part of our population that just doesn't get that exposure. Educating pediatricians to recognize decay earlier and discuss implications with the parents is an important bridge between the dental and medical community. After all, we shouldn't look at this as a 'turf warf' or financially, since it's the welfare of children that is the common goal at stake. Trust me, I work with physicians all day...they want nothing to do with the mouth.

There is no turf war here. No one is asking them to prep or do anything other than wipe the teeth down and paint on some duraphat. It's not going to decrease the amount of work out there, let's not go overboard. It's a simple preventative measure that can go a long way. I think it's great and fully support it as a future pediatric dentist.

 

[dentalman]

This is what is best for kids. Pediatricians have a better chance of seeing high-risk children than the dentist (because it may not even be on the parents radar). If the pediatrician can educate them, then that could prevent a trip to the OR, or losing all of their primary teeth at age 3. My only hope is that parents will listen.

 

[Jaybe]

Wrong. Painting on a little fluoride varnish is hardly a 'dental procedure'.

Really. So you don't think that regulatory boards would have a problem with the general public obtaining and placing fluoride varnish? What about a unlicensed dentist placing Fluoride varnish? You think the dental board in your state would be cool with that???

Actually, placing Fluoride varnish IS a dental procedure. A relatively non-invasive one, yes. But still a dental procedure.

I never said it would be bad for kids to get oral exams and Fluoride varnish placed. However, I think the clinicians who should be engaging in this practice are the ones with the correct education and scope of practice. Dentists, to be specific.

 

[capisce?]

Really. So you don't think that regulatory boards would have a problem with the general public obtaining and placing fluoride varnish? What about a unlicensed dentist placing Fluoride varnish? You think the dental board in your state would be cool with that???

Who said anything about the general public. You took my statement out of context. Since it obviously went above your head, the phrase "hardly a dental procedure" referred to the fact that it takes little outside dental training/knowledge to understand and physically apply varnish. That's a big jump to equate pediatricians to the general public and you knew what I was inferring. The fact that you had to make such a ridiculous analogy shows you are arguing for the mere purpose of arguing. This thread is about MDs placing varnish. Good work equating unlicensed dentists and the general public to physicians with their MDs, sport

Yes, I know my state's dental board is cool with fluoride varnish application by pediatricians because it's already been done. http://aapnews.aappublications.org/cgi/content/full/20/5/212

From article: The oral screening training program for health care providers consists of a review of clinical studies, including the efficacy of fluoride varnish, and review of application procedures. Participants also receive an oral health toolkit, which includes parent/caregiver education materials, supplies for 10 screenings and information on ordering additional supplies, demonstrations on fluoride varnish procedures, and information on filing Medicaid claims. Medicaid has agreed that a child can receive up to six fluoride varnish treatments before the age of 3 years with reimbursement at $43 for the initial screen and $35 for periodic screenings thereafter.

More than 250 North Carolina pediatricians are participating in the program, which provides 1.5 hours of American Medical Association category I continuing medical education credit. Some participants also receive onsite technical assistance.

However, I think the clinicians who should be engaging in this practice are the ones with the correct education and scope of practice. Dentists, to be specific.

How much education does it take to place fluoride varnish? Are you kidding me The answer is in the quote from the article above. You don't think MDs have the proper education to place it? LMAO! Not much is necessarily in the way of dental knowledge to place varnish. Things to know:

1. Fluoride application is proven to increase caries resistance
2. It's a risk for children to ingest F- and the amounts depend on age
3. To place varnish, dry teeth and cover all possible tooth surfaces
4. Provide parents with proper POI

With the exception of how to apply varnish, these are things MDs are taught in medical school. It's laughable for you to say that MDs are not qualified to place a topical varnish because they lack the education. It takes minimal outside information to allow them to properly evaluate and place F-. Using the same argument, you probably would say they are not qualified to discuss oral healthcare to parents either since they're not qualified.

Your arguments are a joke. It's a good thing those writing the laws aren't as shortsighted as you are.

Thank you, please drive through.

 

[docj1]

Will the pediatrician take BWX to rule out interproximal decay? Placing fl varnish is a good thing, but when mom leaves the pediatricians office has her child had a complete dental exam or a dental screening.

What would happen if a dentist placed a sealant on a tooth with interproximal decay? I believe that we should treat our patients with the best care possible. Most pediatricians are excellent at their job, but doing a preventive procedure on a patient who requires treatment is nonsense, and if you do not have radiographs than you are guessing.

 

[docj1]

Jaybe,

You are correct.

 

[capisce?]

Will the pediatrician take BWX to rule out interproximal decay? Placing fl varnish is a good thing, but when mom leaves the pediatricians office has her child had a complete dental exam or a dental screening.

What would happen if a dentist placed a sealant on a tooth with interproximal decay? I believe that we should treat our patients with the best care possible. Most pediatricians are excellent at their job, but doing a preventive procedure on a patient who requires treatment is nonsense, and if you do not have radiographs than you are guessing.

What are you talking about? Equating placing a sealant over decay and varnish on tooth structures is not comparable. Placing varnish on a healthy tooth makes it more resistant to decay. In cases where it's placed on incipient decay, it will allow remineralization. If a pediatrician were to place it over a carious tooth, it wouldn't do anything to mask the caries, as would your example of the sealant. In any case, you might be surprised to learnt there is research that supports sealing over small decay and removing the nutrient source. It's not something we do, but it exists. Also, what you said happens all the time in states with school sealant programs where the people placing the sealants are not dentists and they do not have an exam beforehand. It happens right here in Ohio.

No one said they were getting a complete exam. No one said the MD has to 'take a film to rule out decay' because the issue isn't about them providing a complete oral exam. No one is asking them to look in the mouth and tell the parents they are okay for 6 months. I'd like to know where you assume this from? Was the title of this thread "Pediatricians to Give Complete Oral Exam and Advertise as a Dentist?". No.

