DENTAL ECONOMICS FEBRUARY 1988 VIEWPOINT The Great Dental Mystery

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DENTAL ECONOMICS FEBRUARY 1988

VIEWPOINT: The Great Dental Mystery

by Murray Simon, DDS

Dr. Simon is president of D/R/S HealthCare Consultants, a firm that conducts market research for various health care companies.

   Dentistry, of late, has been besieged by articles detailing the enormous changes that are taking place within the profession. The '60s are now being viewed as the "golden era" of dentistry. Young dentists were graduating relatively debt-free, banks were lending start-up capital at single-digit interest rates and the biggest decision was whether to equip one or two operatories in the new office. The '70s were rather quiet except for tremors from the stock market and an occasional appointment failure due to the gasoline shortage.
     The '80s will most certainly go down in dental history as the "decade of major change". The public's desire for cosmetic procedures, increasing awareness and concern about periodontal disease, employers' demands for cost-containment, shifting patterns of insurance reimbursement, new and complex materials and treatment techniques, computerization, advertising and the concern over infectious diseases are some of the factors having a profound effect on the changing patterns in the delivery of dental care.
     And yet, with all of these major changes, there is one that is long overdue and not yet forth-
coming. A change with profound implications that will permanently alter the dentist-patient relationship and the way dentistry is practiced. But the majority of dentists appear to be ignoring it, and therein lies the great dental mystery. In the hope of solving it, lets examine two important clues.
     One, many dentists are not as busy as they would like to be, with the oversupply of dentists, caries reduction, concern over health care costs and competition for discretionary dollars generally set forth as the reasons for this situation.
     Two, it is estimated that approximately 90 percent of the adult population is afflicted with some form of periodontal disease. Juvenile periodontitis, although not particularly prevalent, is a term being used more and more in dental literature. Periodontal disease is considered second only to the common cold in terms of prevalence.
     In the ADA 1987 Dental Statistics Handbook, a table details the percentage of treatment time spent by dentists in performing various dental procedures. The figure given for periodontally-related treatment is only 5.2 percent! In a study of claims made with a major dental insurer, it was determined that only 4.0 percent of 1986 claims were for periodontally-related procedures! Thus, the great dental mystery. With all of this periodontal disease and with the widespread concern over busyness, why are these percentages so low?
     Although there is some current philosophical conflict between surgical and non-surgical adherents, the parameters of what constitutes successful periodontal treatment have long been established. Every dental school graduate has received a reasonable foundation in periodontal methodology. This is not to imply that current treatment modalities are sacrosanct and not open to question. The point is that valid methods do exist, but are not being widely used. The question remains, why?
     Perhaps the answer to the mystery lies less in the study of methodology and more in the study of motivation. Let's face it, when the dentist is selling periodontal disease therapy, the patient is not in a buying mood! How many dentists have heard these famous words? "Gee, nothing hurts." "My parents had it--I must have inherited it from them." "I'll go out and buy some floss right away." "I know someone who had those treatments and they can't eat anything hot or cold."
     The dentist spends more time in patient education that any other health care professional. Not only is time spent in explaining the nature of the problem, but patients want information on treatment methods, results and potential negatives as well. Unfortunately, all too often these efforts end in frustration for the dentist. Patients either fail to accept proposed treatment plans or treatment sometimes fails because of the patient's failure to follow through with proper maintenance. The latter is a particular problem in the treatment of periodontal disease and provides another clue in our attempt to solve the mystery.
     The practicing dentist is required to wear many hats. He or she must be a metallurgist, physicist, chemist, pharmacologist, physician, psychiatrist, accountant, personnel manager, repairman, etc. Rare indeed is the practitioner who is comfortable wearing all of these hats. One role that many dentists feel particularly uncomfortable with is that of salesperson. Dental schools teach little if anything about it; often, they choose to ignore it. Selling is one of the most important ingredients in establishing a successful practice, but for many, it represents a career-long obstacle.
     Now weigh these considerations in examining our mystery. No area of dental treatment requires a greater commitment to selling and motivation than periodontics. Not only does the patient have to be convinced of the need for therapy, but also the demand of long-term motivation or the case will fail. In this light, the dentist puts on a few more hats--cheerleader, disciplinarian, father confessor. Heavy weighs the head that bears so many crowns.
     Anyone who has been practicing dentistry in a conscientous manner for enough years is bound to have been affected by the average failure rate of periodontal cases. Consider the following observations:

Many dentists are frustrated with those patients whose commitment to oral health is inadequate.
Many patients want the dentist to assume the responsibility for their periodontal problems.
Many dentists are shifting much of the responsibility for periodontally-related education and motivation to the hygienist.
Many practices do not have a clearly-defined program of periodontal therapy and maintenance.
Too much dentistry is "thing" oriented rather than "service"-oriented. Patients find it easier to
accept charges for restorations and dentists find it easier to sell restorative services.
The spectre of malpractice litigation may be contributing to an attitude of conservatism with regard to periodontal treatment.

     Now that the mystery has been defined, how can it be solved? The answer appears to lie in better diagnostic procedures and clearly-defined treatment objectives.
     Periodontal diagnostics establish the presence of the disease, determine the degree of severity and provide a motivational tool and a means of monitoring progress.
     At the present time, methods of periodontal diagnosis are rather lacking. Soft tissue examination is quite subjective and is not reliable in terms of the episodic nature of the disease. Radiographs are flat pictures of a three-dimensional problem and are of questionable value during the earlier stages. Probing is a technique-sensitive procedure and results vary considerably. None of the presently available diagnostic procedures identifies the causative agent(s) or the current degree of activity. Until more definitive procedures are developed, it is imperative that the dentist make use of all existing diagnostics and document each case as thoroughly as possible.
     Clearly defined treatment objectives are essential. At what point does a case go from "you're heading for problems" to "you need treatment"? At what point does the need for soft tissue therapy become a need for surgical intervention? What are the criteria that determine whether or not the patient is ready to assume responsibility?
     The answers to these questions are related to the individual practitioner's level of expertise and how comfortable the dentist is with different treatment and management modalities. The fact remains, there is a lot of periodontal disease in need of treatment and individual dentists must make a stronger effort to meet that need. ¤