It's a simple preventative measure and oral instruction is something that goes along with it. They won't leave with a complete dental exam, but they may leave with a greater understanding of why one is important. That is invaluable. Most parents don't know to see their dentist when the first teeth come in, but they do know to see their pediatrician. This is a great place to start the dental knowledge churning in the parents mind.

For those of you arguing, answer me this: how is this any different than us prescribing prevident 5000 or a fluoride rinse, or fluoride tablets. Don't answer that it's okay because we as prescribers are dentists. The argument has been made that MDs don't have the knowledge to place varnish (laughable, I know). But then we can entrust parents (most of whom aren't the brightest) to administer high F products such as those listed even then they have absolutely no knowledge on the subject?

Those of you who say otherwise are either ignorant, have an unfounded fear of our medical counterparts wanting to do our job, or haven't seen enough kids with decay and ignorant parents to understand the reality of it. I'm still waiting for a valid reason why this shouldn't be allowed. Hopefully someone can come up with a reason or analogy that isn't assinine.

 

[Cyclysm]

What are you talking about? Equating placing a sealant over decay and varnish on tooth structures is not comparable. Placing varnish on a healthy tooth makes it more resistant to decay. In cases where it's placed on incipient decay, it will allow remineralization. If a pediatrician were to place it over a carious tooth, it wouldn't do anything to mask the caries, as would your example of the sealant. In any case, you might be surprised to learnt there is research that supports sealing over small decay and removing the nutrient source. It's not something we do, but it exists. Also, what you said happens all the time in states with school sealant programs where the people placing the sealants are not dentists and they do not have an exam beforehand. It happens right here in Ohio.

No one said they were getting a complete exam. No one said the MD has to 'take a film to rule out decay' because the issue isn't about them providing a complete oral exam. No one is asking them to look in the mouth and tell the parents they are okay for 6 months. I'd like to know where you assume this from? Was the title of this thread "Pediatricians to Give Complete Oral Exam and Advertise as a Dentist?". No.

It's a simple preventative measure and oral instruction is something that goes along with it. They won't leave with a complete dental exam, but they may leave with a greater understanding of why one is important. That is invaluable. Most parents don't know to see their dentist when the first teeth come in, but they do know to see their pediatrician. This is a great place to start the dental knowledge churning in the parents mind.

For those of you arguing, answer me this: how is this any different than us prescribing prevident 5000 or a fluoride rinse, or fluoride tablets. Don't answer that it's okay because we as prescribers are dentists. The argument has been made that MDs don't have the knowledge to place varnish (laughable, I know). But then we can entrust parents (most of whom aren't the brightest) to administer high F products such as those listed even then they have absolutely no knowledge on the subject?

Those of you who say otherwise are either ignorant, have an unfounded fear of our medical counterparts wanting to do our job, or haven't seen enough kids with decay and ignorant parents to understand the reality of it. I'm still waiting for a valid reason why this shouldn't be allowed. Hopefully someone can come up with a reason or analogy that isn't assinine.

i totally agree with what you are saying in all of your posts. anything that can give a child the chance to live a decay free life is a good thing. an MD should be qualified to apply varnish. there should be no turf wars in this field because of what is at stake, and i think that all pediatric dentists would probably agree.

 

[docj1]

I agree that anything to help children live decay free is a good thing. As long as the parents are told by the pediatrician that this is not a complete dental exam and that their childs teeth may have decay which they can not see clinically.

 

[IndianaOD]

I agree that anything to help children live decay free is a good thing. As long as the parents are told by the pediatrician that this is not a complete dental exam and that their childs teeth may have decay which they can not see clinically.

It will be construed my many parents as a dental check-up. Just like when the Ped takes a 2 second look at the infants red eye reflex or the kid can read an eye chart with both eyes open. We have research that shows that over 1/3 of eye problems are missed in this manner. My project is giving mother's surveys and the #1 reason for not bringing their kids in for a full eye exam is because of the "screenings" they receive. Patient education will be key.

 

[capisce?]

I think there is a misconception that we will 'lose patients' by having this. It's important to realize that people are either going to go to a dentist, or they aren't.

The type of parents that understand the need to visit a dentist while their children are young aren't going to be affected by this service. Sure, they will be getting F- applications but they will still go to their dentist because they value the service.

This thing is aimed at Medicaid patients. These aren't the ones who are visiting dentists, so it can have nothing but upside. So big deal if they don't seek out a dentist when they wouldn't before, at least now they are getting education and fluoride varnish at 6 months. That's better then them not going to a dentist and receiving nothing. For those worried about losing patients, fear not because I am sure 99% of you will not be accepting children on medicaid. This is targeting that 25% of the kids that have over 80% of the decay.

I understand to a degree where the people who oppose it are coming from, because in dental school at home in NC I too thought it was a bad idea. It took me some time treating children on medicaid and really understanding the importance of this to realize it is a good thing.

What should be of more concern is that death in DC because there was a huge article about legislative reform in the post today in dentistry. That child died in the worst city politically, Wash DC.

 

[Jaybe]

Who said anything about the general public. You took my statement out of context. Since it obviously went above your head, the phrase "hardly a dental procedure" referred to the fact that it takes little outside dental training/knowledge to understand and physically apply varnish. That's a big jump to equate pediatricians to the general public and you knew what I was inferring. The fact that you had to make such a ridiculous analogy shows you are arguing for the mere purpose of arguing. This thread is about MDs placing varnish. Good work equating unlicensed dentists and the general public to physicians with their MDs, sport

Yes, I know my state's dental board is cool with fluoride varnish application by pediatricians because it's already been done. http://aapnews.aappublications.org/cgi/content/full/20/5/212





How much education does it take to place fluoride varnish? Are you kidding me The answer is in the quote from the article above. You don't think MDs have the proper education to place it? LMAO! Not much is necessarily in the way of dental knowledge to place varnish. Things to know:

1. Fluoride application is proven to increase caries resistance
2. It's a risk for children to ingest F- and the amounts depend on age
3. To place varnish, dry teeth and cover all possible tooth surfaces
4. Provide parents with proper POI

With the exception of how to apply varnish, these are things MDs are taught in medical school. It's laughable for you to say that MDs are not qualified to place a topical varnish because they lack the education. It takes minimal outside information to allow them to properly evaluate and place F-. Using the same argument, you probably would say they are not qualified to discuss oral healthcare to parents either since they're not qualified.

Your arguments are a joke. It's a good thing those writing the laws aren't as shortsighted as you are.

Thank you, please drive through.

Although I appreciate your vitriolic reaction to my disagreement regarding the policy of allowing MD Pediatricians to make dental judgements and conduct noninvasive dental treatments, I must hold my ground on this one. And it won't be hard because I don't have to make elaborate arguments to do so.

I did illustrate an absurd conclusion that could be directly obtained using your statement that "Painting on a little fluoride varnish is hardly a 'dental procedure'. That was merely to demonstrate your failure to make a logical argument that:
1) MD's are educated to make dental diagnosis, treatment plans, and conduct dental treatment. Note it is irrelevant here how invasive or noninvasive the treatment is. It is also irrelevant how much education it takes to know how to place varnish. Also, please realize that the AAP (American Academy of Pediatricians) is outside their jurisdiction if and when they adopt their own policy on what makes a Pediatrician qualified to conduct dental exams and place fluoride varnish. This is akin to the AAO (American Association of Orthodontists) adopting a policy that after attending some workshop, Orthodontists will be considered qualified to set broken arms in their practice. These organizations do not have the authority to make such determinations.

and 2) That the dental judgment and practice falls within the scope of practice of a Pediatrician and under the purview of Medical Licensing Boards.

Just because MD's are smart enough and well educated in their own right, doesn't mean they are qualified or licensed to conduct dental diagnoses/procedures (even noninvasive procedures).

 

[Jaybe]

Jaybe,

You are correct.

docj1, yoiu are also correct.

 

[aphistis]

Civility, please.

 

[Jaybe]

Civility, please.

She hit me first. . .

 

[OceanBlue]

She hit me first. . .

yeah...but you sorta poked her in the eyes!

 

[capisce?]

1) MD's are educated to make dental diagnosis, treatment plans, and conduct dental treatment. Note it is irrelevant here how invasive or noninvasive the treatment is. It is also irrelevant how much education it takes to know how to place varnish.

Parent's aren't either, so I guess using that reasoning they shouldn't be allowed to brush or administer prevident/act rinses.

You are spitting the same, unfounded argument over and over. I'm still waiting for you to post an original thought.

Please tell me what diagnosis, treatment planning etc is truly necessary in order to place fluoride varnish for optimum treatment. In what scenario is placing varnish detrimental to the teeth? Parents don't treatment plan but they still brush their kids teeth with a F- containing toothpaste. Heavens forbid, since they haven't had formal training with the modified bass technique. Again, give me a scenario where placing varnish without a full oral exam is harmful to the children. Ingesting isn't valid, since that same risk is there with OTC dentrifice.

Your arguments and purely semantics and I apologize for wanting improvement in the oral health of our country's children.

Please enlighten us: Fill in the blanks:

Pros:

1. Increased education for parents and caregivers regarding their child's oral healthcare. The pediatricians will get training on how to educate the parents.

2. Exposure to F- for children who otherwise may not make it to a dentist until they are 6. This is self explanatory.

3. Increased awareness of the importance of good oral hygiene from our medical counterparts. This is fact because as the article pointed out, they will be spending time training for this.

4. The ability to recognize decay earlier by pediatricians since they will be spending more time examining the oral cavity. This too is fact because as the article pointed out, they will be spending time training for this.

Cons:

1.

2.

3.


I can't think of any. All you have done is make a weak argument about why MDs lack the capability to place it. I'd like to know the real reasoning behind your issue with this program. For example, saying that "children will no longer see their dentist because they will think they just did" is not valid because it is baseless and purely speculative. I'd like something with evidence behind it.

Everyone always whines about how physicians look at us as a completely different field from them, when in reality we as dentists or dental students realize that in really we are just a subspecialty of medicine as is urology or anything else. Your insistence on saying MDs aren't qualified to place duraflor just validates the former.

I'll repeat it again since you can't seem to grasp it. Your argument has focused on why MDs aren't qualified to place it. What harm can this cause to the health of the child? After all, this is why we are doing it.

Until you do so, this is no longer entertaining because you are recycling the same tired ideas so I'm done.

 

[capisce?]

yeah...but you sorta poked her in the eyes!

Go give Dr. Paquette a squeeze on the tush for me.

 

[Jaybe]

Let me congratulate you on your continued spiteful antics here.

Menses anyone???

To respond to your continued rant, I am merely concerned that Standard of Care be observed in the delivery of dental care. You have claimed that the Pediatricians will mostly be doing this for Medicaid Patients, so dentists shouldn't be worried about losing patients. This isn't even my point. I am merely concerned that the MD will not be able to provide dental care to the Standard of Care, due to the fact that he is not so educated and licensed.

What bothers me about your argument, is that you are insinuating that a Lesser Standard of Care should be acceptable for these Medicaid Patients. I don't agree. Its one Standard of Care = Care By Licensed Dentists, regardless of how poor you are.

Okay, now you can wind up and Scream some more.

Parent's aren't either, so I guess using that reasoning they shouldn't be allowed to brush or administer prevident/act rinses.

You are spitting the same, unfounded argument over and over. I'm still waiting for you to post an original thought.

Please tell me what diagnosis, treatment planning etc is truly necessary in order to place fluoride varnish for optimum treatment. In what scenario is placing varnish detrimental to the teeth? Parents don't treatment plan but they still brush their kids teeth with a F- containing toothpaste. Heavens forbid, since they haven't had formal training with the modified bass technique. Again, give me a scenario where placing varnish without a full oral exam is harmful to the children. Ingesting isn't valid, since that same risk is there with OTC dentrifice.

Your arguments and purely semantics and I apologize for wanting improvement in the oral health of our country's children.

Please enlighten us: Fill in the blanks:

Pros:

1. Increased education for parents and caregivers regarding their child's oral healthcare. The pediatricians will get training on how to educate the parents.

2. Exposure to F- for children who otherwise may not make it to a dentist until they are 6. This is self explanatory.

3. Increased awareness of the importance of good oral hygiene from our medical counterparts. This is fact because as the article pointed out, they will be spending time training for this.

4. The ability to recognize decay earlier by pediatricians since they will be spending more time examining the oral cavity. This too is fact because as the article pointed out, they will be spending time training for this.

Cons:

1.

2.

3.


I can't think of any. All you have done is make a weak argument about why MDs lack the capability to place it. I'd like to know the real reasoning behind your issue with this program. For example, saying that "children will no longer see their dentist because they will think they just did" is not valid because it is baseless and purely speculative. I'd like something with an actual reasoning behind it.

Everyone always whines about how physicians look at us as a completely different field from them, when in reality we as dentists or dental students realize that in really we are just a subspecialty of medicine as is urology or anything else. Your insistence on saying MDs aren't qualified to place duraflor just validates the former.

I'll repeat it again since you can't seem to grasp it. Your argument has focused on why MDs aren't qualified to place it. What harm can this cause to the health of the child? After all, this is why we are doing it.

 

[dentalman]

Although I appreciate your vitriolic reaction to my disagreement regarding the policy of allowing MD Pediatricians to make dental judgements and conduct noninvasive dental treatments, I must hold my ground on this one. And it won't be hard because I don't have to make elaborate arguments to do so.

I did illustrate an absurd conclusion that could be directly obtained using your statement that "Painting on a little fluoride varnish is hardly a 'dental procedure'. That was merely to demonstrate your failure to make a logical argument that:
1) MD's are educated to make dental diagnosis, treatment plans, and conduct dental treatment. Note it is irrelevant here how invasive or noninvasive the treatment is. It is also irrelevant how much education it takes to know how to place varnish. Also, please realize that the AAP (American Academy of Pediatricians) is outside their jurisdiction if and when they adopt their own policy on what makes a Pediatrician qualified to conduct dental exams and place fluoride varnish. This is akin to the AAO (American Association of Orthodontists) adopting a policy that after attending some workshop, Orthodontists will be considered qualified to set broken arms in their practice. These organizations do not have the authority to make such determinations.

and 2) That the dental judgment and practice falls within the scope of practice of a Pediatrician and under the purview of Medical Licensing Boards.

Just because MD's are smart enough and well educated in their own right, doesn't mean they are qualified or licensed to conduct dental diagnoses/procedures (even noninvasive procedures).

Correct me if I am wrong, but you sound like you don't treat caries in pediatric patients. (Because your arguments are more about turf wars than the well being of the child.)

You keep saying that pediatricians are not qualified to perform dental exams. But no one is saying this. Part of the education is that pediatricians will tell them they are not a dentist and still need a full exam. And caries risk assessment forms are designed to be filled out by a lay person. So a pediatrician wouldn't give fluoride to a low risk patient. Of course, some parents will use it as an excuse to not go to the dentist, but they had excuses before. At least now, someone will tell them that they need to go.

This is of most important for 1-3 year olds. Many general dentists are still going off of the old model of not seeing a dentist until they are three. For the uneducated parent (usually low socioeconomic), this can write a ticket to the OR. And this is the population that can least afford it. But it is this small amount of the population that has the most caries.

Which is why I assume you don't restore teeth on the pediatric population. Correct me if I am wrong. I don't mean to be vitriolic, but I feel like someone who does not deal with this population on a regular basis has no basis to stand on. But I commend you on your debating skills, but this is not similar to asking orthodontists to reduce arm fractures.

 

[capisce?]

To respond to your continued rant, I am merely concerned that Standard of Care be observed in the delivery of dental care. You have claimed that the Pediatricians will mostly be doing this for Medicaid Patients, so dentists shouldn't be worried about losing patients. This isn't even my point. I am merely concerned that the MD will not be able to provide dental care to the Standard of Care, due to the fact that he is not so educated and licensed.

Placing varnish up to the standard or care Now that's a good one.

Standard of care would by definition mean that pediatricians have to identify high risk patients and place varnish up to the same standard as a dentist. As dentalman has said, a layperson can be trained to fill out a CAT to identify high risk patients. The actual placement of the varnish, well, doesn't take more than drying of the teeth with gauze and covering all possible surfaces.

A formal definition of standard of care:

"Standard of care: 1. A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. Adjuvant chemotherapy for lung cancer is "a new standard of care, but not necessarily the only standard of care." (New England Journal of Medicine, 2004)

2. In legal terms, the level at which the average, prudent provider in a given community would practice. It is how similarly qualified practitioners would have managed the patient's care under the same or similar circumstances


Following this, then a pediatrician is following the standard of care if they:

1. correctly identify patients in need of therapy (use of a CAT, as defined by the AAPD and included below)

2. Place varnish in the correct manner

Where in that will a pediatrician fall short of the standard of care? The definition of standard of care does not have anything to do with "licensced dentists".

I see you also neglected to list any cons to this program.

Straight from the AAPD Handbook on CAT:

Cat can be used by both dental and nondental personnel. It does not render a diagnosis. However, individuals using CAT must be familiar with the clinical presentation of dental caries and factors related to caries initiation and progression. Advanced technologies (ie, radiographic assessment and microbiologic testing) have been included but are not essential for using this tool.

Just as we said, this is not for diagnosis. Also, MDs not only are taught about caries identification and risk factors, but they would receive additional training. Caries identification does not need to include an explorer, you may be suprised to learn that in Europe they do not use explorers for caries identification. For whoever brought up needing films for interproximal decay, well, you can see the AAPD has not included this. Research has shown that the biggest hesitation the AAPD has nothing to do with turf wars or standard of care, but a cost-benefit ratio with F- application by MDs.

From the AAPD Handbook on Fluoride:

The AAPD recommends an individualized patient caries-risk assessment to determine the use of fluoride-containing products as specified by the Policy on the Use of a Caries-Risk Assessment Tool (CAT) for Infants, Children and Adolescents and Clinical Guideline of Fluoride Therapy.

See, the difference between your posts and my posts is that mine aren't rants because I'm backing them up with factual arguments. Anytime I've posed a question to you, it was dodged and you responded with more unbacked statements. It's a good thing you didn't decide on law school.

 

[Cyclysm]

Placing varnish up to the standard or care Now that's a good one.

i think you could teach a chimp to place varnish correctly.

 

[capisce?]

ahem...dentists a subspecialty of medicine?...I don't think so.

go away

 

[S Files]

go away

several great points here. my concern is this "oral health assessment" i mean it's mutually understood b/w dents and meds that they don't know squat about "teeth" so will pts understand that this oral health assessment is not very meaningful...can MD's make a proper caries risk assessment? (obviously not) will pts (+parents) take this as a substitute for pediatric dental visit? my thinking is why not provide these grants and awards for pediatric health care centers where pts and parents visit a pediatrician and a pediatric dentists under the same roof? one last point, these fluoride varnishes???are they really effective when placed on some plaque infested teeth with incipient decay??aren't they better off getting a cleaning, sealant and proper fluoride application tray?? i'm a little skeptical about placing a varnish without cleaning....it's like putting on cologne after a workout
i don't think there's any turf war b/w pediatricians and pediatric dentists....especially in the underserved population, those two groups in my experience have formed great alliances in a few situations i'm aware of...just don't see much happening from this effort...think ped dentists should be asked to run such a program.

 

[1992Corolla]

Civility, please.

I thought you usually just closed these...

As far as letting a pediatrician apply the varnish...anyone can be trained to do anything but it IS in the scope of DENTISTRY. I think the matter would be better solved if pediatricians can recognize the need and then refer the patient. After all, we do the same things when we feel large bumps in the lymph nodes or see signs of leukemia.

Most people are just naive about the fact that varnishs exist. I didn't even knw about them until 2 years ago. Think about an innercity youth and their parents knowledge about them. If they are referred they are more likely to do something about it. The only thing I was ever given by any pediatrician for my sons for teeth were flouride drops. I was only recommended drops for on of my sones too. Had he said, go get varnish placed then I would have done it, because he said so.

Better networking is what we need.

 

[docj1]

several great points here. my concern is this "oral health assessment" i mean it's mutually understood b/w dents and meds that they don't know squat about "teeth" so will pts understand that this oral health assessment is not very meaningful...can MD's make a proper caries risk assessment? (obviously not) will pts (+parents) take this as a substitute for pediatric dental visit? my thinking is why not provide these grants and awards for pediatric health care centers where pts and parents visit a pediatrician and a pediatric dentists under the same roof? one last point, these fluoride varnishes???are they really effective when placed on some plaque infested teeth with incipient decay??aren't they better off getting a cleaning, sealant and proper fluoride application tray?? i'm a little skeptical about placing a varnish without cleaning....it's like putting on cologne after a workout
i don't think there's any turf war b/w pediatricians and pediatric dentists....especially in the underserved population, those two groups in my experience have formed great alliances in a few situations i'm aware of...just don't see much happening from this effort...think ped dentists should be asked to run such a program.

You have made some great points here. Are the peds going to prophy the teeth prior to varnish placement? Dental plaque as we all know is a good lubricant in the mouth(don't get excited anyone, I know it attaches readily to teeth). But placing fl varnish over it is like trying to paint cottage cheese. I don't know all the research on it but I know that most topical fl applications suggest that they are placed on "clean" teeth

 

[dentalwife]

I agree that anything to help children live decay free is a good thing. As long as the parents are told by the pediatrician that this is not a complete dental exam and that their childs teeth may have decay which they can not see clinically.

After perscribing a vitimin with flouride in it and telling me how much that would help prevent cavities in my baby, my PEDIATRICIAN told me children should see a dentist by 18 months and told me some nice ones in town. I think he would have done the same thing if he had painted flouride on her teeth. Pediatricians dont try to take away your job, nor do they claim to do a full exam. I think this would just make them better resources to parents. Maybe even remind them to tell you about the dentist. I dont know any PEDIATRICIANS who dont send kids to the dentist.

 

[docj1]

After perscribing a vitimin with flouride in it and telling me how much that would help prevent cavities in my baby, my PEDIATRICIAN told me children should see a dentist by 18 months and told me some nice ones in town. I think he would have done the same thing if he had painted flouride on her teeth. Pediatricians dont try to take away your job, nor do they claim to do a full exam. I think this would just make them better resources to parents. Maybe even remind them to tell you about the dentist. I dont know any PEDIATRICIANS who dont send kids to the dentist.

It sounds like you have a very good pediatrician who really cares about his patients. When he/she prescribes fl supplements your child is receiving systemic fl and this is a great thing especially in areas with no fl in their water supply. Topical application of fl varnish is different and should be done after a dental cleaning. I applaud your pediatrician and mine who suggest dental visits early (18-24 months) at this point most primary teeth are normally erupted. I don't think there is a dentist out there who thinks fl application by a pediatrician or anyone else is going to take away our jobs. Dental hygeinists normally apply topical fl after a dental cleaning. I do question the efficacy of fl varnish over dental plaque.

Either way anything that helps parents to understand the importance of having their children receive dental exams early is a good step towards a life of good oral health for their children. That's what it's all about

 

[S Files]

it's not like a visit to a pediatrician trained in oral health could've prevented this poor child's death. aside from a varnish and it's questionable efficacy, it would've meant an extra visit for the mother where essentially nothing aside from a motivational talk would've occured. it would've been solved if a pediatric dentist was in the same community clinic, or gen dentist, oral surgeon. i think it's great that pediatricians recognize the importance of oral health, but they should focus on other initiatives in my opinion. and while i'm at it, an expanded function hygienist, assistant, therapist or any other name doesn't solve the problem here either.

 

[ItsGavinC]

I am merely concerned that the MD will not be able to provide dental care to the Standard of Care, due to the fact that he is not so educated and licensed.

I stand by Capisce's comments that an MD applying Fl- is a standard of care for children is better than the no care they probably would have received otherwise.

 

[ItsGavinC]

That the dental judgment and practice falls within the scope of practice of a Pediatrician and under the purview of Medical Licensing Boards.

Just because MD's are smart enough and well educated in their own right, doesn't mean they are qualified or licensed to conduct dental diagnoses/procedures (even noninvasive procedures).

You must then be against MD's writing scripts for Fl supplements.

 

[Midoc]

This post by Jaybe reminded me of this comic I just saw today. http://www.dilbert.com/comics/dilbert/archive/dilbert-20070302.html

Let me congratulate you on your continued spiteful antics here.

Menses anyone???

To respond to your continued rant, I am merely concerned that Standard of Care be observed in the delivery of dental care. You have claimed that the Pediatricians will mostly be doing this for Medicaid Patients, so dentists shouldn't be worried about losing patients. This isn't even my point. I am merely concerned that the MD will not be able to provide dental care to the Standard of Care, due to the fact that he is not so educated and licensed.

What bothers me about your argument, is that you are insinuating that a Lesser Standard of Care should be acceptable for these Medicaid Patients. I don't agree. Its one Standard of Care = Care By Licensed Dentists, regardless of how poor you are.

Okay, now you can wind up and Scream some more.

 

[OceanBlue]

Go give Dr. Paquette a squeeze on the tush for me.

uhmmmmmm......will do!

 

[Jaybe]

You must then be against MD's writing scripts for Fl supplements.

I am against the Pediatricians' expanding their own Scope of Practice into the realm of the Dental Scope of Practice. Period. Even if the only dental procedure they want to do is a cursory oral exam and Fluoride varnish. I hold to the premise that Dentists are the providers that should be doing these things. That way they can give these children the comprehensive care they deserve.

My reasons for this are simple. Dentists are trained in the comprehensive oral care of patients. Physicians are not. When the AAP creates a position statement and a 1.5 hour CE course to train Pediatricians in 'oral health assessment' and Fluoride varnish placement, I interpret that as expanding their Scope of Practice into the Dental Scope of Practice.

The reason this is significant is that Pediatricians have neither the training nor the license to function as Dentists. These kids need to be seeing a dentist, and by having a Pediatrician conduct an 'oral health assessment' and placing varnish there is a good chance that parents will assume that the doctor has taken care of the kids teeth. Which he/she hasn't. Therefore, the parents are even less likely to take their children to see a dentist.

Again, I never stated that the difficulty of placing varnish was the reason I am opposed to this. I never stated that you couldn't train a Pediatrician to place varnish. I never questioned that it would be good for more kids to get oral exams and Fluoride. Maybe certain people will eventually stop acting like I ever said any of these things.

It may be a better idea to lobby the AAP to adopt a Policy that Pediatricians should be referring their patients to see dentists by a certain age. I'll let the Pedodontists decide the best timing for that. This way the kids are MORE likely to see their dentist, having received specific instructions to do so from their Pediatrician. In my opinion the Parent would be LESS likely to take the child to see their dentist if they were instead told that the Pediatrician "just checked out 'lil Johnny's' teeth and placed some Fluoride to keep him from getting cavities. But you also better take lil Johnny to the dentist, just in case."

 

[Jaybe]

i think you could teach a chimp to place varnish correctly.

Yeah, you can also teach an idiot to place sealants, prep teeth, do pulpotomies, and SSCs, all in addition to placing Fluoride varnish. I know this for a fact, because they taught ME to do them. And I'm a complete dolt! Lets face it, our Pediatric Dental procedures aren't that technically difficult.

But, that's not the point. The point is that we should support policies that are more likely to promote comprehesive oral care for children. I don't think the concept being promoted by the AAP and discussed here on this thread is going to achieve that end.

 

[Jaybe]

Correct me if I am wrong, but you sound like you don't treat caries in pediatric patients. (Because your arguments are more about turf wars than the well being of the child.)

Actually, that comment about "turf wars" was intended to be a little joke. I don't think a full out adoption of this policy by Pediatricians across the country will decrease the number of patients in Pedo dental offices AT ALL. In fact, I think it would INCREASE the number of patients you would be seeing, because it is more likely to DECREASE the number of parents taking their children to the dentist early. Many Parents are likely to take this 'oral health assessment' and Fluoride varnish as sufficient dental care, even if the Doc tells them to "also go and see a dentist". Therefore, you Pedodontists will have even more people show up for the first time at age 4 with a mouth full of bombed out teeth. Those parents will probably tell you right away how their Doctor "put some medicine on the teeth when he was gettin' shots a couple of years ago, and it was supposed to keep him from gettin' cavities"

You keep saying that pediatricians are not qualified to perform dental exams. But no one is saying this.

Actually, capisce? has repeatedly implied that Pediatricians ARE qualified to do this. She keeps making the silly argument that placing Fluoride is easy and blah, blah, blah so pediatricians should be able to do it. . .

But yes, I don't believe Pediatricians are qualified to conduct comprehensive oral exams, which I believe should be the standard of care for all children.

Part of the education is that pediatricians will tell them they are not a dentist and still need a full exam. And caries risk assessment forms are designed to be filled out by a lay person. So a pediatrician wouldn't give fluoride to a low risk patient. Of course, some parents will use it as an excuse to not go to the dentist, but they had excuses before. At least now, someone will tell them that they need to go.

You make a good point. And I agree that absentee parents are excellent at making excuses to NOT do stuff for their children. However, I believe that adopting a policy like this will increase the likelihood that such parents will NOT take their kid to the dentist because they will assume that they got some "free" dental care at the Pediatrician's office, so why go pay for some more of the same at a dentist's office.

Which is why I assume you don't restore teeth on the pediatric population. Correct me if I am wrong. I don't mean to be vitriolic, but I feel like someone who does not deal with this population on a regular basis has no basis to stand on.

Well, I am a licensed dentist, so I believe I have the right to be engaged in this debate, and any other debate surrounding dentistry or any of its specialties. This affects general dentists just as much as it affects Pediatric Dentists, even though a GP has a smaller percentage of children as patients.

More importantly, as a matter of policy, this affects our nation's children. As a citizen and a dentist it is my duty to help steer this debate in the direction that is best for our children.

But I commend you on your debating skills, but this is not similar to asking orthodontists to reduce arm fractures.

Well, I agree that this is not entirely "similar" to asking Orthodontists to reduce arm fractures. I was only making a point that the AAP (a Specialist Physician group) had created a policy statement outlining the parameters under which Pediatricians (medical specialists) could receive CE in a topic (oral exams and Fluoride varnish placement) that I strongly believe falls well within the scope of practice of Dentists (especially Pediatric Dentists). I was only showing how the AAO (a Specialist Dentist group) could just as easily adopt a policy statement outlining the parameters by which Orthodontists (dental specialists) could receive CE in a topic that falls well within the scope of practice of Medicine (broken arms).

This was intended to highlight the absurdity of having a physician group define itself as having jurisdiction over Dental Procedures (even non-invasive procedures such as Varnish placement). In my opinion, this is just as absurd as the AAO defining itself as having jurisdiction over procedures that are clearly within the Scope of Practice of Medicine (fractured arms).

 

[OceanDMD]

All of this over fluoride varnish? Face it, if a mom or dad isn't going to take their child to the dentist, this will remain true regardless of what happens in the pediatric Dr.'s office. Let them prescribe fluoride suppl., place varnish, give advice about hygiene. This advice would include the child to see a DENTIST every 6 months starting when they have their teeth. Its ridiculous stating that a parent would justify a varnish at the Dr.s office as an excuse not to seek dental care. This same parent would justify not taking their kid to the dentist because it costs too much.

Some families cannot afford the typical standard of care comprehensive dental care. ITS NOT THE KIDS FAULT. Why take away anything that helps promote dental care even if its as lame as a SINGLE treatment of varnish .

Let it go. You are right in the basis of your arguments(which you seem very passionate about), but sometimes you can bend a little for those less fortunate.

 

[Jaybe]

You have made some great points here. Are the peds going to prophy the teeth prior to varnish placement? Dental plaque as we all know is a good lubricant in the mouth(don't get excited anyone, I know it attaches readily to teeth). But placing fl varnish over it is like trying to paint cottage cheese. I don't know all the research on it but I know that most topical fl applications suggest that they are placed on "clean" teeth

this is another good example of how this doesn't meet the Standard of Care

 

[Jaybe]

All of this over fluoride varnish? Face it, if a mom or dad isn't going to take their child to the dentist, this will remain true regardless of what happens in the pediatric Dr.'s office. Let them prescribe fluoride suppl., place varnish, give advice about hygiene. This advice would include the child to see a DENTIST every 6 months starting when they have their teeth. Its ridiculous stating that a parent would justify a varnish at the Dr.s office as an excuse not to seek dental care. This same parent would justify not taking their kid to the dentist because it costs too much.

Some families cannot afford the typical standard of care comprehensive dental care. ITS NOT THE KIDS FAULT. Why take away anything that helps promote dental care even if its as lame as a SINGLE treatment of varnish .

Let it go. You are right in the basis of your arguments(which you seem very passionate about), but sometimes you can bend a little for those less fortunate.

Its just that as a matter of Policy, I don't think we should support putting a band aid over a gaping wound. I'm not entirely sure its any better than doing nothing.

Maybe no one else agrees here, but I think better policy could be formulated to increase the chance that these kids are being seen by dentists and getting Standard of Care treatment..

 

[Jaybe]

Standard of care would by definition mean that pediatricians have to identify high risk patients and place varnish up to the same standard as a dentist.

Since you earlier accused me of being shortsighted, I find it humourous that this is how you define Standard of Care.

Standard of Care in dentistry requires the provider to be a licensed dentist. As a corollary, Standard of Care assumes that the provider is capable of offering comprehensive care for the patient. So, unfortunately, a Pediatrician isn't providing Standard of Care treatment, even if he does an excellent job wiping fluoride varnish on the kids teeth.

See, the difference between your posts and my posts is that mine aren't rants because I'm backing them up with factual arguments. Anytime I've posed a question to you, it was dodged and you responded with more unbacked statements. It's a good thing you didn't decide on law school.

This reminds me of a really funny movie idea I have. It would include a scene of you in a courtroom as a laywer. And the other lawyer would stand up and explain that the facts dispute your version of the story. Next, you would stand up and start screaming, then your head would spin around in circles and pea soup would fly from your mouth, splattering the judge, jury and spectators along the way. Then your face would turn purple and your head would explode.

Because that's about how you act on SDN. Sorry, I just had to let you know.

 

[docj1]

Its just that as a matter of Policy, I don't think we should support putting a band aid over a gaping wound. I'm not entirely sure its any better than doing nothing.

Maybe no one else agrees here, but I think better policy could be formulated to increase the chance that these kids are being seen by dentists and getting Standard of Care treatment..

I agree

 

[Dr. Dai Phan]

I see pediatrician placing sealants as a preventive measure is a good idea. However, I am very concerned about them placing sealants over carious teeth. If they can learn to detect caries with the explorer and place sealants ONLY if the teeth are healthy, then I see no problem. What I am concerned is that they put sealants over deep occlusal caries then give the kid a clean bill of health. Detection caries although to us is simple, but to a non-dental personel could be tough. This is the same as listening to the stethescope sound as most of us (me included) don't know what I am hearing. If a person is trained adequately in a particular procedure regardless where he is a DDS or MD or what, I see no problem of them doing it as long as they can deal with complications. It is NOT from complications of the procedure that I am concerned about but a false pretend of "clean bill of oral health" that pediatrician may give to their patients if they are not trained to identify carious teeth. DP

 

[S Files]

I see pediatrician placing sealants as a preventive measure is a good idea. However, I am very concerned about them placing sealants over carious teeth. If they can learn to detect caries with the explorer and place sealants ONLY if the teeth are healthy, then I see no problem. What I am concerned is that they put sealants over deep occlusal caries then give the kid a clean bill of health. Detection caries although to us is simple, but to a non-dental personel could be tough. This is the same as listening to the stethescope sound as most of us (me included) don't know what I am hearing. If a person is trained adequately in a particular procedure regardless where he is a DDS or MD or what, I see no problem of them doing it as long as they can deal with complications. It is NOT from complications of the procedure that I am concerned about but a false pretend of "clean bill of oral health" that pediatrician may give to their patients if they are not trained to identify carious teeth. DP

i'd love to see my buddy (a 2nd yr pediatric resident) attempt a sealant!!!....oh man DP you're my boy and all, but DO NOT open up that can of worms.....we're talking about an oral health assessment and fluoride varnish...sealants/?????let's not go there...just remember our first time w/ a live pt, although a sealant seems brainless procedure to you, a seasoned prosthodontist, to an untrained person, it's actually quite a difficult procedure - in fact i'd say it'd do more damage (decay forming under the sealant, possibly place to much and get high occlusal spot), and let's not forget the behavior management of ped dents, if not done right can scare the crap out of some kid and fall out in a couple hours due to poor moisture control etc).... i agree w/ jaybe's band-aid analogy, although his little courtroom dream's a little strange!!..

 

[dentalman]

Jaybe,

I am so sorry. I just talked to a hospital admin guy, and they have no clue. When he refers to "screenings", he really means an oral exam, with xrays, because physicians can read a chest xray, so why not teeth xrays? Why don't they just start drilling the teeth while they are at it. I mean, how long does learning to drill really take?

You are right Jaybe, it is a bad idea. I should start doing physicals and treating for upper respiratory infections ... because its not that hard to prescribe meds or send off for cultures? Even though it sounds like a good idea, I don't think the administration can handle it correctly.

I have switched to your side, not because of your arguments, but after listening to a real life hospital admin person. They just don't get it.

 

[Jaybe]

Jaybe,

I am so sorry. I just talked to a hospital admin guy, and they have no clue. When he refers to "screenings", he really means an oral exam, with xrays, because physicians can read a chest xray, so why not teeth xrays? Why don't they just start drilling the teeth while they are at it. I mean, how long does learning to drill really take?

You are right Jaybe, it is a bad idea. I should start doing physicals and treating for upper respiratory infections ... because its not that hard to prescribe meds or send off for cultures? Even though it sounds like a good idea, I don't think the administration can handle it correctly.

I have switched to your side, not because of your arguments, but after listening to a real life hospital admin person. They just don't get it.

That was really my point the whole time. Some people seemed to think I was afraid of turf wars, or that physicians are too dumb to wipe fluoride, or that I am a facist who doesn't want kids to get fluoride. . .

I just don't think the physicians will be doing anything of benefit by wiping fluoride on dirty teeth. Why give a false sense of security to parents?

 

[Gradient Echo]

What you guys fail to understand is that ultimately, the argument that carries the day in courts of law and state legislatures regarding scope of practice is not "who is qualified" but "who is willing" to provide these services.

In my state, there are only a handful of dentists in the entire state that will see children on Medicaid. Think about that for a moment. In my residency program, getting dental follow-up on a kid on Medicaid with obvious caries and other dental issues is next to impossible. Dentists simply refuse to see these kids due to poor reimbursement.

Dentists are now going to get burned with the same stuff that burned doctors in the past. If you guys dont step up, somebody WILL step up for you, and they will infiltrate on your scope of practice. It might not be pediatricians, maybe it will be some kind of dental assistant midlevel or something. But at the end of the day, its going to happen as long as dentists refuse to treat these patients. I sympathize with the reimbursement issue, but in state legislatures when these bills get debated, its the access to care issue that will rule the day, not arguments over how much dentists get paid.

 

[jumpingjax]

I think Pediatricians should be allowed to do this, just add a 1 week rotation in residency. Done.

 

[gryffindor]

Dentists are now going to get burned with the same stuff that burned doctors in the past. If you guys dont step up, somebody WILL step up for you, and they will infiltrate on your scope of practice. It might not be pediatricians, maybe it will be some kind of dental assistant midlevel or something. But at the end of the day, its going to happen as long as dentists refuse to treat these patients. I sympathize with the reimbursement issue, but in state legislatures when these bills get debated, its the access to care issue that will rule the day, not arguments over how much dentists get paid.

This isn't a case of "those greedy dentists." Dentists in many states around the country have stated that the reimbursement from treating a medicaid patient doesn't even cover the overhead associated with the procedure. Overhead means paying for the materials, the equipment, the assistant, the building, the staff member filing for the reimbursement, etc. The dentist doesn't even get paid, sometimes he even loses money by seeing a Medicaid patient. I can't see how a mid-level would capitalize on this niche since their overhead is going to be exactly the same. I can see the mid-levels pushing their agenda as being the "solution" and bonehead politicians may eat it up, but when it comes down to actual practice, the mid-levels won't be seeing these patients either for the same reasons.

On the other hand, take the case of the state of Connecticut as Dr. Jeff has posted on here about it a few times. Connecticut had awful Medicaid reimbursement rates and very low levels of dentist participation. Once the legislature upped the reimbursement to realistic fees, the level of participating dentists shot up drastically. Someone sharper than me can quote the actual figures, but they were impressive.